Tag Archives: derailment

Root Cause Analysis - Incident Investigation

Train Derails on Track Just Inspected

By ThinkReliability Staff

A train derailment in the Columbia River Gorge near Mosier, Oregon resulted in a fire that burned for 14 hours. The Federal Railroad Administration (FRA) preliminary investigation says the June 3rd derailment was caused by a broken lag bolt which allowed the track to spread, resulting in the 16-car derailment. Although there is only one other known instance of a broken lag bolt causing a train derailment, the FRA determined that the bolt had been damaged for some time, and had been inspected within days of the incident, raising questions about the effectiveness of these inspections.

Determining all the causes of a complex issue such as a train derailment can be difficult, but doing so will provide the widest selection of possible solutions. A Cause Map, or visual root cause analysis, addresses all aspects of the issue by developing cause-and-effect relationships for all the causes based on the impacts to an organization’s goals. We can create a Cause Map based on the preliminary investigation. Additional causes and evidence can be added to the map as more detail is known.

The first step in the Cause Mapping process is to determine the impacts to the organization’s goals. While there were no injuries in this case, the massive fire resulting from the derailment posed a significant risk to responders and nearby citizens, an impact to the safety goal. The release of 42,000 gallons of oil (although much of it was burned off in the fire) is an impact to the environmental goal. The customer service goal is impacted by the evacuation of at least 50 homes and the regulatory goal is impacted by the potential for penalties, although the National Transportation Safety Board (NTSB) has said it will not investigate the incident. The state of Oregon has requested a halt on oil traffic, which would be an impact to the schedule goal. The property goal is impacted by the damage to the train cars, and the labor/ time goal is impacted by the response and investigation.

The analysis, which is the second step in the Cause Mapping process, begins with one of the impacted goals and develops cause-and-effect relationships by asking ‘Why’ questions. In this case, the safety goal is impacted by the high potential for injuries. This is caused by the massive fire, which burned for 14 hours. There may be more than one cause resulting in an effect, such as a fire, which is caused by heat, fuel, and oxygen. The oxygen in this case is from the atmosphere. The heat source is unknown but could have been a spark caused by the train derailment. The fire was fueled by the 42,000 gallons of crude released due to damage to train cars, which were transporting crude from the Bakken oil fields, caused by the derailment.

The derailment of 16 cars of the train was caused by the broken lag bolt. Any mechanical failure, such as a break, results from the stress on that object exceeding the strength of the object. In this case, the stress was caused by the weight of the 94-car train. The length of a train carrying crude oil is not limited by federal regulations. The strength of the bolts was reduced due to previous damage, which was not identified prior to the failure. While the track strength is evaluated every 18 months by the Gauge Restraint Measurement System (GRMS), it did not identify the damage. It’s unclear the last time it was performed.

Additionally, although the track is visually inspected twice a week by the railroad, it is done by vehicle, which would have made the damage harder to spot. The FRA does not require walking inspections. Nor does the FRA inspect or review the railroad’s inspections very often – there are less than 100 inspectors for the 140,000 miles of track across the country. There are only 3 in Oregon.

As a result of the derailment, the railroad has committed to replacing the existing bolts with heavy-duty ones, performing GRMS four times a year, enhanced hyrail inspections and visual track inspections three times a week, and performing walking inspections on lag curves monthly.

The FRA is still evaluating actions against the railroad and is again calling for the installation of advanced electronic brakes, or positive train control (PTC). It has also recommended PTC after other incidents, such as the deaths of two railroad workers on April 3 (see our previous blog) and the derailment in Philadelphia last year that killed 8 (see our previous blog).

To view a one-page PDF of the Cause Mapping investigation, click on “Download PDF” above. Or, click here to read the FRA’s preliminary investigation.

Uncategorized

Track Workers Killed by Train

By ThinkReliability Staff

A derailment and the fatalities of two railroad workers on April 3, 2016 has led to an investigation by the National Transportation Safety Board (NTSB). In this investigation, the NTSB will address the impacts of the accident, determine what caused the accident and will provide recommendations to prevent similar accidents from recurring. While the investigation is still underway, a wealth of information related to the accident is already available to begin the analysis. We will look at what is currently known regarding the accident in a Cause Map, a visual form of root cause analysis.

