Category: Pictures

Monday Accident & Lessons Learned: UK RAIB Report on Derailment at Paddington Station in London

October 10th, 2016 by


Summary from the UK Rail Accident Investigation Branch …

At 18:12 hrs on Thursday 16 June 2016, a two-car diesel multiple unit train, operated by Great Western Railway (GWR), was driven through open trap points immediately outside Paddington station and derailed. It struck an overhead line equipment (OLE) mast, damaging it severely and causing part of the structure supported by the mast to drop to a position where it was blocking the lines. There were no passengers on the train, and the driver was unhurt. All the the lines at Paddington were closed for the rest of that evening, with some services affected until Sunday 19 June.

For causes and lessons learned, see:

TapRooT® Around the World: 5-Day Public Course in Seattle

October 6th, 2016 by

What a great group in our 5-Day Advanced Root Cause Analysis and Team Leader Training course in Seattle last week. We had a blast!






Interested in taking a public course? See where we’re going next.

Want an onsite course for just your employees? Inquire here.

TapRooT® Around the World: Onsite Course at Dupont

October 4th, 2016 by

TapRooT® recently traveled to Shanghai, China to train professionals at Dupont.

Shanghai Dupont

Monday Accident & Lessons Learned: Overspeed at Fletton Junction

September 19th, 2016 by

This incident notice is from the UK Rail Investigation Branch about an overspeed incident at Fletton Junction, Peterborough on 11 September 2015.

At around 17:11 hrs on 11 September 2015, the 14:25 hrs Virgin Trains East Coast passenger train service from Newcastle to London King’s Cross passed through Fletton Junction, near Peterborough at 51 mph (82 km/h) around twice the permitted speed of 25 mph (40 km/h). This caused the carriages to lurch sideways resulting in minor injuries to three members of staff and one passenger.

It is likely that the train driver had forgotten about the presence of the speed restriction because he was distracted and fatigued due to issues related to his family. Lineside signs and in-cab warnings may have contributed to him not responding appropriately as he approached the speed restriction and engineering controls did not prevent the overspeeding. Neither Virgin Trains East Coast, nor the driver, had realised that family-related distraction and fatigue were likely to be affecting the safety of his driving. Virgin Trains East Coast route risk assessment had not recognised the overspeeding risks particular to Fletton Junction and Network Rail had not identified that a speed limit sign at the start of the speed restriction was smaller than required by its standards.

Screen Shot 2016 08 01 at 4 32 25 PM

The incident could have had more serious consequences if the train had derailed or overturned. The risk of this was present because the track layout was designed for a maximum speed of 27 mph (43 km/h).
As a consequence of this investigation, RAIB has made five recommendations. Two addressed to Virgin Trains East Coast relate to enhancing the management of safety critical staff with problems related to their home life, and considering such issues during the investigation of unsafe events.

A recommendation addressed to Virgin Trains East Coast and an associated recommendation addressed to Network Rail relate to assessing and mitigating risks at speed restrictions.

A further recommendation to Network Rail relates to replacement of operational signage when this is non-compliant with relevant standards.

RAIB report also includes learning points relating to managing personal problems that could affect the safety performance of drivers. A further learning point, arising because of a delay in reporting the incident, stresses the importance of drivers promptly reporting incidents which could have caused track damage. A final learning point encourages a full understanding of the effectiveness of safety mitigation provided by infrastructure and signalling equipment.

For more information see:


TapRooT® Around the World: Dallas Public Course

September 14th, 2016 by

Our 5-Day Advanced Root Cause Analysis and Team Leader Training public course has been having a great week!IMG_3691 IMG_3690 IMG_3689 IMG_3695

Rickover Quote…

September 14th, 2016 by

Success teaches us nothing; only failure teaches.

Admiral Hyman Rickover



Monday Accident & Lessons Learned: Baby Dies After Oxygen Mix-Up at Hospital in Australia

September 12th, 2016 by


Here’s a link to the story:

An Oxygen line had been improperly installed in 2015. It fed nitrous oxide to a neonatal resuscitation unit rather than oxygen.

The Ministry of Health representative said that all lines in all hospitals in New South Wales installed since the Liberal government took over in 2011 will be checked for correct function. 

What can you learn from this?

Think about your installation and testing of new systems. How many Safeguards are in place to protect the targets?

Mark Paradies to Speak on Tuesday at the 2016 FDA/PDA Regulatory Conference

September 11th, 2016 by


Mark Paradies will be talking about root cause analysis at the 2016 Parenternal Drug Associations / Federal Drug Administration Joint Regulatory Conference in Washington, DC, on Tuesday. See page 8 (Session A3) at:

See you there!


