“Authorities launched a criminal investigation Monday into the cause of an explosion that killed five people at a power plant under construction, saying they couldn’t rule out negligence.“
“‘If everything went right, we wouldn’t all be here right now,’ Middletown Mayor Sebastian Giuliano said. ‘There’s a point where negligence raises to the level of criminal conduct, and that’s what we’re investigating.‘”
For the complete story, see this Houston Chronicle link:
Interestingly, The Chemical Safety Board investigators were turned away because this was a “criminal investigation.”
If you thought the only place where accidents can become “criminal” was in the UK where they have a Corporate Manslaughter Law, I guess you are mistaken. If you would like to find out more about “criminal” investigations of accidents, you might want to attend the new pre-Summit Course that is being provided by our UK TapRooT® Instructors. They are both retired detectives with extensive criminal investigation experience, including the criminal investigation of industrial accidents.
The course is new and information about it hasn’t been posted on the Summit site yet, so watch for future announcements for more information.
In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.
The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists really helped avoid common errors and kept planes from crashing. Now, aviation checklists are a staple of the professional pilot.
I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals need to adopt the best practices that are the staple of high performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events. Especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.
That’s just one of the best practices that should be adopted immediately to improve performance in the complex environment of a modern hospital. Where can you learn more? Try a TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. Then attend the TapRooT® Summit in San Antonio (October 27-29) for more best practices to improve performance. You could be part of the movement to save thousands of lives every year by applying known best practices to improve healthcare quality and patient safety.
The patient who was getting an MRI had a knife strapped to his leg (guess he wanted to be ready for anything during the MRI). The story then says…
“The knife got sucked out of its sheath and cut the patient in the abdomen, requiring stitches. Before he was taken to the MRI, the patient was screened for objects that would be attracted to the magnet. He reportedly ’stated that his pockets were empty.‘”
And it talks about the safety and budget issues at WMATA.
I guess that putting the bus driver in jail after the accident last year (or was it two years ago?) didn’t stop the accidents at WMATA.
The blog writer at the Baltimore Sun pins his hopes on the NTSB. But in my book, only management can really change safety after they fully understand the root causes of the problems.
An AP story published in the Houston Chronicle says that Transportation Secretary Ray LaHood said that Toyota was:
“…dragging its feet on safety concerns over its gas pedals, suggesting the automaker was ‘a little safety deaf’ to mounting evidence of problems.”
He also said that:
“… federal safety officials had to ‘wake them up’ to the seriousness of the safety issues that eventually led Toyota to recall millions of cars such as its Camry and Corolla. That included a visit to Toyota’s offices in Japan to persuade them to take action.“
The article also said:
“… the government was considering civil penalties for Toyota over its handling of the recalls…”
This kind of press couldn’t come at a worse time as Toyota struggles with this quality/safety issue and the bad press that it has generated.
How much damage to your reputation can a quality/safety issue do? Toyota is finding out the hard way.
CAPTAIN’S INAPPROPRIATE ACTIONS LED TO
CRASH OF FLIGHT 3407 IN CLARENCE CENTER,
NEW YORK, NTSB SAYS
********************************************
The National Transportation Safety Board determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.
In a report adopted today in a public Board meeting in
Washington, additional flight crew failures were noted as causal to the accident.
On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport.
The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post-crash fire. The flight was a 14 Code of Federal Regulations (CFR)Part 121 scheduled passenger flight from Newark, New Jersey. Night visual meteorological conditions prevailed at the time of the accident.
The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column.
However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall.
Contributing to the cause of the accident were the
Crew members’ failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures.
Other contributing factors were the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots.
At today’s meeting, the Board announced that two issues that had been encountered in the Colgan Air investigation would be studied at greater length in proceedings later this year.
The Board will hold a public forum this Spring exploring pilot and air traffic control high standards.
This accident was one in a series of incidents investigated by the Board in recent years - including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance, and the Northwest Airlines incident last year where the airliner overflew its destination airport in Minneapolis because the pilots were distracted by non-flying activities - that have involved air transportation professionals deviating from expected levels of performance.
In addition, this Fall the Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. For example, this accident occurred on a Continental Connection flight, although the transportation was provided by Colgan Air.
A summary of the findings of the Board’s report are available on the NTSB’s website at:
Here a link to the interview that Charlie Rose did with Jeffery Skiles, the co-pilot of flight 1549. Jeffery will be speaking on Friday at the TapRooT® Summit so please plan to stay for his session.
