Category: Investigations

Will public shaming lead to better safety?

May 12th, 2016 by

This is old news to most (or should be) but OSHA finally published the long awaited rule on injury reporting:

https://www.osha.gov/recordkeeping/finalrule/index.html

So now that information will become more public will companies improve their records to stay out of view? Some things to think about:

*If they did not care about worker’s safety before, why would they care now?
*Will anyone even pay attention?
*Will management put more pressure on the operation to reduce rates?
*Will management give the operation additional resources to accomplish it?
*Will the media misuse the information? Will it be used politically?
*Did you just become your PR Department’s best bud or worst enemy?
*Will it actually help companies choose better business partners? (many companies have been requiring rates during the RFP process anyway)
*Is everyone else in the organization now throwing in their 2 cents on how you run your business?

I look at this a few ways:

*If you already have a good program and record, this should be of little concern to you from the public information standpoint.
*Assuming that is the case, as a former corporate safety manager, I see this as a HUGE cost for companies to comply. But there has been (and still is) plenty of time to get things in place.

At the end of the day, you cannot control regulations. But can you control your injuries? You bet.

Two of the best ways to lower your injury rates? Do better investigations and audits. Why not join us for a future course? You can see the schedule and enroll HERE

Ken Reed invites you to the Investigator Track at the 2016 Global TapRooT® Summit

May 5th, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Investigator Track. Come to the Summit and maximize improvement at your company!

Starring Ken Reed. Produced by Benna Dortch.
Interested in the Asset Optimization Track? Learn about that track here!

Interested in the Safety Track? Learn about that track here!

LEARN MORE about the 2016 Global TapRooT® Summit!

Monday Accident & Lessons Learned: “We are going to find out who is to blame for this …”

May 2nd, 2016 by

“We are going to find out who is to blame because that is the frustrating part about health and safety accidents such as this. When we go back, when we read the report, we find out each and every time that it was preventable. That’s why we need to learn from this,” Kevin Flynn, Ontario’s labour minister, told reporters Tuesday afternoon. 

That’s a quote from CP 24, Toronto’s Breaking News. See the story and watch the video interview about the accident here:

http://www.cp24.com/news/we-need-to-learn-from-this-labour-minister-says-after-building-scaffolding-collapse-1.2864799

Is there a lesson to be learned here?

Interestingly, the “contractor” performing the work in this accident was a branch of the Ontario government.

Rail Accidents: It’s the Entire System that Matters

May 2nd, 2016 by

amtrak

 

On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance.  Two maintenance workers were killed, and about 20 passengers on the train were injured.  For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.

Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC).  These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train.  It is designed to allow for:

  • Train separation and collision avoidance
  • Speed enforcement
  • Rail worker safety

For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance.  Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area.  The system can be pretty sophisticated, but this is the general idea.

Notice that I described the system as a series of sensors, software, and procedures that make up PTC.  While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly.  For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:

  • The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
  • The dispatcher must correctly tell the system that the workers are present.
  • The software must correctly identify the section of track.
  • The communications hardware must properly communicate with the train.
  • The train must know where it is and where it is going.
  • The workers must be on the correct section of track.
  • The workers must be doing the correct maintenance (for example, not also working on an additional siding).
  • If being used, local temporary warning systems being used by the workers must be operating properly.  For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
  • Proper maintenance must be performed on all of the PTC hardware and software.

As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment.  Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc.  People are still involved.

For the Washington Amtrak crash, we know that there was a PTC system in place.  However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc.  I am definitely not trying to apportion any blame, since I’m not involved in the investigation.  However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.

Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system.  Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs.  By finding the human performance issues, we can target more effective corrective actions than just blaming the individual.  Our investigations and audits have to take the entire system into account when looking for improvements.

Monday Accident & Lessons Learned: CSB Issues Report on BP Deepwater Horizon Accident

April 18th, 2016 by

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The CSB press release starts with:

“Washington, DC, April 13, 2016 – Offshore regulatory changes made thus far do not do enough to place the onus on industry to reduce risk, nor do they sufficiently empower the regulator to proactively oversee industry’s efforts to prevent another disaster like the Deepwater Horizon rig explosion and oil spill at the Macondo well in the Gulf of Mexico, an independent investigation by the U.S. Chemical Safety Board (CSB) warns.”

