Washington, DC, April 30, 2008 - The U.S. Chemical Safety Board (CSB) announced that it will convene a public meeting on Tuesday, May 13, 2008, in Danvers, Massachusetts, to review the final CSB investigation report on the causes of the November 2006 explosion at the CAI/Arnel ink and paint manufacturing plant.
The report examines company work practices, state and local licensing and permitting procedures, and state and national fire codes for the safe handling and processing of flammable liquids.
The meeting will begin at 6:30 p.m. at the Sheraton Ferncroft Hotel, North Shore Ballroom, located at 50 Ferncroft Road in Danvers. The meeting is free and open to the public. Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration. The meeting is expected to conclude at approximately 9 p.m.
On the night of November 22, 2006, a CAI mixing tank containing flammable heptane and alcohol solvents overheated, releasing vapor that filled the building and then ignited at about 2:45 a.m. The resulting explosion and fire destroyed the facility and created a blast wave that damaged or destroyed dozens of nearby homes and businesses in the Danversport neighborhood. As CSB investigators noted at a May 2007 public meeting in Danvers, the building’s ventilation system was routinely turned off at night, contributing to the accumulation of the flammable vapor.
The meeting will include a detailed presentation by the CSB investigative team of the findings and conclusions from the agency’s investigation. In preparing the final report, investigators examined the accident site; interviewed numerous company personnel, neighbors, and officials; conducted blast modeling and laboratory testing; and examined relevant federal, state, and local regulations and standards.
The investigation team will present new safety recommendations to prevent future accidents for consideration by the Board.
Following the presentation of the CSB report and recommendations, a panel of outside witnesses will describe changes in state and local oversight of chemical facilities that have been proposed or implemented since the explosion. Officials from the state government and the Massachusetts fire services have been invited to testify, along with a community representative.
For more information, please contact Public Affairs Specialist Hillary J. Cohen at (202) 261-3601.
A company providing aerospace and industrial products seeks a Quality Engineer with 4+ years of experience in quality engineering or quality administration positions. Knowledge and successful application of tools and techniques relating to Process Certification, Root cause analysis, Mistake proofing, standard work, cab and reduction of quality escapes is needed.
Lessons from recent travels . . . Differences between Europe and the US.
Regulators in Europe are convinced that pre-job hazard assessments (safety cases in the UK) are the key to improved safety. Workers wouldn’t be at risk and there would be no accidents if people would just review the job, spot all the hazards, implement effective techniques to remove or ameliorate the hazard, and then conduct the work.
The US regulatory view seems to be to regulate the highest hazard industries with rules to make people safe in the highest hazard jobs. Keeping people safe is the responsibility of the employer. If the employer fails, they are fined to encourage them to do better in the future (and as a warning to other employers). Some companies use pre-job hazard assessments, but a safety case isn’t required across every industry and job.
In the UK, many companies employ consultants to write the safety case. These people are trained and are an external set of eyes. Many (but not all) are experienced in the industries and jobs they are reviewing. They generally don’t use advanced root cause analysis as part of their assessment. They are not part of the workforce and it seems to me that they are viewed as outsiders. Their work isn’t appreciated much by the workers (who often see the restrictions they generate as unnecessary and a waste of time).
In Europe, when an accident happens, it is viewed as:
1) A failure of the pre-job hazard assessment/safety case process,
2) A failure of the hazard removal/amelioration techniques, or
3) A violation of the rules ordered by the pre-job hazard assessment/safety case.
Many in Europe don’t see root cause analysis as a particularly complex task. Their view is that all they need to do is discover which of the the three problems above is to blame, and then do a better job of hazard assessment/safety case, hazard removal/amelioration, and/or enforcing the rules next time . . . then the problems will go away.
In the US, since companies are blamed if something goes wrong and pre-job hazard assessment/safety case is not seen as a universal fix, companies are much more open to process improvement as a solution to problems and accidents. Because process improvement has a wide range of options to improve human and equipment performance, root cause analysis is seen as a more difficult and valuable process. US companies are more open to investing in advanced root cause analysis tools that can be applied across the enterprise to improve not only industrial, process, and public safety, but equipment reliability, product and service quality, process reliability, and environmental stewardship.
How could both cultures improve?
I know you won’t find it surprising that “Mr. TapRooT®” sees the application of advanced root cause analysis both BEFORE and AFTER work as a necessary part of effective improvement.
