Category: Investigations

Monday Accident & Lessons Learned: RAIB Investigation Report -

September 1st, 2014 by

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Here is the summary of the report from the UK Rail Accident Investigation Branch:

At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.

The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.

The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.

The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.

To read the whole report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140717_R152014_Glasgow_Queen_Street.pdf

UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014

August 29th, 2014 by

Here’s the press release …

Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014

RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.

At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.

NewImageImage courtesy of Tyne and Wear Metro 

RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:

  • the reasons for the electrical fault;
  • the response of the staff involved, including the driver and controllers;
  • the adequacy of the electrical protection arrangements; and
  • actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).

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

You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.

RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on enquiries@raib.gov.uk or by telephoning 01332 253300

Monday Accident & Lessons Learned: OPG Safety Alert #259 – FATALITY DURING CONFINED SPACE ENTRY

August 25th, 2014 by

 

FATALITY DURING CONFINED SPACE ENTRY

  • Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
  • After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
  • A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
  • On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.

 

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What Went Wrong?

  • Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
  • Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
  • Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
  • Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.

Corrective Actions and Recommendations

Lessons:

  • As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
  • Before confined space entry:
    - identify and communicate the risks to personnel carrying out the work
    - define requirements, roles and responsibilities to control, monitor and supervise the work
    - check gas presence; understand how the work itself may change the atmospheric conditions
    - ensure adequate ventilation, lighting, means of communication and escape
  • Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
  • During confined space entry:
    - station a trained confined space attendant at the entrance to the space at all times
    - ensure that communication and rescue equipment and resources are readily available
    - carry and use portable/personal gas detectors throughout the activity 

ACTION

Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.

safety alert number: 259 

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.

Monday Accident & Lessons Learned: OPG Safety Alert – Well Control Incident – Managing Gas Breakout in SOBM

August 18th, 2014 by

Safety Alert Number: 258 

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

While drilling at a depth of 4747m, the well was shut-in due to an increase in returns with a total gain of 17bbls recorded. The well kill needed an increase in density from 1.40sg to 1.61sg to achieve a stable situation. With the well open the BHA was pumped out to the shoe and tripped 400m to pick up a BOP test tool to perform the post-kill BOP test.

The BOP and choke manifold test were performed as well as some rig maintenance. The BHA was then tripped into the hole and the last 2 stands were washed to bottom. Total pumps-off time without circulation was 44 hours.

Gas levels during the bottoms-up initially peaked at around 14% and then dropped steadily to around 5%. HPHT procedures were being followed and this operation required circulation through the choke for the last 1/3 of the bottoms up. This corresponds to taking returns through the choke after 162m3 is circulated.

After 124 cubic metres of the bottoms-up had been pumped the gas detector at the bell nipple was triggered. Simultaneously, mud started to be pushed up out of the hole, reaching a height of around 1 joint above the drill floor. The flow continued for around 30 seconds corresponding to a bubble of gas exiting the riser. The pumps and rotation were shut down, followed by closure of the diverter, annular and upper pipe rams. Approximately 2bbls of SBM were lost over-board through the diverter line. The flow stopped by itself after just a few seconds and casing pressure was recorded as zero. No-one was on the drill floor at the time and no movement, damage or displacement of equipment occurred.

After verifying that there was no flow (monitored on the stripping tank) the diverter was opened and 10 cubic metres of mud used to refill the riser, equal to a drop in height of 56m.

The riser was circulated to fresh mud with maximum gas levels recorded at 54%. This was followed by a full bottoms up through the choke.

A full muster of POB was conducted due to the gas alarms being triggered.

What Went Wrong?

Conclusion – An undetected influx was swabbed into the well during the BOP test which was then circulated up inadvertently though a non-closed system breaking out in the riser.