For the whole report, see:

http://www.csb.gov/the-us-chemical-safety-boards-investigation-into-the-macondo-disaster-finds-offshore-risk-management-and-regulatory-oversight-still-inadequate-in-gulf-of-mexico/

 

 

3 Things that Separate the “Best of the Best” from the Rest

April 14th, 2016 by

Are you getting the results you are looking for?

There are some companies out there who “get it.”  We see it all the time at our courses.  Some companies just seem to be able to understand what it takes to not just have an incident investigation program, but actually have an EFFECTIVE program that can demonstrate consistent results.  As a comparison, some companies write great policies, say all the right things, and seem to have a drive to make their businesses better, and yet don’t seem to be able to get the results they are looking over.  By contrast, great companies are able to translate this drive into results.  They have fewer injuries, less downtime, fewer repeat incidents, and happier employees.  What is the difference?

We often see three common threads in these successful world-class companies:

1.  Their investigation teams are given the resources they need to actually perform excellent investigations.  The team members are given time to participate in the process.  This doesn’t mean that they have time during the day, and then (after work) it is time to catch up on everything they missed.  They are truly given dedicated time (without penalty) to perform quality investigations.  They are also given authority to speak to who they need and gather the evidence they need.  Finally, they are given management support throughout the process.  These items allow the team members to focus on the actual investigation process, instead of fighting hurdles and being distracted by outside interference.

2.  The investigation teams are rewarded for their results.  This doesn’t mean they are offered monetary rewards.  However, it is not considered a “bad deal” to have to perform the investigation.  Final reports are reviewed by management and good questions are asked.  However, the team does not feel like they are in front of a firing squad each time they present their results.  Periodic performance reviews recognize their participation on investigation teams, and good performance (both by the teams and by those implementing corrective actions) are recognized in a variety of ways.  Team members should never dread getting a call to perform an investigation.  They should be made to feel that this is an opportunity to make their workplace better, and it’s management’s job to foster that attitude.

3.  Great companies don’t wait for an incident to come along before they apply root cause analysis techniques. They are proactive, looking for small problems in their businesses.  I often hear people tell me, “Luckily, I only have to do a couple investigations each year because we don’t have many incidents.”  That just means they aren’t looking hard enough.  Any company that thinks that everything is going great is sticking their head in the sand.  World-class companies actively seek problems, before they become major incidents.  Why wait until someone gets hurt?  Go find those small, everyday issues that are just waiting to cause a major problem.  Fixing them early is much easier, and this is recognized by the Best of the Best.

Oh, and actually, there is a #4:

4.  The Best of the Best use TapRooT®!!!

REGISTER for a course and build an effective program with consistent results!

Navy Ship Damaged During Startup – Root Cause is Human Error?

April 9th, 2016 by

Here’s the article …

http://www.bloomberg.com/news/articles/2016-04-07/damage-extensive-for-crippled-u-s-littoral-ship-in-singapore?cmpid=yhoo.headline

They have already fired the Commanding Officer … so don’t worry … they won’t start up gears without lube oil again. More video below.

Monday Accident & Lessons Learned: RAIB Report – Serious accident at Clapham South tube station

April 4th, 2016 by

The following is the summary of a report from the UK Rail Accident Investigation Branch.

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Serious accident involving a passenger trapped in train doors and
dragged at Clapham South station, 12 March 2015

At around 08:00 hrs on Thursday 12 March 2015, a passenger fell beneath a train after being dragged along the northbound platform of Clapham South station, in south London. She was dragged because her coat had become trapped between the closing doors of a London Underground Northern line train.

The train had stopped and passengers had alighted and boarded normally, before the driver confirmed that the door closure sequence could begin. The train operator, in the driving cab, started the door closure sequence but, before the doors had fully closed, one set encountered an obstruction and the doors were reopened. A passenger who had just boarded, and found that the available standing space was uncomfortable, stepped back off the train and onto the platform, in order to catch the following train. The edge of this passenger’s coat was then trapped when the doors closed again and she was unable to free it.

The trapped coat was not large enough to be detected by the door control system and the train operator, who was unaware of the situation, started the train moving. While checking the platform camera views displayed in his cab, the train operator saw unusual movements on the platform and applied the train brakes. Before the train came to a stop, the trapped passenger fell to the ground and then, having become separated from her coat, fell into the gap between the platform and the train. The train stopped after travelling about 60 metres. The passenger suffered injuries to her arm, head and shoulder, and was taken to hospital.

