Author Archives: Mark Paradies
Is you day worse than it was for this pilot?
I was thinking about the ways that trying to be cheap when doing root cause analysis could cost companies millions of dollars, when a discussion with a legal counsel gave me an additional idea. Then I thought,
“I need to share these ideas to keep people from making these mistakes.”
1. CHEAP INVESTIGATIONS
I’ve seen many companies assign supervisors to investigate accidents “in their spare time.” This is definitely a cheap investigation. But the problem that results could cost the company millions of dollars.
For example, let’s say that a near-miss doesn’t cost anything and no one is seriously injured. Therefore, a supervisor does a quick investigation without looking into the problem in too much detail. He recommends re-training those involved and the training is conducted days later. Case closed!
However, the root causes and failed safeguards for a bigger accident are never fixed. Nearly a year later, a major accident occurs that could have been prevented IF the root causes of the previous near-miss had been found and fixed. However, because a “cheap” investigation was performed, the causes were never identified and 10 people died needlessly. The company spent $1 million on an OSHA fine and almost $100 million more on legal and settlement costs.
What do you think? Was the savings of a cheap investigation worthwhile?
One key to a world-class incident investigation and root cause analysis program is to spend time identifying which “small incidents” are worthy of a good investigation because they have the potential to prevent major accidents. These near-misses (of a big accident) should be treated as seriously as the big accident itself with a thorough investigation , management review, and implementation of effective corrective actions to prevent recurrence of the causes (and, thus, the big accident that’s waiting to happen).
2. CHEAP CORRECTIVE ACTIONS
I’ve seen companies try to perform a thorough root cause analysis only to try to take the cheap way out when it comes to corrective actions.
You have probably all seen “cheap” corrective actions. Try these:
- Caution workers to be more careful when …
- Re-train employees to follow the procedure.
- Re-emphasize to employees the importance of following the rules.
These seem cheap. (Cautioning employees is almost free.) But the change very little and will be forgotten in days or at least in several months. Plus, new folks who join the organization after the caution, re-train, or re-emphaize occurs, won’t get the repeated emphasis.
What happens? The incident tends to repeat after a period of time. And repeat incidents can be expensive. Thus by saving on corrective actions, you may be costing your company big bucks.
Instead, for investigations that could prevent major accidents, investigators should propose (and management should insist upon) corrective actions that remove the hazard, remove the target, or significantly improve the human factors of the safeguards that are used to prevent a repeat of the accident. These may not be cheap but they will be infinitely more effective.
What if one of these three choices can’t be implemented? Then one or more additional safeguards that are effective should be developed.
3. CHEAP TRAINING
The legal counsel that I was talking to told me that MOST “TapRooT® Users” he ran into during their preparation for trails had never been formally trained in TapRooT®. The attorney had attended one of our public TapRooT® Courses. He was amazed that management at fairly major companies would assign people who had never been to ANY formal root cause analysis training to investigate serious incidents that had potential for expensive legal outcomes.
In one instance, the person using TapRooT® had obtained one of our old TapRooT® Books from a friend. He then “used” the technique after reading “some” of the book. He didn’t have a Root Cause Tree® Dictionary or a Corrective Action Helper®. However, his reading didn’t provide him with the knowledge he needed to use TapRooT® correctly when investigating serious incidents (or not serious ones for that matter).
Don’t get me wrong, the TapRooT® Book is a great read. But I would never recommend it as the only source of training for someone who will be investigating serious accidents (fatalities and major environmental releases). What would I recommend? The 5-Day TapRooT® Advanaced Root Cause Analysis Team Leader Training.
The attorney also mentioned that he frequently meets TapRooT® Users who are out of practice using TapRooT® and really need a refresher because they don’t have many serious accidents to investigate and don’t get any feedback even when they do an investigation. My answer to that was ….
- They should be using TapRooT® proactively to get practice using the techniques.
- They should set up a company peer review process to help users get better at applying the techniques.
- They should attend the Incident Investigation and Root Cause Analysis Track at the Global TapRooT® Summit at least every two years to keep up with the latest improvements in the TapRooT® Techniques.
By the way, what had the “cheap training” cost the company? Over $50 million dollars in settlement costs.
HIGHLY QUALIFIED, COMPETENT, PRACTICED TapRooT® INVESTIGATORS ARE IMPORTANT INVESTMENTS
The first thing management needs to understand is that they need to invest in their incident investigators. Saving on training on root cause analysis is a stupid idea.
THOROUGH ROOT CAUSE ANALYSIS OF INCIDENTS THAT COULD HAVE BEEN MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS
Once you have excellent investigators, make sure they have the time and resources needed to investigate all incidents/near-misses that have a potential to become major accidents. Saving money on investigations is a fool’s mission.
CORRECTIVE ACTIONS THAT COULD PREVENT MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS
Management should insist upon effective corrective actions that go beyond training. Saving money by implementing “cheap” corrective actions is a false savings that will come back to haunt the company.
DON’T MAKE THESE MISTAKES! Invest in effective root cause analysis and prevent major accidents from occurring.