  1. Stroke counter was reset to zero after washing 3 stands to bottom (this resulted in 136 cubic metres of circulation not being accounted for in the bottoms up monitoring).
  2. Review of Monitoring While Drilling Annular Pressure memory logs identified several swabbing events identified – main event was when the BOP test tool was POOH from the wellhead – ESD as measured by APWD dropped to 1.59sg on 10 or 11 occasions.
  3. Swabbing was exacerbated by Kill Weight Mud not having sufficient margin above PP.

Corrective Actions and Recommendations:

  • Take into account all washing to bottom for any circulation where bottoms up is to be via choke.
  • Tool Pushers shall cross check the bottoms up calculation and joint agreement on reset of the stroke counter.
  • All BHA tripping speeds to be modeled so that potential swabbing operations are identified and so that tripping speed limits can be specified.
  • Verify, when possible, actual swabbing magnitude using PWD memory logs (ie after a trip out of the hole).
  • Pumping out (even inside liner/casing) shall be considered in tight tolerance liner/drilling BHA. Modeling shall be used to underpin the decision.

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.

Food Industry Related OSHA General Duty Clause Citations: Did you make the list? Now what?

August 13th, 2014 by

OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities

Untitled

Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.

Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……

Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:

The hazard referenced in Inspection Number [insert 9-digit #]

for violation identified as:

 Citation [insert #] and item [insert #] was corrected on [insert

date] by:

 

Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..

….are the findings correct?

….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?

….is the finding a generic/systemic issue?

As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:

 

o   SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.

o   Root Cause Tree®: an easy-to-use resource to determine root causes of problems.

o   Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.

In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments

Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review

http://www.taproot.com/archives/43841

If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:

BENCHMARKING ROOT CAUSE ANALYSIS

http://www.taproot.com/archives/45408

 

Monday Accident & Lessons Learned: CDC Report on the Potential Exposure to Anthrax

August 11th, 2014 by

Here’s the Executive Summary from the CDC Report:

Executive Summary

The Centers for Disease Control and Prevention (CDC) conducted an internal review of an incident that involved an unintentional release of potentially viable anthrax within its Roybal Campus, in Atlanta, Georgia. On June 5, 2014, a laboratory scientist in the Bioterrorism Rapid Response and Advanced Technology (BRRAT) laboratory prepared extracts from a panel of eight bacterial select agents, including Bacillus anthracis (B. anthracis), under biosafety level (BSL) 3 containment conditions. These samples were being prepared for analysis using matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) mass spectrometry, a technology that can be used for rapid bacterial species identification.

What Happened

This protein extraction procedure was being evaluated as part of a preliminary assessment of whether MALDI-TOF mass spectrometry could provide a faster way to detect anthrax compared to conventional methods and could be utilized by emergency response laboratories. After chemical treatment for 10 minutes and extraction, the samples were checked for sterility by plating portions of them on bacterial growth media. When no growth was observed on sterility plates after 24 hours, the remaining samples, which had been held in the chemical solution for 24 hours, were moved to CDC BSL-2 laboratories. On June 13, 2014, a laboratory scientist in the BRRAT laboratory BSL-3 lab observed unexpected growth on the anthrax sterility plate. While the specimens plated on this plate had only been treated for 10 minutes as opposed to the 24 hours of treatment of specimens sent outside of the BSL-3 lab, this nonetheless indicated that the B. anthracis sample extract may not have been sterile when transferred to BSL-2 laboratories.

Why the Incident Happened

The overriding factor contributing to this incident was the lack of an approved, written study plan reviewed by senior staff or scientific leadership to ensure that the research design was appropriate and met all laboratory safety requirements. Several additional factors contributed to the incident:

  • Use of unapproved sterilization techniques

  • Transfer of material not confirmed to be inactive

  • Use of pathogenic B. anthracis when non-pathogenic strains would have been appropriate for

    this experiment

  • Inadequate knowledge of the peer-reviewed literature

  • Lack of a standard operating procedure or process on inactivation and transfer to cover all procedures done with select agents in the BRRAT laboratory. What Has CDC Done Since the Incident Occurred CDC’s initial response to the incident focused on ensuring that any potentially exposed staff were assessed and, if appropriate, provided preventive treatment to reduce the risk of illness if exposure had occurred. CDC also ceased operations of the BRRAT laboratory pending investigation, decontaminated potentially affected laboratory spaces, undertook research to refine understanding of potential exposures and optimize preventive treatment, and conducted a review of the event to identify key recommendations.