As a result of this accident, RAIB has made one recommendation, addressed to London Underground, seeking further improvements in the processes used to manage risks at the platform-train interface.

RAIB has also identified one learning point for the railway industry, relating to the provision of under platform recesses as a measure to mitigate the consequences of accidents where passengers fall from the platform.

For the complete report, see:

R042016_160309_Clapham_South

Monday Accident & Lessons Learned: IOGP Safety Alert – Dropped Object

March 28th, 2016 by

NewImage

IOGP SAFETY ALERTDROPPED OBJECT: 1.3 POUND LINK PIN FELL 40 FEET

 

A drilling contractor was tripping pipe out of the hole and a link pin came loose from the hook, falling 40 feet (12.2 metres) to the deck below. The pin bounced and struck a glancing blow to the left jaw/neck area of a worker. The link pin is 1 inch by 5 inches (2.5cm x 12.7cm) and weighs 1.3 pounds (0.6 kg).

What Went Wrong?

The type of keeper pin used on the dropped object did not adequately secure the pin. The link pin is threaded and uses a cotter pin to prevent the pin body from backing out. The pin was secured with a coil “diaper pin” instead of a cotter pin. 

Corrective Actions and Recommendations:

Safety pins that can be knocked out must not be used for lifting operations or securing equipment overhead.

Follow cotter pin installation guidelines:

  • Both points on a cotter pin must be bent around the shaft.
  • Cotter pins are a single-use instrument and should never be re-used.

safety alert number: 271
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.

Monday Accident & Lessons Learned: Report by UK RAIB – Serious accident as a passenger left a train and became trapped in the train doors at West Wickham station last April

March 14th, 2016 by

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At around 11:35 hrs on 10 April 2015, a passenger was dragged along the platform at West Wickham station, south London, when the 11:00 hrs Southeastern service from London Cannon Street to Hayes (Kent) departed while her backpack strap was trapped in the doors of the train.

As it moved off, she fell onto the platform and then through the gap between the platform and train, suffering life-changing injuries.

The backpack strap became trapped when the train doors closed unexpectedly and quickly while she was alighting.

Testing showed that this potentially unsafe situation could only occur when a passenger pressed a door-open button, illuminated to show it was available for use, within a period of less than one second beginning shortly after the train driver initiated the door closure sequence.

RAIB identified this door behaviour, which was not known to the owner or operator, and issued urgent safety advice. In response to this, the railway industry undertook a review which identified 21 other types of train that permit passenger doors to be opened for a short period after door closure is initiated by train crew. The industry is now seeking ways to deal with this risk.

The train was being driven by a trainee driver under the supervision of an instructor. The service was driver only operation, which meant that before leaving West Wickham station, and after all train doors were closed, drivers were required to check that it was safe to depart by viewing CCTV monitors located on the platform. Two of these monitor images showed that a passenger appeared to be trapped but, although visible from the driving cab, neither the trainee driver nor the instructor was aware of this. Although the RAIB has not been able to establish why the trapped passenger was not seen before the train departed, a number of possible explanations have been identified.

As a result of this accident, RAIB has made two recommendations. The first, addressed to operators and owners of trains with power operated doors, is intended to identify and correct all train door control systems exhibiting the unsafe characteristics found during this investigation. The second, addressed to RSSB, seeks changes to guidance documents so that, where practicable, staff dispatching trains watch the train doors while they are closing, in addition to checking the doors after they are closed.

RAIB has also identified five learning points relating to: releasing train doors long enough to allow passengers to get on and off trains safely; effective checking of train doors before trains depart (and not relying on the door interlock light); design of door controls; and use of train driving simulators to raise drivers’ awareness of circumstances when it is not safe to depart from a station.

For the entire report, see:

https://assets.digital.cabinet-office.gov.uk/media/56d04f05e5274a10f9000001/R032016_160229_West_Wickham.pdf

Grading Your Investigations

March 10th, 2016 by

How do you grade an incident investigation? Here’s an Excel spreadsheet to use…

RateRootCauseAnalysis03082016.xlsx

How do you use the spreadsheet? Here’s a video from last year’s Summit …

Grading Your Investigation from TapRooT® Root Cause Analysis on Vimeo.

