Author Archives: Mark Paradies
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.
Having a bad day? Look at these pictures and you might feel better by comparison …
We can help you stop bad things from happening.
Is your team trying to prevent fatalities?
Improve your root cause analysis?
Investigate a difficult incident?
Solve equipment reliability issues?
Reduce lost time accidents and workers comp costs?
Stop sentinel events?
Improve process safety?
Meet senior management improvement expectations?
We would be glad to help.
In helping companies all over the world implement TapRooT® and train their personnel to use advanced root cause analysis, we get involved in all types of performance improvement initiatives. We see what works. We see what doesn’t.
What are some common areas where we can help?
IMPROVE YOUR TapRooT® IMPLEMENTATION
We wrote the book on implementing TapRooT®. We know how it should be used and common ways to improve its use. We see best practices from around the world and we can help you catch up by applying best practices that you haven’t tried.
How do you get started? Call us at 865-539-2139. We’ll be glad to listen to the issues you face, what you’ve done so far to make improvement happen, and explain what you can do to take your program to the next level.
Our instructors are experts in applying TapRooT® to investigate problems. accidents, incidents, quality issues, sentinel events, equipment issues, production problems, and cost overruns. We don’t “do” investigations. But we can supply an an experienced TapRooT® facilitator to help your team with a tough investigation or to review an investigation that is nearing completion. Call us at 865-539-2139 or CLICK HERE to drop us a note to get the process started.
Using TapRooT® to investigate accidents and stop them from happening again is good. But is even better to use TapRooT® to stop accidents from ever occurring by being PROACTIVE.
We can show you how to apply TapRooT® proactively to stop accidents, incidents, quality issues, equipment reliability problems, production problems, or sentinel events. We actually have a specific course to teach the skills you will need to apply (Proactive Use of TapRooT® Course). You can attend the public course (next one is scheduled for June 1-2, 2015 in Las Vegas) which is offered just prior to the TapRooT® Summit. Or you can contact us to have a course at your site. And we would be glad to work with you before the course to get your proactive program set up to take advantage of the tools that TapRooT® offers.
Not only do we teach a course on Advanced Trending Techniques, we can help you apply those techniques to analyze your performance issues and help you present the findings to your management. We’ve found that many TapRooT® Users have never had experience in using trends to target improvement initiatives. So we can give you the training you need to understand trending and help you do your first trend analysis to understand how trending can be applied to prevent problems. Call us at 865-539-2139 or drop us a note to find out what we can do to help you look at your trends.
Many people use TapRooT® Software to analyze incidents. But to get the most from your software, you need to do up front business analysis to properly implement the software. Of course, we offer a course – Getting the Most from Your TapRooT® Software – to help TapRooT® Software Administrators and TapRooT® Software Super-Users learn what is needed to set up their software for best results. But we can also consult with TapRooT® Users and Software Administrators to help them develop a TapRooT® Software implementation plan. Call us at 865-539-2139 or drop us a note for more info about this service,
CREATE AN IMPROVEMENT INITIATIVE
If you are considering starting a new performance improvement initiative, why not get us involved from the ground up? We can use our knowledge of improvement programs from around the world to help you implement a world-class initiative. We can also bring in experts that we have worked with in equipment reliability, aviation safety, construction safety, nuclear safety, human factors, process safety, lean/six sigma, and patient safety to give your program a head start. Don’t try to reinvent the wheel. Let us help you get ahead of the game. Call us at 865-539-2139 to discuss your program and find out how we can help.
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That’s just a few ideas. We have many more. But you will never know how we could have helped you unless you give as a call (865-539-2139) or drop us a note. Our initial advice is FREE and we’ll be happy to provide a quote for any services, training, or software needed to help your program become world-class.
Don’t procrastinate – call today.