Category: Accidents

1947 Centralia Mine Disaster

March 25th, 2018 by

On March 25, 1947, the Centralia No. 5 coal mine exploded in Illinois. The explosions took the lives of 111 mine workers. At the time of the explosion, 142 men were in the mine. 65 of these men were killed by burns and the violence of the explosion, and 45 of the men were killed by afterdamp. Only 8 men were rescued, but unfortunately one of the rescued men died due to the effects of afterdamp. The other 24 men were able to escape the mine unaided.

So, what happened? The coal mine was extremely dry and dusty, and there were large deposits of coal dust throughout the mine. Very little effort had been made to to clean/load out excessive dust. Also, water had not been used to allay the dust at its source.  Then, an unfortunate blowout happened when coal dust ignited. Because of the coal dust build up throughout the mine, the explosion worsened. In total, there were six working sections of the mine and 4 out of the 6 sections were affected by flames and explosion violence. The other two sections of the mine were only affected by afterdamp.

The explosion was contained when it reached the rockdusted zones. It traveled through all the active mining rooms, and some abandoned rooms that were not treated with rockdust. The explosion also failed to move through areas that were partly caved in, and in some places filled with incombustible roof rash.

Disasters with a loss of life are often wake-up calls in major industries, and how important is to ensure that it never happens again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid major accidents like this. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes pro-actively and significant issues that may lead to major problems proactively.

Monday Accidents & Lessons Learned: When Exposure to Contaminants Is Part of a Job

March 19th, 2018 by

Recently, a review by Australia’s Department of Mining, Industry, Regulation, and Safety (DMIRS) revealed that workers in some gold rooms have experienced sustained exposure to elevated heavy metal levels, including arsenic, lead, and mercury. Work done in a gold room is specifically identified as occupational exposure work that requires ongoing health surveillance for gold room employees.

Among the biological monitoring results were omissions within the biological and atmospheric monitoring program of some heavy metal contaminants associated with ore mineralization; lack of consideration on the part of sites for the mineralogy of their specific ore deposits that contribute to assessment of heavy metal often present in Western Australia gold deposits; inadequate, ineffective ventilation systems within gold rooms; and a deficiency of ventilation system performance testing and monitoring. Along with these inconsistencies, when equipment is modified or installed in gold rooms, maintenance programs fall short of manufacturer’s recommendations.

Read the Mines Safety Bulletin, Minimizing exposure to hazardous contaminants in gold rooms. Then, learn why professional training in effective investigations and competency in root cause analysis are key to solving workplace problems.

Miami Bridge Collapse – Is Blame Part of Your Investigation Policy?

March 16th, 2018 by

collapse miami bridge

 

 

 

 

 

 

 

I was listening to a news report on the radio this morning about the pedestrian bridge collapse in Miami. At one point, they were interviewing Florida Governor Rick Scott.  Here is what he said:

“There will clearly be an investigation to find out exactly what happened and why this happened…”

My ears perked up, and I thought, “That sounds like a good start to a root cause investigation!”

And then he continued:

“… and we will hold anybody accountable if anybody has done anything wrong,”

Bummer.  His statement had started out so good, and then went directly to blame in the same breath.  He had just arrived on the scene.  Before we had a good feel for what the actual circumstances were, we are assuming our corrective actions are going to pinpoint blame and dish out the required discipline.

This is pretty standard for government and public figures, so I wasn’t too surprised.  However, it got me thinking about our own investigations at our companies.  Do we start out our investigations with the same expectations?  Do we begin with the good intentions of understanding what happened and finding true root causes, but then have this expectation that we need to find someone to blame?

We as companies owe it to ourselves and our employees to do solid, unbiased incident investigations.  Once we get to reliable root causes, our next step should be to put fixes in place that answer the question, “How do we prevent these root causes from occurring in the future?  Will these corrective actions be effective in preventing the mistakes from happening again?”  In my experience, firing the employee / supervisor / official in charge rarely leads to changes that will prevent the tragedy from happening again.

 

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

March 14th, 2018 by

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

Hire a Professional

March 12th, 2018 by

root cause analysis, RCA, investigation

I know every company is trying to do the best they can with the resources that are available. We ask a lot of our employees and managers, trying to be as efficient as we can.

However, sometimes we need to recognize when we need additional expertise to solve a particular problem. Or, alternatively, we need to ensure that our people have the tools they need to properly perform their job functions.  Companies do this for many job descriptions:

  • Oil analyst
  • Design engineer
  • Nurse
  • Aircraft Mechanic

I don’t think we would ask our Safety Manager to repair a jet engine.  THAT would be silly!

