Category: Investigations

Monday Accident & Lessons Learned: OPG Safety Alert – WELL CONTROL INCIDENT

July 21st, 2014 by

OGP Safety Alert

WELL CONTROL INCIDENT

While drilling 8″1/2 hole section @ 5052m with 1.51 SG MW, observe well flowing during pipe connection. Shut well in w/ 76 bbls gain. Establish 550psi SIDPP and 970psi SICP.

It took more than 7 minutes for the Driller to shut in after the well flowing situation was recognized (9 minutes 52 seconds total pumps off until well shut in) as follows: “The Mud Logger calls the dog house to inform the Driller that he has seen a gain in the trip tank; the Assistant Driller takes the call and communicates the information to the Driller. As the Driller is in the process of raising the blocks, he waits until the blocks are at 26m and calls the pit room to check that there is nothing that would affect the trip tank volume. He then waited for the return call which confirms nothing would affect the trip tank. The Driller switches over to the flow line as the trip tank is now nearly full and then lowers the TDS and screws back into the string at the rotary table. The string is then picked up and spaced out to close the annular mid joint; the Driller then unlocks the compensator. The annular is then closed by the Assistant Driller who is at the panel and the lower fail safes on the choke line are opened to monitor pressures.

Well was controlled using Drillers Method to circulate/increase MW up to 1.63 SG & decrease gas levels prior to open the well.

What Went Wrong?

Kick zone actual PP exceeds predicted PP range by ~0.07 SG EMW.

But actual PP < ECD (well not flowing while pumping).

76-bbl Kick Volume due to lengthy shut in Vs. ~30-bbl actual Kick Tolerance (KT) calculated from actual ~0.1 SG EMW Kick Intensity (design KT was 80 bbls calculated from maximum predicted PP). Note: There was gas in the influx, but no H2S. According to kick pressure & volume analysis, it is possible that part of the kick was liquid (influx density calculation). Influx density helped evacuating the kick w/out exceeding MAASP & fraccing @ shoe on exceeded KT.

Corrective Actions and Recommendations:

  1. Flow check each connection prior to starting the physical breaking of the tool joint (rather than flow check during connection).
  2. Ensure effective monitoring of the Mud Logging fingerprint screen during pumps-off real-time (connection & mid-stand “long connection test”).
  3. Correct shut-in procedure to be enforced & applied.
  4. Perform unannounced simulated kicks (kick drills).
  5. Whenever possible, implement a Well-Full-of-Gas capable casing design so that KT is not limited.

Source Contact:

safety alert number: 257 

OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Blame Comes Quickly in Moscow Subway Accident – When Will the Root Causes Be Investigated?

July 16th, 2014 by

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The Cristian Science Monitor reported that the spokesperson for the Kermlin’s Investigative Committee (a police body) said:

As it is a man-caused accident, it is obvious that there are people responsible for it, so soon there will be suspects in the case.

Later the International Business Times published this headline:

Moscow Subway Accident: 2 Arrested Metro Workers Failed To Properly Supervise Track Switch Repair, Authorities Say

It seems the two arrested supervised a job where a track switch was re-wired with the wrong wire.

Twenty-one have died, over a hundred were injured, and over 1000 people had to be evacuated from the subway after the accident. 

What do you think? Will discipline solve the problem? Or does a real root cause analysis need to be done?

Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013

July 14th, 2014 by

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The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:

At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.

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The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.

RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R132014_Winchfield.pdf

 

Press Release from the UK RAIB: Accident to a track worker near Redhill, 24 June 2014

July 8th, 2014 by

NewImageSite of the accident

 RAIB is investigating an accident to a track worker who was supervising a gang carrying out track maintenance work near Redhill in Surrey. The accident occurred at about 10:40 hrs on 24 June 2014. The track worker was struck by a passenger train and suffered serious injuries.

The injured person was with a gang of eleven people engaged in undertaking repairs to the Up Quarry line between Redhill Tunnel and Quarry Tunnel. The train, a passenger service from Gatwick Airport to London Victoria, was travelling at about 80 mph (129 km/h).

RAIB’s investigation will consider the sequence of events and factors that may have led to the accident, and identify any safety lessons.

RAIB’s investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Releases Report on Accident at Balnamore Level Crossing, Ballymoney, Northern Ireland, 31 May 2013

July 7th, 2014 by

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Here’s the Summary from the report:

At approximately 03:10 hrs on Friday, 31 May 2013, a car driver was forced totake action in order to avoid colliding with an engineering train that was traversing Balnamore automatic half barrier level crossing, which is located between Coleraine and Ballymoney stations on Northern Ireland Railways’ Belfast to Londonderry/ Derry line. The car subsequently struck metal fencing forming part of the crossing, causing minor injuries to its two occupants and damage to the car. The crew of the engineering train spoke with the car driver and then continued work without reporting the accident.

At the time of the accident, the engineering train was undertaking weed-spraying operations within a possession of the line, which meant that operation of passenger trains on the line had been suspended. Because the line was under possession, Balnamore level crossing, which is normally automatically operated by approaching trains, was being operated manually via its local controls. However, as the train passed over the crossing, its half barriers had not been lowered and its road traffic signals were not operating, even though this was required by the railway rules relating to this type of level crossing. This meant that the car driver did not have enough warning to stop his car before the level crossing became occupied by the train.

The RAIB has found that the team responsible for undertaking weed-spraying was routinely not complying with the rules relating to the operation of automatic half barrier level crossings within possessions. This was probably due to a combination of factors, including the team possibly having a low perception of the risks presented by this non-compliance and a desire by them to complete the weed-spraying more quickly. In addition, the team may have been influenced by the status of rules relating to the local control of other types of crossing in possessions and the method of work adopted at level crossings during a recent project.