Monday Accident & Lessons Learned: Freight train collision near Logan, UK

September 5th, 2016 by

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From the UK Rail Accident Investigation Branch

On 1 August 2015 at about 11:11 hrs, a freight train travelling within a work site collided with the rear of a stationary freight train at 28 mph (45 km/h).

Engineering staff had authorised the driver of the moving freight train to enter the work site at New Cumnock station, travel about 3 miles (4.8 km) to the start of a track renewal site, and bring the train to a stand behind the stationary train.

There were no injuries but the locomotive and seven wagons from the moving train and eleven wagons from the stationary train were derailed; the locomotive and derailed wagons were damaged. One wagon came to rest across a minor road. There was also substantial damage to the track on both railway lines.

The immediate cause was that the moving train was travelling too fast to stop short of the rear of the stationary train when its driver first sighted the train ahead. This was due to a combination of the train movement in the work site not taking place at the default speed of 5 mph (8 km/h) or at caution, as required by railway rules, and the driver of the moving train believing that the stationary train was further away than it actually was.

An underlying cause was that drivers often do not comply with the rules that require movements within a work site to be made at a speed of no greater than 5 mph (8 km/h) or at caution.

As a consequence of this investigation, RAIB has made four recommendations addressed to freight operating companies.

One relates to the monitoring of drivers when they are driving trains within possessions and work sites.
Two recommendations relate to implementing a method of formally recording information briefed to drivers about making train movements in possessions and work sites.

A further recommendation relates to investigating the practicalities of driving freight trains in possessions and work sites for long distances at a speed of 5 mph (8 km/h) or at other slow speeds, and taking action to address any identified issues.

RAIB has also identified three learning points including:

the importance of providing drivers with all of the information they need to carry out movements in possessions and work sites safelya reminder to provide drivers (before they start a driving duty) with information about how and when they will be relievedthe importance of engineering staff giving instructions to drivers through a face to face conversation when it is safe and practicable to do so.



TapRooT® Around the World: Egypt Onsite Course

September 1st, 2016 by

TapRooT® recently traveled to Egypt to host an Onsite Course at SEGAS. What a great class!







Inquire about an Onsite Course for your company. 

Register for a Public Course.

Rickover Quote…

September 1st, 2016 by

Every hour has sixty golden minutes,
each studded with sixty diamond seconds.

Admiral Hyman Rickover



Monday Accident & Lessons Learned: Passenger Trapped & Dragged by Train

August 29th, 2016 by

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From the Rail Accident Investigation Branch …

At around 13:10 hrs on 25 July 2015, a passenger was dragged along the platform at Hayes & Harlington station, London, when the 11:37 hrs First Great Western service from Oxford to London Paddington departed while her hand was trapped in a door. The passenger, who had arrived on the platform as the doors were about to close, had placed her hand between the closing door leaves.

The train driver did not identify that the passenger was trapped and the train moved off, dragging the passenger along the platform. After being dragged for about 19 metres, the passenger lost her footing and fell onto the platform. The passenger suffered head, hand and back injuries.

RAIB’s investigation found that the passenger had deliberately placed her hand in the closing door in the expectation that it would re-open as a consequence. RAIB has concluded that after closing the doors of the train, the driver either did not make a final check that it was safe to depart, or that the check was insufficiently detailed to allow him to identify the trapped passenger. The driver may have been misled into thinking that it was safe to depart because a door interlock light in his cab had illuminated, indicating that the doors were closed and locked and he was able to take power.

Our investigation identified that the train driver and other railway staff held the same misunderstanding: if someone had a hand trapped in a door it would not be possible for the door interlock light to illuminate and a driver to take power. This is not the case, and the door was found to be compliant with all applicable standards after the accident.

As a consequence of this investigation, RAIB has made two recommendations.
The first, addressed to RSSB to review, and if necessary extend, its research into the passenger/train interface to understand passenger behaviour and identify means for deterring members of the public from obstructing train doors.

The second recommendation is addressed to operators and owners of trains similar to the one involved in the accident at Hayes & Harlington, is intended to continue and expand upon a current review into the practicability of fitting sensitive door edge technology to this type of train.
RAIB has also identified three learning points. The first concerns improving awareness among train drivers of the limitations of train door interlocking technology and the importance of the final safety check when dispatching a train.

The second concerns the potential for drivers to be distracted by the use of mobile communication devices while driving.

The third is aimed at train operators to have the necessary processes in place to identify drivers who are showing signs of sub-standard performance or not engaging positively with measures agreed as part of a Competence Development Plan and the provision of briefing and guidance material for driver managers to enable them to identify behaviours and attitudes which are inconsistent with those expected of train drivers.

For the complete report, see:

Rickover Quote…

August 24th, 2016 by

When you waste your time remember …
Even God cannot undo the past.

Admiral Hyman Rickover 


What does a bad day look like?

August 24th, 2016 by


Bet you will be watching trees for porcupines for a while …

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