How Far Away is Death?

Posted: April 15th, 2014 in Video

Doesn’t take a very big mistake by the excavator operator to make this a fatality…

Monday Accident & Lessons Learned: Was the Baker Report a Failure?

Posted: April 14th, 2014 in Accidents, Performance Improvement

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For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well blowout to name the most prominent), the Baker report is a famous independent review of the failure of process safety at BP.

I was reading a discussion about process safety and someone brought up the Baker report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”

The initial Panel Statement at the start of the report includes this quote:

“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”

I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.

What do you think?

Was the report successful? Did it cause change and help BP have an improved process safety culture?

Or did the report fail to cause change across the company? 

And if it failed, why did it fail?

Let me know your ideas by leaving your comments by clicking on the comments link below.

Monday Motivation: Do You Have the Passion to Keep Going?

Posted: April 14th, 2014 in Performance Improvement, Pictures


Steve Jobs:

You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.

Short Note About the Summit

Posted: April 11th, 2014 in Pictures, Summit

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Best Summit EVER!

Had a great time and learned great new best practices.

Had people tell me that they often attend conferences and this was the best one they have ever attended BY FAR!

Another person told me that they took away practical things to improve performance from EVERY session and they were so excited that they texted, e-mailed, and called people back at work to get things implemented BEFORE they got back.

I post more next week … stay tuned!

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Friday Joke: New Type of Submarine

Posted: April 11th, 2014 in Accidents, Jokes, Pictures

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Doesn’t it need a snorkel?

How Far Away is Death?

Posted: April 8th, 2014 in Accidents, Human Performance, Video

Not too far on this day in 1983…

Pictures from the TapRooT® Pre-Summit Courses

Posted: April 7th, 2014 in Courses, Pictures, TapRooT

What does it look like attending one of the 13 pre-Summit courses? Have a look at these pictures. People are actively learning…

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Monday Motivation: Harriet Tubman

Posted: April 7th, 2014 in Performance Improvement, Pictures



Harriet Tubman:

Every great dream begins with a dreamer. Always remember, you have within you the strength, the patience, and the passion to reach for the stars to change the world.

Monday Accident & Lessons Learned: Incident Report from the UK Rail Accident Investigation Branch: Tram running with doors open on London Tramlink, Croydon

Posted: April 7th, 2014 in Accidents, Current Events, Human Performance, Investigations, Pictures

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There were eight recommendations made by the UK RAIB. here’s a summary of the investigation:

On Saturday 13 April 2013 between 17:33 and 17:38 hrs, a tram travelling from West Croydon to Beckenham Junction, on the London Tramlink system, departed from Lebanon Road and Sandilands tram stops with all of its doors open on the left-hand side. Some of the doors closed automatically during the journey, but one set of doors remained open throughout the incident. The incident ended when a controller monitoring the tram on CCTV noticed that it had departed from Sandilands withits doors open, and arranged for the tram to be stopped. Although there were no casualties, there was potential for serious injury.

The tram was able to move with its doors open because a fault override switch, which disables safety systems such as the door-traction interlock, had been inadvertently operated by the driver while trying to resolve a fault with the tram. The driver didnot close and check the doors before departing from Lebanon Road and Sandilands partly because he was distracted from dealing with the fault, and partly because he did not believe that the tram could be moved with any of its doors open. The design of controls and displays in the driving cab contributed to the driver’s inadvertent operation of the fault override switch. Furthermore, breakdowns in communication between the driver and the passengers, and between the driver and the controller, meant that neither the driver nor the controller were aware of the problem until after the tram left Sandilands.

The RAIB has made eight recommendations. Four of these are to Tram Operations Ltd, aimed at improving the design of tram controls and displays, as well astraining of staff on, and processes for, fault handling and communications. Two recommendations have been made to London Tramlink, one (in consultation with Tram Operations Ltd) relating to improving cab displays and labelling and one on enhancing the quality of the radio system on the network. One recommendation is made to all UK tram operators concerning the accidental operation of safety override switches. The remaining recommendation is to the Office of Rail Regulation regarding the provision of guidance on ergonomics principles for cab interface design.


For the complete report, see:

It’s Summit Week!

Posted: April 7th, 2014 in Summit

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It’s Summit week so you will probably mniss some of our posts on current events because we are at the Summit!

However, we will try to keep you updated with the latest Summit news.

Stay tuned for updates!

Glen Deveaux dies after accident while vacationing in Mexico

Posted: April 6th, 2014 in Accidents

Thought that I’d pass along this sad news to all the TapRooT® Users who knew Glen from previous TapRooT® Summits, or who had worked with him.

Glen had an accident in February while on vacation and died yesterday after surgeries to try to save his life.