To evaluate potential risk, research studies were conducted at a CDC laboratory and at an external laboratory to evaluate the extent to which the chemical treatment used by the BRRAT laboratory inactivated B. anthracis. Two preparations were evaluated: vegetative cells and a high concentration of B. anthracis spores. Results indicated that this treatment was effective at inactivating vegetative cells of B. anthracis under the conditions tested. The treatment was also effective at inactivating a high percentage of, but not all B. anthracis spores from the concentrated spore preparation.

A moratorium is being put into effect on July 11, 2014, on any biological material leaving any CDC BSL-3 or BSL-4 laboratory in order to allow sufficient time to put adequate improvement measures in place.

What’s Next

Since the incident, CDC has put in place multiple steps to reduce the risk of a similar event happening in the future. Key recommendations will address the root causes of this incident and provide redundant safeguards across the agency, these include:

  • The BRRAT laboratory has been closed since June 16, 2014, and will remain closed as it relates to work with any select agent until certain specific actions are taken

  • Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident

  • Protocols for inactivation and transfer of virulent pathogens throughout CDC laboratories will be reviewed

  • CDC will establish a CDC-wide single point of accountability for laboratory safety

  • CDC will establish an external advisory committee to provide ongoing advice and direction for laboratory safety

  • CDC response to future internal incidents will be improved by rapid establishment of an incident command structure

  • Broader implications for the use of select agents, across the United States will be examined.

    This was a serious event that should not have happened. Though it now appears that the risk to any individual was either non-existent or very small, the issues raised by this event are important. CDC has concrete actions underway now to change processes that allowed this to happen, and we will do everything possible to prevent a future occurrence such as this in any CDC laboratory, and to apply the lessons learned to other laboratories across the United States. 

Hydrocarbon Processing Reports: “Propylene leak blamed for fatal Taiwan gas blasts”

August 5th, 2014 by

A fatal gas blast in Taiwan’s biggest port city, Kaohsiung included 24 fatalities and 271 injured, four of which were policemen and fire fighters. Some of the nearby, uninjured residents assisted the injured by assembling makeshift stretchers, while the remaining 1,212 residents were relocated to safer grounds.

What was the root cause of this massive explosion? Local officials are still investigating. As of right now, their assessment is that there was a gas leak in a sewage pipeline that contained propylene, a gas used to make plastic and fabrics. This incident has been described as an “earthquake-like explosion” that knocked out thousands of local residents power and gas supply.

There are two main propylene producers in the area as well as two large oil refineries that are under investigation. All the sewage pipes in the city are being checked for further evidence and to see which company the particular pipe line that exploded is linked to. Until then, each of these companies have experienced stock share drops and are taking as many precautionary measures as possible to prevent a second explosion.

See the story at:

http://www.hydrocarbonprocessing.com/Article/3367621/Latest-News/Propylene-leak-blamed-for-fatal-Taiwan-gas-blast.html

Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013

August 4th, 2014 by

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

At around 18:35 hrs on Sunday 25 August 2013, a London Underground train departing Holland Park station was brought to a halt by the first of many passenger emergency alarm activations, after smoke and a smell of burning entered the train. During the following four minutes, until the train doors still in the platform were opened by the train operator (driver), around 13 passengers, including some children, climbed out of the train via the doors at the ends of carriages.

