First Press Release…
Buffer stop collision at Chester station
At 12:10 hrs on Wednesday 20 November 2013 a passenger train collided with the buffer stop at the end of platform 1 at Chester station and became derailed. The train involved was the 10:10 hrs Virgin Trains service from London Euston to Chester. Two passengers on the train were slightly injured in the collision.
As the train approached Chester station the driver applied the brakes to reduce the speed for the 20 mph speed limit into the platforms. The weather at the time had been dry but a rain shower was just starting and the adhesion between the wheels and rails was reduced. The train’s wheel slide protection system detected that the wheels were sliding on the rails, regulated the application of the brakes, and the train was able to achieve a rate of deceleration sufficient to bring its speed down to within the speed limit as it approached the station.
As the train approached the platform the driver lightly applied the brakes again but the wheels immediately started to slide. Despite the immediate automatic activation of the wheel slide protection system, the train’s deceleration was insufficient to bring it down to a safe speed as it moved along the platform. Consequently, the emergency brakes were applied by train protection and warning system and the driver pressed the emergency stop button very shortly afterwards. The combination of emergency braking and the detection of wheel slide triggered the automatic sanding system on the leading vehicle to drop sand onto the rail head.
The presence of the sand improved adhesion for the wheels that ran over it and the speed was reduced before the train collided with the buffer stop at the end of the platform.
The buffer stop was of an old design with only minimal capacity to absorb energy. The train destroyed it before overriding its remains to mount the platform where it came to rest. The front bogie was lifted off the track as the front of the leading vehicle rode up onto the platform.
Platform 1 was closed to traffic until the following day for recovery of the train and repair of the track and buffer stop.
The RAIB’s investigation will seek to identify the sequence of events. It will include consideration of the braking system on this train, in particular the wheel slide protection system and the sanding equipment. It will also consider adhesion conditions in the area at the time (using information from other trains that experienced low adhesion conditions that day), the condition of the rails on the approach to the platform and the efficacy of any actions taken to treat the rail head.
The RAIB will also take into consideration the findings from other similar events that the RAIB has investigated; most notably the investigation into a series of low adhesion events in the autumn of 2005 (RAIB report 25/2006, parts 1 to 3).
The RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.
The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.
Second Press Release…
Barratt’s Lane No.2 footpath crossing (image courtesy of BTP)
Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottinghamshire
The RAIB is investigating a fatal accident that occurred at Barratt’s Lane No.2 footpath crossing, at Attenborough, Nottinghamshire, on Saturday 26 October 2013. At about 14:50 hrs, an elderly female pedestrian who was crossing the railway, was struck by a train travelling from Nottingham to Birmingham, and killed instantly.
The crossing, which is over two tracks, links two residential areas. Immediately prior to the accident another train, travelling towards Nottingham, had been stopped at a signal near to the crossing and its presence may have distracted the pedestrian.
The RAIB’s investigation will identify the sequence of events which led to the accident and any factors which may have influenced the actions of the user. It will also examine:
• Network Rail’s management of the crossing; and
• the history of the crossing.
The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Rail Regulation) or the British Transport Police.
The RAIB will publish a report, including any recommendations to RAIB website.
Thanks to TapRooT® Instructor Piedad Colmenares for these fantastic photos of our TapRooT®/ Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis course held on December 2-4, 2013 in Bogota, Colombia.
Picture of One Section of a Two Section Public TapRooT® Root Cause Analysis Course in Houston, TexasPosted: December 9th, 2013 in Courses, Pictures, TapRooT
Pictures of the Presentations from the Final Exercise at the Las Vegas Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis CoursePosted: December 8th, 2013 in Courses, Pictures, TapRooT
Some pictures of the students presenting the results of incidents they analyzed using TapRooT® Root Cause Analysis…
And then there was the prize for being on time. A chance to win $10 million dollars! But … the odds were against us…
No instant millionaires today.
Want to find out more about TapRooT® Training? See:
Maybe it’s my nuclear background …
I can’t help but post this song every year during the holiday season.
I don’t know where it originally came from but a nuke industry guy sent it to me by e-mail 5 or 6 years ago.
It brings a whole new meaning to Nuclear Winter!
Happy Holidays to All (especially those that keep the lights and heat on when it’s cold outside)!
Have you read your 2008 TapRooT® Book from cover to cover? If you do, you will find there are many topics that can help you improve investigation efficiency. Appendix C specifically calls out these six:
1) A well thought out strategy
2) The use of technology
3) Management understanding
5) Help from people in the field
6) Proper use of a SnapCharT®
Each of these is explained in detail in pages 466 – 471 of the book. If you are interested, crack open your book and get reading! You’ll find there is lots more to learn and use!
If you don’t already have your own copy, get some ideas about what’s in the TapRooT® Book by reviewing the table of contents at:
Order the TapRooT® Book at:
But don’t procrastinate! There’s important information in the book that can help you save lives, time, and money.
TapRooT® Instructor Steve Swarthout sent over these photos from our recent onsite TapRooT® couse in Korea! Enjoy!