I think there is value in proactive pre-job assessments; they would be even more effective if advanced root cause analysis (TapRooT®) was applied proactively as part of the pre-job assessment/safety case by the employees (workers and supervisors) who would be trained to conduct the hazard assessment, develop the hazard reduction strategies, and even write the safety case (or at least help the consultant write it). This would create more effective pre-job assessment and better compliance with the resulting hazard mitigation rules and strategies and become a great way to improve safety both in the US and Europe.
Second, employers need to see accidents as more than failures of hazard assessment/safety case. They need to use advanced root cause analysis (TapRooT®) to understand the true causes of the accident and take effective steps to reduce the hazard by improving the process. This failure analysis technique - applying TapRooT®’s advanced root cause analysis tools - can then be applied across the enterprise to improve processes, safety, productivity, environmental stewardship, and profitability.
I’m not sure how a voluntary federal medical error reporting system will help. (How can voluntary data be seen as accurate?) But the system set up by law in the 2005 Patient Safety and Quality Act is starting to be implemented. See:
If you think that some root causes were missed, what is your evidence?
Here’s a tip.
Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.
What Causal Factors led to this fatality?
Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.
One final question…
How do you assess the thoroughness of investigations at your facility?
For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).
After being introduced to TapRooT® through a public course, GPIC decided that they were ready to train key employees in TapRooT® Root Cause Analysis onsite. Pictured above and below after teaching the course in the Kingdom of Bahrain is Steve Swarthout (TapRooT® Root Cause Analysis Instructor & President of Performance Improvement of Virginia) with the key GPIC employees who made this course happen and GPIC course attendees.
CNN posted an Associate Press article on their web site that explains FAA efforts to get accurate reports of controller errors that lead to violations of minimum separation requirements.
These efforts follow earlier disclosures (2005) of under-reporting by the same FAA region (Dallas).
What do you do to encourage reporting of near-misses at your facility? Are people afraid to report near-misses? Do they cover up mistakes? Do you need to improve your near-miss program to get even more near-misses reported?
The Summit is a great place to network and benchmark with industry leaders.
Attend the TapRooT® User Best Practices session and hear about industry leading programs to use root cause analysis to improve performance.
Attend the TapRooT® User Success Stories session and hear three TapRooT® Users describe the results of successful improvement programs.
Attend The Good, The Bad, and The Ugly: Rating Improvement Programs and & Incident Investigations session and participate in a evaluation/benchmarking session to evaluate your efforts and programs.
The UK Rail Accident Investigation Branch (UK RAIB) has released a report on a collision between a train and a tractor near Limavady Junction, Northern Ireland, on August 2, 2007. The RAIB has made six recommendations. For the complete report see:
The second is an investigation into a runaway engineering wagon and its subsequent collision with a road-rail vehicle at Armathwaite, Cumbria, on 28 January 2007. See:
Sysmex currently has a great opportunity available for a Failure Analysis Manager in our Technical Services group based in Mundelein, IL. This position will be responsible for the failure analysis and root cause processes within Technical Services. By applying good engineering and quality process disciplines, this individual will own selection of failure analysis tools and techniques and their application to medical device technical service activities. Position calls for associate to develop and conduct training in the use and application of troubleshooting tools and will participate in field escalations to assure appropriate tools and techniques are applied to specific situations. Position will also participate in quality review activities and become a member of the QRM team. This position also requires close cooperation with the Technical Support Managers and Technical Consultant teams. This associate’s main objectives will be to realize productivity business benefits through troubleshooting process improvements in the service business.
1. Achieve business benefits by developing and applying failure analysis processes for medical instrument service and support functions.
2. Select and apply quality tools and techniques to product service processes for in-house and field based service and support such as decision tree, fault tree, cause and effect, and other six-sigma and lean quality tools.
3. Perform trend analysis on service processes to identify improvement opportunities and take actions to realize targeted improvements.
4. Support and audit the field escalation process to assure field staff applies good troubleshooting practices to quickly and accurately determine root causes of failures.
5. Trains technical service staff on effective troubleshooting and analysis processes.
6. Participate in the product quality reviews representing complaint trends and recommendations for corrective action and product improvement to manufacturing and design functions.
7. Work in a team environment with members of the Technical Consultant field escalation team and Technical Support Managers to realize serviceability and product quality improvements.
Education/Experience: Bachelors in science or engineering, 7+ years engineering/process improvement experience, ASQ certification, Lean certification and Six-Sigma experience a plus.
