Author Archives: Mark Paradies
See, your day seems better already …
IT DIDN’T HAVE TO HAPPEN
An anesthesia machine cuts off oxygen to a patient causing extensive brain damage. The investigation team finds a mechanical defect that was undetectable without complex testing. They also find that the sentinel event almost happened before.
The baggage door on a 747 opens after takeoff, tearing off part of the plane. Four people are swept out the hole to their death. The investigation uncovers poor, less catastrophic accidents of a similar nature and a history of problems with the door on this particular aircraft.
A plant upset occurs due to corrective maintenance. A relief lifts but fails to shut when pressure decreases. Operators, initially preoccupied with other alarms, misdiagnose the problem and shut off critical safety equipment. The “impossible” accident – a core meltdown – happens at Three Mile Island. The investigation uncovers similar, precursor incidents and a history of relief valve failure at TMI.
These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?
- Suffering for survivors and surviving loved ones.
- Millions – no billions – of Dollars (Yen, Euros, and Pounds).
We could prevent ALL of them. Why don’t we? Don’t we know that:
An ounce of prevention is worth a pound of cure?
Maybe it is:
- Intellectual laziness?
- Just plain bad management?
- A bad system to identify problems?
- Bad investigation techniques?
- Something else?
What would it take to start learning?
STEP 1: MANAGEMENT UNDERSTANDING
Your management – from the CEO down – must understand the problem … People and machines are variable (you might call them unreliable) BY NATURE.
Our job is to reduce the variability and make systems reliable and safe.
In the long run a safe, reliable system will always out perform an unreliable, unsafe systems.
Therefore, improving reliability and safety provides your company with a competitive advantage.
The competitive advantage IS NOT FREE. It requires up front effort and investment in root cause analysis and improvements. It requires persistent attention to detail.
Thus, attaining reliability and safety is the challenge.
STEP 2: GET A PERFORMANCE IMPROVEMENT & ROOT CAUSE ANALYSIS SYSTEM THAT WORKS
Although Ben Franklin’s advice seems simple, consistently identifying the right “ounce of prevention” can be complex.
How dangerous is it to reason from insufficient data.
Improving safety and reliability requires a systematic approach and the use of sophisticated performance improvement techniques. You need a good performance monitoring system.
A good performance monitoring system includes:
- self-reporting of near misses
- reporting and instigation of accidents and incidents
- audits, observations, and self-assessments
- advanced root cause analysis (TapRooT®)
- advanced statistical analysis of trends
- understanding of how to fix human performance problems
- training for those who make the system work
Is putting together this kind of a system a tall order? You bet. Bit it is worth it.
If you need help putting this type of system together, we have the experience to help you and we can provide the training that people need. Call us at 865-539-2139 or drop us a note.
STEP 3: USE THE SYSTEM & FIX PROBLEMS
Get your facts first.
Then you can distort them as much as you please.
Preventing accidents is NOT a quick fix. Something you can do once and forget. Management needs to stay involved. You must be consistently persistent.
Find and fix the root causes of accidents, incidents, near-misses, and audit findings.
The first measure of the effective of the system IS NOT a reduced accident rate (although this will come along quickly enough). The first measure of success is an increased rate of finding and implementing effective corrective actions.
Management needs to demand that people properly using the system to investigate problems, find their root causes, identify effective fixes, and get them implements. If management doesn’t demand this, it won’t happen.
STEP 4: NEVER STOP IMPROVING
If you aren’t better today than you were yesterday, you are falling behind. As my boss once said:
If you’re not peddling, you are going downhill.
Captain William J. Rodriguez, United Staes Navy
Never stop looking for areas that need improvement. This should include improving your improvement system!
We can help. How? Several ways…
- Call us at 865-539-2139 and we can discuss your plans to improve. The call is FREE and we may be able to suggest ways to make your plan even better.
- We can conduct an independent review of your root cause analysis implementation, trending, and performance improvement systems. Although this isn’t free, we guarantee it will be worth the time and money. Just drop us a note to get things started.
- Attend the TapRooT® Summit. Each year we design the Summit to help people learn to solve the toughest problems facing industry. You will network with some of the world’s most knowledgeable performance improvement experts and peers who have faced the same types of problems that you face and found best practices to solve their problems.
Don’t wait for the next “missed opportunity”. Do something to make improvement happen before a major accident takes place.
Save lives – save money – save jobs – improve quality and reliability – that’s what TapRooT® is all about.
(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)
Where will the Summit be held? The Summit will be held at The Flamingo Las Vegas Hotel. Learn more about the location and determine your budget for travel.
What are the costs for registration? Budget $995 for the Summit, $1295 for a pre-Summit course or budget $2,090 for the Summit and a pre-Summit Course (a $200 savings!).
Summit attendees share experience, learn to apply the latest research, and meet in small groups (best practice sessions) with leading industry experts to share information and ideas across industry and organizational boundaries. The best practice sessions are organized under Best Practice Tracks to make it easier for attendees to create their Summit schedules. The 9 Best Practice Tracks planned for 2015 are:
1. Equipment Reliability Improvement & Troubleshooting
2. Human Error Reduction & Behavior Change
3. Improving Healthcare Quality & Patient Safety
4. Incident Investigation and Root Cause Analysis
5. Process Quality and Corrective Action Programs
6. Safety Improvement
7. TapRooT® Software
8. Certified TapRooT® Instructor
9. Special Topics
But the Best Practice Tracks are not set in stone. Each person that registers has the opportunity to create a custom track.
So, SAVE THE DATE, start thinking about which sessions you’d like to attend, get your registration fees and travel plans in the budget.
We are pleased to announce that Richard Phillips, real life inspiration for the Movie Captain Phillips, starring Tom Hanks; and author of A Captain’s Duty: Somali Pirates, Navy SEALs, and Dangerous Days at Sea has confirmed to be our Keynote Speaker on Friday, June 5, 2015!
Watch for more info in upcoming newsletters and in the future Root Cause Analysis Blog posts.
Visit the Summit website for more info.
The programmer’s wife tells him: “Run to the store and pick up a loaf of bread. If they have eggs, get a dozen.”
The programmer comes home with 12 loaves of bread.
Your day isn’t so bad after all…
What do you have planned to keep walkways clear this winter?
See Andrew G. Rosen’s “7 Ways to Get Motivated” at:
For training at your site, you need to call us (865-539-2139) or CLICK HERE to drop us a note. We still have a few dates open in November and December but you need to get your training scheduled soon or all the 2014 training dates will be full.
For our public TapRooT® Courses, you can see the entire worldwide list of courses remaining for 2014 and the first half of 2015 at:
Or you can click on a particular continent to see the courses being held there. Or just click on the continent below that you are interested in:
Don’t wait to register. TapRooT® Courses fill up fast and there may be a waiting list.
Hope to see you at one of the upcoming courses!
This came to my e-mail account from an on-line retailer …
Maybe it could include an optional Darth Vader voice changer?
Root Cause Tip: Making Team Investigations Work (A Best of Article from the Root Cause Network™ Newsletter)Posted: October 9th, 2014 in Investigations, Performance Improvement, Pictures
Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.
MAKING TEAM INVESTIGATIONS WORK
WHY USE A TEAM?
First, team investigations are now required for process safety related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?
Quite simply because two heads are better than one! Why? Several reasons:
- A team’s resources can more quickly investigate an incident before the trail goes cold.
- For complex systems, more than one person is usually needed to understand the problem.
- Several organizations that were involved in the incident need to participate in the investigation.
- A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrom.)
MAKING THE TEAM WORK
Investigating an incident using a team is different than performing an individual investigation. To make the team work, you need to consider several factors:
- Who to include on the team.
- The training required for team members.
- Division of work between team members and coordinating the team’s activities.
- Record keeping of the team’s meetings.
- Software to facilitate the team’s work.
- Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.
WHO’S ON THE TEAM?
The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:
- Engineering/technical assistance for hardware expertise.
- Human engineering/ergonomics experts for human performance analysis.
