Root Cause Analysis Blog

A diesel fuel spill is moving away from land after a fishing boat hit a tanker off the coast of South Korea. For details, see:

http://www.abc.net.au/news/stories/2008/03/12/2187944.htm

Carolyn Griffiths is the Chief Inspector of the UK Rail Accident Investigation Branch.

The UK RAIB is an independent investigative organization that by law investigates the UK’s railway accidents and incidents. The purpose of their investigations is not to apportion blame or to enforce laws, but rather to improve railway safety and prevent future accidents. For questions about the UK RAIB see:

http://www.raib.gov.uk/about_us/index.cfm

Carolyn is a Keynote Speaker at the TapRooT® Summit in Las Vegas on June 25-27. She will speak about her experiences starting up the UK RAIB in 2004/2005 and some investigation lessons learned from the RAIB’s initial investigations.

What can you learn?

Every investigator or head of an investigation organization can learn from the experiences of others. In talking to Carolyn, I found that her approach to getting good investigations, the training she requires for her investigators, and the challenges of getting investigations completed were all interesting topics to hear about.

That’s what’s great about the Summit. You will not only hear the RAIB’s Chief Inspector talk, but also, you will have the opportunity for one-on-one conversations to ask questions, share best practices, and make a new contact in your network of professional associates.

For more Summit information and to register, see:

http://www.taproot.com/summit.php

CNN reports that the FAA has required air carriers to install improved black boxes to collect more flight data and longer periods of voice communication. The requirement call for the devices to be installed by March 7, 2012.

The requirement comes 9 years after it was requested by the National Transportation Safety Board.

The FAA did not require cockpit cameras as requested by the NTSB. The FAA said the cameras were not justified by a cost/benefit analysis.

IF YOU ARE NOT in the aviation industry, why do you care?

You should think about automatic data recording for your facility (in case of an accident).

Things to think about include:

1. Recording radio communications.
2. Videos in the control room.
3. Data recording.
4. Security camera recordings.
5. Security access data (swipe card data to see who went where).

Don’t wait until it is too late! Think through your data recording requirements before an accident occurs.

He was just standing around, minding his own business when…

Time for some simple root cause analysis?

Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.

There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.

First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:

http://www.icao.int/icao/en/dgca/Annex13attE_en.pdf

Or you can purchase it on-line at:

http://icaodsu.openface.ca/documentItemView.ch2?ID=6594

The International Civil Aviation Organization - Air Navigation Bureau also has a Accident Invesigation & Prevention web page at:

http://www.icao.int/icao/en/anb/aig/

Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See:

http://www.iprr.org/manuals/ntsbaviationman.pdf

Many countries have their equivalent of the NTSB. A list of national aviation investigation boards with links to their web sites can be found at:

http://aviation-safety.net/investigation/aaibs.php

These links should keep you busy and lead to many other sites with more information on aviation accident investigation.

This short newspaper article starts to provide the information needed to draw a SnapCharT® that would have many Causal Factors. Read the story and then try drawing a SnapCharT®.

Link to story:

http://www.news.com.au/heraldsun/story/0,21985,23323474-29277,00.html

For details, see:

http://www.abc.net.au/news/stories/2008/03/07/2183092.htm?section=australia

The recent BP Annual Report (page 26), BP increased the reserve to settle legal claims from the Texas City Refinery explosion from $1.6 Billion to $2.125 Billion.

Also, the Houston Chronicle reported that a Federal Appeals Court must rule on whether the blast victims were properly consulted before a federal Judge can rule on the $50 million EPA Clean Air Act violation settlement agreement between BP and the EPA.

A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.

Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.

What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).

Bill Sirois, VP and COO of Circadian Technologies, will be presenting three sessions on fatigue and the investigation of fatigue as the cause of accidents. The sessions are:

Human Error Reduction & Behavior Change Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Investigation & Root Cause Analysis Best Practices Track:

• FACTS - Computerized Analysis of Fatigue as a Cause of an Incident

Medical Error Reduction Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

For additional Summit information, see:

http://www.taproot.com/summit.php

Watch the sailor come out of a door on the fantail. Just another day at sea until …

Did the ship not wait it’s turn or did the bridge operator lower the bridge too soon? The SnapCharT® for this accident would be interesting…

(more…)

Interested in learning lessons about accidents, accident investigation, and root cause analysis? Then attend the TapRooT® Summit in Las Vegas on June 25-27!

