It is the largest environmental settlement ever.
BP will pay the US Government,Alabama, Florida, Louisiana,Mississippi, and Texas $18.7 billion to compensate for environmental damage done by the Deepwater Horizon spill.
“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.
No matter what the industry and even if the root causes found for an issue were accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions while on the other extreme, some use the Trial and Error Method… with a little bit of.. this is good enough and they will tell us if it doesn’t work.
You can use the formal methods listed above or it can be as simple for some risks, to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with a couple of basic rules first:
1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)
2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. Hint, it is okay to use outside sources too.
3. Never forget or lose site of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!
4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.
Simple… yes? maybe? Feel free to post your examples and thoughts.
The Chicago Tribune reported “Fall from ladder nets Merrillville man $2.4 million jury verdict.”
Part of the reason that the company was found liable is that the ladder was “out of code.” It had been produced before standards for ladders were developed.
Have any old ladders out there that need to be replaced?
Is thinking that you are the best a sign of potential problems? (Especially for “routine” work?)
By any measure, the X-31 was a highly successful flight research program at NASA’s Dryden Flight Research Center, now the Armstrong Flight Research Center. It regularly flew several flights a day, accumulating over 550 flights during the course of the program, with a superlative safety record. And yet, on Jan. 19, 1995, on the very last scheduled flight of the X-31 ship No. 1, disaster struck.
View the video below or read about it here: http://www.nasa.gov/centers/dryden/news/X-Press/stories/2004/013004/new_x31.html
Leave your comments below. Complacency? Leave your comments below.
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
A tragic workplace accident.
A life lost.
You see the resolve on the faces in this video to never lose a co-worker … a friend … to this type of accident again.
What do you think about “paying attention” for preventing potential tragedies such as this? Leave your comments below and let’s share ideas to find and fix root causes.
What do you think of this accident investigation and lessons learned?
What can you learn from a 1964 video?
How they viewed human performance was certainly different.
What do we know that helps us do better today?
Could better root cause analysis have helped them then? After all, an engine failure in a helicopter is a serious accident to blame on the pilot.
Could root cause analysis help learn more from this accident? How about a Safeguards Analysis before you hunt?
When a major accident happens, look out. The tradition is for “heads to roll.”
That’s right, people get fired.
Who get’s fired? Those that are seen as “part of the problem.”
You need to be part of the solution.
Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.
Then you are part of the answer … Not part of the problem.
Or you could just sit around and wait to get fired.
The choice is yours.
Get trained to use TapRooT® root cause analysis to solve problems. See:
Accident News: The Washington Times Reports “Amtrak train from D.C. derails in Philadelphia; 6 dead, dozens injured”May 13th, 2015 by Mark Paradies
I read an article in the Houston Chronicle about failed corrective actions at Blue Bell® Ice Cream.
It made me wonder:
“Did Blue Bell perform an adequate root cause analysis?”
Sometimes people jump tp conclusions and implement inadequate corrective actions because they don’t address the root causes of the problem.
Its hard to tell without more information, but better root cause analysis sure couldn’t have hurt.
Find out how TapRooT® Root Cause Analysis can help find and fix the root causes of problems by reading about TapRooT®’s history at:
On May 5, 1988, one of United States’ worst oil refinery explosions occurred in Norco, Louisiana. There were six employees that were killed and 42 local residents injured. The blast was said to have reached up to 3o miles away shattering windows, lifting roofs and sending a black fog over the entire town of Norco. Residents were forced to evacuate while officials died the fires down and gathered as much rubble as possible to recover any bodies. In order to discover the root cause of this disaster, the Federal Occupational Health and Safety Administration as well as the Environment Protection Agency came and investigated the scene to gather information. The only possible root cause they could find was the catalytic cracking unit, machine used to break down crude oil into gasoline, because it was at the center of the explosion, but there was no definite cause found. Overall, the amount of damage done cost Shell millions of dollars and set an incredible amount of fear into the residents.
Click below to download a report from the European Major Accidents Reporting System (eMARS) about contractor related safety.
Monday Accident & Lessons Learned: How Many People Will Die Waiting for Management to Implement an Effective Improvement Program?April 27th, 2015 by Mark Paradies
You see the results of ineffective improvement programs in the headlines …
Ten Die in Refinery Explosion
Four Asphyxiated in Confined Space Accident
Fire Kills There Workers
Forklift Accident Kills Teenage Worker
Scaffold Collapse Kills Two Construction Workers
Trench Collapse Kills Father of Three
Welder Killed When Tank Explodes
Eleven Killed in Offshore Platform Explosion
Mine Accident Kills 13
Perhaps you think these were just bad days. That accidents just happen. The truth is that most fatalities are the result of bad programs. They were accidents waiting to happen. If management had effective reactive and proactive improvement programs, these accidents, and others ones like them, would not have had to happen.
