Author Archives: Mark Paradies

A Quote from Admiral Rickover…

Posted: April 28th, 2016 in Performance Improvement, Pictures

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“Responsibility is a unique concept,
it can only reside and inhere in a single individual.
You may share it with others, but your portion is not diminished.
You may delegate it, but it is still with you.
You may disclaim it, but you cannot divest yourself of it.
Even if you do not recognize it or admit is presence, you cannot escape it.
If responsibility is rightfully yours, no evasion, or ignorance,
or passing the blame cna shift the burden to someone else.
Unless you can point your finger at the man who is responsible when something goes wrong,
then you never had anyone really responsible.” 

What Does a Bad Day Look Like?

Posted: April 26th, 2016 in Video

Certainly was an impressive way to arrive for the prom. But a bad day for the pilot!

Monday Accident & Lessons Learned: Human Error + Equipment Failure = 911 System Outage

Posted: April 25th, 2016 in Accidents, Current Events

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The following sequence is from the Clarence Bee

First, an air conditioning unit for a power supply room failed.

No big deal … There’s an automatic backup and a system to notify the engineer.

Oops … It failed too.

Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?

Sorry. In the “heat” of the moment, he pushed the “kill” button.

Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it. 

Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.

What can you learn from this incident?

  • Do your people know what to do when things go wrong? 
  • Do you do drills? 
  • Are things clearly labeled? 
  • Are there response procedures? 
  • How long has it been since people were trained?

Summit Flashback

Posted: April 19th, 2016 in Summit, Summit Videos, TapRooT, Video

This is a great flashback. Remember when we were this young? It wasn’t all that long ago. And everything we said then is still true today – just even more so!

Don’t miss the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. See:

http://www.taproot.com/taproot-summit

Improve your root cause analysis.

  • Network
  • Benchmark
  • Learn best practices
  • Refresh your TapRooT® skills
  • Be inspired!
  • Get motivated!

That’s what the Global tapRooT® Summit is all about.

Monday Accident & Lessons Learned: CSB Issues Report on BP Deepwater Horizon Accident

Posted: April 18th, 2016 in Accidents, Current Events, Investigations, Pictures

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The CSB press release starts with:

“Washington, DC, April 13, 2016 – Offshore regulatory changes made thus far do not do enough to place the onus on industry to reduce risk, nor do they sufficiently empower the regulator to proactively oversee industry’s efforts to prevent another disaster like the Deepwater Horizon rig explosion and oil spill at the Macondo well in the Gulf of Mexico, an independent investigation by the U.S. Chemical Safety Board (CSB) warns.”

For the whole report, see:

http://www.csb.gov/the-us-chemical-safety-boards-investigation-into-the-macondo-disaster-finds-offshore-risk-management-and-regulatory-oversight-still-inadequate-in-gulf-of-mexico/

 

 

Managing Risk the Matrix Way

Posted: April 16th, 2016 in Performance Improvement

Our partners in Scotland are sponsoring a charity event. Here’s a video that explains a little about it…

 Mhorven Sherret Promo.mp4

And below is a flier to tell you more…

Alan Smith Flyer copy

For more information, see:

http://www.stillincontrol.co.uk

 

Friday Joke: Quality NI

Posted: April 15th, 2016 in Jokes, Pictures, Quality

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COMPLETE SERIES – Admiral Rickover: Stopping the Normalization of Deviation with the Normalization of Excellence

Posted: April 14th, 2016 in Documents, Performance Improvement, Pictures

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You may have dropped in on this series of articles somewhere in the middle. Here are links to each article with a quick summary…

1. There is No Such Thing and the Normalization of Deviation

Point of this article is that deviation IS NORMAL. Management must do something SPECIAL to make deviation abnormal.

2. Stop Normalization of Deviation with Normalization of Excellence

A brief history of how Admiral Rickover created the first high performance organization. The Nuclear navy has a history of over 50 years of operating hundreds of reactors with ZERO process safety (nuclear safety) accidents. He stopped the normalization of deviation with the NORMALIZATION OF EXCELLENCE. Excellence was the only standard that he would tolerate.

3. Normalization of Excellence – The Rickover Legacy – Technical Competency

This article describes the first of Rickover’s three keys to process safety: TECHNICAL COMPETENCE. The big difference here is this isn’t just competence for operators or supervisors. Rickover required technical competence all the way to the CEO.

4. Normalization of Excellence – The Rickover Legacy – Responsibility

The second key to process safety excellence (the normalization of excellence) – RESPONSIBILITY.

Do you think you know what responsibility means? See what Rickover expected from himself, his staff, and everyone responsible for nuclear safety.

5. Normalization of Excellence – The Rickover Legacy – Facing the Facts

FACING THE FACTS is probably the most important of Rickover’s keys to achieving excellence. 

Read examples from the Nuclear Navy and think about what your management does when their is a difficult decision to make.

6. Normalization of Excellence – The Rickover Legacy – 18 Other Elements of Rickover’s Approach to Process Safety

Here is the other 18 elements that Rickover said were essential (as well as the first three keys).

That’s right, the keys are the start but you must do all of these 18 well.

7. Statement of Admiral Rickover in front of the Subcommittee on Energy Research and Production of the Committee on Science and Technology of the US House of Representatives – May 24, 1979

Here is Rickover’s own writing on what makes the Nuclear Navy special. What to this day (over 35 years after Rickover was retired) keeps the reactor safety record spotless.

That’s it. The whole series. I’m thinking about writing about some recent process safety related accidents and showing how management failed to follow Rickover’s guidance and how this lead to poor process safety performance. Would you be interested in reading about bad examples?

What does a bad day look like?

Posted: April 12th, 2016 in Accidents, Human Performance, Video

And it could have been much worse!

Monday Accident & Lessons Learned: CEO gets 1 year in prison for fatal accident

Posted: April 11th, 2016 in Accidents, Current Events

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Press reports that the ex-CEO of Massey Coal faces a year in prison as a result of Upper Big Branch Mine explosion. As a CEO, putting the safety of your workers at risk to improve profits can be costly.

Navy Ship Damaged During Startup – Root Cause is Human Error?

Posted: April 9th, 2016 in Accidents, Equipment/Equifactor®, Investigations

Here’s the article …

http://www.bloomberg.com/news/articles/2016-04-07/damage-extensive-for-crippled-u-s-littoral-ship-in-singapore?cmpid=yhoo.headline

They have already fired the Commanding Officer … so don’t worry … they won’t start up gears without lube oil again. More video below.

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