Author Archives: Mark Paradies
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The last paragraph of the article was:
“Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.“
So here is what the Aiken Standard wrote about the SRNS root cause analysis:
“Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”
What do you think? Did they look into Management System causes?
If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident?
In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures.
I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes.
This is how a culture of expediency exists alongside a culture of blame.
What can you learn from this incident?
One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame.
Had an interesting discussion today about cross industry / cross discipline performance improvement benchmarking.
It seems that many people benchmark inside their industry. Oil industry people benchmark with oil industry people. Heathcare with Healthcare. Nuclear with Nuclear. The list goes on and on.
Also, safety people go to safety conferences. Quality people go to quality conferences. Maintenance and reliability people go to maintenance and reliability conference.
So, I had someone ask me where they could do cross industry/cross discipline benchmarking. Nuclear safety people with Pharmaceutical Quality folks. Aviation safety folks with healthcare quality people. Refining process safety folks with Aviation safety people.
The answer? Plan on attending the 2016 Global TapRooT® Summit on August 1-5 in San Antonio.
We don’t have the final schedule out yet but it will be out soon. But I can guarantee that there will be sessions from all sorts of experts and people attending from all sorts of industries and disciplines. That’s what is so special about the TapRooT® Summit. We make a special effort to get people from different industries and different disciplines together to meet, make friends, and benchmark their improvement initiatives.
So start planning to attend.
There will be people there from all over the world.
And consider bringing a team from your company that includes people from safety, process safety, quality, operations, and maintenance. Contact us by clicking HERE for information about group discounts.
Hope to see someone from every TapRooT® User company (and some folks who are only thinking about using TapRooT®) there!
Like this for a sports writer … Howard will never live this one down …
With an MS in Nuclear Engineering, I couldn’t help but post this video…
Think they will need root cause analysis?
System Improvements is a member company of CCPS.
What could happen when this lets go?
An article in the Aiken Standard got me thinking again about the topic of safety stand-downs (this time called a “safety pause”).
These temporary “stop work” activities where safe work practices are suppose to be reviewed, and where new emphasis is suppose to be applied to ensure safety, are common in government operations (this time a DOE site) and the nuclear industry. I’ve written about them before:
- Monday Accident & Lessons Learned: When is a “Safety Standdown” a “Standdown”
- Monday Accident & Lessons Learned: Mistakes at TVA Reactors Results in Safety Stand Down
- Nuclear Plant “Near-Miss” in Canada Leads to Safety Stand Down
- 22 Near-Fatal Accidents in 12 Months at a UK Steel Mill – Is a Safety Standdown Adequate?
The safety pause at Savannah River Nuclear Solutions is a really long pause. It started on September 11 after a September 3 incident in the H Canyon – HB Line portion of their operations where Plutonium was being handled.
An SRNS spokesperson is quoted by the paper as saying that: “SRNS is a stronger, healthier company as a result of these actions and we are working for sustained improvement.”
Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the “pause” to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.
If you are a hospital, and you send the wrong body to a member of Parliments family … that’s a bad day!
See the story here.
In 2011 the mining recession started. The price of commodities (iron ore, copper, and other metals) suffered when demand from China dropped. This recession was somewhat independent from the housing crash of 2008.
What is the natural tendency of an industry faced with falling prices and falling demand? To cut costs. And that happened across the mining industry.
The Wall Street Journal is now pointing to the increased number of fatalities at large mining companies “when most are enacting heavy cost cuts as they battle to remain profitable amid a downturn in world commodity prices.” (See articles here and here.)
This negative press coverage by the WSJ resulted from the recent dam failure at a mine co-owned by BHP and Vale (the mine operator is named Samarco) (see article here).
Has cost cutting led to increased mining accidents? Will falling oil prices result in more oil industry fatalities? It is difficult to prove a cause and effect link but statistics point to negative trends.
The Wall Street Journal story above raises a great question. How effective is a federal prosecution in improving corporate and employee behavior?
Of course, the article was written by Kurt Mix, the accused, but it seems to raise very valid points that government investigations can go out of control, and that individuals have a very hard time fighting back against “the system.”
Why is the advice of any good attorney to “say nothing” to a criminal investigator before you have an attorney advising you? Because you may not know what serious laws you are breaking by what you see as non-criminal behavior.
Can this “don’t talk” advice make it harder for investigators to find the root causes of an accident? You bet!
So the next time you think that a criminal investigation is the answer to improve safety performance, maybe you should think again.
IOGP SAFETY ALERT
WELL KICK DUE TO LINER TOP SEAL FAILURE
After several attempts and a dedicated leak detection run, the 7” and 5” x 4-1/2” liner were inflow tested successfully to max difference of +10 bar.
Ran completion in heavy brine and displaced well to packer fluid (underbalanced).
Rigged up wireline pressure control equipment to install plug and prong in tubing tailpipe. While RIH with the plug on WL, a sudden pressure increase was observed in the well. Pressure increased to 125 bar on the tubing side.
Attempted to bleed off pressure, but pressure increased to 125 bar immediately.
Continued operation to install plug, pressure up tubing and set production packer.
Performed pump and bleed operation to remove gas from A-annulus. The general gas alarm was triggered during his operation due to losing the liquid seal on the poorboy degasser.
Continued pump and bleed operation until no pressure on tubing and A-annulus side, and the tubing and A-annulus were tested successfully.
What Went Wrong?
Failure of the 5″ liner hanger and 5″ tie-back packer.
Corrective Actions and Recommendations:
Difficult to bleed out gas in a controlled way due to sensitive choke and no pressure readings from poorboy degasser.
When performing pump and bleed operations, line up to pump down one line and take returns in a different line to optimize the operation.
Consider adequacy of the testing of the 5″ liner hanger.
Safety Alert Number: 267
IOGP Safety Alerts http://safetyzone.iogp.org/
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.
The new EPA emission regulation (not yet published in the Federal Register, but available here), requires a root cause analysis and corrective actions for upset emission releases including flare events.
Not only is a root cause analysis with corrective actions required, but a second event from the same equipment for the same root cause would trigger a diviation of the standard (read “fine”). In addition, the same device with more than 3 events per 3 years or the combination of 3 releases becomes a deviation.
This means it is time for effective, advanced root cause analysis of emission events. Time to send your folks to TapRooT® Root Cause Analysis Training!