Category: Investigations

Monday Accident & Lessons Learned: Freight Train Derailment in the UK – Three New Recommendations

July 18th, 2016 by

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Derailment of freight train near Angerstein Junction, south east London, 3 June 2015

At about 12:10 hrs on 3 June 2015, one wagon of an empty freight train derailed on the approach to Angerstein Junction, near Charlton in south east London. The train continued over the junction, derailing two further wagons, before it stopped on the Blackheath to Charlton line. The three derailed wagons were partly obstructing the line used by trains travelling in the opposite direction. No other trains were involved in the accident and no-one was injured, but there was significant damage to the railway infrastructure.

The wagons derailed because the leading right-hand wheel on one of them was carrying insufficient load to prevent the wheel climbing up the outer rail on a curved section of track. The insufficient load was due to a combination of the suspension on that wheel being locked in one position, a twisted bogie frame and an intended twist in the track.

As a consequence of this investigation, RAIB has made three recommendations.

The first, addressed to VTG (the wagon owner), seeks improvements to its wagon maintenance processes.

The second, also addressed to VTG, seeks liaison with industry to improve understanding of how wagon suspension wear characteristics relate to maintenance processes.

The third, addressed to Network Rail, seeks a review of infrastructure arrangements at the accident location.

The report also includes a learning point reinforcing a previous recommendation intended to encourage use of currently available wheel load data to enable identification of wagons with defects or uneven loads that are running on Network Rail’s infrastructure.

To see the complete report, go to:

https://assets.digital.cabinet-office.gov.uk/media/5748532b40f0b60366000016/R102016_160601_Angerstein_Junction.pdf

The above information and report are from the UK Rail Accident Investigation Branck. See their web site at:

https://www.gov.uk/government/organisations/rail-accident-investigation-branch

Monday Accident & Lessons Learned: WELL CONTROL EVENT WHEN USING AN MPD SYSTEM

July 4th, 2016 by

IOGP SAFETY ALERT

WELL CONTROL EVENT WHEN USING AN MPD SYSTEM

A High Pressure exploration gas-condensate bearing reservoir section was being drilled using automated Managed Pressure Drilling (MPD) and Rig Pump Divertor (RPD) equipment. Total gas and Connection Gas (TG/CG) peaks were noted the day before during drilling so the degasser was run. The drilled stand was backreamed at normal drilling flow rate prior to taking a MWD survey, making a connection and then taking Slow Circulating Rates (SCRs) on all 3 mud pumps. During taking SCRs an initial pit gain of 16bbl was noticed and reported.

It was suspected that pit gain was continuing, so a dynamic flow check was carried out in which it was confirmed that the well was flowing. Subsequently the well was shut in on the BOP (SICP=5,800psi, SIDPP=0psi). Dual float valves behind the bit were holding; total pit gain was estimated at 306bbls. Due to high casing pressure/MAASP concerns, an attempt was made to lower the annulus casing pressure by bleeding off gas through the choke and ‘poor boy’ mud-gas separator (MGS). This attempt was quickly aborted due to inadequate choke control leading to loss of the MGS liquid seal (SICP=7,470psi, SIDPP=0psi (floats holding).

After mobilization of high pressure bleed down facilities, the casing pressure was successfully reduced to zero psi through the “Lubricate and Bleed” well control method.

What Went Wrong?

During “pump off” events the Bottom Hole Pressure (BHP) dropped below Pore Pressure (Po) which resulted in initial small influxes into the wellbore. These were not recognized and therefore not reported as and when they occurred.

In MPD-RPD mode, fluid density dropped below the setpoint of 16.6 ppg (0.86 psi/ft) during pump off events (first and second survey and connections) due to a ‘sluggish’ RPD auto-choke. The RPD system had not been properly calibrated and the choke not run in the optimum position for effective control.

The formation pressure gradient of the gas-condensate bearing reservoir was evaluated to be 0.84psi/ft (Po~13,950psi).

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Corrective Actions and Recommendations:

  • Comprehensive and clear communication and action protocols (eg. close-in) should be tested, and verified as effective, across all Crews and Shifts.
  • Drillers must be clear that immediately on detecting an influx, they need to shut-in the well (applies for both MPD and non-MPD operations). The deployment of MPD does not change this basic principle.
  • Choke drills (A/B Crews and Day/Night shifts), including operation of remote choke(s) through a remote choke control panel, are critical to verifying that the total system (equipment, procedures, people including actions and communication protocols) are effective to operate the chokes against the maximum anticipated casing pressure.

Safety Alert Number: 272 

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: Derailment at Godmersham, Kent, UK

June 27th, 2016 by

 

 

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Here’s a summary of the report from the UK Rail Accident Investigation Branch about a derailment at Godmersham, UK:

 

“At around 21:40 hrs on 26 July 2015, a passenger train derailed after striking eight cows that had gained access to the railway at Godmersham in Kent, between Wye and Chilham stations. There had been a report of a cow on the railway an hour earlier, but a subsequent examination by the driver of the next passing train did not find anything. There were no further reports from other trains that passed before the accident occurred.