The RAIB has also found that this non-compliance was not detected or corrected by safety checks conducted by Northern Ireland Railways. In addition, the investigation identified that the appointment of additional competent staff to operate crossings within the possession may have prevented the accident from occurring.

The RAIB has identified three key learning points. These are: 1) that the person in charge of a possession should correctly complete the form intended to help them keep track of level crossings; 2) that boarding moving trains, where it is prohibited, should be avoided; and 3) that accidents should be reported.

The RAIB has also made three recommendations addressed to Northern Ireland Railways. These relate to: 1) ensuring that activities undertaken at level crossings within possessions are subject to effective risk controls; 2) ensuring that method statements relating to track engineering are supported by risk assessments; and 3) increasing the opportunities for non-compliances to be detected and corrected.

For the complete report, CLICK HERE.

Monday Accident & Lessons Learned: OGP Safety Alert – WELLHEAD GLAND NUT/LOCKSCREW ASSEMBLY EJECTION

June 30th, 2014 by

OGP SAFETY ALERT

A gas well installation suffered a loss of containment when a gland nut and lockscrew assembly was ejected from a wellhead while the well was under pressure, shortly before commencing tubing installation. The release of gas resulted in a fire which caused the death of a field service technician.

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Lockscrews are commonly used in surface wellhead equipment to mechanically energize or retain internal wellhead components. Lockscrews are not standardized across the industry, so manufacturers’ procedures should always be used for operations that may require manipulation of lockscrews. Work involving gland nut and lockscrew assemblies should be done under the supervision of qualified service personnel from the wellhead equipment provider who have access to the operational procedures, key dimensions, and torque ratings necessary for correct use.

Operators should consider working with their wellhead equipment and service providers to validate the integrity of gland nut and lockscrew assemblies that are exposed to wellbore pressure in the field by taking the following steps:

 

  1. Verify adequate engagement of gland nuts;
  2. Confirm lockscrew assemblies’ torque values are consistent with manufacturer’s specifications;
  3. Inspect lockscrew assemblies for any debris or damage such as scarring or bending;
  4. Follow manufacturer’s procedures if checks show any of the above are inconsistent with the manufacturer’s specifications;
  5. Conduct a pressure test to rated maximum working pressure to ensure gland nut and lockscrew assemblies have pressure integrity;
  6. Consider isolating gland nut and lockscrew assemblies from wellbore pressure by having tubing hangers and adapters installed;
  7. Reinforce with relevant personnel training and the use of procedures to address hazards associated with performing work on wellhead assemblies exposed to wellbore pressure; and
  8. Review and implement appropriate engineering and well design controls (physical design of equipment) and administrative controls (procedures) to address the hazards of work involving gland nut and lockscrew assemblies.

These same validation steps should be taken prior to commencing any well work during which gland nut and lockscrew assemblies will be exposed to wellbore pressure.

safety alert number: 256
OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

 

 

Bad Day for the Blog…

June 25th, 2014 by

We had a technical malfunction this week and lost all the pictures, pdf’s, and other attachments that were uploaded to the blog. In addition, our whole web site was down for a little over 24 hours.

We will be working to recover the lost material but if you have trouble finding something … please be understanding.

Dan Verlinde is doing a TapRooT® investigation of the issue so we can prevent a recurrence.

Thanks for your understanding.

Monday Accident & Lessons Learned: Human Error Leads to Near-Miss at Railroad Crossing in UK – Can We Learn Lessons From This?

June 23rd, 2014 by

Here’s the summary from the UK RAIB report:

 

At around 05:56 hrs on Thursday 6 June 2013, train 2M43, the 04:34 hrs passenger service from Swansea to Shrewsbury, was driven over Llandovery level crossing in the town of Llandovery in Carmarthenshire, Wales, while the crossing was open to road traffic. As the train approached the level crossing, a van drove over immediately in front of it. A witness working in a garage next to the level crossing saw what had happened and reported the incident to the police.

The level crossing is operated by the train’s conductor using a control panel located on the station platform. The level crossing was still open to road traffic because the conductor of train 2M43 had not operated the level crossing controls. The conductor did not operate the level crossing because he may have had a lapse in concentration, and may have become distracted by other events at Llandovery station.

The train driver did not notice that the level crossing had not been operated because he may have been distracted by events before and during the train’s stop at Llandovery, and the positioning of equipment provided at Llandovery station relating to the operation of trains over the level crossing was sub-optimal.

The RAIB identified that an opportunity to integrate the operation of Llandovery level crossing into the signalling arrangements (which would have prevented this incident) was missed when signalling works were planned and commissioned at Llandovery between 2007 and 2010. The RAIB also identified that there was no formalised method of work for train operations at Llandovery.

The RAIB has made six recommendations. Four are to the train operator, Arriva Trains Wales, and focus on improving the position of platform equipment, identifying locations where traincrew carry out operational tasks and issuing methods of work for those locations, improvements to its operational risk management arrangements and improving the guidance given to its duty control managers on handling serious operational irregularities such as the one that occurred at Llandovery.

Two recommendations are made to Network Rail. These relate to improvements to its processes for signalling projects, to require the wider consideration of reasonable opportunities to make improvements when defining the scope of these projects, and consideration of the practicability of providing a clear indication to train crew when Llandovery level crossing, and other crossings of a similar design, are still open to road traffic.

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The full report has very interesting information about the possibility of fatigue playing a part in this near miss. See the whole report HERE.

This report is an excellent example of how much can be learned from a near-miss. People are more whilling to talk when a potential near-fatal accident happens than when a fatality happens. And all of this started because a bystander reported the near-miss (not the train crew or the driver).

