Author Archives: Mark Paradies

Do You Follow the Instructions? (Miller Auto Darkening Helments)

Posted: December 19th, 2014 in Current Events, Pictures

A TapRooT® User sent us this warning to distribute …

 Miller Auto Darkening Helmets 

The manufacturer’s safety instructions found in the top of the Miller Auto Darkening Helmet states the following:
Do not weld in the overhead position while using this helmet.

This warning was noticed by Vale employees after reading the warning label in the top of the helmet.

Although auto darkening helmets are an often used tool, they must be used as per manufacturer’s directions and design.

Please see the pictures below for further clarification.

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Friday Joke: Make It So!

Posted: December 19th, 2014 in Jokes, Video

PC World Headline: “Human error root cause of November Microsoft Azure outage”

Posted: December 18th, 2014 in Current Events, Root Causes

There they go again. HUMAN ERROR as a root cause.

See the story at: http://www.pcworld.com/article/2860936/human-error-root-cause-of-november-microsoft-azure-outage.html

Haven’t they read my article at:

http://www.taproot.com/archives/44542

Human error is a symptom, not the root cause.

Attend a TapRooT® Course and find out how you can find and fix the real causes of human error.

What does a bad day look like?

Posted: December 18th, 2014 in Pictures

Next time it is snowing, and you think you are having a bad day … it could be worse …

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Keeping TapRooT® Investigations Out of Court

Posted: December 18th, 2014 in Accidents, Investigations, Performance Improvement

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We would all agree that performing accident investigations and investigations of quality issues to prevent repeat accidents is a good idea. But some may be reluctant to perform investigations because of the legal liability they think the investigation report may represent.

Of course, they are at least partially right. Frequently, significant accidents result in lawsuits. And if your investigators aren’t careful, they may put poorly chosen words or even un-true statements in their investigation report. Thus, company counsel or outside counsel may prefer that the actual accident investigation reports be excluded from evidence in a court proceeding to reduce the liability that an accident investigation report may represent.

Excluding a report performed after an accident to look for ways to prevent future accidents is a protected activity under federal law. FRE Rule 407. Subsequent Remedial Measures, states:

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

How can you help preserve your right to exclude your report from discovery and use at trial? Outside counsel for one of our clients has suggested that all TapRooT® users add one of the following preambles or appendices to every TapRooT® Investigation. We thought this sounded like a good idea and so we are passing along the following preambles or appendices for you to consider when writing your investigations….

For safety investigations at a company, the preamble suggested by the attorneys was as follows:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

COMPANY TapRooT® Investigation Preamble

In order improve COMPANY’s overall safety performance and to prevent or significantly reduce the likelihood of the same or a similar work-related incident/injury/illness (“incident”) from reoccurring, COMPANY conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant performance problems and/or equipment failures that may arise from time to time during its operations. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow COMPANY to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within COMPANY’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes COMPANY management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of COMPANY’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures COMPANY may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging COMPANY to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage COMPANY to take, or at least not discourage them from taking steps in furtherance of added safety.

Incidents, injuries and illness may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors and/or vendors. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT® inasmuch as COMPANY management has no control over errors made by these vendors except expected conformance with their duties owed to COMPANY.

Even though COMPANY makes every effort to determine what happened during an incident and to minimize future incidents through the COMPANY investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT® determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside COMPANY retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

For quality investigations subsequent to an issue with a product, the following preamble/appendix is suggested:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

VENDOR TapRooT® Investigation Preamble

In order improve VENDOR’s overall quality performance and to prevent or significantly reduce the likelihood of the same or a similar quality issues from reoccurring which may lead to work-related incident/injury/illness or client related issues (“incident”), VENDOR conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant quality and/or performance problems and/or equipment failures that may arise from time to time during the use or manufacture of its products. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow VENDOR to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within VENDOR’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes VENDOR management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of VENDOR’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures VENDOR may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging VENDOR to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage VENDOR to take, or at least not discourage them from taking steps in furtherance of added safety and quality.

Incidents, injuries, illness, and quality issues may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors, vendors, and/or clients. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT inasmuch as VENDOR management has no control over errors made by these third parties except expected conformance with their duties owed to VENDOR.

Even though VENDOR makes every effort to determine what happened during an incident and to minimize future incidents through the VENDOR investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside VENDOR retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

Of course, before adopting any advice to reduce potential liabilities in future courtroom actions, you should consult your own in-house or outside counsel. They may modify the forms provided above or have other wording that they prefer.

So consider the advice provided above and get your own protective wording added to all your standard reports. We are looking at ways to add this to the TapRooT® Software and we’ll let you know when we’ve figured out a way to do it. Until then, we suggest manually adding the wording to your official final reports.

How Far Away is Death?

Posted: December 16th, 2014 in Pictures

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Can TapRooT® Help You Stop Quality Issues?

Posted: December 16th, 2014 in Performance Improvement, Quality, Root Cause Analysis Tips

Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:

“Can TapRooT® be used to solve quality issues?”

I was surprised by the question. Of course, the answer is YES!

We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.

Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?

The only answer was … We had not told him!

Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors. 

Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.

For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.

That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.

So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!

Attend one of our public 2-Day, 3-Day, or 5-Day TapRooT® Courses and find out how well TapRooT® can help you solve your toughest issues.