They question Toyota’s management, organization, and cost cutting efforts.
Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.
The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”
The story also said:
“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“
Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!
While dumping the contents of a hydrovac unit, a swamper was killed when he was caught in the closing hydrovac tank door.
What Went Wrong?:
The truck operator and swamper were offloading the contents of the hydrovac truck at a designated area. The hydrovac truck tank had been elevated and the rear door was opened to allow the crew to clean out the tank.
Other relevant incident information:
Photograph of rear door configuration of a typical hydrovac truck. Note crush point.
The workers had cleaned the tank and had both stepped down from the rear tank access platforms (also known as beavertails).
The operator walked around to the drivers side of the truck to access the hydraulic control levers located directly behind the cab of the truck.
Unknown to the truck operator, the swamper had climbed back up onto the right, rear beavertail and became caught in the swing radius of the rear tank door as it was closing.
Corrective actions and Recommendations:
To prevent future incidents, the employer and the hydrovac truck supplier have worked together to implement a number of corrective actions.
Equipment Modifications (Engineering Controls)
The hydrovac truck supplier has altered the hydrovac truck involved in the incident including:
The bank of four control levers for the vacuum tank operation were changed;
Two control levers have been routed to other locations. The removal of these levers may allow for additional room between the remaining control levers to minimize an inadvertent activation due to their proximity; and
The control lever that operates the rear tank door was moved to the rear of the hydrovac tank, which allows the operator to maintain a clear line of sight of the door during opening and closing operations.
Flow restrictors have been installed on the hydraulic lines to the cylinder for the opening and closing of the rear tank door. This alteration slows down and controls the door’s rate of travel;
Hydraulic controls have been tagged with permanent markings to provide clearer identification of the function of the control; and,
Signs warning of the hazardous pinch point have been installed on both sides of the rear of the vacuum tank.
The supplier intends to make similar alterations to all new vacuum/hydrovac truck assemblies and all vacuum/hydrovac trucks, which are returned for service and recertification.
Revisions to Operating Procedures (Administrative Controls)
The employer has modified its hydrovac truck operating procedures to include:
An enhancement and ordering of the steps that will be followed for closing the tank door and lowering of the tank;
Added a requirement that the hydraulic rear door operator visually identifies any workers for whom the closing tank door may be a hazard, before the operator activates the controls; and
Added a provision for the engagement of the tank safety bar when the tank door is open. This provision would include a requirement that, when the tank is clean, the swamper should remove the bar while remaining in the operator’s line of sight and then instruct the truck operator to close the door.
The employer and hydrovac truck supplier involved in this incident believe that the actions summarized above are relevant to the manufacture, supply and associated procedures of similar equipment used at energy and construction work sites. They are urging other companies to reassess their operations in light of the measures identified above and identify if there is a need for similar preventive actions in their operations.
Source Contact:
This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).
According the the study/story, the rates where a ban has been passed mirror those of neighboring states with no law. Thus no decrease was seen by having a criminal penalty for hand held cell phone use.
Almost everyone agrees that drivers can be distracted by cell phone use so why didn’t this bans work? Here are some of my ideas…
1. Hand held cell phones is only one of many distractions.
2. Enforcement - people still use their phones.
3. People use phones in hands fee mode and are still distracted.
Have other ideas why this ban doesn’t improve accident statistics? Leave them here as a comment.
One more note …
I was over in the UK recently. They have all sorts of laws to make a driver pay attention. One of the big stories was a man who got a ticket for blowing his nose while he was stopped in traffic. The officer thought he was not “in full control of his vehicle.”
Some accidents are so historic that every accident investigator should know about them. The Challenger is one of those. It happened 24 years ago today. Dana Barclay, one of our TapRooT® Instructors with an Navy flight background, assisted with this massive investigation. Here is a link to the Report of the Presidential Commission:
The Associated Press reports that Toyota is stopping production for at least a day at six assembly plants and is stopping sales of eight models until accelerator sticking problems are solved.
National Transportation Safety Board
Washington, DC 20594
January 26, 2010
The National Transportation Safety Board has launched a team of investigators to today’s Washington Metropolitan Area Transit Authority (WMATA) accident in Rockville, MD. At 1:45 am (EST) a hi-rail vehicle, in the work zone on the red line near Rockville Station, struck and killed two employees on the track.