The UK RAIB and the French Bureau d’Enquetes sur les Accidents de Transport Terrestre (BEA-TT) are jointly investigating a fire on-board a train in the Channel Tunnel. For more information, see:
Monday Accident & Lessons Learned: The US Chemical Safety Board Releases Bulletin on Anhydrous Ammonia Incident near Mobile, AlabamaPosted: January 26th, 2015 in Accidents, Current Events, Investigations, Pictures
CSB Releases Safety Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama
Safety Bulletin Notes Five Key Lessons to Prevent Hydraulic Shock
January 15, 2014, East Rutherford, NJ – Today the U.S. Chemical Safety Board released a safety bulletin intended to inform industries that utilize anhydrous ammonia in bulk refrigeration operations on how to avoid a hazard referred to as hydraulic shock. The safety lessons were derived from an investigation into a 2010 anhydrous ammonia release that occurred at Millard Refrigerated Services Inc., located in Theodore,
The accident occurred before 9:00 am on the morning of August 23, 2010. Two international ships were being loaded when the facility’s refrigeration system experienced “hydraulic shock” which is defined as a sudden, localized pressure surge in piping or equipment resulting from a rapid change in the velocity of a flowing liquid. The highest pressures often occur when vapor and liquid ammonia are present in a single line and are disturbed by a sudden change in volume.
This abnormal transient condition results in a sharp pressure rise with the potential to cause catastrophic failure of piping, valves, and other components – often prior to a hydraulic shock incident there is an audible “hammering” in refrigeration piping. The incident at Millard caused a roof-mounted 12-inch suction pipe to catastrophically fail, resulting in the release of more than 32,000 pounds of anhydrous ammonia.
The release led to one Millard employee sustaining injuries when he fell while attempting to escape from a crane was after it became engulfed in the traveling ammonia cloud. The large cloud traveled a quarter mile from the facility south toward an area where 800 contractors were working outdoors at a clean-up site for the Deepwater Horizon oil spill. A total of 152 offsite workers and ship crew members reported symptomatic illnesses from ammonia exposure. Thirty two of the offsite workers required hospitalization, four of them in an intensive care unit.
Chairperson Rafael Moure-Eraso said, “The CSB believes that if companies in the ammonia refrigeration industry follow the key lessons from its investigation into the accident at Millard Refrigeration Services, dangerous hydraulic shock events can be avoided – preventing injuries, environmental damage, and potential fatalities.”
Entitled, “Key Lessons for Preventing Hydraulic Shock in Industrial Refrigeration Systems” the bulletin describes that on the day before the incident, on August 22, 2010, the Millard facility experienced a loss of power that lasted over seven hours. During that time the refrigeration system was shut down. The next day the system regained power and was up and running, though operators reported some problems. While doing some troubleshooting an operator cleared alarms in the control system, which reset the refrigeration cycle on a group of freezer evaporators that were in the process of defrosting. The control system reset caused the freezer evaporator to switch directly from a step in the defrost cycle into refrigeration mode while the evaporator coil still contained hot, high-pressure gas.
The reset triggered a valve to open and low temperature liquid ammonia was fed back into all four evaporator coils before removing the hot ammonia gas. This resulted in both hot, high-pressure gas and extremely low temperature liquid ammonia to be present in the coils and associated piping at the same time. This caused the hot high-pressure ammonia gas to rapidly condense into a liquid. Because liquid ammonia takes up less volume than ammonia gas – a vacuum was created where the gas had been. The void sent a wave of liquid ammonia through the piping – causing the “hydraulic shock.”
The pressure surge ruptured the evaporator piping manifold inside one of the freezers and its associated 12-inch piping on the roof of the facility. An estimated 32,100 pounds of ammonia were released into the surrounding environment.
Investigator Lucy Tyler said, “The CSB notes that one key lesson is to avoid the manual interruption of evaporators in defrost and ensure control systems are equipped with password protection to ensure only trained and authorized personnel have the authority to manually override systems.“
The CSB also found that the evaporators at the Millard facility were designed so that one set of valves controlled four separate evaporator coils. As a result, the contents of all four coils connected to that valve group were involved in the hydraulic shock event – leading to a larger, more hazardous pressure surge.
As a result, the CSB notes that when designing ammonia refrigeration systems each evaporator coil should be controlled by a separate set of valves.
The CSB found that immediately after discovering the ammonia release, a decision was made to isolate the source of the leak while the refrigeration system was still operating instead of initiating an emergency shutdown. Shutting down the refrigeration system may have resulted in a smaller release, since all other ammonia-containing equipment associated with the failed rooftop piping continued to operate.
A final key lesson from the CSB’s investigation is that an emergency shutdown should be activated in the event of an ammonia release if a leak cannot be promptly isolated and controlled. Doing so can greatly reduce the amount of ammonia released during an accident.
Linda Unger, VP at SI, sent these pictures of Ken Turnbull, one of our contract instructors, teaching a bunch of great students.
It’s easy for a CEO and management to claim to support safety. But the proof comes when times get tough.
The price of oil has declined more that 50% in just six months. That has the oil field in crisis mode. Knee jerk budget cuts, travel restrictions, and layoffs have already started.