There are some great sessions in the Investigation & Root Cause Analysis Best Practices Track, including:

Root Cause Analysis of Major Accidents - This session will have three presentations about investigations. The first presentation (Lexington Airport Runway Mixup) shows how TapRooT® can be applied to publicly available information to analyze a real aviation accident’s root causes. The second (Cameco Cigar Lake Mine Flood) presents the investigation of an accident that was investigated using TapRooT®. The third (investigating Fatalities) shares experiences of an investigator from Cal OSHA.

Investigations Learned from the Field - Three experienced investigators (Ken Turnbull, Brian Locker, and Barry Baumgardner) will share lessons that they have learned over their extensive experience investigating accidents and incident.

FACTS - Computerized Analysis of Fatigue as the Cause of an Incident - Bill Sirois, VP & COO of Circadian Technologies, will share the results of research they have performed that has helped them build a tool for accident analysis of fatigue as a cause of an accident.

What’s New in Investigations and Corrective Actions - This session has three talks that share information of interest to investigators. First, Brian Locker will share the latest methods for defining Causal Factors that was developed as part of the 2008 TapRooT® Book. Next, Kay Gallogly will share the progress being made by an IEEE committee that is developing a root cause analysis standard for the nuclear power industry. Third, Bryce Donaldson will show some advanced multimedia techniques for sharing lessons learned after an investigation.

Root Cause Analysis of the Accident at Three Mile Island - This interactive session will provide an opportunity for investigators to use their investigative skills to analyze the root causes of the accident at Three Mile Island. The session will be facilitated by one of the operators present at the time of the accident.

That’s just a sample of the sessions in the Investigation & Root Cause Analysis Best Practices Track. For the complete schedule, click on the track title at:

http://www.taproot.com/summit_schedule.php

Beyond the Best Practice Tracks at the Summit, there are also three Keynote Speakers that should be of special interest to those looking to learn lessons from accidents.

First, Gulf War veteran Lt Col Ralph Hayles will speak about the aftermath of a friendly fire accident at the start of the first Gulf War. His story will show how an investigation focussed on blame can harm those it is meant to help.

Second, the Chief Inspector of the UK Rail Accident Investigation Branch, Carolyn Griffiths, will share the lessons she has learned from starting a new, independent investigation organization.

Third, Ed Frederick, Board Operator during the accident at Three Mile Island, will share his account of the accident and the post accident investigation.

These are three great speakers that will enlighten and motivate accident investigators.

Beyond the great speakers and sessions, perhaps the most valuable activity at the Summit is NETWORKING with other from leading organizations from around the world. How do I know that? Watch this video of what past Summit attendees have to say:

http://www.taproot.com/download/summit08_networking.mov

And watch this link to Summit attendees discussing the BEST PRACTICES they learned.

http://www.taproot.com/download/summit08_bestpractices.mov

So if you are interested in accident investigation and root cause analysis, don’t miss this Summit!

To register and for more information, see:

http://www.taproot.com/summit.php

For more info, see:

http://www.signonsandiego.com/news/state/20080229-1927-wst-columbiarivernavigation.html

The Food and Drug Administration (FDA) found that a Chinese plant is at the center of a controversy over the safety of Baxter’s blood thinning drug heparin. Changzhou SPL has problems with impurities, the quality and use of its equipment, and overall quality control. These problems were found in a preliminary inspection by the FDA.

You may remember that in a previous blog entry, the FDA had declined to inspect the plant because of a name mix-up in the FDA’s manufacturer database.

For more information, see:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/28/AR2008022803046.html?hpid=moreheadlines

The UK Rail Accident Investigation Branch has released two new accident investigation reports.

The first is about the derailment at Hooley Cutting, near Merstham, Surry. The report includes seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/2008-02-28_R052008_Merstham.pdf

The second report is about a track worker fatality at Ruscombe Junction. It also has seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/080228_R42008_Ruscombe.pdf

The following is news release by Oregon’s Occupational Safety and Health Division:

The Oregon Department of Consumer and Business Services, Occupational Safety and Health Division (Oregon OSHA) has fined Siemens Power Generation Inc. a total of $10,500 for safety violations related to an Aug. 25, 2007 wind turbine tower collapse that killed one worker and injured another.

