Author Archives: Ken Reed

Can Regulators Use TapRooT® Investigation Tools?

Posted: August 15th, 2017 in Investigations, Performance Improvement

Regulator Inspection Investigation

I had a question recently from one of our friends who works as a regulator in his country. He was wondering about the advantages of using TapRooT® as a regulator as opposed to an industry user. I think this is a great question.  We often think about doing incident investigations for ourselves, but how do you help those you oversee as a regulating body?

As a government agency, you have great potential to affect the safety and health of both your employees and those you oversee.

  • Just attending the TapRooT® training will give your staff the basic understanding of true, human-performance based root causes.  It gives your team a new perspective on why people make poor decisions, and just as importantly, why people make good decisions.  This understanding will guide your thinking as to why problems occur.   Once this perspective is clear, your team will no longer be tempted to just blame the individual for problems.  They will think more deeply about the organizational issues that are causing people to make bad decisions.
  • The training will give you the tools to perform accurate, consistent investigations.  You can have confidence in knowing that your team has discovered not one or 2 issues, but all the problems that led to an incident.
  • Your investigations and investigation report reviews using TapRooT® will be based on human performance expertise, helping to eliminate your team’s biases.  EVERYONE has biases, and using TapRooT® helps keep you focused on the true reasons people make mistakes.
  • You will also have the tools to be able to more accurately assess the adequacy of the investigations and corrective actions that are submitted to you by those you oversee.  You can see where they are doing good investigations, and where they probably need to improve.  The corrective actions that are suggested by those you oversee are often poorly written and do not address the real reasons for the incident.  The TapRooT® training will ensure you are seeing effective corrective actions.
  • If your agency conducts trending of the their results, you’ll be able to produce consistent, trendable data from your investigations.  If you ensure your industry constituents are also using TapRooT®, the data you receive from them will also allow for more accurate trending results.
  • Finally, you can use the TapRooT® tools learned during the course to perform proactive audits of your industry partners.  When you perform onsite inspections, you can ensure you are looking for the right problems, and assigning effective corrective actions for the problems encountered.  Instead of just looking for the same problems, the tools allow you to look deeper at the processes you are inspecting to find and correct potential issues before they become incidents.

TapRooT® gives you confidence that the results of your investigations, and those of those you oversee, result in fixable root causes and effective corrective actions.

Root Cause Analysis Tip: 3 Tips for Drawing a Better SnapCharT®

Posted: March 15th, 2017 in Root Cause Analysis Tips

 

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Visualize each step of an incident with a SnapCharT®.

It’s nearly impossible to conduct a useful root cause analysis unless you actually have some data to analyze. Many systems seem to think that you can dive right into an analysis before you have a full understanding of what actually happened. During the development of the TapRooT® System, one of the first items of business was to develop an easy way to visualize the problem and document the gathered facts. Thus, SnapCharT® was born.

SnapCharT®s are pretty easy to build. With just three shapes to worry about, and a few simple rules, the SnapCharT® gets you moving in the right direction right from the get-go.

Here are a few tips to help make the SnapCharT® even easier and more useful.

1. Avoid the word “and” in your Events. Events are meant to show a single action that occurred in the course of the incident investigation. Some people have an aversion to having a bunch of Events, and therefore put several actions in each one.  For example, if I wanted to document that the driver stopped at the stop sign, looked both ways, and then pulled out into the intersection, I would not want to write this as a single Event.  This should be 3 separate (short) Events, one after the other.

The reason this is important is because we want to see if any mistakes are made during each step in the sequence of events.  If we put several actions into a single Event, we find it is easy to miss one of these mistakes.  On the other hand, with 3 separate Events, I can ask, “Did the driver make a mistake while stopping?  Did she make a mistake while looking both ways?  Did she make a mistake by pulling forward?”  Having separate Events makes it much easier to catch individual problems.

Keep in mind that, later in the investigation, you may find that there were no mistakes made in any of these Events.  When you complete your SnapCharT®, it might then make sense to combine some Events to make the final SnapCharT® easier to read.  It is OK to combine Events later on; just leave them separate during your initial data-gathering phase.

2. Leave lots of space.  Many people tend to cram all their Events close together, I suppose to conserve real estate.  Don’t worry about it; leave lots of room between your individual Events.  Spread everything out.  You’ll be adding Conditions underneath each of these Events, and you’ll almost certainly end up moving everything to make room for these Conditions anyway.  Give yourself plenty of room to work at the beginning.  If using the software, I usually only put 2 or 3 Events on each page to start out.  Later on, once you have all of your Conditions documented and grouped, you can compress everything down a bit and get rid of extra spaces.  But even then, don’t try to squeeze everything tightly together.  It can make it hard to read, even after everything is set.  And you might also find new Conditions that need to be added once you start the root cause analysis.

