German ICE 884 Train crash
Writing about web page http://www.youtube.com/watch?v=6xFI_MjtrbY
I was so touched by the video that was played by Jane in class today on the crash of Germany's ICE 884 train on June 3, 1998 so I decided to watch it again. I believe it was an eye opener to many Engineers and nations across the world. The version of the video I watched showed that some faults were earlier identified on the faulty wheel that led to the crash but they were neglected by the maintenance department which is so bad.
I particularly liked the way the investigators picked each evident one after the other and analysed it until all the causes were identified. I see a root cause analysis being used here. For example, after they saw the first metal that pierced through the floor of train from the wheel that was broken as a result of fatigue caused by load and wear and tear, they kept analysing further to find other causes. the from the gaurd rail that pierced through the
As I was watching I kept thinking and saying "okay that was cause so sad..." but before I knew it, they would find another evident, they did not conclude hastily but kept digging on to come out with a rich analysis and true causes which were a combination of so many factors. This is good case of FRACAS. Failure Reporting and Corrective action system. Where the failure of the wheel was reported after the investigation and corrective measures taken in the production of next batches and I also I am not wrong if I add that some level of fault tree analysis was used here.
This incident also makes it clear the imporatance of DFX, if the wheels were tested to understand what its limits are in terms of life cycle, how much load it can take over a period of time and also considering the speed limit (125miles per hour) of the train i believe a better design would have been made.
I would like to link this to the aerospace sector in Nigeria, We are seriously hoping for a turn around in the maintenance culture. We have recorded lots of plane crashes in the past 10years and near misses. just last december while in Dubai we got a phone call that a plane lost a tire while landing but fortunately no serious casualty was recorded. I want to add that it is not enough to design for reliability. "Maintainability" should always be a factor to support "Reliability" because even we human beings we sometimes need the expertise of our GPs (Doctors) to fix a part of us that needs to be fixed. (smiles).
May the lost souls continue to rest in peace.