 

The train involved in the accident was travelling at 69 mph (111 km/h) at the point of impact. There were 67 passengers on board plus three members of staff; no injuries were reported at the time of the accident. Because the train’s radio had ceased to work during the accident, the driver ran for about three-quarters of a mile towards an oncoming train, which had already been stopped by the signaller, and used its radio to report the accident.

 

The accident occurred because the fence had not been maintained so as to restrain cows from breaching it, and because the railway’s response to the earlier report of a cow on the railway side of the fence was insufficient to prevent the accident. In addition, the absence of an obstacle deflector on the leading unit of the train made the derailment more likely.

 

As a result of this accident, RAIB has made five recommendations addressing the fence inspection process, clarification of railway rules in response to reports of large animals within the boundary fence, the fitting of obstacle deflectors to rolling stock (two recommendations), and the reliability of the train radio equipment.

 

RAIB has also identified two learning points for the railway industry, relating to the railway’s response to emergency situations, including the response to reports of large animals within the boundary fence and the actions to take following an accident.

Here is a link to read the report…

R052016_160406_Godmersham

Have a Plan! Using the TapRooT® Tools to Plan Your Investigation

June 22nd, 2016 by

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Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?

Unfortunately, most systems kind of leave you hanging.  They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt.  Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!

Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process.  We have recently tweaked this guidance to make it even easier to quickly progress through the investigation.  Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.

Some of these tools are required for every investigation; some are optional data-gathering tools.  Let’s first take a look at the required tools.

Mandatory Tools

SnapCharT®:

One of the first things you need to do is get a good understanding of exactly what happened.  Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred.  By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out.  It helps you figure out what questions to ask and who to ask.  Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason.  There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask.  It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.

Root Cause Tree®:

Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process.  However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®.  In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation.  You’ll need the answers to these questions once you get to the root cause analysis phase.  Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?

The tools I listed above are used during EVERY investigation.  However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®.  Let’s look at the non-required tools.

Optional Tools

Change Analysis:  This is a great tool to use to help you ask thought-provoking questions.  It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances.  The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident.  It is actually an extremely easy tool to use, and yet it is very powerful.  I find this to be my most-used optional tool.  The results of this analysis are now added to your SnapCharT® for later root cause analysis.

Critical Human Action Profile (CHAP):  Sometimes, you need help understanding those “dumb” mistakes.  How can someone be walking down the stairs and just plain fall down?  The person must just be clumsy!  This is a great time to use CHAP.  It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task.  What tools were they using (and supposed to be using)?  How did we expect them to perform the individual steps in the task?  This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing.  The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.

Equifactor®:  If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure.  You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem.  For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring.  Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration.  The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure.  These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure.  Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.

The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with.  The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations.  If you need some help getting started, the TapRooT® tools will get you going!  Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.

Monday Accident & Lessons Learned: Collision between a tram and a pedestrian, Manchester

June 20th, 2016 by

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The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.

A summary of the report says:

At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.

The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.

As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.

A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.

A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.

For the complete report, see:

https://assets.digital.cabinet-office.gov.uk/media/5705107640f0b6038500004d/R062016_160412_Market_Street.pdf

 

Don’t be afraid of Causal Factors!

May 27th, 2016 by

Is this your brain on Causal Factors:

What is a Causal Factor?  

What is NOT a Causal Factor?

Wait, is a Causal Factor the same as a root cause?  

When I find the Causal Factor, does that mean I know who/what to blame?  

Are you just plain tired and confused of all this root cause analysis terminology? REGISTER for this course and don’t be afraid of the big bad wolf Causal Factor!  Taught by one of my favorite people, Mr. Ken Turnbull.  You won’t regret it!

 

Special 2-Day Equifactor® Equipment Troubleshooting + TapRooT® Root Cause Analysis

May 27th, 2016 by

In just two days (right before the 2016 Global TapRooT® Summit), learn how to troubleshoot equipment failures along with the essentials to conduct a TapRooT® root cause analysis incident investigation.  Then stay for the 3-day Summit!  LEARN MORE!

 

 

Where do you draw the line on what to investigate?

May 27th, 2016 by

At what point is something important enough to investigate? View the Slideshare below to examine this important question and REGISTER for Advanced Trending Techniques.

 

 

Interviewing & Evidence Collection Techniques

May 26th, 2016 by

I’m so excited to be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit with Alan Smith. If you want to learn a little about Alan, click here.  With Alan’s background as a former Detective Superintendent with the Grampian Police in Scotland, and my background in psychology and legal (preparing accident/injury cases for court), we will leave no stone unturned.  I guarantee there is no other course like this anywhere. Register today!

 

 

Are you Using these FIVE Dynamic NEW Features of TapRooT® VI?

May 26th, 2016 by

LEARN MORE!

We have a 3-day Software Track at the 2016 Global Summit too!  
Look for “Software” on the left menu bar HERE to view the track schedule!

 

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

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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

Screen Shot 2016 02 29 at 11 29 09 AM

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

Screen Shot 2016 02 24 at 12 15 46 PM

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

Screen Shot 2016 02 03 at 4 02 46 PM

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

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