How can you improve the reporting and investigation of potentially fatal near-miss accidents? Could your improvements in this area help stop fatalities?

 

 

Press Release from the UK RAIB: Derailment at London Paddington station 25 May 2014

June 12th, 2014 by

 

RAIB is investigating a derailment that occurred at London Paddington main line station, on Sunday 25 May 2014.

The train that derailed was an empty five car Class 360/2 passenger train (reporting number 5T08), manufactured by Siemens and operated by Heathrow Express. It was travelling from Old Oak Common to Paddington in preparation for entering passenger service.

At 05:20 hrs, both sets of wheels on the leading bogie of the third vehicle derailed to the left when the vehicle was about 150 metres from the buffer stops in platform 3 and travelling at between 12 and 14 mph (19.3 and 22.5 km/h).

The driver twice stopped the train after it derailed. On both occasions, unaware of what had happened, he restarted the train. As a consequence, the train ran nearly 100 metres in a derailed state and was finally stopped with the right side of the derailed bogie in a pit that was located between the rails, which lifted both wheels on the left side of the rear bogie off the rails. No one was injured.

Platform 3 remained closed for the remainder of the day.

NewImageImage of derailed vehicle at Paddington station

RAIB’s investigation will examine the sequence of events leading up to the derailment and will seek to identify the causes. This will include consideration of the design, maintenance and condition of both the track and the derailed vehicle.

RAIB’s investigation is independent of any investigation by the safety authority (the Office of Railway Regulation).

RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. These findings will be available on the RAIB website.

Maintenance Error Causes Fire at Power Plant in Colorado

June 10th, 2014 by

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A mechanic opened the wrong end of a filter causing oil to spray on hot piping. The immediate flash fire caused extensive damage at the Martin Drake power plant run by Colorado Springs Utilities.

See the Colorado Springs Fire Department report here:

http://www.pennenergy.com/content/dam/Pennenergy/online-articles/2014/06/CSFD%2BDuty%2BReport%2Bfor%2BDrake%2BFire%2B052314.pdf

Press Release from the US CSB: CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

June 5th, 2014 by

 

CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

 Report Says Similar Accident Could Still Occur, Calls for Better Management
of Safety-Critical Elements by Offshore Industry, Regulators

 Houston, Texas, June 5, 2014— The blowout preventer (BOP) that was intended to shut off the flow of high-pressure oil and gas from the Macondo well in the Gulf of Mexico during the disaster on the Deepwater Horizon drilling rig on April 20, 2010, failed to seal the well because drill pipe buckled for reasons the offshore drilling industry remains largely unaware of, according to a new two-volume draft investigation report released today by the U.S. Chemical Safety Board (CSB).

CLICK HERE to access Overview
CLICK HERE to access Volume 1
CLICK HERE to access Volume 2

The blowout caused explosions and a fire on the Deepwater Horizon rig, leading to the deaths of 11 personnel onboard and serious injuries to 17 others.  Nearly 100 others escaped from the burning rig, which sank two days later, leaving the Macondo well spewing oil and gas into Gulf waters for a total of 87 days. By that time the resulting oil spill was the largest in offshore history.  The failure of the BOP directly led to the oil spill and contributed to the severity of the incident on the rig.

The draft report will be considered for approval by the Board at a public meeting scheduled for 4 p.m. CDT at the Hilton Americas Hotel, 1600 Lamar St., Houston, TX 77010.  The meeting will include a detailed staff presentation, Board questions, and public comments, and will be webcast at:

http://www.csb.gov/investigations/webcast/.

The CSB report concluded that the pipe buckling likely occurred during the first minutes of the blowout, as crews desperately sought to regain control of oil and gas surging up from the Macondo well.  Although other investigations had previously noted that the Macondo drill pipe was found in a bent or buckled state, this was assumed to have occurred days later, after the blowout was well underway.

After testing individual components of the blowout preventer (BOP) and analyzing all the data from post-accident examinations, the CSB draft report concluded that the BOP’s blind shear ram – an emergency hydraulic device with two sharp cutting blades, intended to seal an out-of-control well – likely did activate on the night of the accident, days earlier than other investigations found.  However, the pipe buckling that likely occurred on the night of April 20 prevented the blind shear ram from functioning properly.  Instead of cleanly cutting and sealing the well’s drill pipe, the shear ram actually punctured the buckled, off-center pipe, sending huge additional volumes of oil and gas surging toward the surface and initiating the 87-day-long oil and gas release into the Gulf that defied multiple efforts to bring it under control.

The identification of the new buckling mechanism for the drill pipe ­– called “effective compression” – was a central technical finding of the draft report.  The report concludes that under certain conditions, the “effective compression” phenomenon could compromise the proper functioning of other blowout preventers still deployed around the world at offshore wells.  The complete BOP failure scenario is detailed in a new 11-minute computer video animation the CSB developed and released along with the draft report.

The CSB draft report also revealed for the first time that there were two instances of mis-wiring and two backup battery failures affecting the electronic and hydraulic controls for the BOP’s blind shear ram.  One mis-wiring, which led to a battery failure, disabled the BOP’s “blue pod” – a control system designed to activate the blind shear ram in an emergency.  The BOP’s “yellow pod” – an identical, redundant system that could also activate the blind shear ram – had a different miswiring and a different battery failure.  In the case of the yellow pod, however, the two failures fortuitously cancelled each other out, and the pod was likely able to operate the blind shear ram on the night of April 20.

“Although both regulators and the industry itself have made significant progress since the 2010 calamity, more must be done to ensure the correct functioning of blowout preventers and other safety-critical elements that protect workers and the environment from major offshore accidents,” said Dr. Rafael Moure-Eraso, the CSB chairperson. “The two-volume report we are releasing today makes clear why the current offshore safety framework needs to be further strengthened.”