…to build a promising future.
If you’re ready to work in a dynamic, real-world setting and have a positive impact, then apply today!
We offer competitive benefit choices that support both physical and emotional well-being, including medical/vision/dental plans, life insurance, and company-matched 401K.
For example, some companies don’t allow travel to Las Vegas for conventions or meetings.
Why? The only answers that I’ve heard is that these companies believe that employees won’t work (or learn) in the “What Happens in vegas Stays in Vegas” environment that is portrayed on TV.
We’ve had courses in Las Vegas for years and can report that students who attend there learn just as well as students in other venues. But that still doesn’t satisfy some corporate policy makers.
So here is a new idea…
If your corporate travel approval team says no travel to Vegas … suggest that you attend with a chaperone. Ask your boss to attend with you to make sure that you both spend your work time productively learning all the best practices available at the Summit.
The two of you can make plans for developing your improvement program at the “Planning Your Improvements” session on Friday of the Summit.
Policies shouldn’t stand in the way of improvement. Don’t let an arbitrary rule stop the progress of your improvement program. get signed up for the Summit NOW!
The Alberta Centre for Injury Control & Research (ACICR) is recruiting an individual to work with Métis communities throughout Alberta to coordinate and integrate regional and local community support for the Alberta Traffic Safety Plan. In this role, you will partner with local Métis communities to identify traffic safety issues, develop strategies; and provide traffic safety resources which link local, regional and provincial safety initiatives. Critical to your success will be facilitating the development of traffic safety committees and networks and providing support to existing partnerships and initiatives.
The ideal candidate will have a related degree or an equivalent combination of training and experience. Knowledge and experience in the areas of traffic safety and/or community development strategies is essential along with a working knowledge of the Métis culture and Métis governance. The incumbent will work out of Edmonton in the Métis Nation of Alberta Offices and will travel extensively to Métis communities located throughout Alberta.
Salary range for the position is $4,707.73 – $6,006.00 per month and includes an excellent benefits plan (note: the salary is currently under review and dependent on the successful candidate’s experience and education). The position is a joint initiative of Alberta Health and Wellness, Alberta Infrastructure and Transportation and ACICR for an initial term of 30 months with the possibility for extension. The final candidate must have access to a reliable vehicle and be willing to undergo a security screening. To view full position details and to apply online, go to: http://www.careers.ualberta.ca/. Please forward applications before May 15, 2008 to:
Patti Stark, ACICR
School of Public Health
4075 RTF, 8308 – 114 Street
Edmonton, Alberta T6G 2E1
This week we have a full 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Knoxville. I was teaching with Linda Unger, VP at SI, on Monday and too these “action” photos of the class listening, learning, and participating.
Why are so many people from industry leading companies attending TapRooT® Training? Because TapRooT® is so effective finding and helping people fix the root causes of problems. Also, our courses are interesting, fun, and effective.
The father of a 12-year-old boy who was crushed to death by a tractor has been fined £1000 for letting his son drive the machinery while underage.
Sam Stanbridge was towing a roller on 25 March 2007 at the family farm at Kibworth Harcourt, Leicestershire, magistrates in Leicester heard on 28 February. There were no witnesses to the incident, but his mother found him unconscious while out riding. He had sustained a fatal injury to the head, having apparently been crushed by a two-and-a-half-tonne roller attached to the tractor he was driving. The tractor fell into a nearby canal. Sam was pronounced dead at Leicester Royal Infirmary.
A coroner’s inquest into his death concluded that Sam either slipped, tripped, or fell out of the cab; while getting in and out of the cab; or while already out of the cab. He had undertaken the same activity the day before the incident, and during the previous year, despite the law banning children under 13 years of age from driving or riding on agricultural machinery.
There was no evidence that the tractor had been driven recklessly, nor could any horseplay on Sam’s part be attributed to the cause of the incident.
In court, the boy’s father, Mark Stanbridge, pleaded guilty to breaching reg. 4 of the Prevention of Accidents to Children in Agriculture Regulations 1998, in that he allowed Sam to drive a tractor while carrying out agricultural work, which culminated in his death. He was fined £1000 and ordered to pay costs of £1500. http://www.shponline.co.uk/article.asp?pagename=incourt&article_id=7308
How much punishment is enough?
Do you think the father needs to be fined £1000 to prevent future accidents?