However, for some reason, many companies think that it is OK to ask their aircraft mechanics to perform a root cause analysis without giving them any additional training.  “Looks like we had a problem with that 737 yesterday.  Joe, go investigate that and let me know what you find.”  Why would we expect Joe, who is an excellent mechanic, to be able to perform a professional root cause analysis without being properly trained?  Would we send our Safety Manager out to repair a jet engine?

It might be tempting to assume that performing an RCA is “easy,” and therefore does not require professional training.  This is somewhat true.  It is easy to perform bad RCA’s without professional training.  While performing effective  investigations does not require years of training, there is a certain minimum competency you should expect from your team, and it is not fair to them to throw them into a situation which they are not trained to handle.

Ensure you are giving your team the support they need by giving them the training required to perform excellent investigations.  A 2-Day TapRooT® Essential Techniques Course is probably all your people will need to perform investigations with terrific results.

 

Monday Accidents & Lessons Learned: When a Disruption Potentially Saves Lives

March 12th, 2018 by

Early news of an incident often does not convey the complexity behind the incident. Granted, many facts are not initially available. On Tuesday, January 24, 2017, a Network Rail freight train derailed in southeast London between Lewisham and Hither Green just before 6:00 am, with the rear two wagons of the one-kilometer-long train off the tracks. Soon after, the Southeastern network sent a tweet to report the accident, alerting passengers that, “All services through the area will be disrupted, with some services suspended.” Then came the advice, “Disruption is expected to last all day. Please make sure you check before travelling.” While southeastern passengers were venting their frustrations on Twitter, a team of engineers was at the site by 6:15 am, according to Network Rail. At the scene, the engineers observed that no passengers were aboard and that no one was injured. They also noted a damaged track and the spillage of a payload of sand.

The newly laid track at Courthill Loop South Junction was constructed of separate panels of switch and crossing track, with most of the panels arriving to the site preassembled. Bearer ties, or mechanical connectors, joined the rail supports. The February 2018 report from the Rail Accident Investigation Branch (RAIB), including five recommendations, noted that follow-up engineering work took place the weekend after the new track was laid, and the derailment occurred the next day. Further inspection found the incident to be caused by a significant track twist and other contributing factors. Repair disrupted commuters for days as round-the-clock engineers accomplished a complete rebuild of a 50-meter railway stretch and employed cranes to lift the overturned wagons. Now factor in time, business, resources saved—in addition to lives that are often spared—when TapRooT® advanced root cause analysis is used to proactively reach solutions.

What does bad root cause analysis cost?

March 7th, 2018 by

NewImage

Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

Protection Against Hydrogen Sulfide

March 6th, 2018 by

On January 16, 2017, a private construction company sent four utility works to handle complaints about sewage backup in Key Largo, Florida. Three of the four works descended into the the 15-foot-deep drainage hole, and within seconds all voice communication was lost amongst the construction workers.

The Key Largo Fire Department was the first to respond to the scene. Leonardo Moreno, a volunteer firefighter, tried to enter the hole with his air tank but failed. So, he descended without his air tank and lost consciousness within seconds of entering the drainage hole. Eventually, another firefighter was able to enter the hole with an air tank and pull Moreno out. Unfortunately, the other three construction workers weren’t so lucky. All of them died from hydrogen sulfide poisoning, and Moreno was in critical condition.

Unfortunate events like this are completely avoidable. Comment below how this could have been avoided/prevented by using TapRooT® proactively.

To learn more about this tragic incident click here.

Is Having the Highest Number of Serious Incidents Good or Bad?

March 6th, 2018 by

NewImage

I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

Monday Accidents & Lessons Learned: When a Critical Team Meets the Unexpected

March 5th, 2018 by

Teamwork can break down or go awry in difficult circumstances. During normal operations, team members adhere to policy for their roles, but a single incident can challenge or splinter even the most prepared team. Flight passengers can create a variety of circumstances that require quick and exceptional thinking and action; many of these circumstances are not delineated or addressed in the Quick Reference Handbook (QRH) or by company policy.

This happened to an air carrier crew in an aircraft on the runway awaiting takeoff. The crew was suddenly caught up in a passenger’s panic-stricken, emotionally charged request to deplane. CALLBACK, from NASA’s Aviation Safety Reporting System, allows us six crew debriefing perspectives from this incident. From the First Officer’s report to both Flight Attendants’ summaries, we can view and, using TapRooT@ Techniques, interact with the complications that accompanied each vantage point.

Big Fines for Safety Incidents in the UK

February 27th, 2018 by

NewImage

$1.1m £ fine for ejection seat manufacturer after Red Arrow pilot killed. Click here.

$120k £ fine for employee injured by circular saw. Click here.

$1.4m £ fine for Tata Steel after crane crushes worker. Click here.

