Root Cause Analysis Blog

PRESS RELEASE:

At about 07:19 hrs on Thursday 5 January 2011, two windows in the passenger compartment of train 1T53, the 06:51 hrs service from Kings Lynn to London Kings Cross, were broken when part of the train’s equipment fell from the roof about 2 miles (3.2 km) south of Littleport, Cambridgeshire.  The equipment, a pantograph assembly mounted on top of the carriage which is used to collect electricity from overhead lines, became detached after hitting one of the structures which support the overhead lines.  Two passengers were injured, and there was some damage to both the train and the overhead line equipment.

The RAIB’s preliminary examination has found that the accident occurred because the head of the pantograph lost contact with the overhead line when travelling at a speed of about 80 mph (128 km/h) through an area where high winds were blowing across the railway.  The train brakes were applied and the driver brought the train to a controlled stop in a distance of about 1.5 miles (2.4 km), near Queen Adelaide level crossing, a location where he could obtain assistance.

Image showing damage to incident train

The RAIB’s further investigation will examine the way in which Network Rail implemented its procedure for dealing with the effect of high winds and the factors which led to the loss of contact between the pantograph and the overhead line.  It will also consider why the pantograph assembly failed in such a way that damage was caused to the windows on the side of the train.

The RAIB’s investigation is independent of any investigation by the police or safety authority (the Office of Rail Regulation).

The RAIB will publish a report or a bulletin to present the findings of this investigation. This will be available on the RAIB website.

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The grounding of the Costa Concordia was not the first accident for the Costa line.

A previous fatal accident happened while mooring in Egypt in February of 2010.

However, after two years, the analysis of that investigation has not been submitted to the International Maritime Organization by the Italian authorities.

And even if it had, the company is arguing that the crash with the pier was caused by “bad wether” while others say it was “crew error.” Neither of these are a root cause.

See a BBC report on the previous accident and the failure to file a report at:

http://www.bbc.co.uk/news/world-europe-16823955
And see our previous post about another grounding – this time of the Costa Fortuna – at:

http://www.taproot.com/wordpress/archives/28627

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This ship does look a little close to the beach.

But who needs root cause analysis when we already know the answer … The Captain was to blame!

Here’s the article:

http://www.sacbee.com/2012/01/15/4189696/captain-may-be-to-blame-for-cruise.html

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At 19:41 hrs on Wednesday 30 November 2011, train 2W29, the 18:43 hrs service from Cambridge to Ipswich, struck a car that was lying foul of the up main line near Old Newton, Suffolk, about 1 mile north of Stowmarket station.

The collision occurred when the train was travelling at about 55 mph (89 km/h).  The train did not derail and incurred only minor damage.  None of the people onboard suffered injuries.

The RAIB’s preliminary examination has found that the car was being driven north on the B1113 Stowmarket Road when it left the carriageway. The car then passed through the wire fence marking the railway boundary and over a low earth bund, before coming to a rest on the up main line.

Accident site at Stowmarket

The car driver suffered minor injuries as a result of this accident but was able to leave his vehicle and to telephone the emergency services. However, before this call was completed, train 2W29 approached on the up main line (heading south) and struck the car. Although the train driver had applied the brakes as soon as he became aware of the obstruction on the track, he was unable to stop the train in time to avoid a collision.

At this location the B1113 approaches to close to the railway line before curving away again into a right-hand corner. The railway line at this location is a double track line with a maximum permitted speed of 100 mph (165 km/h). Where it is considered credible that there may be an incursion of road vehicles at such locations, the risk to the railway is required to be assessed by the local highway authority and/or Network Rail.

There was a previous incident at this location in January 2010 which also resulted in a road vehicle breaching the boundary fence and approaching the railway. In this incident the car landed on its roof about three metres clear of the up main line.

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 (Suffolk County Council) and Network Rail, and what subsequent actions, if any, were taken to control the risks relating to such incursions. The investigation will also review the current national policies and processes for the management of road incursion risk at locations of this type.

The RAIB’s investigation is independent of any investigations by the police or safety authority (the Office of Rail Regulation).

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.

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Here’s a press release from the CSB about their investigation and findings …

CSB Releases Final Investigation Report on Three Accidents at the Hoeganaes Iron Powder Facility in Gallatin, Tennessee

January 5, 2011, Nashville, TN – The U.S. Chemical Safety Board today released its final report on three accidents that occurred in 2011 at the Hoeganaes powdered metals plant in Gallatin, Tennessee. Flash fires and an explosion killed a total of five workers and injured three others.

The CSB investigation found that significant amounts of fine iron powder had accumulated over time at the Hoeganaes facility, and that while the company knew from its own testing and experience with flash fires in the plant that the dust was combustible, it did not take the necessary action to reduce the hazards through engineering controls and basic housekeeping. The investigation also found that Hoeganaes did not institute procedures such as combustible gas monitoring or provide training for employees on avoiding flammable gas fires and explosions.

The Board issued several safety recommendations, including that the Occupational Safety and Health Administration (OSHA), develop and publish a proposed combustible dust standard within one year and ensure that the new standard includes coverage for combustible iron and steel powders.

CSB Chairperson Rafael Moure-Eraso said, “The three accidents at the Hoeganaes facility were entirely preventable. Despite evidence released by the CSB and information that Hoeganaes had in its possession even before the first accident in January 2011, the company did not institute adequate dust control or housekeeping measures. Dust fires and explosions continue to claim lives and destroy property in many industries. More must be done to control this hazard. No more lives should be lost from these preventable accidents.”

