Author Archives: Mark Paradies

Times are Tough … How Can TapRooT® Root Cause Analysis Help?

Posted: February 4th, 2016 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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Many industries have dropped into a recession or a downright depression.

Oil, coal, iron ore, gas, and many other commodity prices are at near term (or all time) lows.

When the economy goes bad, the natural tendency is for companies to cut costs (and lay people off). Of course, we’ve seen this in many industries and the repercussion have been felt around the world.

Since many of our clients are in the effected industries, we think about how we could help. 

If you could use some help … read on!

FIRST

I think the first way we can help is to remind TapRooT® Users and management at companies that use TapRooT® that in hard times, it is easy for employees to hear they wrong message.

What is the wrong message?

Workers and supervisors think that because of the tough economic times, they need to cut corners to save money. Therefore, they shortcut safety requirements.

For example:

  • A mechanic might save time by not locking out a piece of equipment while making an adjustment. 
  • An operator might take shortcuts when using a procedure to save time. 
  • Pre-job hazard analyses or pre-job brief might be skipped to save time.
  • Facility management might cut operating staff or maintenance personnel below the level needed to operate and maintain a facility safely.
  • Supervisors may have to use excessive overtime to make up for short staffing after layoffs.
  • Maintenance may be delayed way past the point of being safe because funds weren’t available.

These changes might seem OK at first. When shortcuts are taken and no immediate problems are seen, the decision to take the shortcut seems justified. This starts a culture shift. More shortcuts are deemed acceptable. 

In facilities that have multiple Safeguards (often true in the oil, mining, and other industries that ascribe to process safety management), the failure of a single Safeguard or even multiple Safeguards may go unnoticed because there is still one Safeguard left that is preventing a disaster. But every Safeguard has weaknesses and when the final Safeguard fails … BOOM!

This phenomenon of shortcuts becoming normal has a PhD term … Normalization of Deviation

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The result of normalization of deviation? Usually a major accident that causes extensive damage, kills multiple people, and ruins a company’s reputation.

So, the first thing that we at System Improvements can do to help you through tough times is to say …

WATCH OUT!

This could be happening to your operators, your mechanics, or your local management and supervision. 

When times are bad you MUST double up on safety audits and management walk arounds to make sure that supervisors and workers know that bad times are not the time to take shortcuts. Certain costs can’t be cut. There are requirements that can’t be eliminated because times are tough and the economy is bad. 

SECOND

When times are tough you need the very BEST performance just to get by.

When times are tough, you need to make sure that your incident investigation programs and trending are catching problems and keeping performance at the highest levels to assure that major accidents don’t happen.

Your incident investigation system and your audit programs should produce KPI’s (key performance indicators) that help management see if the problems mentioned above are happening (or are being prevented).

If you aren’t positive if your systems are working 100%, give us a call (865-539-2139) and we would be happy to discuss your concerns and provide ideas to get your site back on the right track. For industries that are in tough times, we will even provide a free assessment to help you decide if you need to request additional resources before something bad happens. 

Believe me, you don’t want a major accident to be your wake up call that your cost cutting gone too far.

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THIRD

How would you like to save time and effort and still have effective root cause analysis of small problems (to prevent big problems from happening)? 

For years I’ve had users request “TapRooT®-Lite” for less severe incidents and near-misses. I’ve tried to help people by explaining what needed to be done but we didn’t have explicit instructions.

Last summer I started working on a new book about using TapRooT® to find the root causes of low-to-medium risk incidents. And the book is now finished and back from the printers.

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Good news:

  • The book is only 50 pages long.
  • It makes using TapRooT® easy.
  • It provides the tools needed to produce excellent quality investigations with the minimum effort.
  • It will become the basis for our 2-Day TapRooT® Root Cause Analysis Course.

When can you get the book? NOW! Our IT guys have a NEW LINK to the new book on our store.

By April, we should have our 2-Day TapRooT® Course modified and everything should be interlinked with our new TapRooT® Version VI Software.

In hard economic times, getting a boost in productivity and effectiveness in a mission critical activity (like root cause analysis) is a great helping hand for our clients.

The new book is the first of eight new books that we will be publishing this year. Watch for our new releases and take advantage of the latest improvements in root cause analysis to help your facility improve safety, quality, and efficiency even when your industry is in tough economic times. For more information on the first of the new books, see:

http://www.taproot.com/products-services/taproot-book

FINALLY

If you need help, give us a call. (865-539-2139)

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Are you having a backlog of investigations because of staff cuts? We can get you someone to help perform investigations on a short term basis.

Need to get people trained to investigate low-to-medium risk incidents effectively (and quickly)? We can quote a new 2-Day TapRooT® Root Cause Analysis Course t to be held at your site.

Need a job because of downsizing at your company? Watch the postings at the Root Cause Analysis Blog. We pass along job notices that require TapRooT® Root Cause Analysis skills.

This isn’t the first time that commodity prices have plummeted. Do you remember the bad times in the oil patch back in 1998? We helped our clients then and we stand by to help you today! We can’t afford to stop improvement efforts! Nobody wants to see people die to maintain a profit margin or a stock’s price. Let’s keep things going and avoid major accidents while we wait for the next economic boom.

Will They Really Find the Root Causes?

Posted: February 3rd, 2016 in Current Events, Investigations, Pictures

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

What does a bad day look like?

Posted: February 3rd, 2016 in Video

They try to make this sound like a good day … but when you wreck your boat … it is never a good day.

Eagle Takes Down a Drone

Posted: February 2nd, 2016 in Video

I thought this was interesting …

Friday Joke for Nukes …

Posted: January 29th, 2016 in Jokes, Pictures

Screen Shot 2015 02 20 at 8 41 57 AM

What does a bad day look like?

Posted: January 27th, 2016 in Video

Monday Accident & Lessons Learned: UK RAIB Report – Collision at Froxfield

Posted: January 25th, 2016 in Accidents, Current Events, Investigations, Pictures

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Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)

 

RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015

 

At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.

The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.

The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.

Recommendations

RAIB has made four recommendations relating to the following:

  • installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
  • enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
  • introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.

RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles

Notes to editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
  2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
  3. For media enquiries, please call 020 7944 3108.

For the complete report, see:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493315/R022016_160120_Froxfield.pdf

What does a bad day look like?

Posted: January 20th, 2016 in Video

Warning – this guy goes off the deep end – strong/foul language – don’t listen if you would be offended.

What does a bad day look like?

Posted: January 13th, 2016 in Video

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