3. Draw your lines at the very end.  It is tempting to start drawing lines early in the process.  You want to see those arrows showing your progression from one Event to the next.  And you want to arrange your Conditions into neat groups right from the start.  Unfortunately, this can cause problems later on.  There is a good chance you’ll be adding new Events, changing the order of the Events you have, or regrouping your Conditions into Causal Factor groups.  If you have already drawn your lines, you’ll just have to delete them, make your changes, and then draw them back in.  And then probably do it again later on.

I normally don’t draw any lines between Events or Conditions until after I’ve identified my Causal Factor groups.  My SnapCharT® is probably pretty close to being complete by that point, so I’m reasonably confident that I won’t be making a lot of changes.  This can be a tough lesson for those that are REALLY detail oriented (you know who you are!), and just have to have those lines drawn in early in the process.  Resist the temptation; it’ll save you some time (and frustration!) later on.

Let me know what you think about these tips.  If you have other tips that you’ve found that make it easier and quicker to produce your SnapCharT®s, share the best practices you’ve learned in the comments below.

We hope that you will also consider coming to the 2016 Global TapRooT® Summit, San Antonio, Texas, August 1-5 to share best practices.  Click here to learn more about the Summit.

 

Carnival Pride NTSB Allision Report – Causal Factor Challenge

Posted: March 7th, 2017 in Accidents, Investigations

collision, allision, carnival

The NTSB released their report on the allision of the Carnival Pride cruise ship with the pier in Baltimore last may. It caused over $2 million in damages to the pier and the ship, and crushed several vehicles when the passenger access gangway collapsed onto them. Luckily, no one was under or on the walkway when it fell.  You can read the report here.

Pride

The report found that the second in command was conning the ship at the time.  He had too much speed and was at the wrong angle when he was approaching the pier.  The report states that the accident occurred because the captain misjudged the power available when shifting to an alternate method of control to stop the ship.  It states there may have been a problem with the controls, or maybe just human error.  It also concluded that the passenger gangway was extended into the path of the ship, and that it did not have to be extended until ready for passengers to debark.

collision, allision, carnival

Gangway collapse after allision

While I’m sure these findings are true, I wonder what the actual root causes would be?  If the findings are read as written, we are really only looking at Causal Factors, and only a few of those to boot.  Based on only this information, I’m not sure what corrective actions could be implemented that would really prevent this in the future.  As I’m reading through the report, I actually see quite a few additional potential Causal Factors that would need to be researched and analyzed in order to find real root causes.

YOUR CHALLENGES:

  1. Identify the Causal Factors you see in this report.  I know you only have this limited information, but try to find the mistakes, errors, or equipment failures that lead directly to this incident (assuming no other information is available)
  2. What additional information would you need to find root causes for the Causal Factors you have identified?
  3. What additional information would you like in order to identify additional Causal Factors?

Reading through this incident, it is apparent to me that there is a lot of missing information.  The problems identified are not related to human performance-based root causes; there are only a few Causal Factors identified.  Unfortunately, I’m also pretty sure that the corrective actions will probably be pretty basic (Train the officer, update procedure, etc.).

BONUS QUESTION:

For those that think I spelled “collision” wrong, what is the meaning of the word “allision”?  How many knew that without using Google?

Avoid the Danger of New Hires

Posted: March 1st, 2017 in Accidents, Current Events, Performance Improvement

 

Is your safety program ready?

Is your safety program ready?

There is a feeling of cautious optimism in the oil sector, as the price of oil seems to have stabilized above $50/barrel. Rig count in the Permian has more than doubled since last spring. US EIA and JPMorgan are forecasting US production at near record levels of over 9.5 million barrels per day by the end of next year. US exports are up, with China ramping up oil purchases from the US, while OPEC production cuts are holding.

This all sounds good for the US oil sector. It is expected that hiring will start picking up, and in fact Jeff Bush, president of oil and gas recruiting firm CSI Recruiting, has said, “When things come back online, there’s going to be an enormous talent shortage of epic proportions.”

So, once you start hiring, who will you hire? Unfortunately, much of the 170,000 oil workers laid off over the past couple of years are no longer available. That experience gap is going to be keenly felt as you try to bring on new people. In fact, you’re probably going to be hiring many people with little to no experience in safe operation of your systems.

Are you prepared for this? How will you ensure your HSE, Quality, and Equipment Reliability programs are set up to handle this young, eager, inexperienced workforce? What you certainly do NOT want to see are your new hires getting hurt, breaking equipment, or causing environmental releases. Here are some things you should think about:

– Review old incidents and look for recurring mistakes (Causal Factors). Analyze for generic root causes. Conduct a TapRooT® analysis of any recurring issues to help eliminate those root causes.
– Update on-boarding processes to ensure your new hires are receiving the proper training.
– Ensure your HSE staff are prepared to perform more frequent audits and subsequent root cause analysis.
– Ensure your HSE staff are fully trained to investigate problems as they arise.
– Train your supervisors to conduct audits and detailed RCA.
– Conduct human factors audits of your processes. You can use the TapRooT® Root Cause Tree® to help you look for potential issues.
– Take a look at your corrective action program. Are you closing out actions? Are you satisfied with the types of actions that are in there?
– Your HSE team may also be new. Make sure they’ve attended a recent TapRooT® course to make sure they are proficient in using TapRooT®.

Don’t wait until you have these new hires on board before you start thinking about these items. Your team is going to be excited and enthusiastic, trying to do their best to meet your goals. You need to be ready to give them the support and tools they need to be successful for themselves and for your company.

TapRooT® training may be part of your preparation.  You can see a list of upcoming courses HERE.

Simple Root Cause Analysis (Don’t Settle!)

Posted: February 23rd, 2017 in Root Cause Analysis Tips, TapRooT, Training, Uncategorized

 

RCA, Root Cause analysis, 5-why, 5-whys
OK, show of hands:

How many companies are using TapRooT® for their “hard,” “high-risk” incident analyses and using something like 5-Whys for the “simple” stuff?  Yep, I thought so.  A lot of companies are doing this for various reasons. I’ll get into that more in a minute.

Now, another poll:

How many of you are performing effective root cause analyses on your “important,” “high-consequence” investigations, and performing nearly useless analyses on the “easy” stuff?  Of course, you know this is really exactly the same question, but you’re not as comfortable raising your hand the second time, are you?

Those of you that follow this blog have already read why using inferior RCA methods don’t work well, but let me recap.  I’m going to talk about 5-Whys specifically, but you can probably insert any of your other, less-robust analysis techniques here:

5-Whys

  • It does not use an expert system.  It relies on the investigator to know what questions to ask.
  • Because of this, it allows for investigator bias.  If you are a training person, you will (amazingly enough) end up with “training” root causes.
  • The process does not rely on human performance expertise.  Again, it relies on the skill of the investigator.  Yes, I know, we’re all EXCELLENT investigators!
  • It does not produce consistent results.  If I give the same investigation to 3 different teams, I always get 3 different sets of answers.
  • There is no assistance in developing effective corrective action.  When 80% of your corrective actions fall into the “Training” “Procedures” and “Discipline” categories, you are not really expecting any new results, are you?

So, knowing this to be true, why are we doing this?  Why are we allowing ourselves to knowingly get poor results?

  • These are low risk problems, anyway.  It doesn’t matter if we get good answers (Why bother, then?)
  • It’s quick.  (Of course, quickly getting poor results just doesn’t seem to be an effective use of your time.)
  • It’s easy (to get poor results).
  • TapRooT® takes too long.  Finally, an answer that, while not true, at least makes sense.

So what you’re really telling me is that if TapRooT® were just easier to use, you would be able to ditch those other less robust methods, and use TapRooT® for the “easy” stuff, too.

Guess what?  We’ve now made TapRooT® even easier to use!  The 7-step TapRooT® process can now be shortened for those “easy” investigations, and still get the excellent results you’re used to getting.

Simple RCA, TapRooT, root cause analysisWe now teach the normal 7-Step method for major incidents, where you need the optional data-collection tools.  However, we are now showing you how to use TapRooT® in low to medium-risk investigations.  You are still using the tools that make TapRooT® a great root cause analysis tool.  However, we show you how to shorten the time it takes to perform these less-complex analyses.

The 2-Day TapRooT® Incident Investigation Course concentrates on these low to medium-risk investigations.  The 5-Day TapRooT® Advanced Team Leader Course teaches both the simple method, but also teaches the full suite of TapRooT® tools.

Don’t settle for poor investigations, knowing the results are not what you need.  Take a look at the new TapRooT® courses and see how to use the system for all of your investigations.  You can register for one of these courses here.

Starting Your Investigations: The Power of the SnapCharT®

Posted: November 7th, 2016 in Investigations, Root Cause Analysis Tips

Beginning your investigation can sometimes be quite a challenge. Deciding on who to talk to, what documents you need, what questions you need to ask, etc. can lead to feeling slightly overwhelmed. As General Creighton Abrams said,

When eating an elephant, take one bite at a time.

In other words, you just need to get started with the first step, and then methodically work your way through to the end.

In TapRooT®, that first bite is the SnapCharT®. The rest of your investigation is going to depend on the data you gather in that SnapCharT®, so it is critical that you begin in a simple, methodical manner.

Let’s say you get that initial notification phone call (usually at 3:00 am). You don’t get much information. Maybe all you know is, “Ken, we had a pipe rupture this morning during a hydrostatic test. Looks like the mechanics didn’t know what they were doing.  They had hooked up a test pump to the piping, started the pump, and almost immediately ruptured the piping.  We’ve cleaned up the water, and no one was hurt.  We need you to investigate this.”  This is a pretty common initial report.  Not a lot of data, some opinions thrown in, and a request for answers.  Without a structured process, most investigations would now start off with some interviews, asking pretty generic questions.  It would be really nice if we could start off with some detailed, intelligent questions.