Would you like to learn this and hear about someone who has been using it to improve their company’s investigations? Go to the Grading Your Investigations Breakout Session (Wednesday – 1:30-2:30) at the 2016 Global TapRooT® Summit.

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

book_graphic_1511

If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Monday Accident & Lessons Learned: Button Pushed “Accidentally” Shuts Down Refinery

March 7th, 2016 by

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Here’s the press report about an incident at a west coast refinery …

http://ww2.kqed.org/news/2016/02/26/martinez-refinery-incident-triggered-when-someone-hit-the-wrong-button

They think that someone working in the area accidentally hit a button that shut down fuel to a boiler. That caused a major portion of the refinery to shut down.

 At least one Causal Factor for this incident would be “Worker accidentally hits button with elbow.”

If you were analyzing this Causal Factor using the Root Cause Tree®, where would you go?

Of course, it would be a Human Performance Difficulty.

When you reviewed The Human Performance Troubleshooting Guide, you would answer “Yes” to question 5:

“Were displays, alarms, controls, tools, or equipment identified or operated improperly?”

 That would lead you do evaluating the equipment’s Human Engineering.

Under the Human-Nachine Interface Basic Cause Category, you would identify the “controls need improvement” root cause because you would answer “Yes” to the Root Cause Tree® Dictionary question:

“Did controls need mistake-proofing to prevent unintentional or incorrect actuation?”

That’s just one root cause for one Causal Factor. How many other Causal Factors were there? It’s hard to tell with the level of detail provided by the article. I would guess there was at least one more, and maybe several (there usually should be for an incident of this magnitude). 

At least one of the corrective actions by the refinery management was to initially put a guard on the button. Later, the button was removed to eliminate the chance for human error. 

Are there more human-machine interface problems at this refinery? Are they checking for them to look for Generic Causes? You can’t tell from the article.

Would you like to learn more about understanding human errors and advanced root cause analysis? Then you should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See public course dates at:

http://www.taproot.com/store/5-Day-Courses/

And click on the link for the continent where you would like to attend the training.

Monday Accident & Lessons Learned: Is Human Error the Root Cause of the German Train Crash?

February 29th, 2016 by

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When the press covers an accident, they like instant answers, The BBC is reporting that “human error” is to “blame” for the cause of two trains crashing head on in Germany. Here’s the article:

http://www.bbc.com/news/world-europe-35585302

Of course, prosecutors are pressing charges against the area controller who “… opened the track to the two trains and tried to warn the drivers.”

What do you think … is “human error” THE cause?

Monday Accident & Lessons Learned: FAA Shares Lessons from Transport Airplane Accidents

February 22nd, 2016 by

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The FAA has a library of lessons learned from aviation transport accidents. See what you can learn by visiting their web site:

http://lessonslearned.faa.gov

Using the Essential TapRooT® Techniques to Perform Apparent Cause Analysis

February 17th, 2016 by

If you are in the nuclear industry you have probably read my rant on apparent cause analysis. I said that apparent cause analysis was a curse.

The curse as been lifted!

We published a book that describes how to use TapRooT® for low-to-moderate risk incidents. And this new way of using TapRoot® is perfect for apparent cause analysis!

EssentialsBook

What’s in the book? Here’s the Table of Contents …

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

WHEN CAN YOU BUY THIS NEW BOOK??? NOW!!!

See this link: 

http://www.taproot.com/products-services/taproot-book

The “Force” was with HSE this time in Star Wars Accident

February 11th, 2016 by

“The actor, Harrison Ford, was struck by a hydraulic metal door on the Pinewood set of the Millennium Falcon in June 2014.”

“The Health And Safety Executive has brought four criminal charges against Foodles Production (UK) Ltd – a subsidiary of Disney.”

“Foodles Production said it was “disappointed” by the HSE’s decision.”

Read more here

 

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

February 10th, 2016 by

In 2008 we wrote the book TapRooT® – Changing the Way the World Solves Problems. In one book we stuffed in all the information we thought was needed for anyone from a beginner to an expert trying to improve their root cause analysis program. It was a great book – very complete.