Monday Accident & Lessons Learned: OPG Safety Alert 262 – Shallow Gas Leads to Well Control Incident

Posted: December 15th, 2014 in Accidents, Current Events, Investigations

SHALLOW GAS LEADS TO WELL CONTROL INCIDENT

  • The well is located in a well-known, shallow gas prone area.
  • Deep gas wells with high pressurized layers.
  • Crowded platforms with wells anti-collision complex management.
  • SIMOPS including construction and well intervention
  • After each incident, procedures for shallow section drilling were enhanced.

The sequence of events were:

  • 0:00 – Skid rig on well. Batch drilled 12 ¼’’ hole section + 9 5/8’’ intermediate casing
  • 08:30 – Cleaned out CP 24’’ with 17 ½’’ BHA to 131m
  • 16:30 – Drilled 12 ¼’’ hole to 286m with 1.15+ SG mud. Heavy losses (67 m3/h)
  • 20:20 – Homogenize mud to 1.12 SG
  • 20:33 – Resume drilling to 296m. Heavy losses (70 m3/h)21:10 – Spot 10m3 LCM pill. POOH wet.
  • 22:20 – Well swabbing and started to flow. Closed diverter. Started pumping 1.12 SG mud at high flow rate.
  • 23:04 – Pumped kill mud 1.50 SG, followed by sea water at high rate.
  • 00:30 – Flow outside CP. Well out of control. Full rig evacuation.

What Went Wrong?

The cause of the incident could be listed as follows:

1. Supervision on rig

  • POOH wet (no pump out)
  • Continue with pulling operations, despite swabbing, until well kicked in. Shallow gas procedure not followed

2. Mud weight

  • Inconsistency in MW control and reporting
  • Pack off at 291m interpreted as a (new) loss zone

3. Documentation

  • No comprehensive instructions concerning total loss situation

Corrective Actions and Recommendations

  • Maintain a continuous awareness on shallow gas hazard, even when the shallow gas section has already been penetrated in other wells. This aims at avoiding routine approach hence complacency.
  • The standard drilling Instructions should be enriched and reinforced with lessons learnt e.g. Management of Change, the required concentration of KCl for the top hole section, the threshold of heavy losses, hole cleaning procedure for the top hole, responsibility assignment for key personnel, ‘Ready to drill’ checklist.

Disclaimer

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.

Safety Alert Number: 262
OGP Safety Alerts http://info.ogp.org.uk/safety/

Friday Joke: Safety Santa

Posted: December 12th, 2014 in Jokes, Pictures

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What does a bad day look like?

Posted: December 11th, 2014 in Pictures

The sun is shinning, you have a new convertible, … what could go wrong?

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See, don’t you feel better already? (By comparison.)

Plan a Trip to Roma Next Spring … And Get Some Great TapRooT® Training!

Posted: December 10th, 2014 in Courses, Pictures, TapRooT, Video

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Rome is a great place for a spring vacation. The sights, the food, and the shopping are amazing!

And when you can combine the trip with some great TapRooT® Training (a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course), you are getting two great experiences at once!

The 2-Day TapRooT® Course is a great value. In two days you will learn how to apply the standard TapRooT® Tools (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, the Corrective Action Helper®, and SMARTER) to find and fix the root causes of problems.

What kind of problems can you solve using TapRooT®?

  • Major safety accidents
  • Drug/medical device quality issues
  • Medical sentinel events
  • Process safety accidents/incidents
  • Equipment reliability issues
  • Neat-miss accidents
  • Production issues
  • Cost overruns
  • Schedule slippage issues
  • Customer complaints
  • Security issues
  • Product waste issues
  • Hardware/software failures

And that’s just to name a few!

And the instructors scheduled to teach the course are Mark Paradies and Linda Unger – the inventors of TapRooT®!

The course is being held at a great hotel in the center of Rome. Watch this video for a bird’s eye view of the location…

 

Here’s the hotel’s web site:

http://www.hotelnazionale.it

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As you can see, the hotel is just a couple of blocks from the Pantheon. And near many of Rome’s tourist attractions.

You probably won’t get an opportunity like this again. Because this course is so special, you should register today for the March 18-19, 2015 course to make sure you save your spot! Also, get your hotel reservation set. You don’t want to miss this great training in a great location.

How far Away is Death?

Posted: December 9th, 2014 in Pictures

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How much money can TapRooT® save your company?

Posted: December 9th, 2014 in Performance Improvement

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s a 40000% instant ROI.

That made me think … do TapRooT® Users think about how much they are saving their company?

Do they track the savings?

Do they know how much problems are costing their company and have a goal for cost saving?

Let me know if you have saved money for your company by leaving a note below as a comment…

Monday Accident & Lessons Learned: Fatal Auto Accidents

Posted: December 8th, 2014 in Accidents, Performance Improvement, Pictures

REDWRECK

If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.

When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?

What is the difference?

Why are fatal traffic accidents seemingly acceptable?

Could we learn from fatal car accidents and make sure they never happen again?

What would have to change to make this learning possible?

Could we save 10,000, 20,000, or 30,000 lives per year here in the US?

Friday Joke: Snow Day Fun…

Posted: December 5th, 2014 in Jokes, Video

What does a bad day look like?

Posted: December 4th, 2014 in Pictures

Sometimes a good day is just so close…

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Building a Nuclear Plant – 5 Years in 2 Minutes

Posted: December 4th, 2014 in Video

Still lot’s more to go!

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