The first step of the analysis is to define the problem. This includes the what, when, and where of the incident, as well as the impacts to the organizational goals. Capturing the impacts to the goals is particularly important because the recommendations that will result from the analysis aim to reduce these impacts. If we define the problem as simply a “derailment”, recommendations may be limited to those that prevent future derailments. Not only are we looking for recommendations to prevent future derailments, we are looking for recommendations to prevent all the impacted goals. In this case, that includes worker safety: 2 workers died, public safety: 37 passengers were injured, customer service: the train derailed, property: the train and some construction equipment was damaged, and labor: response and investigation are required.

The analysis is performed by beginning with the impacted goals and developing the cause-and-effect relationships that led to those impacts. Asking “why” questions can help to identify some of the cause-and-effect relationships, but there may be more than one cause that results in an effect. In this case, the worker fatalities occurred because the train struck heavy equipment and the workers were in/on/near the equipment. Both of these causes had to occur for the effect to result. The workers were on the equipment performing routine maintenance. In addition, their watch was ineffective. When capturing causes, it’s important to also include evidence, which validates the cause.

We know the watch was ineffective, because federal regulation requires a watch for incoming trains that gives at least a fifteen second warning. Fifteen seconds should have been sufficient time for the workers to exit the equipment. Because this did not happen, it follows that the watch was ineffective.

The train struck the heavy equipment because the equipment was on track 3, the train was on track 3, and the train was unable to brake in time. It’s unclear why the heavy equipment was on the track; rail safety experts say heavy equipment should never be directly on the track. The train was on track 3 because it was allowed on the track. Work crews are permitted to shut off the current to preclude passage of trains into the work zone, but they did not in this case, for reasons that are still being investigated. Additionally, the dispatcher allowed the train onto the track. Per federal regulations, when workers are on the track, train dispatchers may not allow trains on track until roadway worker gives permission. It appears that in this case the workers either failed to secure permission to work on the track (thus notifying the dispatcher of their presence) or the work notification was improperly cancelled, allowing trains to return to the track, possibly due to a miscommunication between the night and day crews. This is also still under investigation.

While inspection of the cars and maintenance records found no anomalies, the braking system is under investigation to determine whether or not it affected the train’s ability to brake. Also under investigation is the Positive Train Control (PTC), which should have emitted warnings and slowed the train automatically. However, the supplemental shunting device, which alerts the signaling system that the track is occupied, and is required by Amtrak rules, was not in place. Whether this was sufficient to prevent the PTC from stopping the train in time is also under investigation. The conductor placed the train in emergency mode 5 seconds before the collision. As the train was traveling at 106 mph (the speed limit was 110 mph in the area), this did not give adequate time to brake. There should have been a flagman to notify the train that a crew was on the track, but was not. The flagman also carries an air horn, which provides another notification to the track crew that a train is coming.

Says Ashley Halsey III, reporting in The Washington Post, “Basic rules of railroading and federal regulations should have prevented the Amtrak derailment near Philadelphia on Sunday that killed two maintenance workers.” It appears that multiple procedural requirements were not followed, but more thorough investigation is required to determine why and what can be done in the future to improve safety by preventing derailments and worker fatalities.

To view the available information in a Cause Map, please click “Download PDF” above.

Root Cause Analysis - Incident Investigation

Deadly Train Derailment Near Philadelphia

By Kim Smiley

On the evening of May 12, 2015, an Amtrak train derailed near Philadelphia, killing 8 and injuring more than 200.  The investigation is still ongoing with significant information about the accident still unknown, but changes are already being implemented to help reduce the risk of future rail accidents and improve investigations.

Data collected from the train’s onboard event recorder shows that the train sped up in the moments before the accident until it was traveling 106 mph in a 50 mph zone where the train track curved.  The excessive speed clearly played a role in the accident, but there has been little information released about why the train was traveling so fast going into a curve.  The engineer controlling the train suffered a head injury during the accident and has stated that he has no recollection of the accident. The engineer was familiar with the route and appears to have had all required training and qualifications.

As a result of this accident and the difficulty determining exactly what happened, Amtrak has announced that cameras will be installed inside locomotives to record the actions of engineers.  While the cameras may not directly reduce the risk of future accidents, the recorded data will help future investigations be more accurate and timely.

The excessive speed at the time of the accident is also fueling the ongoing debate about how trains should be controlled and the implementation of positive train control (PTC) systems that can automatically reduce speed.  There was no PTC system in place at the curve in the northbound direction where the derailment occurred and experts have speculated that one would have prevented the accident. In 2008, Congress mandated nationwide installation and operation of positive train control systems by 2015.  Prior to the recent accident, the Association of America Railroads stated that more than 80 percent of the track covered by the mandate will not have functional PTC systems by the deadline. The installation of PTC systems requires a large commitment of funds and resources as well as communication bandwidth that has been difficult to secure in some area and some think the end of year deadline is unrealistic. Congress is currently considering two different bills that would address some of the issues.  The recent deadly crash is sure to be front and center in their debates.