Sometimes I wonder about courts and enforcement of regulations.
The Ontario Workplace Safety and Insurance Board created a set of fairly gruesome commercials that dramatically show the results of “accidents.” The message is that there are no accidents. Accidents are caused.
Here’s the video:
These are also available at the WSIB web site for download:
The real question I have about these videos is the focus on blaming the worker, the supervisor, and management. We see the accident happen, but do we know what set the accident up?
To me, the video also shows the difficulties of finding and fixing the real root causes of an accident when our culture first looks to blame.
Makes you think though…. what would you invest in if it would prevent an accident, production loss, or loss of a customer? Upon purchase and “LITTLE” effort, you could throw away all your post-investment prevention programs. After all, prevention would come overnight…. silly, but don’t some mangers expect quick fixes with little effort to make problems go away? Sorry, even removing this curse took 5 hours of digging through freshly poured concrete to remove the curse.
On the other hand, all effort is not equal. investing in a robust reactive and proactive process to prevent problems from occurring would reward your efforts. Many have already invested in the TapRooT® System for finding the root causes of problems PLUS the Equifactor® Equipment Troubleshooting Technique for Root Cause Failure Analysis of Equipment Problems. If not ready yet to expend the effort, then you must believe that there are shirts buried under all our favorite teams’ stadiums and company facilities.
Pictures below are from a test of the new light rail line being put in service by the Charlotte Area Transit System. CATS is a TapRooT® User and two of their safety professionals are on The TapRooT® Advisory Board.
The video above shows the BC Ferry Spirit of British Columbia exiting the narrow Active Pass.
On March 17, 2008, the same ferry had a near-miss when they came within 180 meters of a Seaspan ferry that carried trucks. This passing distance was legal but violated BC Ferry policy that does not allow passing of vessels in the narrow south pass entrance.
The reason given for the near-miss was that the BC Ferry miscalculated the speed of the other vessel and arrived at the narrow passage before the other vessel had cleared the entrance to the pass. According to press reports, the vessels were in communication and had planned to pass each other outside the entrance to the pass.
The Captain that was fired was a long time BC Ferry employee who had retired and was brought back to work on a contract basis as a relief captain.
Questions from this “near-miss:”
1. Is this how to handle a near-miss?
2. All agree that a mistake was made, but does the Captain deserve to be fired?
3. What are the root causes of this near-miss?
4. What role did the vessel from Seaspan play? Did it have a similar rule? Or did Seaspan allow passing in the Active Pass entrance?
5. Is the BC Ferry system safer after firing an experienced Captain?
6. Have the root causes of this near-miss been fixed?
This certainly is an interesting maritime near-miss and there may be valuable lessons learned. The problem is that the press statements from BC Ferry and the press reports don’t seem to include much useful information for learning lessons.
If you have any more information about this near-miss and it’s causes or know where to find reports that detail the root causes, leave us a message here.
Washington, D.C. - The National Transportation Safety Board today released preliminary aviation accident statistics for 2007.
“The U.S. aviation industry has produced an admirable safety record in recent years,” said NTSB Chairman Mark V. Rosenker. “However, we must not become complacent. We must continue to take the lessons learned from our investigations and use them to create even safer skies for all aircraft operators and their passengers.”
The Safety Board’s aviation accident statistics show that in 2007, there were 24 nonfatal accidents involving Part 121 airlines (aircraft with 10 or more seats). One fatality occurred involving a nonscheduled Part 121 aircraft when a mechanic was fatally injured while working on a Boeing 737 in Tunica, Mississippi.
No fatalities occurred among Part 135 commuter operators (fewer than 10 seats). However, on-demand (charters, air taxis, air tours and medical services when a patient is on board) Part 135 operations reported 43 fatalities (62 accidents, 14 fatal accidents), up from the 16 fatalities that occurred in 2006.
While the overall number of general aviation accidents rose from 1,518 in 2006 to 1,631 in 2007, the number of fatalities in 2007 was down from 703 to 491 (a 30 percent decrease), making it the lowest annual total in more than 40 years.
Foreign registered aircraft accounted for 11 accidents in the U.S. in 2007, with 3 fatalities from a single fatal accident. Of the 14 accidents involving unregistered aircraft, 6 were fatal and resulted in 7 fatalities.