“The investigation found no structural problems with the tower,” said Michael Wood, Oregon OSHA  administrator. “This tragedy was the result of a system that allowed the operator to restart the turbine after  service while the blades were locked in a hazardous position. Siemens has made changes to the tower’s engineering controls to ensure it does not happen again.”

The event took place at the Klondike III Wind Farm near Wasco, where three wind technicians were performing  maintenance on a wind turbine tower. After applying a service brake to stop the blades from moving, one of the  workers entered the hub of the turbine. He then positioned all three blades to the maximum wind resistance  position and closed all three energy isolation devices on the blades. The devices are designed to control the  mechanism that directs the blade pitch so that workers don’t get injured while they are working in the hub.

Before leaving the confined space, the worker did not return the energy isolation devices to the operational  position. As a result, when he released the service brake, wind energy on the out-of-position blades caused an  “overspeed” condition, causing one of the blades to strike the tower and the tower to collapse, the Oregon  OSHA investigation found.

Chadd Mitchell, who was working at the top of the tower, died in the collapse. William Trossen, who was on  his way down a ladder in the tower when it collapsed, was injured. The third worker was outside the tower and  unharmed.

During the investigation, Oregon OSHA found several violations of safety rules:

• Workers were not properly instructed and supervised in the safe operation of machinery, tools,  equipment, process, or practice they were authorized to use or apply. The technicians working on the  turbine each had less than two months’ experience, and there was no supervisor on site. The workers  were unaware of the potential for catastrophic failure of the turbine that could occur as a result of not  restoring energy isolation devices to the operational position.

• The company’s procedures for controlling potentially hazardous energy during service or maintenance  activities did not fully comply with Oregon OSHA regulations. Oregon OSHA requirements include developing, documenting, and using detailed procedures and applying lockout or tagout devices to secure hazardous energy in a “safe” or “off” position during service or maintenance. Several energy  isolation devices in the towers, such as valves and lock pins, were not designed to hold a lockout device, and energy control procedures in place at the time of the accident did not include the application and removal of tagout devices.

• Employees who were required to enter the hub (a permit-required confined space) or act as attendants to employees entering the hub had not been trained in emergency rescue procedures from the hub.

Siemens Power Generation has 30 days to appeal the citation.

Here are some links for more information:

http://www.reuters.com/article/domesticNews/idUSN2664121920080227

http://ap.google.com/article/ALeqM5hHI4Ql8XfZuPMktRM7fQxHjXbz1QD8V2O01O0

http://www.miamiherald.com/news/breaking_news/story/434132.html

http://www.ktvu.com/news/15424754/detail.html

http://www.cnn.com/2008/US/02/26/florida.power/index.html

I see snowflakes in Tennessee! Let’s run and get some bread and find a ditch to slide into!

Here’s a dramatic example of the problems people (and pedestrians) have when driving in the snow…

(Click the Read More link to see it!)

(more…)

Watch the video below and see how NOT to make a quick turn at sea…

Software written internally by HSBC caused an intermittent failure (don’t you hate those) of Mastercard’s Maestro system last weekend. This caused thousands of HSBC’s customers to be unable to make purchases or withdraw cash.

The bank is now conducting a “major incident review” that should be completed by Friday. The review will look at the problems with the software and why recovery took so long (four hours after the offending software was removed).

How is a root cause analysis of a software failure different than the root cause analysis of a equipment failure or a human error that causes an explosion or plant shutdown? Really, there isn’t a difference in the tools to use. The only difference is the technology involved.

I found this out back in the 90’s when working with Gerald Starling at BellSouth. He used TapRooT® to investigate telecommunications incidents (network reliability, 911 outages, etc.). These were often software issues. And using TapRooT®, he found fixable root causes that improved performance.

The technology (network reliability) was very different than the types of investigations I had perviously performed. Even though I am an electrical engineer, the terminology of network reliability was completely foreign to me. Yet the reasons for human errors and system failures were in the Root Cause Tree® (part of the TapRooT® System).

The reason for this is that the causes of unreliable human performance (mistakes - human errors) are the same no matter what type of technology the human is involved with. Therefore, the ways to achieve reliable human performance are a basic part of the analysis that TapRooT® helps an investigator perform.