The investigation found that rising fear spread through the train when passengers perceived little or no response from the train operator to the activation of the passenger emergency alarms, the train side-doors remained locked and they were unable to open them, and they could not see any staff on the platform to deal with the situation. Believing they were in danger, a number of people in different parts of the train identified that they could climb over the top of safety barriers in the gaps between carriages to reach the platform.

A burning smell from the train had been reported when the train was at the previous station, Notting Hill Gate, and although a request had been made for staff at Holland Park station to investigate the report, the train was not held in the platform for staff to respond. A traction motor on the train was later found to have suffered an electrical fault, known as a ‘flash-over’, which was the main cause of the smoke and smell.

A factor underlying the passengers’ response was the train operator’s lack of training and experience to deal with incidents involving the activation of multiple passenger emergency alarms.

The report observes that London Underground Limited (LUL) commenced an internal investigation of the incident after details appeared in the media.

RAIB has made six recommendations to LUL. These seek to achieve a better ergonomic design of the interface between the train operator and passenger emergency alarm equipment, to improve the ability of train operators to respond appropriately to incidents of this type, and to ensure that train operators carryradios when leaving the cab to go back into the train so that they can maintain communications with line controllers. LUL is also recommended to review the procedures for line controllers to enable a timely response to safety critical conditions on trains and to ensure continuity at shift changeover when dealing with incidents. In addition, LUL is recommended to review the training and competencies of its staff to provide a joined-up response to incidents involving trains in platforms and to reinforce its procedures on the prompt and accurate reporting of incidents so that they may be properly investigated.

Monday Accident & Lessons Learned: UK RAIB Accident Report – Near-miss at Butterswood level crossing, North Lincolnshire, 25 June 2013

July 28th, 2014 by

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The UK Rail Accident Investigation Branch issued a report about a train/car near miss at a crossing. Here is a summary of the report:

At around 07:35 hrs on Tuesday 25 June 2013 a passenger train was involved in a near-miss with a car on a level crossing near Butterswood in North Lincolnshire. The train passed over the level crossing with the barriers in the raised position and the road traffic signals extinguished. No injuries or damage were caused as a result of the incident.

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Normally, the approach of the train would have automatically initiated the closure of the crossing. However, the crossing was not working normally because the power supply to the crossing equipment had been interrupted. The crossing was of a type where train drivers are required to check that it is not obstructed as they approach and that it has operated correctly. A flashing light is provided for this purpose, just before the crossing, with a flashing white light displayed if the crossing has correctly closed against road users, and a flashing red light displayed at all other times (including those occasions when the crossing has failed to close on the approach of a train). The driver of the train involved in the near-miss did not notice until it was too late to stop that the flashing light was indicating that the crossing was not working normally, and was still open for road traffic.

The RAIB’s investigation found that the train driver had the expectation that the crossing would operate normally as the train approached and that he had not focused his attention on the flashing light at the point where he needed to confirm that the crossing had operated correctly for the passage of his train. Although the level crossing had probably failed around nine hours before the incident, the fact of its failure was not known to any railway staff.

The investigation also found that the crossing was not protected with automatic warning system equipment and that the maintenance arrangements at the crossing were not effective in ensuring reliable performance of the equipment. In addition, the train operator’s briefing material did not clearly explain to drivers their role in respect of failures at this type of level crossing.

The RAIB has identified four key learning points relating to non-provision of the automatic warning system at locations where it is mandated by standards, recording of the condition of assets during inspection, storage of batteries, and involving people with relevant technical expertise in industry investigations into incidents and accidents.The RAIB has made four recommendations. Three recommendations have been made to Network Rail addressing the indications given to train drivers approaching crossings where they are required to monitor the crossing’s status, improvements to the reliability of power supplies to crossings such as Butterswood and considering remote monitoring of the power supply at similar crossings. One recommendation has been made to First TransPennine Express regarding the briefing that it gives its drivers on this type of level crossing.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R122014_Butterswood.pdf

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 Christian Science Monitor reported that the spokesperson for the Kremlin’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

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