As part of its ongoing focus on improving health care quality, CIGNA HealthCare is taking steps to stop reimbursing hospitals for so-called “never events” and avoidable hospital conditions, which are errors in patient care that can and should be prevented. CIGNA’s new policy is consistent with and based on the policy of the Centers for Medicare and Medicaid Services (CMS), and both policies will become effective on Oct. 1, 2008.
“CIGNA is committed to improving quality for our members throughout the health care system,” said Jeff Kang, MD, chief medical officer for CIGNA HealthCare. “Our policy on never events and avoidable hospital conditions is designed to put patient safety first and to encourage hospitals to improve quality every day, one patient at a time.”
“We commend CIGNA for its commitment to patient safety and quality improvement,” said Helen Darling, president of the National Business Group on Health. “Hospitals, health care professionals and health plans must all work together to ensure that ‘never events’ never happen, avoidable conditions are always avoided, and every patient receives quality treatment in a safe and caring environment.”
As defined in CIGNA’s policy, “never events” are surgical procedures that are performed on the wrong side, wrong site, wrong body part or wrong person. They earned that name because they should never happen in medical practice. For example, surgery erroneously performed on the right knee instead of the left knee, or the erroneous removal of a gall bladder instead of an appendix, are considered to be never events.
CIGNA will not reimburse for never events because they are not “medically necessary.” Surgery performed on the wrong side, wrong site, wrong body part or wrong person is not considered medically necessary to diagnose or treat an illness, injury or disease, and is therefore not reimbursable.
The BBC reported that an accident in Scotland caused by a 30-ton digger falling off a truck while being moved and hitting car (killing a passenger) would have been prevented if the truck driver had been properly trained.
“I express surprise and some concern at the absence of any requirement for compulsory training for drivers of heavy goods vehicles in relation to loading and securing of loads.”
“It seems to me that if such training had existed prior to July 5 in 2006 then there is at least the possibility that the accident which occurred might not have taken place.”
Training always seems like a potential solution after an accident with 20/20 hindsight. Without additional details of the sequence of events, the causal factors, and a thorough root cause analysis, the actual root causes may never be known.
We’ve all heard about the cancelled flights at American, Southwest, and others. And then there are the Congressional hearings with FAA whistleblowers explaining how the FAA and airlines are too close. You would think our air transport system was on the verge of disaster - planes falling from the sky.
A press release from the US Chemical Safety Board (CSB):
Apex, North Carolina, April 16, 2008 - In a case study report released today on the October 2006 hazardous waste fire at the Environmental Quality Company (EQ), the U.S. Chemical Safety Board (CSB) called for a new national fire code for hazardous waste facilities and for improving the information provided to community emergency planners about the chemicals those facilities store and handle.
The fire occurred on the night of October 5, 2006, at the EQ hazardous waste transfer facility on Investment Boulevard in Apex, a suburb of Raleigh, North Carolina. The facility was not staffed or monitored after hours, and no EQ employees were present at the time of the fire. Emergency responders did not have access to specific information on the hazardous chemicals stored at the site and ordered the precautionary evacuation of thousands of Apex residents. The evacuation order remained in place for two days, until the fire had subsided.
The CSB also today released a new 16-minute CSB safety video, entitled ‘Emergency in Apex - Hazardous Waste Fire and Community Evacuation,’ available on free DVDs and on the agency’s video website, Safetyvideos.gov.
The CSB investigation found that a small fire originated in the facility’s oxidizer storage bay, one of six storage bays where different wastes were consolidated, stored, and prepared for transfer off-site to treatment and disposal facilities. Within the oxidizer bay were a number of chemical oxygen generators, which had earlier been removed from aircraft during routine maintenance at a facility in Mobile, Alabama. However, they had not been safely activated and discharged before entering the waste stream. Solid chlorine-based pool chemicals were stacked on top of the box containing still functional oxygen generators.
Apex firefighters initially responded to a 911 emergency call from a resident driving past the facility, who reported observing a haze with a ’strong chlorine smell.’ When firefighters arrived, they discovered what was still a small ’sofa-size’ fire. But that fire spread quickly, most likely as the aircraft oxygen generators discharged and accelerated the blaze.
‘The only fire control equipment on-site consisted of portable, manually operated fire extinguishers,’ said CSB Supervisory Investigator Rob Hall, P.E., who led the investigation. ‘The facility lacked fire walls and automatic fire suppression systems. As a result, the fire spread quickly into other bays where flammables, corrosives, laboratory wastes, paints, and pesticides were stored.’ The bays were separated by six-inch-high curbs only designed to contain liquid spills.