NTSB rail investigator Stephen Klejst has been designated as the Investigator-in-charge and is accompanied by two investigators with expertise in operations and human performance.
Washington, DC, January 25, 2010 – The U.S. Chemical Safety Board (CSB) today voted to initiate an investigation of recent accidents at the DuPont chemical complex in Belle, West Virginia, following a release of highly toxic phosgene on Saturday that fatally injured a veteran operator.
DuPont officials told the CSB that a braided steel hose connected to a one-ton capacity phosgene tank suddenly ruptured, releasing phosgene into the air. An operator who was exposed to the chemical was transported to the hospital, where he died the following day.
The phosgene release followed two other accidents at the same plant this week, including an ongoing release of chloromethane from the plant’s Hexazinone unit, which went undetected for several days, and a release of sulfur dioxide from a spent sulfuric acid unit. The plant announced over the weekend that it would be shutting down a number of process units immediately for safety checks.
Speaking for the three-member board, Member William E. Wright said: “The Board is concerned by these releases, which had tragic consequences, and will proceed with an investigation to understand why these unfortunate events occurred.” Mr. Wright cautioned that the new case would likely delay efforts to complete other investigations that are being conducted by same investigative team, including those at the Bayer CropScience facility in Institute, West Virginia, and an Ohio environmental services company. Including DuPont, the CSB has 17 open investigations, the largest number in its 11-year history.
In voting to approve the investigation, the Board noted that the CSB was aware of six other releases from the plant since December 2006. The DuPont Belle complex is a large facility that is regulated under the EPA Risk Management Program and the OSHA Process Safety Management standard because of the volume and hazards of the materials it handles and the potential risk to workers and the community.
CSB investigator Johnnie Banks will lead the four-member team which is expected at the site on Tuesday.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz, (202) 261-7613, cell (202) 441-6074, or Public Affairs Specialist Hillary Cohen, (202) 261-3601, cell (202) 446-8094.
NTSB ASSISTS U.S. COAST GUARD INVESTIGATION INTO TANKER COLLISION AND OIL SPILL NEAR PORT ARTHUR, TEXAS
*************************************************
The National Transportation Safety Board has launched a go-team to participate with the U.S. Coast Guard (USCG) in its investigation of Saturday’s collision involving the tank vessel EAGLE OTOME and the tug DIXIE VENGEANCE near Port
Arthur, Texas, in accordance with the Memorandum of Understanding between the two federal agencies.
Marine investigator Rob Jones is leading the NTSB team and is accompanied by specialists in engineering and hazardous materials.
Media inquiries about the status of the investigation should be directed to the USCG Joint Information Center for Port Arthur at 409-812-0261.
If you had the unexpected worst case accident at your plant, would you be ready to complete a root cause analysis that would stand up to regulatory and press scrutiny in just 60 days?
“And within 60 days, the company must provide a corrective action plan, hazard and operability study, and a ‘root cause analysis’ of what triggered the disaster. The company could face fines of $500 a day or more if the information isn’t submitted on time, according to an agreed order among NDK, the Boone County state’s attorney’s office and the Illinois attorney general’s office.“
Let’s hope NDK Crystals has some experienced root cause analysts ready to go with advanced root cause analysis techniques ready to apply and maybe a Corrective Action Helper® Module in their patented software. Because on the day you sign the consent order with the EPA, it’s too late to start looking for a TapRooT® Class for your investigators.
“WASHINGTON — Accident investigators uncovered such egregious behavior by train operators in the fatal 2008 accident near Los Angeles that they suggested Thursday that all railroads monitor crews with video surveillance.
In a controversial recommendation intended to draw a line in the sand against the rapid rise in accidents triggered by distractions from cellphones and other technology, the National Transportation Safety Board (NTSB) not only endorsed placing video cameras in train cabs, but said railroads should regularly monitor the videos to ensure that engineers follow safety rules.“
These recommendations by the NTSB will not only help improve the accountability for and the enforcement of SPAC (Standards, Policies, and Administrative Controls), they will also make future investigations much easier.
Have you thought about video/audio monitoring of key personnel and workspaces to provide increased accountability, better enforcement of SPAC, and better root cause analysis?
The RAIB is carrying out an investigation into a fatal accident that occurred at Moreton-on-Lugg level crossing, Herefordshire, on the railway between Shrewsbury and Hereford, on 16 January 2010. For more info, see the UK RAIB web site at:
See the accident report at:
