Author Archives: Web Admin

Tech Support Thursday: TapRooT® System Software 4.0.x Vista Compatibility

Posted: August 23rd, 2007 in Technical Support

Hello everybody and welcome to another edition of Tech Support Thursday.

This week we tackle the hottest topic in the tech support area here at TapRooT HQ: What to do about Vista? Some version of Vista will run the 4.0.x System Software just fine, while others give an error such as “Run Time Error 52”.

How do you fix this? There’s more inside!

Senate Committee Webcast about to Begin on CSB Lessons Learned

Posted: July 10th, 2007 in Accidents, Current Events, Investigations

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

Senate Committee Webcast about to Begin on CSB Lessons Learned

Washington, DC, July 10, 2007 – U.S. Chemical Safety Board Chairman Carolyn W. Merritt will testify today as the first witness in a Senate hearing entitled, ‘Lessons Learned from Chemical Safety Board (CSB) Investigations, Including Texas City, Texas.’ The hearing is scheduled to begin at 10:00 a.m. eastern time today, in the Dirksen Senate Building, Room 406. Please visit to view the hearing webcast. The webcast link will be posted on the committee website once the hearing begins.

The hearing has been convened by the U.S. Senate Committee on Environment and Public Works, Subcommittee on Transportation Safety, Infrastructure Security, and Water Quality, chaired by Senator Frank R. Lautenberg (D-NJ). Senator David Vitter (R-LA) is the ranking member.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website,

For more information, please contact Jennifer Jones at (202) 261-3603 or Daniel Horowitz at (202) 261-7613.

Human Factors Job Posting that Requires Root Cause Skills

Posted: July 7th, 2007 in Job Postings

Root cause analysis skills needed.

see this link

CSB Root Cause Analysis Work Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued

Posted: June 27th, 2007 in Accidents, Current Events, Investigations, Pictures

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

CSB Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued

Raleigh, N.C., June 27, 2007 -  The U.S. Chemical Safety Board (CSB) today announced it is issuing  a Safety Advisory concerning the dangers of transporting and handling unspent aircraft chemical oxygen generators. The action follows a CSB investigative finding that the devices most likely contributed to the rapid spread of a fire at the EQ Industrial Services (EQ) hazardous waste facility in Apex, NC on the  night of October 5, 2006.  The fire resulted in the evacuation of thousands of residents of Apex, located about 16 miles southwest of Raleigh, and destroyed the EQ facility’s hazardous waste building. 

Comments in a WMV Format

Posted: June 27th, 2007 in Summit, Video

Here’s the same comments in a WMV format. Just click on the object below…

New CEO aims to help BP overcome deadly past

Posted: June 16th, 2007 in Accidents, Current Events, Investigations, Performance Improvement

Has BP learned from fatalities and the Alaska pipeline spill? The new CEO speaks out. For story see:

CSB Press Release – Dangers of a Major Chlorine Release During Railcar Unloading

Posted: June 14th, 2007 in Accidents, Current Events

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

CSB Issues Safety Bulletin on Dangers of a Major Chlorine Release During Railcar Unloading; Agency Calls on U.S. Department of Transportation to Expand Regulatory Coverage to Require Emergency Shutdown Systems

Washington, DC, June 14, 2007 – The U.S. Chemical Safety Board (CSB) today released a safety bulletin warning that some chlorine railcar transfer systems lack effective detection and emergency shutdown devices, leaving the public vulnerable to potential large-scale toxic releases. 

The Board formally recommended that the U.S. Department of Transportation (DOT) expand its regulatory coverage to require facilities that unload chlorine railcars to install remotely operated emergency isolation devices to quickly shut down the flow of chlorine in the event of a hose rupture or other failure in the unloading equipment. The safety bulletin cites two previous incidents of accidental chlorine releases that occurred as a result of ruptured transfer hoses.   

Chlorine railcars are equipped with an internal excess flow valve (EFV) that is designed to stop the flow of chlorine if an external valve breaks off while the railcar is in transit.  However, these EFVs are not designed to stop leaks during railcar unloading, and the failure of a transfer hose may not activate the EFV and the toxic chlorine will continue to escape.  Companies should install emergency shutdown systems that can quickly stop the flow of chlorine if a hose ruptures during the unloading operation, the bulletin said.
In August 2002 a hose ruptured at a DPC Enterprises plant near Festus, Missouri.  The emergency shutdown valves did not close as designed due to poor maintenance, and the EFV did not close.  The only way to stop the release of chlorine from the railcar was to send emergency responders through a four-foot deep yellowish-green fog of chlorine vapor to manually close shutdown valves located on top of the railcar. Incidents such as the one at DPC demonstrate why EFVs should not be relied upon to stop hazardous material releases during unloading operations.

However, in a survey of drinking water and wastewater treatment facilities conducted by the CSB, investigators found that approximately 30 percent of the bulk chlorine users contacted continue to rely solely on the EFV to stop chlorine flow in the event of a transfer hose rupture.

Tech Support Thursday: SnapCharT Rescue!

Posted: June 14th, 2007 in TapRooT, Technical Support

Hello everybody and welcome to another edition of Tech Support Thursday. It’s been awhile since we last spoke, but I assure it is not because I’ve had nothing to do. On the contrary, we’re plenty busy over here at TapRooT HQ.

Today we’re going to be talking about rescuing SnapCharTs that have crashed. If the chart your working on has crashed, DON’T DO ANYTHING until you read these directions!



Posted: June 12th, 2007 in Current Events

For more information, see the story in the Houston Chronicle:

OSHA steps up refinery oversight

Job Opening – RAM Studies and Maintenance Root Cause Analysis Using TapRooT®

Posted: June 7th, 2007 in Job Postings

We have a refining client in the LA area that is looking for an employee or a local consultant that is TapRooT® Trained and can perform RAM Studies. If you have already attended TapRooT® Training and you are interested in this position, drop me a note at

Deadly Train Wreck in Australia

Posted: June 5th, 2007 in Accidents, Current Events, Investigations

AP reports that at least 10 people were killed when a truck collided with a train. For more info see the AP article on CNN’s web site:

More details can be found in a story in The West, an Australian paper:

Memorial Day – Let’s Remember Those Who Sacrificed so that We Can Enjoy Freedom

Posted: May 28th, 2007 in Current Events, Pictures

 2004 Memorial Day
Sometimes it seems that our freedom is so easily obtained by most in the US today, that we forget the price that others have paid and are paying. This isn’t to suggest that the price should be higher for all. Rather, that all should stop and remember the price that others have paid to provide the freedom that we enjoy.

 2007 Common Pix Flags-In-Memorial-Day

The other aspect of Memorial Day that we need to remember is the thanks that we owe to those who currently serve to protect our freedom. Even if they don’t have to fight for our freedom, they sacrifice with long deployments away from those they love.

 Memorialday05 Arlington Laying Wreath

So thanks to all who serve from all of us at System Improvements.

US Government May Stop Paying Hospitals Extra for Common Medical Errors

Posted: May 24th, 2007 in Accidents, Medical/Healthcare, Performance Improvement, Quality

It’s an interesting concept … The hospital makes an error – like a caretaker contaminating a needle and causing a bloodstream infection – and the government then pays the hospital more to cure the disease they created.

This process seems to reward the hospital with additional payments for making errors. It certainly doesn’t reward a hospital that spends more to stop medical errors.

An article in the May 22 edition of the Indy Star indicates that Medicare is rethinking this payment policy and may stop paying for the following conditions acquired after admissions:

1. Catheter-associated urinary tract infections.
2. Bed sores.
3. Objects left in after surgery.
4. Air embolism, or bubbles, in bloodstream from injection.
5. Patients given incompatible blood type.
6. Bloodstream staph infection.
7. Ventilator-associated pneumonia.
8. Vascular-catheter-associated infection.
9. Clostridium difficile-associated disease (gastrointestinal infections).
10. Drug-resistant staph infection.
11. Surgical site infections.
12. Wrong surgery.
13. Falls.

With Medicare being such a large payer of claims, this would certainly give hospitals a much bigger reason to improve – their profitability!

And as a taxpayer I can’t see why they have waited this long.

For the complete article, see:

Interesting Personal Observation on Fatigue in the OR

Posted: May 23rd, 2007 in Human Performance, Medical/Healthcare

I know I’ve posted many entries on fatigue and medical errors, but I got an e-mail from a reader and they pointed me to a web blog with an interesting personal story about fatigue in the OR.

To read it (it is long) go to:

Monday Accident & Lessons Learned: Can BP Learn from Texas City and Alaska Pipeline Failures

Posted: May 21st, 2007 in Accidents, Current Events, Investigations, Performance Improvement

In the “Continue reading …” section below is a Press Release from the CSB that says there are “striking similarities” between the root causes discovered by the CSB’s investigation of the BP’s Texas City Refinery Explosion and the causes of the pipeline leak at BP’s Prudhoe Bay oil field as outlined in a study by Booz Allen Hamilton.

With the considerable turnover among BP’s senior management ranks, it leaves one to wonder, can BP learn from these accidents, or will the senior management turnover just lead to a new culture without any real learning from the accidents?

Some may say that the disciplinary documents released recently point to a culture of blame – not a learning culture. If after a year and a half after the tragedy at Texas City, BP executives are still looking higher and higher in the corporation for people to blame, perhaps they haven’t learned that they need to put strict systems in place rather than relying on managements’ changing priorities to manage safety at highly hazardous workplaces.

You may consider this to be a harsh evaluation, but getting beyond blame and putting effective systems in place – systems that are supported by management – is the only way to stop the kind of unwise cost cutting that lead to unsafe conditions at the BP Texas City Refinery and the BP Prudhoe Bay Oil Pipeline.

Working Hard in Las Vegas

Posted: May 16th, 2007 in Courses, TapRooT


Here’s pictures of people working hard at 4 PM in a Public TapRooT® Advanced Root Cause Analysis Team Leader Course in  Las Vegas.