As the years went on, I realized that everybody didn’t need everything. In fact, everything might even seem confusing to those who were just getting started. They just wanted to be able to apply the proven essential TapRooT® Techniques too investigate low-to-moderate risk incidents.

Finally I understood. For a majority of users, the big book was overkill. They wanted something simpler. Something that was easy to understand and as easy as possible to use and get consistent, high-quality results. They wanted to use TapRooT® but didn’t care about trending, investigating fatalities, advanced interviewing techniques, or optional techniques that they would not be applying.

Therefore, I spent months deciding was were the bare essentials and how they could be applied as simply as possible while still being effective. Then Linda Unger and I spent more months writing an easy to read 50 page book that explained it all. (Yes … it takes more work to write something simply.)

 

EssentialsBook

Book Contents:

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

By April, the new book and philosophy will be incorporated into our 2-Day TapRooT® Root Cause Analysis Course. But you can buy the new book (that comes with the latest Dictionary, Root Cause Tree®, and TapRooT® Corrective Action Helper® Guide) from our web site NOW. See:

 http://www.taproot.com/products-services/taproot-book

I think you will find the book invaluable because it has just what you need to get everything you need for root cause analysis of low-to-medium risk incidents in just 10% of the old book’s pages.

Eventually, we are developing another eight books and the whole set will take the place of the old 2008 TapRooT® Book. You will be able to buy the books separately or in a boxed set. Watch for us to release each of them as they are finished and the final box set when everything is complete. 

Will They Really Find the Root Causes?

February 3rd, 2016 by

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

Monday Accident & Lessons Learned: UK RAIB Report – Collision at Froxfield

January 25th, 2016 by

NewImage

Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)

 

RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015

 

At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.

The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.

The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.

Recommendations

RAIB has made four recommendations relating to the following:

  • installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
  • enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
  • introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.

RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles

Notes to editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
  2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
  3. For media enquiries, please call 020 7944 3108.

For the complete report, see:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493315/R022016_160120_Froxfield.pdf

Root Cause Tips – What Should You Investigate?

January 13th, 2016 by
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What if you have more than you can possibly investigate?

Hello and welcome to this week’s root cause analysis tips column.

One of the questions I am asked often is “what should we investigate?”

The answer is it really depends on your company, your numbers, and your resources. I have some ideas, and these apply to anything, but I will use safety as an example.

First of all, your company may have a policy on what has to be investigated; for example, all lost time injuries or all recordable injuries. So you already know you are required to do those. But what if something is not required?

What I say is investigate as much as possible based on your numbers and your resources. If you work at a site that has 10 injuries a year but only 2 are recordable, if you have the resources to do all 10, I certainly would. It is likely the only difference between the 2 and the other 8 is……LUCK.

What if you have more than you can possibly investigate? Then you should do a really good job at categorization, and do investigations on the TRENDS. In other words, I would rather have you do one really good investigation on a trend than dozens of sub-standard investigations. You will use less resources but get better results.

How do you do an investigation on a trend? It is really very simple – instead of mapping out an incident with a SnapCharT®, you map out the process. You can leave the circle for the incident off the chart or you can make the circle the trend itself. The events timeline is simply the way the process flows from start to finish, and this is very easy to do if you understand the process. If you need help from the process owner, an SME, or employee, you can do that too. For conditions, you add everything you know about the process, as well as any data (evidence) available from the reports or other sources. You mark significant issues (the equivalent of causal factors) for things that you know have gone wrong in the past. You can take it a step further any also mark as significant issues things that COULD go wrong (think of this as potential causal factors). You then do your root cause analysis and corrective actions. This is not hard, it is just a different way of thinking.

Just a few more thoughts about what to investigate; basically, anything that is causing you pain. Process delays, customer complaints, downtime, etc. can all be investigated. But by all means, make sure it is worth your time and that there is really something to learn from it. Please don’t investigate paper cuts!

I hope my ideas give you some food for thought. Keep pushing the boulder up the hill and improving your business. Thanks for visiting the blog.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

 

Monday Accident & Lessons Learned: Dust Explosion Prevention

January 4th, 2016 by

Screen Shot 2015 12 16 at 1 13 10 PM

See the link below to the pdf of the Dangerous Goods Safety Significant Incident Report Number 01-15 from the Government of Western Australia Department of Mines and Petroleum.

DGS_SIR_0115.pdf

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