Lugs not Torqued Leads to Crash (KV 145)

 

What Happened?

Two rear wheels flew off a Palm Tran bus causing the driver to lose control as it traveled northbound on Interstate 95 near Woolbright Road in Boynton Beach, according to Palm Tran Public Transportation. The ensuing crash involved a total of 5 vehicles.

Further investigation revealed that a maintenance contractor had recently replaced four rear tires on the bus. Two of the rear wheels were not torqued and subsequently fell off during operation.

Contributing Factors

There were no known contributing factors.

What Can We Learn?

Tools

A Second Check from a co-worker or supervisor on the completed work could have caught the error before releasing the bus into service.

Self Checking could have prompted the technician to focus properly on the task at hand and remember to torque the wheels correctly.

Traps

Time Pressure to get the bus back in service.

Overconfidence on the part of the technician performing a repetitive task.

Ask the Right Questions

How does this relate to our work?

Where do we have similar traps?

What Tools can we use to avoid a similar incident?

Was a stop work point missed?