- Operations/maintenance personnel who understand the work practices.
- An investigation coach/facilitator who is experienced in performing investigation.
- A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
- A union rep.
- A safety professional.
TRAINING THE TEAM
A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgement to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. Hopever, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.
What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…
- Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
- Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
- People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness.
KEEPING ON TRACK
One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice.
MORE TO LEARN
This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE. Or contact us to schedule a course at your site.
You think you are having a bad day? Have a look at these pictures of a bad day in the military and you might feel better by comparison…
TapRooT® is a systematic process for the investigation of problems and root cause analysis of their causes.
If you been to one of our TapRooT® Root Cause Analysis Courses, you know the basis of TapRooT® and how to use it to find the root causes of accidents, incidents, and near-misses. You also know how to use TapRooT® proactively to stop accidents BEFORE they happen.
But for those who HAVE NOT yet attended a TapRooT® Course, here’s a link where you can learn more about how TapRooT® works.
Hope to see you at a course in the future!
Monday Accident & Lessons Learned: OPG Safety Alert #260 – Planning & Preparation … Key Elements for Prevention of MPD Well Control AccidentsPosted: October 6th, 2014 in Accidents, Investigations, Pictures
OPG Safety Alert #260
PLANNING AND PREPARATION – KEY ELEMENTS FOR PREVENTION OF MPD WELL CONTROL INCIDENTS
During drilling the 6″ reservoir section in an unconventional well, a kick-loss situation occurred. After opening the circulation port in a drillstring sub-assembly, LCM was pumped to combat losses. When LCM subsequently returned to surface it plugged the choke. Circulation was stopped, the upper auto-Internal BOP (IBOP) was activated, and the choke manifold was lined up for flushing using a mud pump. During the course of this operation mud backflow was observed at the Shaker Box. The Stand Pipe Manifold and mud pumps were isolated to investigate. After a period of monitoring the stand pipe pressure, the upper IBOP, located at the top of the drillpipe, was opened to attempt to bullhead mud into the drillstring. Upon opening, a pressure, above 6500psi and exceeding the surface system safe working pressure, was observed. The upper IBOP was closed immediately and the surface system bled down. An attempt to close the lower manual IBOP as a second barrier was not successful. Due to the presence of high pressure, the Stand Pipe Manifold could not be used as the second barrier, nor could it be used for circulation. Well control experts were mobilised to perform hot tapping and freeze operations which were successfully executed and allowed a high-pressure drillpipe tree to be installed in order to re-instate 2 barriers on the drillpipe.
What Went Wrong?
- With the down-hole circulation sub-assembly open in the drillstring, the upper IBOP was either leaking or remained open due to activation malfunction (this could not be substantiated), and a flow path developed up the drill pipe.
- The line up for flushing the Choke Manifold with the mud pumps did not allow for adequate well monitoring. The set up as used resulted in unexpected flow up the drillstring to go undetected.
- It was incorrectly assumed that monitored volume gains were due only to mud transfer.
- Assessment of flow, volume and pressure risks did not consider in sufficient detail the concurrent operations involving pumping mud off line and a pressurized drill string.
- Operational focus was on choke manifold flushing whereas supervision should have maintained oversight of the broader situation including well monitoring.
Corrective Actions and Recommendations
- Develop a barrier plan for all operational steps; always update the plan as a result of operational changes prior to continuing (ie. ensure a robust Management of Change process).
- Take the time required to verify that intended barriers are in place as per the Barrier Plan and, when activated, have operated properly (eg. IBOP’s).
- Install a landing nipple above the down hole circulation sub-assembly to allow a sealing drop dart to be run if required.
- Always close-in, or line-up, in such a way that allows for monitoring of all the closed-in pressures at all times.
- “Walk the lines” prior to commencing (concurrent) operations involving pressure and flow.
- Develop procedures in advance for flushing of the Well Control system, especially for recognisable potential cases of concurrent operations.
- Develop clear procedures covering all aspects of unconventional operations, including reasonably expected scenarios, and ensure effective communication of these to all relevant staff.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.
This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.