In response to the recent accident, the Federal Railroad Administration ordered Amtrak to submit plans for PTC systems at all curves where the speed limit is 20 mph less than the track leading to the curve for the main Northeast Corridor (running between Washington, D.C. and Boston).  Only time will tell how quickly positive train control systems will be implemented on the Northeast Corridor as well as the rest of the nation, and the debate on the best course of action will not be a simple one.

An initial Cause Map, a visual root cause analysis, can be created to capture the information that is known at this time.  Additional information can easily be incorporated into the Cause Map as it becomes available.  To view a high level initial Cause Map of this accident, click on “Download PDF”.

Root Cause Analysis - Incident Investigation

Train Derails in West Virginia

By Kim Smiley

On February 16, 2015, a train hauling 109 tank cars of crude oil derailed in Mount Carbon, West Virginia.  It has been reported that 27 tank cars in the train derailed.  Some of the tank cars were damaged and released an unknown amount of crude oil, resulting in a large fire.  Hundreds of families in the surrounding area were evacuated, but only one injury was reported.

The accident investigation is still ongoing, but what information is known can be used to build an initial Cause Map, a visual format for performing a root cause analysis.  The Cause Map can be easily expanded as needed to document additional information as it becomes available.

The first step in the Cause Mapping process is to fill in an Outline with the basic background information for the issue as well as how the overall goals were impacted. In this example, there were many impacted goals.  The safety goal is impacted because there was an injury, the property goal is impacted because of the damage to the train, the environmental goal is impacted because of the release of oil, etc.  Once the Outline is complete, the Cause Map itself is built by starting with an impact to a goal, asking “why” questions, and laying out all the causes that contributed to an issue.

The significant aftermath of this derailment is known, but little has been released about what specifically caused the train to derail.  It was snowing heavily at the time of the accident, which may have played a role, but since more evidence is needed, a “?” is included on the Cause Map.  Data from the digital data recorder has shown that the train was not speeding at the time of the accident, which has been a factor in previous derailments.  Another fact worth noting is that the damaged train cars were a newer design that incorporated modern safety upgrades.

With so many unknowns, the Federal Railroad Administration is conducting a full-scale investigation to determine exactly what happened.  The damaged tank cars, track, and other components along with relevant maintenance and inspection records will be all be analyzed to better understand this derailment.

Unfortunately, crude oil train accidents are predicted to become increasingly common as the volume of flammable liquids being transported by rail continues to rise.  According to the Association of American Railroad, 40 times more oil was transported by rail in 2012 than in 2008. Hopefully, the lessons learned from this derailment can be used to help reduce the risk of future rail accidents.

To view the Outline and initial Cause Map for this accident, click on “Download PDF” above.

Root Cause Analysis - Incident Investigation

Chicago O’Hare Commuter Train Derailment Injures 33

By Sarah Wrenn

At 2:49 AM on March 24, 2014, a Blue Line Commuter train entered the Chicago-O’Hare International Airport Station, collided with the track bumper post, and proceeded to derail landing on an escalator and stairway.  Thirty-two passengers and the train operator were injured and transported to nearby hospitals.  Images showing the lead rail car perched on the escalator look like the train was involved in filming an action movie.

So what caused a Chicago Transit Authority (CTA) train, part of the nation’s second largest public transportation system, to derail?  We can use the Cause Mapping process to analyze this specific incident with the following three steps: 1) Define the problem, 2) Conduct the analysis and 3) Identify the best solutions.

We start by defining the problem.  In the problem outline, you’ll notice we’ve asked four questions: What is the problem? When did it happen? Where did it happen? And how did it impact the goals?

Next we’ll analyze the incident.  We start with the impacted goals and begin asking “why” questions while documenting the answers to visually lay out all the causes that contributed to the incident.  The cause and effect relationships lay out from left to right.  As can be seen in the problem outline, this incident resulted in multiple goals being impacted.