This is where the SnapCharT® comes in.  Once you receive that initial phone call, just build your SnapCharT® with the information you have.  It honestly won’t have much data, but that’s OK; it’s only your starting point:

Initial SnapCharT®

Initial SnapCharT®

However, with this initial SnapCharT®, it is now easier to visualize what you already know, and what you still need to know.  For example, I’d have a lot of questions about the pump, the mechanics themselves, recovery actions, etc.  I’d use the Root Cause Tree® to help me figure out what questions to ask.  I’d take each Event and ask, “What do I already know about this Event, and what questions do I have about it?”  These would all be added to the SnapCharT®.  It might look more like this:

Questions to ask

Questions to ask

Keep in mind that these questions were developed before I even went to the scene or questioned anybody about the facts.  I still need to interview people, but I now have a much better set of questions to begin my investigations.  Many more questions will arise as I ask this initial set of questions, but I’ll feel much better prepared to start talking to people about the issue.

The SnapCharT® is a simple yet effective tool to help the investigator get started with the investigation.  It may seem like an inconsequential step, easy to dismiss.  However, using the SnapCharT® as your very first tool, before you start gathering data, can greatly speed up the investigation.  It allows you to start on the right path, with a set of intelligent questions to ask.  Once you have this moving, you’ll find the rest of the investigation falls into place in a logical, easy to follow format.  ALWAYS START WITH A SNAPCHART®!

LEARN MORE about TapRooT® essentials in our 2-day course (View schedule and register!)

 

Equipment Reliability: What Happens as Pumps Wear Out?

Posted: October 11th, 2016 in Equipment/Equifactor®

Equipment reliability - Pump wear

When we are faced with the prospect of installing a new pump, we have to take a look at several factors to decide what the best course of action will be. For example, we have to look at:
– Fit for purpose
– Initial cost
– Life-cycle maintenance costs
– Electrical efficiency
– Ease of maintenance
– etc.

An additional consideration is how the characteristics of the pump vary over time.  It is fairly straight forward to calculate flow rates and pressures using the specs of a new pump.  However, how do these specs vary over time?  As the pump wears, how will the characteristics of the pump change, and how will this affect the overall fitness of the pump for the service environment?

Here is a nice article that describes how pump nameplate characteristics will change as the pump wears, and what to expect as the components wear.

Equipment Failure: Mechanical Seal Basics

Posted: October 3rd, 2016 in Equipment/Equifactor®

Mechanical seal

 

Modern pump systems are moving more and more away from traditional pump packing, and more towards mechanical seals.  There are many advantages to using a mechanical seal instead of pump packing.  However, using these seals brings along some additional potential problems.

Before we can look at these additional issues, we first need to make sure we understand exactly what we mean by a “mechanical seal.”  Here is a quick refresher on how these seals work.  Next week, we’ll look a little more deeply into the advantages and disadvantages of these systems.

Infection Control: Corrective Actions Much More Expensive then Proactive Improvement

Posted: October 3rd, 2016 in Medical/Healthcare

Infection 2

Here’s a story about a healthcare facility who has agreed to hire an infectious control consultant as part of an agreement to fix problems found by regulators.

What I found interesting is that the original inspection found “11 years of misconduct that led to the contamination of surgical instruments, among other issues.” What this really tells me is that no one was looking at normal day-to-day practices at the center. If there had been a robust audit and observation program, they probably would have been able to do their own internal improvements at much lower cost and without the attendant loss of confidence in their facility.

Learn about using TapRooT® proactively in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Equipment Failure: Crane Gearbox Failure

Posted: September 30th, 2016 in Accidents, Equipment/Equifactor®

Equipment Failure - Broken Gear

While performing a lift using a tower crane, a failure of the gearbox cause about 1.000 lbs of hook and rigging gear to fall to the ground, narrowly missing workers in the area. Here is the report.

The investigation revealed several issues, most relating to proper inspections of the gearboxes to identify defective gears.  While again this appears to be a straight equipment failure, we would also want to know:

  • How did the deficient gear end up in the gearbox (it was the wrong material)?
  • Are we looking for repeat failures (this had happened before)?
  • How close were the workers in the vicinity?
  • What was the preventative maintenance plan for this gearbox?  Was it required be the vendor?

Lots of other directions a good investigation will lead you.

 

Equipment Failure? Delta Airlines “Computer” Failure

Posted: September 6th, 2016 in Accidents, Equipment/Equifactor®

equipment failure 2

Last month, Delta Airlines experienced an equipment failure that caused their reservation system to shut down, Media reports indicate close to 2,000 flights were canceled. This is only a few weeks after Southwest Airlines experienced a similar computer failure, causing numerous flight delays and cancellations.

