Ocean Rig recently sponsored their first TapRooT® 5-Day and Train the Trainer Courses, one of many scheduled this year. Here are just a few pictures with our contract instructor, Alan Scott, teaching the onsite courses in Athens, Greece this July. Notice also Ocean Rig’s newly certified trainers getting their certification.
Monday Accident & Lessons Learned: UK RAIB Accident Report – Near-miss at Butterswood level crossing, North Lincolnshire, 25 June 2013July 28th, 2014 by Mark Paradies
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.
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:
Don’t be afraid to give up the good to go for the great. ~ John D. Rockefeller
Ralph Blessing shared this photo of our July 22-23, 2014 class hard at work in Bowling Green, Kentucky. Thanks, all, for a great course!
The picture below is of Mark Paradies helping attendees with their final TapRooT® training exercise. This course was held in beautiful Gatlinburg, TN located in the Great Smokey Mountains.
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What could go wrong here?
First, identify all sources of energy nearby.
Next, identify the safeguards for all sources of energy.
Are those safeguards adequate? Do we need more? Are any safeguards being violated (rules broken)?
Leave comments about your Safeguard Analysis.
What seems to us as bitter trials are often blessings in disguise. ~ Oscar Wilde
Throwback to 2009 in Chile. Chile is just one of the many places where you can receive training and hands on experience with a certified TapRooT® instructor.
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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!
Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013July 14th, 2014 by Mark Paradies
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.
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:
We held a great onsite course in Paris, France on June 10-11, 2014. Here are a few photos.
If you’re going through hell keep going. ~ Winston Churchill
Thanks, TapRooT® Instructor Harry Thorburn, for these photos and a great onsite TapRooT® Course in Egypt held July 5-10, 2014! Contact us for more info on bringing world-class root cause analysis training to your facility.
Do my eyes deceive me or is that Mark Paradies with a mustache!? Can you believe that this picture is 14 years old?
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.
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TapRooT® Instructor Harry Thorburn sent over these photos from our recent onsite TapRooT® training course in Kazakhstan. Enjoy!
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Thanks, TapRooT® instructor Piedad Colmenares, for these great photos of our June 2-6, 2014 onsite course in Punta Arenas, Chile!
Site 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 2013July 7th, 2014 by Mark Paradies
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.
TapRooT® Instructor Ken Reed shared these photos of our June 17-18, 2014 course in Vancouver, BC, Canada. Enjoy!
Things work out best for those who make the best of how things work out. ~ John Wooden
TapRooT® Instructor Harry Thorburn shared these photos from our onsite course held June 24-26, 2014 in Romania. Enjoy!