- Why didn’t management push for better safety improvement?
- Why wasn’t improving their improvement program one of their highest (or their highest) priority?
- How many people have to die to get management’s attention and make them get excited about investing in effective improvement?
The fatalities continue while we wait for the answer.
If YOU are excited about improving your improvement program and PREVENTING FATALITIES, I have a few ideas for you …
- Take your senior manager on a hazard walk around. Go to one or two places in your plant and challenge the manager to spot all the hazards (sources of energy that could cause a fatality). Did they miss height, lack of breathable air, moving equipment, or other sources that you have seen? Next, take several sources of energy and ask what are the safeguards that keep a fatal accident from happening. Then ask for each safeguard, when was the last time that the manager heard of an audit of the effectiveness of that safeguard? When was the last time the manager checked the effectiveness of that safeguard? Do this once a week and the manager will start thinking hazards, safeguards, and audits of safeguards effectiveness.
- Take your manager to the 2015 TapRooT® Summit. They will network with the leaders in performance improvement that attend the Summit and they can benchmark their improvement efforts against others. They will probably find that they have some good practices to share. But they will also discover some gaps in their programs that need improvement and best practices to make that improvement occur.
- Have on-site training for your management team. Consider the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. Or the Proactive Use of TapRooT® Course. One company even had all their Senior Project Managers (who manage construction programs over $500 million) attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. One of these senior managers pulled me aside to tell me that it was the most valuable management training he had ever had!
Don’t just sit around waiting for management to get excited about improvement after major accident. Prevent the accident. Get them excited about preventing fatalities!
In the city of Chernobyl, Ukraine in April of 1986, there was a major accident in the city’s largest nuclear power plant. The inadequately trained personnel paired with a flawed reactor design did not produce smooth results. The lack of safety precautions caused a steam explosion and fire that released 5% of the radioactive reactor core into the environment. Onsite death toll totaled to two plant workers, however, the overall death toll, due to the release of the radioactive poison, totaled to 56. In order to decrease the amount of poison released and put the fires out, officials poured sand and boron over the entire site. Additionally, they covered the plant with a concrete structure, but that still did not prevent all the residents from relocating and over 9,000 of them being diagnosed with cancer several months later.
Read this article from the United States Nuclear Regulatory Commission for more detailed information: http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/chernobyl-bg.html
Below is a video of the 20 year anniversary news story that ABC News covered in 2006. Take a look at just how deadly and devastating this accident was.
Being proactive is just one way you can help prevent a catastrophic event such as this one. Learn root cause analysis techniques to investigate near-misses, and take proactive steps to avoid a major disaster. (Click here to find out more about TapRooT® Root Cause Analysis Training.)
As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section:
“Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 for more than 160 million work-hours. This equals one lost-time incident for every 6.2 million hours on the job. These numbers are a testament to our safety record and a reason why we are in the top tier of safest companies in the industry.”
CB&I’s lost time incident rate is 50 times better than the industry average (.03 compared to 1.5). That might make you wonder, how do they do that?
Answering that question is learning from a lack of accidents!
Here are a couple of thoughts that I have…
First, when you see this kind of success, you know it is because of management, supervisory, and employee involvement in accomplishing a safe workplace. Everybody has to be involved. There can’t be finger pointing and blame. Everybody has to work together.
Second, I know CB&I is a TapRooT® User. CB&I has trained TapRooT® Investigators to find and fix the root causes of incidents and, thereby, keep major accidents (LTI’s and fatalities) from occurring.
So, congratulations CB&I on your excellent performance! Congratulations on the lives you have saved and the injuries you have avoided!
If you are interested in having industry leading safety performance, perhaps you should get your folks trained to find and fix the root causes of problems by using advanced TapRooT® root cause analysis. Find out about our courses at THIS LINK.
And consider attending the 2015 Global TapRooT® Summit on June 1-5 in Las Vegas. You can:
- meet industry leaders who are achieving world-class performance
- benchmark your programs with their programs
- learn industry leading best practices
- get motivated to take your safety performance to the next level.
See the 2015 Global TapRooT® Summit schedule at:
Watch this video and see if you think they learned all the lessons they should have learned …