Reports continue to indicate that this was an equipment failure, due to a small fire in a power supply in there server room.  Here is their description:

“Monday morning (August 8) an uninterrupted power source switch experienced a small fire which resulted in a massive failure at Delta’s Technology Command Center. This caused the power control module to malfunction, sending a surge to a transformer outside of Delta, resulting in the loss of power. The power was stabilized and power was restored quickly. But when this happened, critical systems and network equipment didn’t switch over to backups. Around 300 of about 7,000 data center components were discovered to not have been configured appropriately to avail backup power. In addition to restoring Delta’s systems to normal operations, Delta teams this week have been working to ensure reliable redundancies of electrical power as well as network connectivity and applications are in place.”

Keep in mind that the “uninterrupted power supply switch” is actually known as an “uninterruptible” power supply (UPS).  This normally swaps you over to another power source if your primary source fails.  You may have a simple UPS on your computer systems at the office, providing battery backup while power is restored.  In Delta’s case, their UPS system attempted to switch over, but configuration issues prevented a significant number of their devices from actually shifting over.

Additionally, other reports indicate that the reservation system is an extremely antiquated system, linked into other airlines’ (also extremely antiquated) systems.  They have all patched together and upgraded their individuals systems to the point that it is almost impossible to upgrade; it really requires a complete replacement, which would be EXTREMELY difficult and expensive to replace while still being used for current reservations.

So while this is discussed by the airlines as an equipment failure, I think there are more than likely multiple causal factors, of which only one (the initiating problem) was a burned up component.  Without knowing the details, we can see several Causal Factors:

  • A UPS caught fire
  • This small fire caused a large surge and widespread power loss
  • Other equipment was not properly configured to shift to backup power
  • There is no backup in the event of a loss of the primary reservation system
  • The reservation computer system has not been upgraded to modern standards

I always question when a failure is classed as “equipment failure.”  Unless the equipment failure is an allowed event (Tolerable Failure), it is much more likely that humans were much more involved in the failure, with the broken equipment as only a result.

Cheap Root Cause Analysis?

Posted: August 30th, 2016 in Performance Improvement
cheap; root cause analysis

Cheaper is rarely better

I saw this picture today, and I thought about how people often make decisions based entirely on direct cost. For some things, we make a deliberate analysis of the long-range costs, benefits, and applicability of a product. For example, when we buy a new car, we might decide to pass on a particular brand of vehicle based on what we know (or at least, what we have heard) about the quality of that vehicle, its features, its reliability, and the fit to what we need. Remember the Yugo? I don’t see many of them on the road any more!

And yet, when we are making the decision on the best way to improve the health and safety of our coworkers, we seem to jump right on, “What does it cost?” I heard someone in Australia just the other day tell me about an RCA “methodology” that is being evaluated for use in some for their critical improvement programs. I asked why they were considering this other method. Does it work better? The answer made me sad. “Well, no, we don’t think it works as well as TapRooT®. Using [this other system] gives pretty ambiguous results, depending on who is using it. But it’s a little bit cheaper, so my manager wants to go that way.”

This doesn’t seem to make a lot of sense to me. If you can save 10%, but get poor results, what have you actually saved? I encourage you to look at the costs of even a single “simple” incident, and then bounce that against a few percent savings in poor-quality training.  I think you’ll find that the initial savings are lost in the noise.

You wouldn’t buy a car based solely on price. I encourage you to take the same due diligence when you are selecting an RCA program that has the potential to save the lives of your teammates.

WANTED: New Equifactor® Equipment Troubleshooting Tables

Posted: August 29th, 2016 in Equipment/Equifactor®

equipment troubleshooting table

We’re pretty excited about the new TapRooT® VI software service that we released this year. It has some terrific features that are a definite upgrade to the older Version 5 software.

As part of the conversion over to TapRooT® VI, we did an in-depth review of the Equifactor® equipment troubleshooting tables. We found we were able to streamline those tables to make them even easier to use. We dropped some redundant items, standardized some of the terminology, and generally mde them easier to use. Additionally, TapRooT® VI allows you to take the items from the Equifactor® table and drop them right onto your SnapCharT®. It’s a feature we’ve been asked about for quite a while, and the TapRooT® VI architecture finally let us add this enhancement.

I am currently looking for new ideas for tables you would be interested in seeing added to Equifactor®. What general categories of equipment would you like to see developed and added to the system? Some we might be able to do; some aren’t really very conducive to putting into a table format. For example, I was asked to develop tables to troubleshoot PLC problems. While this would be great, there are unfortunately hundreds of different models and types of PLC’s out there, and a simple set of tables would be really tough to do.

Another idea was for hydraulic system troubleshooting. Again, this might be to broad a category. However, I am researching the possibility of doing more specific tables on things like hydraulic cylinders and motors. These might be specific and generic enough that we can put together a useful set of tables.

