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:
Develop success from failures.
Discouragement and failure are two of the surest stepping stones to success. ~ Dale Carnegie
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 2014August 29th, 2014 by Mark Paradies
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.
Image 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 firstname.lastname@example.org or by telephoning 01332 253300
Throwback to the 2012 Las Vegas Summit. System Improvements had a wonderful time preparing and planning for this Summit. The bar has been set very high for next year’s 2015 Las Vegas Summit. Help us make it the greatest Summit ever!
Dan Verlinde and Summit attendees hanging out after a full day.
System Improvements staff Ken and Michelle at the 2012 Vegas Summit.
Attend the 2015 Summit and have fun while learning. Click on the link below to find out more about the 2015 Global TapRooT® Summit in Las Vegas, Nevada.
What is your favorite Summit memory? Please leave comments below and tell us what you remember…
Our onsite course in Lima, Peru held August 5-6, 2014 was a great success! Thanks to TapRooT® Instructor Piedad Colmenares for these photos and for teaching a great course.
Want to learn more about how you can bring world-class root cause analysis training to your facility?
Click here to contact us for more information about our onsite courses.
We held an on-site course in Santiago, Chile on July 30-31, 2014, with Piedad Colmenares as the TapRooT® Instructor. She sent us these photos of the class. Enjoy!
Interested in bringing root cause analysis training to your facility?
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.
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
- 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
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/
The successful warrior is the average man, with laser-like focus. ~ Bruce Lee
Or do they need better painter quality control?
Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
Just before starting the exercise …
Teams working on their incidents …
Instructions just prior to the presentations …
Teams presenting …
For more information about TapRooT® Root Cause Analysis Courses, see:
The only place where success comes before work is in the dictionary. ~ Vidal Sassoon
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
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
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
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
Every company I’ve worked with has an existing improvement program.
Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some still have a long ways to go, but have started their improvement process.
No matter where you are, one question that always seems to come up is …
“What should we improve next?“
The interesting answer to this question is that your plant is telling you if you are listening.
But before I talk about that, let’s look at several other ways to decide what to improve…
1. The Regulator Is Emphasizing This
Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.
2. Management Hot Topic
Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…
- A recent accident (at your facility or someone else’s).
- A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
- That the CEO has a new initiative.
You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.
3. Industry Initiative
Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.
All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.
So how should you decide what to improve next?
By listening to your plant/facility.
What does “listening to you plant” mean?
To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.
Reactively collecting signals comes from your accident, incident, near-miss investigation programs.
It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.
I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.
Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.
Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).
Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.
Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler - see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)
Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.
Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.
Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.
Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…
Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:
TapRooT® Instructor Reb Brickey sent over these photos of our recent onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Lagos, Nigeria. Enjoy!
People often say that motivation doesn’t last.
Well, neither does bathing – that’s why we recommend it daily. ~ Zig Ziglar
Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis CourseAugust 6th, 2014 by Mark Paradies
Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…
Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at:
Pictures from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course at Lake TahoeAugust 5th, 2014 by Mark Paradies
The students below are hard at work reading the Root Cause Tree® Dictionary to discover why someone would break a rule. Ever wonder why people break the rules? Then maybe you should attend one of our 2-Day or 5-Day TapRooT® Courses!
View more photos from Tahoe here: http://www.taproot.com/archives/45935
Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013August 4th, 2014 by Mark Paradies
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.