The facility was destroyed in the ensuing fire and explosions, which sent fireballs hundreds of feet into the air. About 30 people, including one firefighter and 12 police officers, required medical evaluation at local hospitals for respiratory distress and other symptoms that occurred as a plume from the fire drifted across the area.
Hazardous waste facilities like EQ’s are regulated under the federal Resource Conservation and Recovery Act (RCRA). The investigation noted that RCRA regulations developed by the Environmental Protection Agency (EPA) require facilities to have ‘fire control equipment’ but do not specify what equipment and systems should be in place. In addition, there is no national fire code to define good fire protection practices for hazardous waste facilities.
The CSB investigation identified 22 other hazardous waste fires, explosions, and releases that have occurred at U.S. hazardous waste facilities in past five years. More than a third had adverse community impacts, such as evacuations, orders to shelter, and transportation disruptions.
Federal RCRA regulations require operators to ‘familiarize’ local responders in advance concerning facility hazards, but do not describe what specific information must be shared about stored chemicals, or define the frequency of communications. Similarly, EPA regulations under the 1986 Emergency Planning and Community Right-to-Know Act do not require facilities to share information about hazardous wastes with local agencies, since those wastes are generally exempt from Occupational Safety and Health Administration (OSHA) rules requiring preparation of material safety data sheets (MSDSs).
In fact, the investigation found that EQ had had limited contact with the Apex Fire Department prior to the October 2006 fire.
‘Specific, accurate, up-to-date information on chemical hazards is essential to emergency response planning,’ said CSB Board Member William Wark, who accompanied the investigative team to Apex in October 2006. ‘Communities have a fundamental right to know about stored hazardous chemicals that may affect their health and well-being. For first responders, having prompt access to such information is a matter of basic life safety.’
The CSB report recommended the EPA require that permitted hazardous waste facilities periodically provide specific, written information to state and local response officials on the type, approximate quantities, and location of hazardous materials.
The Board called on the Environmental Technology Council, a trade association representing about 80% of the U.S. hazardous waste industry, to develop standardized guidance on waste handling and storage to prevent releases and fires. The CSB also recommended that the Council petition the National Fire Protection Association (NFPA) - an organization that authors national fire codes - to develop a specific fire protection standard for the hazardous waste industry. The new standard should address fire prevention, detection, control, and suppression. Similar NFPA standards already exist for other industries, such as wastewater treatment.
Earlier, in June 2007, the CSB issued a safety advisory and urgent recommendations designed to ensure that chemical oxygen generators are safely activated and discharged prior to transportation and disposal. The advisory cited findings of the National Transportation Safety Board (NTSB) following the 1996 ValuJet crash in Florida, which was caused when generators activated and ignited in the plane’s cargo bay.
For more information, in Apex contact Dr. Daniel Horowitz at (202) 441-6074. In Washington, DC, contact Mr. Sandy Gilmour at (202) 261-7614 / (202) 251-5496 or Ms. Hillary Cohen at (202) 261-3601 / (202) 446-8094.
The video isn’t an accident. It is a 1993 United Airlines safety video for the ground operations personnel. But accidents of this type have happened.
What lesson can you learn from this video? Think about how are you training your employees to recognize hazards in the workplace. Before they can report and avoid hazards, they need to be able to recognize them.
One of the pre-Summit courses (June 23-24 in Las Vegas) is the:
HAZARD RECOGNITION BEST PRACTICES TRAINING
Peter Burkholz, one or our TapRooT® Instructors from Australia with 25 years of industrial and mining experience, will teach tried and true methods of hazard recognition including at risk or safe behavior, legislation implications, and hazard identification and rectification. The course includes a site visit to a Caterpillar site for practical application of the theories learned.
A press release from the UK Rail Accident Investigation Board:
The RAIB is carrying out an investigation into a derailment of a Docklands Light Railway train near Deptford Bridge station on 4 April 2008.
At 05:27 hrs on 4 April the 05:19 hrs service from Lewisham had just left Deptford Bridge station, and was traveling towards Greenwich, when it struck an object on the track and was derailed by the second axle of the first bogie. The front of the train came to a rest 88 meters after hitting the object. There were no injuries to the 59 persons on board the train and all were evacuated safely back to Deptford Bridge station.
The train, which was the first train of the day from Lewisham, was under automatic operation. T