A man was struck and killed by the red line Luas Tram last weekend. The tram operator, Veolia Transport, is conducting an investigation in coordination with the Irish Railway Safety Agency. This is the first fatal accident since the tram was inaugurated in 2004. There were 17 “contact” incidents between people and the tram in 2007. A December 2007 incident caused serious head injuries to another man.

For a video report see:
http://www.rte.ie/news/2008/0225/luas_av.html

The Air Force has declared a “temporary pause” to review safety procedures for flying the B-2 after a crash at a Guam air base.

This is the first time a B-2 had crashed. However, even a single crash is significant because each B-2 is worth more than $1 billion. Perhaps that is why all B-2’s will be grounded (oops - I mean temporarily paused) while safety reviews are conducted.

Air Force officials were careful to explain that this action was not a “stand-down” or “grounding” and that the planes could return to service at any time they were needed. A stand-down or grounding occurs only if senior Air Force commander order it. Officials said that has not happened.

What happens when you lie to the Coast Guard during an investigation of a maritime accident? You end up facing federal charges! See this story from the San Francisco Chronicle:

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/02/23/BAVTV7DN8.DTL

How far will some people go to break a rule?

A 39 year old man in New Zealand was ticketed 32 times in 5 years for not wearing a seatbelt. His answer? He created a fake seatbelt.

He died in a low speed crash on 2/24/08. He was wearing his fake seatbelt. If he had been wearing a real seatbelt, he probably would have survived.

Here’s a short story about the accident:

http://www.shortnews.com/start.cfm?id=68733

The following accident took place in Denmark during a storm on 2/22/08.

Here’s the first view:

Here’s the second:

Yes - that is a truck at the base of the windmill when it self-destructs. I’m not sure if I can see people near the truck in the video or not.

The “cause” of the accident was the failure of the brake that limits the speed of the windmill during a storm. The speed of the blades were approaching the speed of sound when they failed.

International Cooling Tower pleaded guilty to a violation of the Occupational Health and Safety Act after a July 2005 accident. An apprentice carpenter fell through an uncovered opening in platform and suffering serious spinal injuries that left him paralyzed.

A Labour Ministry investigation found the worker was wearing a full-body harness with a single lanyard that wasn’t attached to a fixed support or lifeline. The ministry’s also found the worker was unaware of the opening because lighting was inadequate and that the worker was inadequately trained in safety procedures.

The Labour Ministry has finally fined the company $150,000.

The 10th person died from burns received from the blast at Imperial Sugar’s plant in Georgia. Thirteen are still in critical condition. For more details see:

http://www.chron.com/disp/story.mpl/business/5563790.html

For details, see:

http://www.chron.com/disp/story.mpl/business/5563715.html

Another data point on the cost of an accident.

We noted the accident at the Trump Hotel in SoHo on a blog entry on January 14.

Today I saw an article that said the construction contractor at the Trump Hotel SoHo was just allowed to resume work on the first 23 stories of the building, but is NOT being allowed to use cranes, resume pouring concrete, or work above the 23 floor.

Imagine the costs of this construction delay.

Yes, this was a fatality. The first concern should be for the lives (health and safety) of employees. But one of the overlooked costs of an accident is the regulatory consequences (in this case a stop work order by the New York Department of Buildings).

Construction accident prevention, proactive risk reduction, and good root cause analysis of problems can help companies avoid the unexpected and costly constructions delays that a major accident can cause.

The Air Accident Investigation Branch’s official web page for the investigation of the 777 crash at Heathrow is:

http://www.aaib.dft.gov.uk/publications/special_bulletins/s1_2008___boeing_777_236_er__g_ymmm.cfm

The International Herald Tribune had an interesting article on the progress of the investigation into the crash of the 777 landing at Heathrow. See:

http://www.iht.com/articles/ap/2008/02/19/europe/EU-GEN-Britain-BA-Crash-Landing.php

(Lt Col Ralph Hayles - left)

For those that investigate accidents and incidents, Lt Col Ralph Hayles story is immensely interesting.

Involved in a “friendly fire” accident at the start of Gulf War I, Lt Col Hayles was singled out for blame, discipline, and public vilification.
His “accident” was similar to many others. A combination of mistakes and equipment failures that led to a fatal result. And like many others, the last person to touch it (in this case the trigger) is blamed for all of the consequences.