So what would you like to see? Let me know, and I’ll be happy to take a look.

Medical Errors: Are You Preventing Pressure Ulcers?

Posted: August 26th, 2016 in Medical/Healthcare

Medical Error Prevention

My wife was in a cast a few years ago. After about a day, she noticed it was itchy on the bottom of her foot, near her big toe. We didn’t think anything of it (never in a cast before). When we went in for a checkup after a few days, she told the doctor. They pulled off the cast and found a blistery area on the bottom of her foot. It was caused by a slight pressure from a bump in the cast, which cut off blood flow to that small area on the ball of her foot. It ended up being pretty minor (big blister the size of a half dollar), and it healed up just fine.

I was amazed to find out that this can be fairly common after only a few hours in a stationary position, for example, during surgery. They can turn out to be very painful and potentially disfiguring. DO NOT, under any circumstances, Google for pictures of pressure ulcers!

Here is a guide on how the medical community can help prevent pressure ulcers. It is meant to be a proactive means of looking for opportunities to prevent or detect the circumstances and risk factors associated with perioperative pressure injuries.

Hand Hygiene: Patient Safety Through Infection Control

Posted: August 24th, 2016 in Medical/Healthcare, Performance Improvement

Hand Hygiene_Patient Safety Through Infection Control

I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.

How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.

Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances.  It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.

The Joint Commission Summary of Sentinel Events – 2Q 2016

Posted: August 22nd, 2016 in Medical/Healthcare

Clamp

 

Here’s a summary for reported sentinel events for the 2nd quarter of this year, compiled by The Joint Commission. It also compares some of the data against previous years.
It is almost impossible to make accurate comparisons on this data, since all reports are voluntary and, as stated in the report:

Data Limitations: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Without knowing who is reporting, who is not reporting, how these numbers are compiled or arrived at, how the problem types are assigned, etc., I’m having a tough time viewing the data in an objective light.

While the data is interesting, I’m not sure how this data is used.  Can anyone give me an example of how the data in this summary might be used?

Severe Pump Damage Due To Inadequate Analysis

Posted: August 22nd, 2016 in Equipment/Equifactor®

Cavitation

Here is a great example of damage to large pumps resulting from a poor understanding of the operating environment. When coupled with inferior manufacturing techniques, rapid failure of critical equipment can occur.

Pump Life Cycle Cost Analysis – Numbers Matter!

Posted: August 15th, 2016 in Equipment/Equifactor®

LCC Graphic

When designing spacecraft, there is a humorous (yet amazingly accurate) list of laws to keep in mind to ensure you are not going down the wrong path when developing spacecraft and their associated systems. Akin’s Laws of Spacecraft Design are a set of well-known nuggets that can be adapted to everyday life. But the one that I want to mention here is Akin’s Law #1:

1. Engineering is done with numbers. Analysis without numbers is only an opinion.

When you are looking at your pumping systems, and trying to decide on the best maintenance or repair strategy for a particular pump failure, you may have several options. For example:

– Should I just replace the failed pump with another identical pump?
– Should I replace it with a more efficient design?
– Is the current pump optimized for the system design?
– What other options are available for this repair?
– Why did it fail in the first place?

Iceberg

Life Cycle Cost analysis can be done after almost any failure to help you decide on the best repair strategy.  This analysis includes things like the costs of the initial purchase, installation and commissioning costs, energy and operation costs, and maintenance costs.  You can perform a relatively accurate cost comparison for various repair / replacement options so that you can make an educated decision on the best course of action.  Pump Life Cycle Costs: A Guide to LCC Analysis for Pumping Systems is the result of a collaboration between the Hydraulic Institute, Europump, and the US Department of Energy’s Office of Industrial Technologies (OIT).  It is definitely worth a few minutes to read through this and get a basic understanding of how to calculate the LCC of a particular installation or repair.

There were a couple of take-aways for me, neither of which was particularly surprising, yet both of which are important to keep in mind:

  1.  Energy consumption is often one of the larger cost elements and may dominate the LCC, especially if pumps are run more than 2000 hours per year
  2.  The cost of unexpected downtime and lost production is a very significant item in the total LCC and can rival the energy costs and replacement parts costs in its impact.

Pie Chart

Which drives home the importance of a good root cause analysis to ensure that your failures (and therefore your downtime) are minimized, as the costs of these failures can rapid skew the entire LCC analysis.  Don’t live with repeat or avoidable failures.