I do not have any information about where to send condolences to his family or any memorials, but if other TapRooT® Users have information, please post it in the comments.






Was it Taxes, Bad Decicions, or a “Complex Chain of Events” that caused the grounding of the drilling rig Kulluk near Kodiak Island?

Posted: April 4th, 2014 in Accidents, Current Events, Investigations


Alaska winters are notorious. And the seas in the Gulf of Alaska are particularly bad in mid-winter. The Houston Chronicle reported that Rear Admiral Thomas Ostebo said, “the most significant factor was the decision to attempt the voyage during the winter in the unique and challenging operating environment of Alaska.”

Interestingly, Shell may have been encouraged to move the rig because if they didn’t, they might have to pay the state of Alaska a multi-million dollar tax bill. 

See the whole story at:

2014 TapRooT® Charity Golf Tournament Pairings

Posted: April 3rd, 2014 in Summit

Yes! It is time again for the TapRooT® Charity Golf Tournament that supports the Oasis of Love Women’s Shelter. 

This year the tournament is being held at the Horseshoe Bay Golf Club near Austin, TX.

There’s still time to sign up. See more details by CLICKING HERE.

And the pdf below shows the preliminary team pairings (subject to change with additional registrations).

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We’ll see who can put together the best combination of skill and luck to win the coveted TapRooT® Cup.

Root Cause Analysis Tip: Targeting Investigations

Posted: April 2nd, 2014 in Root Cause Analysis Tips




A client complained, “I just can’t get everything investigated using TapRooT®.” I asked, “What are you investigating?”

The answer?


They were investigating lost-time injuries, medical treatment cases, reportables, near-misses, equipment failures, quality issues, issues management was interested in, the list went on and on …

Don’t get me wrong, I think you can learn valuable information from investigations of small problems. But you have to have a limit. They needed to target their investigations on their highest priority improvements. They need to answer the question: “What are the most important things to improve?”

For example, if your objective is to prevent fatalities, you certainly would investigate fatalities. But you would also investigate incidents with the potential for fatalities. They could be medical treatment cases, near misses, equipment failures, or even serious rule violations. But you would NOT investigate problems that could not produce a fatality … even if it might be a lost-day or medical treatment case. That’s focus!

When resources are scarce, you must focus on your most important improvement opportunities. Once fatalities have been eliminated you can target your efforts on the next issue.

This focus helps you manage your improvement initiative to fit your resources. What if you don’t have enough resources for your most important improvement initiative? Then you have justification to ask for additional resources for the high priority objective.

Don’t be overwhelmed. There are only 24 hours in a day. Target your investigations.


How Far Away is Death?

Posted: April 1st, 2014 in Pictures

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Preliminary (Spring) SnapCharT® of the Lost Flight MH 370

Posted: March 31st, 2014 in Accidents, Current Events, Documents, Investigations, Pictures

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(Photo of remains from cockpit fire of an Egypt Air 777 while parked at a gate in Cairo)


One of our TapRooT® Users sent the attached PDF of a SnapCharT® for the loss of Malaysia Air MH 370. 

Have a look. See what you think. Then leave comments here…


Three Mile Island Accident Anniversary: The Nuclear Industry Discovers Human Factors

Posted: March 28th, 2014 in Accidents, Human Performance, Investigations


Five days of panic. 140,000 residents voluntarily evacuate. Fourteen years of clean-up.

The 35th anniversary of the Three Mile Island Nuclear Disaster.

On the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I can still remember that morning.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

the midnight shift on March 28, 1979, things started to go wrong at TMI. A simple instrument problem started a chain of events that led to a core meltdown.

I was learning to operate a nuclear plant (S1W near Idaho Falls, ID) at the time. I can still remember that morning. I was in the front seat of the bus riding out to the site. The bus driver had a transistor radio on and the news reported that there had been a nuclear accident at TMI. They switched to a live report from a farmer across the river. He said he could smell the radiation in the air. Also, his cows weren’t giving as much milk.

Years later, I attended the University of Illinois while also being a Assistant Professor (teaching midshipmen naval weapons and naval history). I was the first in a new program that was a cooperative effort between the Nuclear Engineering and Psychology Departments to research human factors and nuclear power plants. My advisor and mentor was Dr. Charles O. Hopkins, a human factors expert. In 1981-1982, he headed group of human factors professionals who wrote a report for the NRC on what they should do to more fully consider human factors in nuclear reactor regulation.


As part of my studies I developed a course on the accident at TMI and published my thesis on function allocation and automation for the next generation of nuclear power plants.

So, each year when the anniversary of the accident comes around I think back to those days and how little we have learned (or should I say applied) about using good human factors to prevent industrial accidents.


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