To read his story see:

http://books.google.com/books?id=2tI8erYfxbwC&pg=PA8&lpg=PA8&dq=wall+street+journal+ralph+hayles&source=web&ots=j79QgRdLFK&sig=SW0sWVXDrmF2gbS85v5NiPVa2xY#PPP1,M1

Better yet, attend the Summit and hear Lt Col Hayles tell his story. Learn the impact of an investigation and discipline gone awry.

For more Summit information and registration, see:

http://www.taproot.com/summit.php

Legal representatives of those injured or the loved ones of those who were killed, are asking Judge Lee Rosenthal to reject the $50 million dollar fine for BP. They say the fine should be between $400 million and $3.2 billion.

For additional information, see:

http://www.chron.com/disp/story.mpl/business/5550899.html

Two different plants. Two similar names. Oops! Wrong plant!

If you’ve been following the FDA investigation of allergic reactions to Baxter’s heparin blood thinner, you know that a Chinese manufacturer is supplying a key ingredient. The supplier that produces the ingredient was not previously inspected by the FDA because the FDA went to the wrong plant. It seems there are two plants with similar names in the agency’s database.

Joseph Famulare, Deputy Director of the Compliance Department at the FDA’s Center for Drug Evaluation and Research said that the wrong factory had a history of positive inspections and wasn’t re-inspected. This month, they discovered their error. Famulare says that as far as the FDA knows, this is an isolated error. FDA inspectors will travel to China this week to check the right plant.

The FDA has notified Doctors to stop using Baxter’s heparin because of 350 reports of adverse reactions (including deaths) this year.

For more information see the Associated Press story at:

http://www.chron.com/disp/story.mpl/world/5550954.html

Initial reports are that five people were hurt by the blast and fire. One person was injured by flying debris that landed on her car. One worker was hospitalized with burns.

For details, see the article at Fox News:
http://www.foxnews.com/story/0,2933,331039,00.html

The following press release is from the UK Rail Accident Investigation Branch:

The RAIB is carrying out an investigation into a fatal level crossing accident at West Lodge level crossing, near Haltwhistle, Northumberland, on 22 January 2008.

The accident occurred at 17:13 hrs, when English, Welsh and Scottish Railways freight train 6E62, from Carlisle to Middlesbrough, struck and killed a young man delivering coal to a house adjacent to the West Lodge user worked level crossing on Network Rail’s Carlisle to Newcastle line.

The RAIB’s preliminary examination indicates no issues with the condition or operation of the train or the signalling system that could have contributed to the accident.

The RAIB’s investigation into the accident is proceeding independently of any parallel investigations by the safety authority.

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.

It was a bad day at the rail yard in DC.

An Amtrak MARC Train from Baltimore was still unloading passengers when an Amtrak rail yard locomotive decided to hook up to move the train for maintenance. Amtrak spokeswoman Katrina Romero said that the yard locomotive “…came in to fast.” One car of the train was derailed and 7 people were injured with bumps, bruises, and minor head/neck injuries.

What were the Safeguards that should have kept this from happening?

What Safeguards could be added to make this operation safer for passengers?

Leave comments to let me know what you think.

The following press release is from the U.S. Chemical Safety Board, Washington DC.

Statement of CSB Investigations Manager Stephen Selk, P.E., Updating the Public on the Investigation of the Imperial Sugar Company Explosion and Fire, Savannah, Georgia –  February 17, 2008, 1 p.m.

Good afternoon and welcome to this first U.S. Chemical Safety Board briefing on the Imperial Sugar Company explosion and fire.

I will begin this afternoon by explaining the Chemical Safety Board’s role.  Following that I will present a primer on dust explosions.  And then I will show you a pair of large photographs and describe some of the devastation to the Imperial sugar refinery.  Finally, I will try and answer any questions you may have.

(more…)

For more info, see:

http://www.chron.com/disp/story.mpl/metropolitan/5547297.html

A seal failure led to a small oil spill in the Terra Nova oil field. The immediate cause reported in the article was a seal failure. This seems like a good opportunity to apply Equifactor® to help analyze the root causes of the seal failure.

The approach discussed in the article (link below) seems similar to Change Analysis. What are the differences in lots of the drug that lead to adverse patient reactions?

To read about this problem see:

http://www.nj.com/business/index.ssf/2008/02/heparin_probe_finds_us_tie_to.html

And the root cause is???