UK Rail Accident Investigation Press Release: Road vehicle incursion onto the railway at Aspatria, Cumbria, 26 October 2013Posted: December 3rd, 2013 in Accidents, Current Events, Investigations, Pictures
The RAIB is investigating the incursion of a road vehicle onto the railway at Aspatria, between Carlisle and Workington, on Saturday 26 October 2013. A train was prevented from colliding with the vehicle and nobody was injured.
Just before 10:03 hrs, a 2.5 tonne builder’s pick up vehicle ran away from the B5299 Brayton Road, broke through the railway boundary fence and fell down the embankment, coming to rest on its roof in the middle of the line used by trains going in the direction of Workington (see figure). The 09:39 hrs train from Carlisle to Lancaster was approaching at the time, but its driver was alerted by an emergency stop call over the train’s radio system and was able to stop 1.5 (2.4 km) miles from the obstruction on the line.
Figure: The builder’s pick up vehicle on the Carlisle – Workington line (by courtesy of Network Rail)
At the accident location, the B5299 joins the main A596 road at a junction adjacent to the railway, and at a point where the A596 runs parallel to the railway, before crossing it over Aspatria Tunnel. Locations where a road is close to a railway are required to be assessed by the local highway authority and/or Network Rail to determine the risk of road vehicle incursion to the operational railway.
The RAIB’s investigation will include a review of how the risk of road vehicle incursion at this site was assessed by both the local highway authority (Cumbria County Council) and Network Rail, and what subsequent actions, if any, were taken to control the risk of such incursions. The investigation will also review the current national policies and processes for the management of road vehicle incursion at locations of this type.
The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Railway Regulation).
The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.
TapRooT® Instructor Piedad Colmenares sent over these photos from our recent onsite TapRooT® Course in El Salvador last week November 25-29, 2013. Enjoy.
Here is my Thanksgiving posting. I post it every year, lest we forget.
In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!
One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.
During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.
The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.
With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.
Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.
The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.
Is this the root cause of Thanksgiving?
This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:
“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”
William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.
Diana Munevar shared these photos from our Bogota, Colombia course we held November 2-4, 2013. Enjoy!
Marco Flores sent over these photos from the Bogota, Colombia course held October 21-22, 2013. Enjoy!
Thanks for a great course in Kuala Lumpur, Malaysia! Here’s a photo from the class:
TapRooT® Instructor Sanjay Gandhi has shared these course photos from our recent Johannesburg, South Africa course November 18-22, 2013. Enjoy!
Are you interested in increasing the effectiveness of your root cause analysis? Click here to learn more about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
TapRooT® Instructor Boris Risnic sent over these photos from our Novemeber 12-13, 2013 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Sao Paulo, Brazil. Enjoy!
Ralph Brickey sent over these photos from our recent onsite training in Iraq. Enjoy!
Thanks Ralph Brickey for a great onsite course in Angola! Here are a few photos he sent of the training:
Our 5-Day TapRooT® Advanced Root Cause analysis Team Leader Training in Phoenix, Arizona November 11-15, 2013 was a great success! Instructor Chris Vallee shared these photos from the week.
Interested in taking your root cause analysis to the next level? Join us at the 2014 Global TapRooT® Summit! Click here to learn more about our fantastic keynote speakers, networking, and best practice sessions!
© Copyright 2013 By System Improvements Inc. Used by Permission.
WHAT IS YOUR PURPOSE?
Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.
For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.
Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.
The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.
This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…
WAITING FOR BIG ACCIDENTS
Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?
I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:
Near-Misses Not Reported
If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.
Hazards Not Recognized
Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).
Shortcuts Become a Way of Life (standards not enforced)
This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.
Process Safety Not Understood
We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.
Ineffective Root Cause Analysis
If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.
Inadequate Corrective Actions
I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?
Corrective Actions Not Implemented
Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.
Trends Not Identified
If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.
INVESTIGATING PAPER CUTS
Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.
Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.
WHAT SHOULD YOU DO?
You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.
“An ounce of prevention is worth a pound of cure.”
TapRooT® Instructor Chris Vallee shared these photos from our recent 2-Day TapRooT® Incident Investigation & Root Cause Analysis course in Houston, TX Nov 4-5, 2013. Enjoy!
Interested in our 2-day TapRooT® Course? Click here to learn more about how you can master incident investigation at our courses around the world.
If you can’t see yourself ending up in jail because of an accident, how about your attorney’s office?
What’s the point of the headline?
You have a choice. You can either be proactive and prevent accidents or reactive and fight fires after the accidents occur.
What is better … hiring good lawyers to keep you out of jail after a fatal accident or spending time and effort being proactive to prevent the accident from happening?
In both cases, TapRooT® is a great tool for finding and fixing the root causes of problems. But we believe being proactive is much better than being reactive.
Would you like to be proactive in preventing fatalities? Then attend the Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT®.
Whatever you do, DON’T sit by idly waiting for a major accident to occur. Develop you plan to improve performance and prevent fatalities and serious injuries from happening.
Do it today or you may have plenty of time to contemplate your plan while sitting in a jail cell!