The CSB also released a safety video entitled “Iron in the Fire,” which features computer animations depicting each accident.

The first of the three 2011 accidents at the Hoeganaes plant occurred on January 31 when fine particles of iron dust ignited while a maintenance mechanic and an electrician were troubleshooting a problem with a bucket elevator. Both employees suffered burns and later died from their injuries. The CSB investigation into that accident was underway when, just two months later, on March 29th, a similar flash fire burned another Hoeganaes worker.

At a news conference in Tennessee on May 11, 2011, the CSB released laboratory test results on dust samples taken from the plant after the second accident. The testing demonstrated the combustibility of even small amounts of the iron dust when dispersed in air in the presence of an ignition source.

Just sixteen days after the CSB released those test results, on May 27th, a hydrogen explosion erupted in the plant, after the gas began leaking from a corroded furnace pipe. The blast shook loose iron dust accumulations from the upper reaches of the building, which ignited and rained down on workers. The explosion and ensuing fire killed three workers and injured two others. The CSB found that the company did not require atmospheric testing for hydrogen or other explosive gases.

Investigator Johnnie Banks said, “When the Hoeganaes facility was built, more than thirty years ago, it was not designed according to good practice guidelines on combustible dust, such as those set forth by the National Fire Protection Association, or NFPA. And during its decades of operation, it was never redesigned to address the serious dust hazard. The CSB is recommending that Hoeganaes conduct periodic audits to ensure compliance with the appropriate NFPA codes and standards.”

The CSB report notes that engineering controls, such as enclosing conveyors and installing properly designed dust collection equipment are the best ways to prevent dust accumulations. CSB investigators found that the plant’s powder handling equipment was not adequately sealed.

The Hoeganaes facility has numerous flat overhead surfaces where dust can accumulate, such areas are difficult to reach and clean. The CSB case study noted that NFPA 484, the Standard for Combustible Metals, recommends that floors, elevated platforms, and gratings be designed to prevent dust accumulations and to facilitate cleaning. The NFPA standard also requires that all machines that release combustible dust be connected to a dust collection system.

The CSB is recommending that the International Code Council, which sets safety standards that may be adopted by state and local governments, revise its standards to require mandatory compliance and enforcement with the detailed requirements of NFPA standards related to preventing accumulation of combustible dust in workplaces. Additionally, the CSB is recommending that the City of Gallatin require all facilities covered by the International Fire Code to conform to National Fire Protection Association standards for combustible dusts.

Investigator Banks said, “It is a tragedy that five lives were lost at Hoeganaes from these accidents. The CSB believes that adhering to recommended industry practices will greatly reduce the potential for a future dust fire or explosion. ”

In 2006 the CSB released a study on the hazards of combustible dust, ultimately recommending that the Occupational Safety and Health Administration create a combustible dust standard for general industry.

In response, OSHA initiated a National Emphasis Program in 2007 to target industries with combustible dust hazards for additional inspections and enforcement. Two years later, OSHA announced it would begin rulemaking on a comprehensive standard for general industry. Yet, in 2011, at the time of the accidents at Hoeganaes, a specific standard had not yet been proposed or completed.

As a result, the CSB is recommending that OSHA develop and publish a proposed combustible dust standard within one year – ensuring that the new standard includes coverage for combustible iron and steel powders. The Board is also recommending that the Tennessee Occupational Safety and Health Administration target facilities that generate metal dust.

The Board also is making recommendations to Hoeganaes, the Metal Powder Producers Association, the Gallatin Fire Department and City of Gallatin.

CLICK HERE to view the CSB’s case study

CLICK HERE to view the CSB’s safety video “Iron in the Fire”

CLICK HERE to view the CSB Hoeganaes Investigation Information Page

For more information, contact Communications Manager Hillary Cohen, (202) 261-3601, cell (202) 446-8094.

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Collision at Llanboidy level crossing

Investigation into a collision between a train and a lorry at Llanboidy level crossing, near Whitland, Carmarthenshire on 19 December 2011

At 09:45 hrs on Monday 19 December 2011, train 1W21, the 09:10 hrs service from Milford Haven to Manchester Piccadilly, struck a lorry on Llanboidy automatic half barrier (AHB) level crossing, which is located about 14 miles (22 km) west of Carmarthen, near the village of Whitland.  The train did not derail but serious damage was caused to the driving cab.  Several people on the train suffered minor injuries or shock during the accident, and a passenger became ill while the train was being evacuated.  The lorry driver was not injured.

The RAIB’s preliminary examination has found that the lorry, which was carrying straw bales and towing a similarly loaded trailer, had stopped on the level crossing, with the crossing barrier on the exit side lowered in front of it.  The train, a two coach diesel multiple unit, had been approaching the crossing at about 68 mph (109 km/h), but an emergency brake application had reduced the speed to about 41 mph (66 km/h) when the collision occurred.  The train pushed the lorry about 80 metres along the railway.

The investigation will identify the exact sequence of events that led to the accident.  It will also include consideration of the layout of the level crossing, the actions of the lorry driver, the factors which caused the lorry to stop on the crossing and the crashworthiness of the Class 175 unit involved in the collision.

The RAIB’s investigation is independent of any investigation by the police or safety authority (the Office of Rail Regulation).

The RAIB will report on its findings, including any recommendations to improve safety, at the conclusion of its investigation.  This information will be available on the RAIB website.

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