What does this mean to safety improvement? Many oil industry safety professionals get ideas about ways to improve by attending the TapRooT® Summit, networking with industry leaders and performance improvement experts, hearing about the latest best practices that will help them solve their toughest problems, and developing plans to take safety to a whole new and better level. But if travel budgets are slashed and conferences are not allowed, these new best practices won’t be learned, safety improvement will stop, and lives that could have been saved will be lost.
Now is the time for management to show their commitment to safety improvement. They can stand up, resist the fear of low oil prices, and demand that safety improvement continues even in times of budget restraint.
After all, safety is not just a priority that can be discarded when times get tough. Safety is a value that must be supported every day, year in and year out, in good times and bad, or people will start to believe that safety is option and the only real value is profit.
Don’t let safety improvement become an unsupported slogan. Register for the TapRooT® Summit today!
Just like this if you own a Subway …
Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014Posted: January 19th, 2015 in Accidents, Current Events, Investigations, Performance Improvement, Pictures
UK Rail Accident Investigation Branch Press Release…
The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.
Yellow engineering trolley underneath the train after the collision (image courtesy of Carillion)
The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley.
The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.
To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.
Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.
RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.
RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.
The RAIB investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.
- – – – –
What can we learn BEFORE the investigation is complete?
First, this “near-miss” was actually a hit.
In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.
Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.
Today, Schlumberger announced it was planning on laying off 9,000 employees worldwide. The rapid drop in oil prices is having a negative employment impact.
If any TapRooT® Users find themselves unemployed, I’d like to remind them to watch for job opportunities here:
We post new job openings every week for people that have TapRooT® Root Cause Analysis Skills.
What? You haven’t attended a TapRooT® Root Cause Analysis Course?
NOW is the time BEFORE you need a new job that requires TapRooT® Root Cause Analysis Training.
See our course schedule around the world and click on your continent to see local courses at:
Donkey In The Well Story…
One day a farmer’s donkey fell down into a well. The animal cried piteously for hours as the farmer tried to figure out what to do.
Finally, he decided the animal was old, and the well needed to be covered up anyway; it just wasn’t worth it to retrieve the donkey.He invited all his neighbors to come over and help him. They all grabbed a shovel and began to shovel dirt into the well.
At first, the donkey realized what was happening and cried horribly. Then, to everyone’s amazement he quieted down.
A few shovel loads later, the farmer finally looked down the well. He was astonished at what he saw. With each shovel of dirt that hit his back, the donkey was doing something amazing. He would shake it off and take a step up.
As the farmer’s neighbors continued to shovel dirt on top of the animal, he would shake it off and take a step up. Pretty soon, everyone was amazed as the donkey stepped up over the edge of the well and happily trotted off!
Life is going to shovel dirt on you, all kinds of dirt. The trick to getting out of the well is to shake it off and take a step up. Each of our troubles is a steppingstone. We can get out of the deepest wells just by not stopping, never giving up! Shake it off and take a step up.NOW ——–
Enough of this BS . . .
The donkey later came back and bit the the farmer who had tried to bury him.
The gash from the bite got infected, and the farmer eventually died in agony from septic shock.
MORAL FROM TODAY’S LESSON: When you do something wrong and try to cover your ass, it always comes back to bite you.
Why not try advanced root cause analysis instead!
I was in Las Vegas teaching a TapRooT® Course when I realized … We are the only no-lose game in town!
What do I mean? TapRooT® Training is GUARANTEED.
Here’s the guarantee:
Attend this course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.
It’s that simple.
But there’s more.
On June 1-5, System Improvements is holding the only GUARANTEED conference that I know about. The 2015 Global TapRooT® Summit. If you need to learn best practices from around the world that will help you improve performance, you need to be in attendance!
Here’s the Summit guarantee:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
Another great guarantee because we know you will love the Summit.
UK RAIB Press Release: Investigating tram derailment near Mitcham Junction, London, 29 December 2014Posted: January 12th, 2015 in Accidents, Current Events, Investigations, Pictures
At about 23:55 hrs on Monday 29 December 2014, a tram travelling from New Addington to Wimbledon on the Croydon Tramlink system became derailed shortly after leaving the tram stop at Mitcham Junction, while travelling at about 11 km/h (7 mph). There were about 20 passengers, plus the driver, on board the tram, and no-one was hurt. There was some minor damage to the tram.
To the west of Mitcham Junction tram stop, the single tram line becomes two lines at a set of spring-operated points. On leaving the tram stop, the tram driver noticed that an indicator, which shows the position of these points, was indicating that the points were not correctly set. He stopped the tram before reaching the points, and after speaking to the tramway control room by radio, he left the tram and used an operating lever to manually move the points until he observed that the indicator was showing that they were correctly set. He then drove the tram slowly over the points, but the centre bogie and one wheelset of the trailing bogie became derailed.
Image showing derailed tram near Mitcham Junction
RAIB’s investigation will focus on the points mechanism and the way that it behaves in degraded operating conditions.
RAIB’s investigation is independent of any investigation by the railway industry or the Office of Rail Regulation.
The UK RAIB will publish their findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available at http://www.raib.gov.uk.