In this incident, 33 people were injured when the train they were riding derailed in the O’Hare station thereby affecting our safety goal of zero injuries.  The injuries were caused by the train derailing, so let’s dig in to why the train derailed.  Let’s first ask why the train operator was unable to stop the train.  Operator statements are crucial to understanding exactly what happened.  Here, it is important to avoid blame by asking questions about the process followed by the operator.  Interestingly, 45 seconds before the crash, the operator manually reduced the train speed.  However, at some point, the train operator dozed off.  The train operator’s schedule (working nearly 60 hours the previous week), length of shift, and time off are all possible causes of the lack of rest.  Evidence that the operator was coming off of an 18 hour break allows us to eliminate insufficient time off between shifts as a cause.  In addition, the train operator was relatively new (qualified train operator in January 2014), but also she was an “extra-board” employee meaning she substituted for other train operators who were out sick or on vacation.

Next, let’s ask why the train was unable to stop.  An automatic breaking system is installed at this station and the system activated when the train crossed the fixed trip stop.  The train was unable to stop, because there was an insufficient stopping distance for the train’s speed.  At the location of the trip stop, the train speed limit was 25 mph and the train was traveling 26 mph.  While the emergency braking system functioned correctly, the limited distance and the speed of the train did not allow the train to stop.

The train derailing impacted multiple organizational goals, but also the personal goal of the train operator who was fired.  During the investigation, we learn that the train operator failed to appear at a disciplinary hearing and had a previous safety violation in which she dozed off and overshot a station.  These details reveal themselves on the cause map by asking why questions.

The final step of the investigation is to use the cause map to identify and select the best solutions that will reduce the risk of the incident recurring.  On April 4, 2014, the CTA announced proposed changes to the train operator scheduling policy.  In addition, the CTA changed the speed limit when entering a station and moved the trip stops to increase the stopping distance.   Each of these identified solutions reduce the risk of a future incident by addressing many of the causes identified during the investigation.

Root Cause Analysis - Incident Investigation

Train Derailment Kills 79 in Spain

By Kim Smiley

On July 24, 2013, a train carrying 247 people violently derailed near Santiago de Compostela Spain.  Over 130 were injured and 79 were killed as a result of the accident.  Many details are still unknown, but investigators have determined that the train was traveling about twice the posted speed over a curved section of track.

The derailment was the worst train accident Spain has suffered in 40 years.  Obviously, an investigation is underway and authorities are eager to identify what caused the accident and are working to prevent anything similar from occurring in the future. One of the ways this accident can be analyzed is by building a Cause Map, a visual format for performing a root cause analysis.  A Cause Map visually lays out the different causes that contributed to an accident in an intuitive format that shows the cause-and-effect relationships.

The Cause Mapping process begins by filling in the basic background information for an issue as well as identifying how the incident impacted the goals.  In this example, the safety goal is clearly impacted because there were fatalities and injuries.  The schedule, labor, and material goals were also impacted because of the time and resources needed to investigate and clean up the accident and the damage to the train.  The negative publicity surrounding the accident can also be considered an impact to the customer service goal because people may be hesitant to ride trains if they have concerns about safety.

So why did the train derail?  The train was going too fast to safely navigate a curved section of track.  The train was going fast because it had previously been running on track designed for high speed trains where high speeds were permitted and it didn’t slow down as it entered a section of track where the posted speed was lower.  Operator action was required to slow down the train and it appears that the operator failed to take action.   Investigators are looking to whether there was a mechanical problem of some kind that prevented the train from reducing speed, but early indication is that the operator simply failed to brake and reduce the speed of the train.

A number of factors seem to have contributed to this deadly error by an experienced train operator who was familiar with this portion of track.  European Rail Traffic Management System (ERTMS) automatically controls braking and is installed on most of the track high speed trains operate on in the region, but not on the track where the accident occurred.  The accident occurred at the first potentially dangerous curve after the transition to  track where operator action is necessary to brake the train.  Based on statements by the driver,  he missed the transition to  the track where manual braking is required and didn’t realize that the train was in danger.  It has also come to light that the train driver was on the phone with the train’s ticket inspector immediately prior to the derailment and this distraction likely played a role in the accident.  The initial investigation findings have led to the train’s driver being provisionally charged with multiple counts of homicide by professional recklessness on 28 July 2013.

Regardless of whether the driver is convicted on the charges, the automatic systems involved should be a focus of the investigation.  The safety system sent a warning to the operator about the high speed prior to the accident, but it failed to prevent the accident.  Investigators need to review the timing of the warning and determine whether it came too late.  Other automatic systems such as the ERTMS also have the ability to stop a train that is operating at unsafe speeds, which raises the question of whether the safety systems used on this portion of track are adequate since the accident happened.  Ideally, a single error by a train driver for any reason won’t result in dozens of deaths.

To view a high level Cause Map of this incident, click on “Download PDF” above.  Click here to view a video of the accident.