A Houston Metro statement about an accident at a crossing stated that the accident was “…preventable…”.

Aren’t all accidents “preventable”?

Maybe what the statement implied was that the train driver was at fault?

For the story see:

http://www.chron.com/disp/story.mpl/headline/metro/5535446.html

For more information, see:

http://www.china.org.cn/english/international/242504.htm

Two long time employees apparently died of carbon monoxide poisoning after a fire in an air handling unit at a corn processing plant in Decatur, IL.

For more information, see:

http://money.cnn.com/news/newsfeeds/articles/newstex/AFX-0013-22958799.htm

A deadly mine accident in Kazakstan - the “commission” investigating the accident issues a preliminary report in 18 days. They found a “likely cause” and issued 18 recommendations to improve safety.

The BP Texas City Refinery explodes killing 15. The CSB issues a final report after 3 years. (They did issue preliminary reports and make several improvement suggestions prior to the final report.)

A bridge over the Mississippi River collapses in Minnesota. Six months later the NTSB says that they don’t know the root cause.

How long should an accident investigation take?

Are we being served by reports that come out years after fatal accidents?

Are politicians and company officials waiting for these slow reports before taking action? Or id a report years later too little too late?

What should we be doing “in the mean time” if investigations take years to complete.

Let me know your thoughts by clicking on the word “Comments” below.

For a brief statement by the company, see:

http://www.foxbusiness.com/article/propex-comments-accident-ringgold-plant_474281_1.html

New York Times:

http://www.nytimes.com/2008/02/09/us/09sugar.html?_r=2&oref=slogin&oref=slogin

Savannah Now:

http://savannahnow.com/node/445094

Link to the story:

http://www.cnn.com/2008/US/02/11/refinery.blast/index.html

Link to video:

http://www.cnn.com/2008/US/02/11/refinery.blast/index.html#cnnSTCVideo

One of our TapRooT® Course attendees recommend this article:

The Lessons of Value Jet 592

As a reconstruction of this terrible crash suggests, in complex systems some accidents may be “normal” — and trying to prevent them all could even make operations more dangerous
By William Langewiesche
Published in The Atlantic

I found it interesting and I thought others might be interested in it as well.

A press release from the Chemical Safety Board:

A six-member investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the site of last night’s explosion at the Imperial Sugar refinery in Port Wentworth, Georgia, near Savannah.

Preliminary media reports, citing the company chief executive, attributed the blast to an explosion of sugar dust.  Dozens were reported to be critically injured, and others were reported missing.

The investigative team is led by John B. Vorderbrueggen, P.E., and includes CSB Board Member William Wark, who will serve as the principal spokesperson, and CSB investigations manager Stephen Selk, P.E.  The team is expected to arrive in South Carolina midday on Friday.

The CSB completed a study of combustible dust explosions in November 2006, which identified 281 combustible dust incidents between 1980 and 2005 that killed 119 workers and injured 718, and extensively damaged industrial facilities.  A total of 24% of the explosions occurred in the food industry, including several at sugar plants.

The CSB report on Combustible Dust Hazards is available from CSB.gov under Completed Investigations.

For more information, please contact a member of the CSB public affairs office:  (1) Daniel Horowitz, (202) 261-7613 / 441-6074 cell (2) Sandy Gilmour (202) 261-7614 / (202) 251-5496 cell (3) Jennifer Jones (202) 261-3603 / (202) 577-8448 cell (4) Hillary Cohen (202) 261-3601 / (202) 446-8094 cell.

For a good story with details, see:

http://www.eurasianet.org/departments/insight/articles/eav020708a.shtml

A line of storms and a tornado may have set off a huge fire at a natural gas pumping plant in Tennessee.

(Not a sunrise, that’s the glow from the fire!)

Would this qualify as a “Sabotage/Natural Disaster” category on the Root Cause Tree®? check your Root Cause Tree® Dictionary before you answer!

For the story about the fire, see:

http://www.chron.com/disp/story.mpl/nation/5517482.html
http://www.wtopnews.com/?nid=104&sid=1339964

http://tennessean.com/apps/pbcs.dll/article?AID=/20080206/NEWS01/80206104

Six months of NTSB investigation and the politics of failure are starting to heat up.

A recent article claimed that a “design flaw” was the root cause of the I-3