“Our investigation has produced several important findings that were not identified in earlier examinations of the blowout preventer failure,” said CSB Investigator Cheryl MacKenzie, who led the investigative team.  “The CSB team performed a comprehensive examination of the full set of BOP testing data, which were not available to other investigative organizations when their various reports were completed.  From this analysis, we were able to draw new conclusions about how the drill pipe buckled and moved off-center within the BOP, preventing the well from being sealed in an emergency.”

The April 2010 blowout in the Gulf of Mexico occurred during operations to “temporarily abandon” the Macondo oil well, located in approximately 5,000-foot-deep waters some 50 miles off the coast of Louisiana.  Mineral rights to the area were leased to oil major BP, which contracted with Transocean and other companies to drill the exploratory Macondo well under BP’s oversight, using Transocean’s football-field-size Deepwater Horizon drilling rig.

The blowout followed a failure of the cementing job to temporarily seal the well, while a series of pressure tests were misinterpreted to indicate that the well was in fact properly sealed.  The final set of failures on April 20 involved the Deepwater Horizon’s blowout preventer (BOP), a large and complex device on the sea floor that was connected to the rig nearly a mile above on the sea surface.

Effective compression, as described in the draft report, occurs when there is a large pressure difference between the inside and outside of a pipe.  That condition likely occurred during emergency response actions by the Deepwater Horizon crew to the blowout occurring on the night of April 20, when operators closed BOP pipe rams at the wellhead, temporarily sealing the well.  This unfortunately established a large pressure differential that buckled the steel drill pipe inside the BOP, bending it outside the effective reach of the BOP’s last-resort safety device, the blind shear ram.

“The CSB’s model differs from other buckling theories that have been presented over the years but for which insufficient supporting evidence has been produced,” according to CSB Investigator Dr. Mary Beth Mulcahy, who oversaw the technical analysis.  “The CSB’s conclusions are based on real-time pressure data from the Deepwater Horizon and calculations about the behavior of the drill pipe under extreme conditions.  The findings reveal that pipe buckling could occur even when a well is shut-in and apparently in a safe and stable condition.  The pipe buckling – unlikely to be detected by the drilling crew – could render the BOP inoperable in an emergency.  This hazard could impact even the best offshore companies, those who are maintaining their blowout preventers and other equipment to a high standard.  However, there are straightforward methods to avoid pipe buckling if you recognize it as a hazard.”

The CSB investigation found that while Deepwater Horizon personnel performed regular tests and inspections of those BOP components that were necessary for day-to-day drilling operations, neither Transocean nor BP had performed regular inspections or testing to identify latent failures of the BOP’s emergency systems. As a result, the safety-critical BOP systems responsible for shearing drill pipe in emergency situations – and safely sealing an out-of-control well – were compromised before the BOP was even deployed to the Macondo wellhead.  The CSB report pointed to the multiple miswirings and battery failures within the BOP’s subsea control equipment as evidence of the need for more rigorous identification, testing, and management of critical safety devices.  The report also noted that the BOP lacked the capacity to reliably cut and seal the 6-5/8 inch drill pipe that was used during most of the drilling at the Macondo well prior to April 20 – even if the pipe had been properly centered in the blind shear ram’s blades.

Despite the multiple maintenance problems found in the Deepwater Horizon BOP, which could have been detected prior to the accident, CSB investigators ultimately concluded the blind shear ram likely did close on the night of April 20, and the drill pipe could have been successfully sealed but for the buckling of the pipe. 

“Although there have been regulatory improvements since the accident, the effective management of safety critical elements has yet to be established,” Investigator MacKenzie said.  “This results in potential safety gaps in U.S. offshore operations and leaves open the possibility of another similar catastrophic accident.”

The draft report, subject to Board approval, makes a number of recommendations to the U.S. Department of Interior’s Bureau of Safety and Environmental Enforcement (BSEE), the federal organization established following the Macondo accident to oversee U.S. offshore safety. These recommendations call on BSEE to require drilling operators to effectively manage technical, operational, and organizational safety-critical elements in order to reduce major accident risk to an acceptably low level, known as “as low as reasonably practicable.”

“Although blowout preventers are just one of the important barriers for avoiding a major offshore accident, the specific findings from the investigation about this BOP’s unreliability illustrate how the current system of regulations and standards can be improved to make offshore operations safer,” Investigator MacKenzie said.  “Ultimately the barriers against a blowout or other offshore disaster include not only equipment like the BOP, but also operational and organizational factors.  And all of these need to be rigorously defined, actively monitored, and verified through an effective management system if safety is to be assured.”  Companies should be required to identify these safety-critical elements in advance, define their performance requirements, and prove to the regulator and outside auditors that these elements will perform reliably when called upon, according to the draft report.

The report also proposes recommendations to the American Petroleum Institute (API), the U.S. trade association for both upstream and downstream petroleum industry. The first recommendation is to revise API Standard 53, Blowout Prevention Equipment Systems for Drilling Wells, calling for critical testing of the redundant control systems within BOP’s, and another for new guidance for the effective management of safety-critical elements in general.

CSB Chairperson Rafael Moure-Eraso said, “Drilling continues to extend to new depths, and operations in increasingly challenging environments, such as the Arctic, are being planned.  The CSB report and its key findings and recommendations are intended to put the United States in a leading role for improving well-control procedures and practices.  To maintain a leadership position, the U.S. should adopt rigorous management methods that go beyond current industry best practices.”

Two forthcoming volumes of the CSB’s Macondo investigation report are planned to address additional regulatory matters as well as organizational and human factors safety issues raised by the accident.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Report: Collision at Buttington Hall user worked crossing, Welshpool, 16 July 2013

June 2nd, 2014 by

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Here’s the summary of the UK RAIB’s report:

At 11:44 hrs on Tuesday 16 July 2013 a collision occurred between a passengertrain and a farm trailer at Buttington Hall farm crossing near Welshpool on the line between Shrewsbury and Machynlleth. The tractor driver and two other people nearby sustained minor injuries and two passengers on the train were injured and taken to hospital, but were discharged later that day.

The train involved was operated by Arriva Trains Wales and consisted of two 2-car units. It was travelling at 120 km/h (75 mph) at the time of the collision. The train was running from Birmingham International to Aberystwyth and Pwllheli and there were 140 passengers and two crew members on board. On the day of the accident, the farm crossing was being used by tractors bringing in a harvest from fields on the opposite side of the line to the farm. The farmer had appointed a contractor to carry out the harvesting operation, and an attendant had been provided at the crossing to phone the signaller and operate the gates.

The accident occurred because the system of work in use at the crossing was inherently unsafe, leading to ineffective control of road vehicle movements over the crossing and frequent use of the crossing without the signaller being contacted. This system broke down. There were also underlying management factors:

  • the harvest contractor did not implement an effective safe system of work at the crossing;
  • Network Rail’s process for risk assessment of these types of crossing did not adequately deal with periods of intensive use; and
  • Network Rail’s instructions to users of these crossings did not cover periods of intensive use.

The RAIB has made three recommendations:

  • main line infrastructure managers should improve the risk assessment process at these crossings to take into account the increased risk during periods of intensive use;
  • main line infrastructure managers should define safe and practical methods of working to be adopted at these crossings during periods of intensive use; and
  • RSSB should update the level crossing risk management toolkit to reflect the changes brought about by the second recommendation.

The RAIB has also noted a learning point from an observation made during the investigation concerning the prolonged closure of an adjacent level crossing on a main road after the accident.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140327_R062014_Buttington_Hall.pdf

UK RAIB Press Release: Collision at Loughborough Central on the Great Central Railway (GCR), 12 May 2014

May 30th, 2014 by

NewImageThe incident train following the collision

 RAIB is investigating a collision that occurred at around 12:35 hrs on Monday 12 May 2014 between an unmanned runaway train and a set of five coaches that was stabled on the down main line about 450 metres on the approach to Loughborough Central station. Nobody was injured as a result of the collision, although significant damage was sustained by some of the rail vehicles involved. The GCR was not open to the public when the collision occurred.

The train consisted of a Class 37 locomotive coupled to a single preserved Travelling Post Office (TPO) coach. It ran away on the down main line, with the TPO coach leading, from a position opposite Quorn signal box for a distance of about 1.8 miles (2.9 km) before the collision occurred.

The RAIB’s preliminary examination has shown that the locomotive had been used during the morning of 12 May to undertake shunting operations within a section of line, around 4.4 miles (7 km) in length, that was closed to normal railway traffic (ie it was under a ‘possession’). As part of these shunting operations, the locomotive had been coupled to the TPO coach, although the braking systems of the locomotive and coach were not connected.

At around 11:50 hrs, the train was left unattended on the down main line opposite Quorn signal box (still within the possession). At this location the line has a 1 in 330 gradient, descending towards Loughborough. This descending gradient becomes steeper beyond Quorn before reducing and subsequently levelling out on the approach to where the collision occurred.

Evidence suggests that, before leaving the train unattended, the crew applied the locomotive’s air brakes, shut-down its engine and applied a single wheel scotch (also known as a chock) underneath one of the locomotive’s wheels. Neither of the two parking brakes (also known as hand brakes) on the locomotive were applied (the TPO coach is not equipped with a parking brake). While the train was unattended it ran away in the direction of Loughborough and exited the possession. Fortunately, no staff were working on the portion of line over which the train ran away.

The set of five coaches which was struck by the train had been stabled on the down main line outside of the possession and within the station limits of Loughborough Central station. The set had been secured by the parking brake of one of its coaches.

RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. These findings will be available on the RAIB website.

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Report – Locomotive derailment at Ordsall Lane Junction, Salford, 23 January 2013

May 19th, 2014 by

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Here’s the summary from the UK RAIB’s report:

At 14:34 hrs on 23 January 2013 a class 47 diesel electric locomotive derailed on a small radius curve, approaching Ordsall Lane Junction in Salford, and caught fire. The locomotive derailed to the outside of the curve. It was being hauled on the rear of an empty train, which was formed of another class 47 locomotive and five coaches.

The cause of the derailment was that the lateral forces acting at the wheel-rail interface, as the locomotive negotiated the curve, were sufficient to cause the leading right-hand wheel to climb the rail. Despite being required by standards, there was no check rail on the curve. This safeguard would have restricted the lateral displacement of the wheels and prevented the derailment.

The RAIB found that the following factors had resulted in the lateral forces being high enough to initiate wheel climbing conditions:

  • The dry and clean state of the inside face of the outer rail on the curve that enabled high levels of wheel-rail contact friction to be established; recently-modified arrangements for lubricating the rails did not prevent this.
  • Machining work that had recently been undertaken to restore the wheel profiles on the locomotive; this removed any pre-existing lubricant and contaminant from the locomotive wheels that would otherwise have helped reduce wheel-rail contact friction levels.
  • The relatively low angle of contact between the wheel and rail associated with the newly-restored wheels on the locomotive; this reduced the locomotive’s ability to resist the climbing forces acting at the wheel-rail interface.
  • The wider than normal distance between the rails (track gauge) that had developed on the curve.

The above combined to generate the conditions necessary for derailment, but none of these factors involved non-compliance with applicable standards.

Although it was found that the reprofiling of the wheels had left the wheel surface slightly rougher than specified, the RAIB decided not to investigate this factor any further. This was because the surface was only marginally non-compliant and there is contradictory evidence regarding its effect on wheel-rail friction.

The basic approach to managing the risk of derailment on small radius curves on the national network relies on vehicles and track complying with separate technical standards. However, because these standards do not require consideration of the worst possible combination of conditions, there remains a residual risk of derailment. It is generally recognised by the railway industry that the level of this residual riskis reduced by certain traditional features, such as check rails and trackside rail lubricators. Therefore, although not generally relied upon, RAIB observed that any change in the provision of such features has the potential to reduce the overall level of derailment safety.

The RAIB has directed three recommendations to Network Rail. They are concerned with:

  • ensuring that non-compliances with currently prescribed requirements for check rails are identified and mitigated;
  • understanding any changes to infrastructure management processes that have increased derailment risk on small radius curves, and the need to take actions to reduce this risk; and
  • determining when it is necessary to bring existing track assets in line with latest design standards.

For the complete UK RAIB report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140331_R072014_Ordsall_Lane_Junction.pdf

Monday Accident & Lessons Learned: Sentinel Event Discipline or Root Cause Analysis

May 12th, 2014 by

Watch this video and see how TapRooT® could have been used for root cause analysis…

Press Release from the UK RAIB: Derailment of a freight train at Angerstein Junction, near Charlton, London

May 9th, 2014 by

RAIB is investigating the derailment of a freight train at Angerstein Junction, near Charlton in south east London, at about 12:16 hrs on 2 April 2014. The train comprised 20 wagons, of the JRA and JGA types, hauled by a class 66 locomotive. It had just left sidings at Angerstein Wharf, where the wagons had been unloaded, and was travelling to Bardon Hill, Leicestershire. It then derailed, at a low speed, on a curved section of the single line track which links the sidings to the North Kent line at Angerstein Junction.

The RAIB’s preliminary examination revealed that the leading bogie of the 9th wagon had derailed shortly after passing over a set of trap points about 30 metres before the junction with the North Kent Line, and that these points had been correctly set to allow the passage of the train. Shortly after the derailment occurred the front of the train stopped at a signal on the North Kent line. The driver was still unaware of the derailment and he restarted his train from this signal when it cleared. The trailing bogies of the 8th and 9th wagons were then pulled off the track as the derailed bogie ran over part of a cross-over between the Up and Down North Kent lines. The train continued along the Down line and was then stopped, about 180 metres from the initial point of derailment, by an automatic brake application caused when the brake pipe broke between the 9th and 10th wagons.

Although routed onto the Down North Kent line, the derailed wagons stopped in a position where they were foul of the adjacent Up line. Fortunately, there was no train on this part of the Up line when the derailment occurred.

NewImageImage of derailed train at Angerstein Junction

In addition to damage to the derailed wagons, cabling and signal equipment, the derailment caused track damage. Train services on the North Kent line suffered disruption until 5 April.

RAIB’s investigation will seek to identify the sequence of events leading to the derailment and the factors that played a part. The investigation will include consideration of both track and wagon characteristics.

RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.

RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. These findings will be available on the RAIB website.

Eight injured after carabiner failure causes collapse at circus

May 7th, 2014 by

Providence fire department investigator Paul Doughty says that the stationary load was within the caribiner’s rating but they are looking into other dynamic forces.

For more details about the accident that caused eight circus performers to plummet to the floor in front of an audience, see:

http://articles.chicagotribune.com/2014-05-05/news/chi-acrobats-injured-rhode-island-20140504_1_acrobats-critical-condition-performers

No Causes Found Yet for Train Derailment in Downtown Lynchburg, VA

May 3rd, 2014 by

The Houston Chronicle reported that the NTSB hasn’t found any causes of a recent train derailment in Lynchburg, VA. For the whole story, see: http://fuelfix.com/blog/2014/05/02/investigators-narrow-possible-causes-of-oil-train-derailment/.  

Monday Accident & Lessons Learned: PONTOON COMPARTMENT EXPLOSION ON FLOATING ROOF TANKS

April 28th, 2014 by

An incident report and lessons learned from the OPG Safety Alert network:

An explosion occurred at a location during restoration activities on a crude oil tank which had been cleaned up (Figure 1). Two workers were carrying out hot work on the top of the tank floating roof (cutting rim seal brackets in close proximity to the pontoon). One of the pontoon compartments exploded. Flammable residue was released onto the tank floor causing a small fire.

In this case, workers sustained moderate injuries. However similar accidents (e.g. Figure 2) involving hot work on floating roofs after tank clean-up have taken place in the past and led to more severe injuries and fatalities.

 

What Went Wrong?:

Ignition sources generated by the hot work came in contact with the flammable mixture of hydrocarbons inside a nearby pontoon compartment that was contaminated.

 

  • Tank Cleaning activities had been executed by contractors with little / no experience with tank cleaning
  • There was no detailed procedure describing the tank cleaning activities
  • The tank cleanliness inspection was incomplete as the pontoon compartments were not inspected
  • The possible presence of hydrocarbons in the pontoon had not been anticipated during risk assessments (hence gas testing was ineffective because not done inside pontoon).

Figure 1

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Figure 2

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Corrective Actions and Recommendations:

Have engagement sessions with staff to increase awareness on risks related to tank cleaning and hot work inside, on or near tanks.

NB:Consider very carefully the risks of enclosed volumes, e.g: tank pontoons. Unless clearly proven otherwise, they should always be treated as if they contain volatile hydrocarbons!

 

  • Tank cleaning activities are critical operations that require specialized interventions using detailed procedures.
  • Pontoon compartments are enclosed volumes potentially containing hydrocarbons that sometimes go unnoticed.
  • Other enclosed volumes exist on floating roofs and present the same risks as with pontoons (e.g. some parts of seal systems, radial stiffeners).
  • Risk assessments must systematically address the hazards related to enclosed volumes and include adequate safety measures (e.g. pontoon cleanliness verification, inside pontoon gas detection).

 safety alert number: 255 

OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Press Release from the US Chemical Safety Board: Chemical Safety Board Ongoing Investigation Emphasizes Lack of Protection for Communities at Risk from Ammonium Nitrate Storage Facilities; Finds Lack of Regulation at All Levels of Government

April 23rd, 2014 by

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Chemical Safety Board Ongoing Investigation Emphasizes Lack of Protection for Communities at Risk from Ammonium Nitrate Storage Facilities; Finds Lack of Regulation at All Levels of Government

 Dallas, TX April 22, 2014 – Today the CSB released preliminary findings into the April 17, 2013, West Fertilizer explosion and fire in West, Texas, which resulted in at least 14 fatalities, 226 injuries, and widespread community damage.  Large quantities of ammonium nitrate (AN) fertilizer exploded after being heated by a fire at the storage and distribution facility.  The CSB’s investigation focuses on shortcomings in existing regulations, standards, and guidance at the federal, state and county level.  

The investigative team’s presentation will occur this evening at a public meeting in West, Texas, at 5:30 pm CDT.
CSB Chairperson Rafael Moure-Eraso said, “The fire and explosion at West Fertilizer was preventable. It should never have occurred. It resulted from the failure of a company to take the necessary steps to avert a preventable fire and explosion and from the inability of federal, state and local regulatory agencies to identify a serious hazard and correct it.”

The CSB’s investigation found that at the state level, there is no fire code and in fact counties under a certain population are prohibited from having them.  “Local authorities and specifically—local fire departments—need fire codes so they can hold industrial operators accountable for safe storage and handling of chemicals,” said Dr. Moure-Eraso. 

CSB Supervisory Investigator Johnnie Banks said “The CSB found at all levels of government a failure to adopt codes to keep populated areas away from hazardous facilities, not just in West, Texas. We found 1,351 facilities across the country that store ammonium nitrate.  Farm communities are just starting to collect data on how close homes or schools are to AN storage, but there can be little doubt that West is not alone and that other communities should act to determine what hazards might exist in proximity.”

The CSB’s preliminary findings follow a yearlong investigation which has focused on learning how to prevent a similar accident from occurring in another community. “It is imperative that people learn from the tragedy at West,” Dr. Moure-Eraso said.

The investigation notes other AN explosions have occurred, causing widespread devastation. A 2001 explosion in France caused 31 fatalities, 2500 injuries and widespread community damage. In the United States, a 1994 incident caused 4 fatalities and eighteen injuries. More recently a July 2009 AN fire in Bryan, Texas, led to an evacuation of tens of thousands of residents. Fortunately no explosion occurred in the Bryan, Texas, incident which highlights the unpredictable nature of AN. 

The CSB’s investigation determined that lessons learned during emergency responses to AN incidents – in which firefighters perished —  have not been effectively disseminated to firefighters and emergency responders in other communities where AN is stored and utilized. 

The CSB has found that on April 17, 2013, West volunteer firefighters were not aware of the explosion hazard from the AN stored at West Fertilizer and were caught in harm’s way when the blast occurred.

Investigators note that the National Fire Protection Association (NFPA) recommends that firefighters evacuate from AN fires of “massive and uncontrollable proportions.” Federal DOT guidance contained in the Emergency Response Guidebook, which is widely used by firefighters, suggests fighting even large ammonium nitrate fertilizer fires by “flood[ing] the area with water from a distance.”  However, the investigation has found,  the response guidance appears to be vague since terms such as “massive,” “uncontrollable,” “large,” and “distance” are not clearly defined. 
Investigator Banks said, “All of these provisions should be reviewed and harmonized in light of the West disaster to ensure that firefighters are adequately protected and are not put into danger protecting property alone.” 

The CSB has previously noted that while U.S. standards for ammonium nitrate have apparently remained static for decades, other countries have more rigorous standards covering both storage and siting of nearby buildings. For example, the U.K.’s Health and Safety Executive states in guidance dating to 1996 that “ammonium nitrate should normally be stored in single story, dedicated, well-ventilated buildings that are constructed from materials that will not burn, such as concrete, bricks or steel.”  The U.K. guidance calls for storage bays “constructed of a material that does not burn, preferably concrete.”

At the county level, McLennan County’s local emergency planning committee did not have an emergency response plan for West Fertilizer as it might have done under the federal Emergency Planning and Community Right to Know Act.  The community clearly was not aware of the potential hazard at West Fertilizer.

Chairperson Moure-Eraso commended recent action by the Fertilizer Institute in establishing an auditing and outreach program for fertilizer retailers called ResponsibleAg, and for disseminating with the Agricultural Retailers Association a document called “Safety and Security Guidelines for the Storage and Transportation of Fertilizer Grade Ammonium Nitrate at Fertilizer Retail Facilities.” It also contains recommendations for first responders in the event of a fire.  

“We welcome this very positive step,” Dr. Moure-Eraso said, “We hope that the whole industry embraces these voluntary guidelines rather than being accepted only by the companies that choose to volunteer.”