 

Using TapRooT® for Simple Investigations

Posted: August 9th, 2016 in Investigations, Root Cause Analysis Tips, Uncategorized

Investigation
It is almost a no-brainer to perform a complete, extensive root cause analysis for high-risk, high-consequence incidents. There are many reasons for this:

– Required by regulators or law
– Required by company policy
– Perceived higher return on investment

However, companies often default to less developed (and therefore less accurate) analyses for lower risk, lower consequence problems. For example, almost everyone will perform a TapRooT® investigation when there is a serious injury; this is a high-consequence incident, and preventing it in the future is perceived to have the highest ROI.  But what about a near miss?  Or maybe someone tripped over an air line on the floor, dropping a repair part and damaging it?  Most companies will either not perform any investigation, or they will default to “easy” methods (5-Why’s, etc.).  Why spend any time on these “simple” incidents?  Let’s just do a quick “analysis” and move on?

While I completely understand this thought process, there are some serious flaws in this thinking.

  1.  Low ROI.  While a particular incident may not have caused a large loss, this dos not mean it automatically deserves no attention.  Maybe tripping over the air line only caused $800 in damage this time.  But what about the other issues that have been caused by poor housekeeping in the past?  What if the person had tripped and fallen over the edge of a platform?  Making a quick assumption like this can allow you to miss potentially serious issues when taken together.  Performing a poor analysis will lead to repeats of the problem.
  2. Poor results of “quick” RCA methods.  Keep in mind that a quick method probably means that you did not gather any information.  You are therefore performing an “analysis” without any data to analyze.  If your analysis method takes 5 minutes, you have probably just wasted 5 minutes of your time.  If you’re going to perform an RCA, make sure it gets to useable and consistent answers.
  3. TapRooT® is only for the big stuff.  This thought often frustrates me.  It is true that you will not perform a TapRooT® investigation in 5 minutes.  However, any method that purports to give you magic answers in a few minutes is not being honest.  See #2 above.  However, that does NOT mean that TapRooT® must take days of your time.  For simple investigations, the results of a TapRooT® investigation may be found in just an hour or so.

So, how do we use TapRooT® for lower risk or low consequence problems?  This year, we have modified the TapRooT® methodology to allow you to use the steps of the process that you need to perform a great investigation on simple problems.  This updated process isn’t really new; it just codifies how we’ve taught you to use TapRooT® in the past for these simpler problems.  We make the process more efficient and give you the opportunity to optionally skip some of the steps.

Here is the new process flow for low to medium risk incidents:

Flowchart with no paragraphs
 

There are some important points that I wanted to highlight about this new process flow:

  1. You always start with a SnapCharT®.  There is no way to perform any type of analysis unless you first gather some information.  Again, any other process that advocates performing an analysis on the information you received in a quick phone call is not a real analysis.  The SnapCharT® ensures you have the right information to actually look for root causes.
  2. There is an off-ramp right at the beginning.  Once you’ve gathered information in a SnapCharT®, you can then make an intelligent decision as to whether this problem has the potential to uncover significant problems.  You may find, after building your SnapCharT®, that this really was an extremely low potential problem, with minimal consequences.  You will then stop the analysis at that point, put simple corrective actions in place to fix what you found, and then document the problem for later trends.  That’s it.  While most investigations will continue on with the rest of the process, there are some issues that do not require any further analysis and don’t deserve any further resources.
  3. For most investigations, you will continue by identifying Causal Factors, and run those Causal Factors through the Root Cause Tree®.  No different than before.
  4. For these simpler problems, it probably is not worth the effort of looking for generic causes.  We have made this step optional.  It you feel the problem has the potential to be more widespread, you can continue to look for generic issues, otherwise, go straight to corrective actions.
  5. Low to medium risk incidents probably do not need the resources you would normally expend writing full SMARTER corrective actions.  We encourage you to write corrective actions based on the guidance in the Corrective Action Helper®, but writing fully SMARTER fixes is probably not necessary.

For more serious incidents, we would still use the full 7-Step TapRooT® Process that you are familiar with.  However, for lower risk or lower consequence problems, this abbreviated process flow is much easier to use, allowing you to more quickly work through a TapRooT® investigation.  Why use 5-Why’s and get poor results (as expected) just to “save time,” when you can use the simplified TapRooT® process to get MUCH better answers with less effort than before?

The 2-Day TapRooT® Root Cause Analysis Course not covers this simpler method of performing TapRooT® investigations.  Attendees will still be able to perform investigations on any incident, but we stress this more efficient process flow.

Choose a course and register here!

Tips for Maintaining your Air Compressor

Posted: August 9th, 2016 in Equipment/Equifactor®

Compressor Maintenance

A new air compressor can be a significant investment at your facility. While most people assume that they are performing adequate maintenance on their equipment, I am often surprised by how many companies are not performing or tracking even the most basic maintenance.
Here are some fairly simple yet important tips on maintaining your air compressors, courtesy of Ingersoll Rand. Bounce these tips against your preventative maintenance plan and see if you’re fully covered.

Bearing Failures: Keep Them Clean!

Posted: August 1st, 2016 in Equipment/Equifactor®

Contaminated Bearing

According to the chart below, almost half of all pump bearing failures are due to lubricant contamination.  In the chart, you can probably add the “Corrosion” cause to this, since bearing corrosion is most likely due to a poorly sealed bearing.

