Category: Pictures

Root Cause Analysis Training in the UK – Onsite Course Photos

July 16th, 2014 by

Thanks to Mhorvan Sherret, the TapRooT® Instructor who sent over these photos from a great course he taught in Warwick England June 12-18, 2014. Enjoy!

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Contact us for more info on bringing world-class root cause analysis training to your facility.

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

 

Monday Motivation: Winston Churchill

July 14th, 2014 by

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If you’re going through hell keep going. ~ Winston Churchill

Root Cause Analysis Training in Egypt – Onsite Course Photos

July 11th, 2014 by

Thanks, TapRooT® Instructor Harry Thorburn, for these photos and a great onsite TapRooT® Course in Egypt held July 5-10, 2014! DSC03896 DSC03898 DSC03899 DSC03902 DSC03903 DSC03910DSC03882   Contact us for more info on bringing world-class root cause analysis training to your facility.

Throwback Thursday: Blast From The Past

July 10th, 2014 by

Do my eyes deceive me or is that Mark Paradies with a mustache!? Can you believe that this picture is 14 years old?

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Pictured Left to Right: Linda Unger, Astronaut Mike Mullane, and Mark Paradies. Astronaut Mike Mullane was a speakers at the 6th Summit in 2000 located in Gatlinburg, TN.

To learn more about who will be speaking at next year’s 2015 Global Summit in Las Vegas, Nevada click here.

Who was your favorite speaker at any Summit you have attended? Please leave comment below.

Root Cause Analysis Training in Kazakhstan – Onsite Course Photos

July 10th, 2014 by

TapRooT® Instructor Harry Thorburn sent over these photos from our recent onsite TapRooT® training course in Kazakhstan. Enjoy!

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Want to learn our world-class root cause analysis system in the convenience of your own facility? Contact us for more information on on-site courses by clicking here.

Root Cause Analysis Training in Chile – Onsite Course Photos

July 9th, 2014 by

Thanks, TapRooT® instructor Piedad Colmenares, for these great photos of our June 2-6, 2014 onsite course in Punta Arenas, Chile!

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ENAP- Punta Arenas - Chile, 6 June 2014.

Contact us for more info on bringing world-class root cause analysis training to your facility.

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

July 8th, 2014 by

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 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.

Root Cause Analysis Training in Vancouver – Course Photos

July 7th, 2014 by

TapRooT® Instructor Ken Reed shared these photos of our June 17-18, 2014 course in Vancouver, BC, Canada. Enjoy!

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Click here to learn more about our root cause analysis training around the world.

Monday Motivation: John Wooden

July 7th, 2014 by

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Things work out best for those who make the best of how things work out. ~ John Wooden

Root Cause Analysis Training in Romania – Onsite Course Photos

July 4th, 2014 by

TapRooT® Instructor Harry Thorburn shared these photos from our onsite course held June 24-26, 2014 in Romania. Enjoy!

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Click here to contact us and learn more about bringing our world-class investigation training to your facility.

Root Cause Analysis Training in Vermont: Onsite Course Photos

July 3rd, 2014 by

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Thanks to Ralph Brickey for this great photo of our onsite 5-Day TapRooT® Root Cause Analysis Team Leader Training in Wilder, Vermont.

If you’d like to learn more about bringing TapRooT® Training to your facility, click here to contact us.

Root Cause Analysis Training in Alaska – Train-the-Trainer Course Photos

July 1st, 2014 by

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Reb Brickey shared this photo of our newest in-facility TapRooT® trainers in Anchorage, Alaska.

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.

 

 

Baby on Board! Welcome to the SI Family.

June 23rd, 2014 by

Our new attorney, Katherine, had a beautiful baby girl recently. Mother and baby are well. Welcome to the family, baby Rebecca!

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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?

 

 

Monday Motivation: Thomas Jefferson

June 23rd, 2014 by

 

 

I find that the harder I work, the more luck I seem to have.
Thomas Jefferson

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