The Chairperson called on states and counties across the country to take action in identifying hazards and requiring the safe storage and handling of ammonium nitrate. “Regulations need to be updated and new ones put in place. The state of Texas, McLennan County, OSHA and the EPA have work to do, because this hazard exists in hundreds of locations across the U.S.  However, it is important to note that there is no substitute for an efficient regulatory system that ensures that all companies are operating to the same high standards. We cannot depend on voluntary compliance.” 

The CSB is an independent federal agency charged with investigating serious chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

For more information, contact Communications Manager Hillary Cohen, cell  202-446-8094  or Sandy Gilmour, Public Affairs, cell  202-251-5496 .

Press Release: CSB Announces Upcoming Report on the BP Deepwater Horizon Accident

April 20th, 2014 by

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Statement by CSB Chairperson Rafael Moure-Eraso on Fourth Anniversary
of Deepwater Horizon Tragedy in Gulf of Mexico;
CSB Investigation Reports to be Released at June 5th Public Meeting in Houston, Texas

As we approach the fourth anniversary of the April 20, 2010, Deepwater Horizon tragedy and environmental disaster in the Gulf of Mexico, I would like to announce that the comprehensive Chemical Safety Board investigation of the Macondo well blowout is in the final stages of completion and the first two volumes are planned to be released at a public meeting in Houston on June 5.

The death and destruction of that day are seared in our consciousness. The forthcoming CSB investigation report has a singular focus: preventing such an accident from happening again.

Eleven workers lost their lives, many others were injured, and oil and other hydrocarbons flowed uncontrolled out of the well for months after the explosion on the rig, owned and operated by Transocean under contract with BP. The CSB, at the request of Congress, launched an independent investigation with a broad mandate to examine not only the technical reasons that the incident occurred, but also any possible organizational and cultural causal factors, and opportunities for improving regulatory standards and industry practices to promote safe and reliable offshore energy supplies.

While a number of reports have been published on the incident, and changes made within the U.S. offshore regulatory regime, more can be done. On June 5, the CSB will release the first two volumes of our four-volume investigation report, covering technical, regulatory, and organizational issues.

The CSB examines this event from a process safety perspective, integrating fundamental safety concepts, such as the hierarchy of controls, human factors, and inherent safety into the U.S. offshore vernacular. While these concepts are not new in the petrochemical world or in other offshore regions around the globe, they are not as commonplace in the U.S. outer continental shelf.

At the public meeting, investigators will present for board consideration what I believe is a very comprehensive examination of various aspects of the incident.
Going beyond other previously released reports on the accident, the CSB explores issues not fully covered elsewhere, including:

  • The publication of new findings concerning the failures of a key piece of safety equipment—the blowout preventer—that was, and continues to be, relied upon as a final barrier to loss of well control.
  • A comprehensive examination and comparison of the attributes of  regulatory regimes in other parts of the world to that of the existing framework and the safety regulations established in the US offshore since Macondo.
  • In-depth analysis and discussion of needed safety improvements on a number of organizational factors, such as the industry’s approach to risk management and  corporate governance of safety management for major accident prevention, and  workforce involvement through the lifecycle of hazardous operations.

Recommendations will be included in the various volumes of the CSB’s Macondo investigation report.
Volume 1 will recount a summary of events leading up to the Macondo explosions and fire on the rig, providing descriptive information on drilling and well completion activities.

Volume 2 will present several new critical technical findings, with an emphasis on the functioning of the blowout preventer (BOP), a complex subsea system that was intended to help mitigate and prevent a loss of well control. This volume examines the failures of the BOP as a safety-critical piece of equipment and explores deficiencies in the management systems meant to ensure that the BOP was reliable and available as a barrier on April 20, 2010.

Later in the year, the board will consider report Volume 3 which will delve into the role of the regulator in the oversight of the offshore industry. Finally, Volume 4 will explore several organizational and cultural factors that contributed to the incident.

We look forward to presenting this vital information to the public, industry, Congress, and all others interested in fostering safety in the offshore drilling and production industry. 

END STATEMENT  For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496. 

Monday Accident & Lessons Learned: Incident Report from the UK Rail Accident Investigation Branch: Tram running with doors open on London Tramlink, Croydon

April 7th, 2014 by

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There were eight recommendations made by the UK RAIB. here’s a summary of the investigation:

On Saturday 13 April 2013 between 17:33 and 17:38 hrs, a tram travelling from West Croydon to Beckenham Junction, on the London Tramlink system, departed from Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors closed automatically during the journey, but one set of doors remained open throughout the incident. The incident ended when a controller monitoring the tram on CCTV noticed that it had departed from Sandilands withits doors open, and arranged for the tram to be stopped. Although there were no casualties, there was potential for serious injury.

The tram was able to move with its doors open because a fault override switch, which disables safety systems such as the door-traction interlock, had been inadvertently operated by the driver while trying to resolve a fault with the tram. The driver didnot close and check the doors before departing from Lebanon Road and Sandilands partly because he was distracted from dealing with the fault, and partly because he did not believe that the tram could be moved with any of its doors open. The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch. Furthermore, breakdowns in communication between the driver and the passengers, and between the driver and the controller, meant that neither the driver nor the controller were aware of the problem until after the tram left Sandilands.

The RAIB has made eight recommendations. Four of these are to Tram Operations Ltd, aimed at improving the design of tram controls and displays, as well astraining of staff on, and processes for, fault handling and communications. Two recommendations have been made to London Tramlink, one (in consultation with Tram Operations Ltd) relating to improving cab displays and labelling and one on enhancing the quality of the radio system on the network. One recommendation is made to all UK tram operators concerning the accidental operation of safety override switches. The remaining recommendation is to the Office of Rail Regulation regarding the provision of guidance on ergonomics principles for cab interface design.

 

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140306_R052014_Lebanon_Road.pdf

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