Failure Chart

Credit: SKF

Heinz Bloch has written a great article on the importance of keeping up with bearing seal technology. He notes that only 10% of rolling-element bearings ever reach their expected end of life. While we seem to put a lot of effort into ensuring we have the right bearings with the proper lubrication, we then do a poor job of maintain those bearings. Imagine if your bearings actually lasted until the calculated end of life!

Heinz Bloch will be leading 2 sessions at our Global TapRooT® Summit in San Antonio this week. I always look forward to his talks!!

Tappan Zee Crane Collapse: What We Know

Posted: July 25th, 2016 in Accidents, Equipment/Equifactor®

Crane boom collapse

Last week’s collapse of the 235 foot boom on a crane building the new Tappan Zee bridge is still under investigation. There are apparently 3 separate investigations in progress, and as expected, not much information has been released.

The boom came down across all lanes of traffic on the old (still active) portion of the bridge. Amazingly enough, there were only 4 minor injuries, and it cause direct damage to a single vehicle. If you’ve ever driven across that bridge (I was on it just 30 days before the incident), you understand how lucky we were not to have any fatalities.

What we know so far:

– There was almost no wind, and this has been eliminated as a cause.
– The crane was being used to drive piles into the river bottom using a 60 ton vibratory hammer.
– There is a “black box” on the crane which will supply data on the boom angle, weight, etc.
– The operator says he knows what caused it (it wasn’t him).
– This is a new model crane with several safety features designed to eliminate human error.
– This is the only crane of this model being used on the project.
– The crane operator is licensed, with over 30 years of experience.

Tappan Zee Before

This seems to be a good start to an investigation. And as expected, there are a lot of questions (and “expert” opinions) about what happened.  Some of the questions that might be asked:

  • Was the crane properly inspected and certified?
  • What was the condition of the vibratory hammer?
  • Was there any sense of urgency that may have caused someone to make a mistake?  The contract specified $120,000 per day fine of the project finished late.
  • Was there an adequate review and approval of the safe zone around the crane operation?

It’s important not to just ask the hard questions, but also to give the hard answers.  For example, one option that could have been in place (20/20 hindsight) would be to close the operating section of the bridge during construction.  While this would definitely have been 100% safer, does it actually make sense to do this?  Were there adequate safeguards in place to allow continued use of the old span?  The answers here might be yes, and it was perfectly appropriate to operate the old bridge during contruction.  I’ve seen hundreds of construction projects that have cranes in near proximity to the public.  In fact, almost every downtown construction project has the potential to cause injury to the public if a crane collapses.  Some of the criticism I’ve seen written about this accident (“Why wasn’t the old span closed during this constructiuon project?”) is too simplistic for the real world.  The real question should be, “Were there adequate safeguards put in place for the level of risk imposed by this projct?”  We don’t know the answers yet, but just asking these questions in an unbiased investigation can provide useful information.

Crane Collapse

It appears that there is plenty of information available to the investigators. I’m very interested to see the results after the investigations are complete.

Water Hammer – What is it, and how we can prevent equipment damage?

Posted: July 20th, 2016 in Equipment/Equifactor®

water_hammer

If you’ve ever heard your pipes rattle in your house after flushing the toilet, you’ve experienced water hammer. While this is just a noisy occurrence in your home, it can cause major damage in industrial situations.
We talk about water hammer during our 5-Day TapRooT® course as a great root cause analysis example. It’s a fairly easy concept on the surface, but it’s actually a fascinating phenomenon. I found this great article that discusses the causes of water hammer and describes some ideas to keep in mind that can prevent or at least mitigate the consequences.

Equipment Failure? No, the Sloth Did It!!

Posted: July 6th, 2016 in Equipment/Equifactor®, Jokes

Worker: But boss, I swear I didn’t shut that valve!

Boss:   Well, who do you think shut it? Aliens? Gremlins?

Apparently, it was just a sloth!


Gear Coupling Troubleshooting and Reliability

Posted: June 28th, 2016 in Equipment/Equifactor®

Coupling

Gear couplings have been around for a long time. And yet there are still frequent equipment failures due to improper selection, use, and maintenance of couplings.
Keep in mind that a coupling problem can manifest itself in subtle ways. A broken coupling is pretty obvious. However, you could see symptoms such as:
– Increased vibration readings in the equipment
– Overheating of shaft bearings
– Unusual resonances in your vibration data
– Overload and overheating of motors

The Equifactor® module of the TapRooT® VI software service has some great troubleshooting tables, one of which is focused on gear couplings. Once you determine that you have a coupling issue, you can look up the symptoms you are seeing and determine what could be causing that symptom.

Coupling

I also found a nice article describing problems you might have with a coupling, and how to maintain the reliable operation of a gear coupling. Take a look and let me know what you think.

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