If you have facilities in the UK, are you doing all you can to avoid HSE issues? You should consider improving your root cause analysis to improve your efforts to stop accidents. Learn about advanced root cause analysis by CLICKING HERE. Then attend one of these public courses in the UK and Europe.

 

 

 

Monday Accident & Lessons Learned: Runaway Trailer Investigation Provides Context for Action Sequence

February 26th, 2018 by

The Rail Accident Investigation Branch (RAIB) investigated and released its report on a runaway trailer that occurred May 28, 2017, in England’s Hope, Derbyshire. The incident occurred when a trailer propelled by a small rail tractor became detached and traveled approximately one mile before coming to a stop. RAIB found that a linchpin had been erroneously inserted.

Chief Inspector of Rail Accidents, Simon French, remarked, “The whole episode, as our report shows, was a saga arising from lack of training, care, and caution.” Peruse the report delineating the circumstances and recommendations here. Read the RAIB report here. Enroll in a TapRooT® course to gain the training necessary to investigate and, further, to prevent incidents.

‘Equipment Failure’ is the cause?

February 22nd, 2018 by
Fire, equipment. failure

Drone view of tank farm fire Photo: West Fargo Fire Department

 

 

 

 

 

 

 

On Sunday, there was a diesel fuel oil fire at a tank farm in West Fargo, ND. About 1200 barrels of diesel leaked from the tank.  The fire appears to have burned for about 9 hours or so.  They had help from fire dapartments from the local airport and local railway company, and drone support from the National Guard.  There were evacuations of nearby residents.  Soil remediation is in progress, and operations at the facility have resumed.  Read more about the story here.

The fire chief said it looks like there was a failure of the piping and pumping system for the tank. He said that the owners of the tank are investigating. However, one item caught my attention. He said, “In the world of petroleum fires, it wasn’t very big at all. It might not get a full investigation.”

This is a troublesome statement.  Since it wasn’t a big, major fire, and no one was seriously hurt, it doesn’t warrent an investigation.  However, just think of all the terrific lessons learned that could be discovered and learned from.  How major a fire must it be in order to get a “full investigation?”

I often see people minimize issues that were just “equipment failures.”  There isn’t anyone to blame, no bad people to fire, it was just bad equipment.  We’ll just chalk this one up to “equipment failure” and move on.  In this case, that mindset can cause people to ignore the entire accident, and that determining it was equipment failure is as deep as we need to go.

Don’t get caught in this trap.  While I’m sure the tank owner is going to go deeper, I encourage the response teams to do their own root cause analyses to determine if their response was adequate, if notifications correct, if they had reliable lines of communications with external aganecies, etc.  It’s a great opportunity to improve, even if it was only “equipment failure,” and even if you are “only” the response team.

Deepwater Horizon … The Movie

February 20th, 2018 by

Last night, to prepare for the 2018 Global TapRooT® Summit, I watched the movie Deepwater Horizon.

I’m interviewing Mike Williams (who was played by Mark Wahlberg in the movie … see the trailer above).

I have a hard time watching the movie. The needless death of those men and the needless pain and suffering of the rest of the crew was totally avoidable.

What we do at System Improvements is to teach people to use TapRooT® Root Cause Analysis to find and fix the root causes of problems BEFORE major accidents happen. This could have been done BEFORE the Deepwater Horizon accident. I sometimes think that I didn’t do enough to get people who don’t use TapRooT® to fix problems and improve performance. If only I could have convinced BP and Transocean to use TapRooT®, maybe the accident would have been prevented.

That’s why we hold the TapRooT® Summit each year. It is one more way to get people fired up about performance improvement and stopping major accidents.

Hope to see you next week at the Summit and spend an hour talking to a survivor of the Deepwater Horizon accident.

Mike Williams 442x450

If you want to watch the movie before the Summit, you can download it at Amazon by CLICKING HERE.

Or you can read the Presidential Commission report, by clicking on this link: DEEPWATERPresidentCommission.

Ot read the Chemical Safety Board Executive Summary report: CSB BP Deepwater Horizon Exec Summary.

Monday Accident & Lesson Learned: Quick action by mother prevents toddler from falling through hole in moving train

February 19th, 2018 by


A child was rescued from death when his mom grabbed him before he fell through a hole in a moving train.  In a 39-page report published by the Rail Accident Investigation Board, it was revealed that “The child entered the toilet, and as the door opened and the child stepped through it, he fell forward because the floor was missing in the compartment he had entered.” Read the report here.

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Monday Accident & Lessons Learned: The Lac-Mégantic rail disaster

February 12th, 2018 by

The Lac-Mégantic rail disaster occurred when an unattended 74-car freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings were destroyed. The death toll of 47 makes it the fourth-deadliest rail accident in Canadian history.

 

Click image to view or download .pdf

 

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