I’m always amazed at how involved people get in our courses and how hard people work learning to improve performance so that they can save lives, improve quality, prevent injuries, save jobs, and generally make the workplace  a better place.


So even though we are in a location that some might see as a distraction to learning, people in TapRooT® Courses are hard at work.


If you are interested in learning advanced root cause analysis skills to improve performance at your facility, see our upcoming course list, pick a great location, and get registered!


What are some of my favorite locations that are coming up this Summer?


Aberdeen, Scotland

Niagara Falls, Canada

Dallas, Texas

Lake Tahoe, Nevada


3-Day Equifactor®

Aberdeen, Scotland

Dallas, Texas

Lake Tahoe, Nevada



Charleston, South Carolina (Kiawah Island)

Gatlinburg, Tennessee

Leamington Spa, England

Calgary, Canada (during the Stampede)

Seattle, Washington

A Few More Photos of the Buncefield Fire

Posted: May 16th, 2007 in Accidents, Pictures

Recently received these photos … once again was amazed …

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P3B2F4115 7
P3B2F4115 2
P3B2F4115 4
P3B2F4115 6
P3B2F4115 5
P3B2F4115 1


Monday Accident & Lessons Learned – Blackberry Outage Shows Need for IT Root Cause Analysis

Posted: May 14th, 2007 in Accidents, Current Events, Investigations, TapRooT

Several of weeks ago, the network that carries BlackBerry messages went down. Why? That’s a question for a good root cause analysis.

For details see these articles …

What is the lesson learned? That IT folks need thorough, systematic root cause analysis as much as safety, equipment, environmental, or hospital quality improvement people do.

One common root cause analysis problem is that investigators stop with the symptoms of the failure and call these symptoms the cause. The don’t dig deep enough to find the true system root causes. They don’t know the questions to ask to get beyond the symptoms.

That’s one of the benefits of TapRooT® – it helps investigators get beyond symptoms to the fixable root causes and generic causes of accident, incidents, qiality problems, equipment failures, and even IT problems.

For more information about TapRooT® see:

And for a success story about improving network reliability at BellSouth, see:

Don’t Be Left Out – TapRooT® Root Cause Analysis Courses Sometimes Fill Up Fast – Register NOW!

Posted: May 9th, 2007 in Courses, TapRooT

Next week I’m teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Las Vegas. The course is full.

Today, four instructors are teaching two 2-Day Incident Investigation and Root Cause Analysis Courses in Calgary. Both are full.

The 5-Day Course in Houston this week? Full.

Last week we had a 2-Day Course in Portland. Full.

The two courses we had in San Antonio prior to the Summit? Full.

On June 20-21, we have a 2-Day Course in Edmonton. It has 19 people signed up already and it will be full. We don’t have room to schedule an additional class (or instructors), so if you wait until the last minute to register, you will probably be out of luck (and have to wait for the next course in November or travel somewhere else to get the training).


Why are TapRooT® Courses is so popular? I think it is because TapRooT® is so effective finding the root causes of problems and developing effective corrective actions. That’s why our public courses – which have been significantly increased this year (the number of courses was doubled this year in Canada and Australia and increased 20% in the US and Europe) – are often nearly full or are full and have a waiting lists.

Don’t be left out and miss your chance to learn great performance improvement technology. Think of the performance improvement opportunities you will miss while you are waiting for training. If you have a particular course that you are planning to attend … sign up NOW!

For course dates and details see:


Monday Accident & Lessons Learned: Do Heads Need to Roll to Make People Happy?

Posted: May 7th, 2007 in Accidents, Current Events, Investigations, Root Causes

After a major flooding incident at a mine in Canada, Cameco published a report on their root cause analysis of the accident. The Regina Leader-Post published an article about the report and the reaction of some financial analysts that I thought was quite interesting.

First, the article said:

“The root-cause report into that flood concluded neither Cameco nor its contractor had identified risk scenarios, nor did they have necessary controls in place to prevent the flooding of the shaft.”

Later in the article it provided some quotes from analysts. One analyst was quoted as follows:

“William Vogel, an analyst with Harbor View Growth Equity Management in Connecticut, said Cameco appeared to have a ‘lax’ corporate culture. He said he would have expected the company would ‘have fired a lot of people,’ considering that lives were at stake in the mine. ‘I don’t think you have a standards problem. I think you have a people problem,’ Vogel said.”

What can you learn from this article?

Some people just aren’t happy until heads roll (discipline is taken by firing people).

This brings up the whole issue of the basis of performance improvement.

Do we BLAME incidents on people and fire them to improve performance OR do we find the system problems and fix them to ensure improved performance?

It seems that the analyst is in the blame camp. Without performing an investigation, he knew the answer … fire a lot of people!

Where does your corporate performance improvement philosophy fall? Is it oriented toward blame or system improvements? And what approach will yield the best long term results? This could be a major lesson learned!

People Learning and Sharing Best Practices at the TapRooT® Summit

Posted: May 5th, 2007 in Pictures, Summit


Click on the continue link below for more pictures…

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We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…


If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

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