Category: Current Events

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

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Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Are you attending Safety 2017 (otherwise known as ASSE)?

May 30th, 2017 by

If you are attending, please stop by the TapRooT® Booth (#508) and say hello. Barb Phillips and I will both be there.

Ask Barb about the new course and book for Interviewing and Evidence Collection that will be out soon.

Ask me about the new TapRooT® for Audits Course and book.

Free gift for the first 500 people!

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Freeze on New RMP Rule linked to the ATF announcement about the West, TX, Fertilizer Explosion

May 5th, 2017 by

The new EPA RMP rule which had an effective date March 14, 2017, has been “frozen” under the Trump administration regulatory freeze until February 19, 2019.

The main reason for the freeze in the case of the RMP rule is that the rule modifications were largely based on the West, TX fertilizer explosion. However, two days before the comment period ended, the ATF announced that they suspected that the West, TX, fertilizer explosion was NOT an accident, but rather was an intentional act.

Now the whole rule is being reconsidered.

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

Should We Continue to Fund the CSB?

April 17th, 2017 by

The Trump Administration has cut funding for several independent agencies in their 2017 budget request. One is the US Chemical Safety Board.

The CSB has produced this video and a report to justify their continued funding.

REPORT LINK

The question taxpayers need to ask and answer is, what are the returns on the investment in the CSB?

The CSB produces investigation reports, videos, and a wish list of improvements.  In 2016 the agency published seven reports and two videos  (it has six investigations that are currently open). That makes it a cost of $1.2 million per report/video produced when you divide their $11 million 2016 budget by their key products.

The 2017 budget request from the CSB was $12,436,000 (a 13% increase from their 2016 budget).

Should the government spend about $12 million per year on this independent agency? Or are these types of improvements better developed by industry, other regulatory agencies (EPA and OSHA), and not-for-profit organizations (like the Center for Chemical Process Safety)?

Leave your comments here (click on the comments link below) to share your ideas. I’d be interested in what you think. Or write your representatives to provide your thoughts.

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

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To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

Avoid the Danger of New Hires

March 1st, 2017 by

 

Is your safety program ready?

Is your safety program ready?

There is a feeling of cautious optimism in the oil sector, as the price of oil seems to have stabilized above $50/barrel. Rig count in the Permian has more than doubled since last spring. US EIA and JPMorgan are forecasting US production at near record levels of over 9.5 million barrels per day by the end of next year. US exports are up, with China ramping up oil purchases from the US, while OPEC production cuts are holding.

This all sounds good for the US oil sector. It is expected that hiring will start picking up, and in fact Jeff Bush, president of oil and gas recruiting firm CSI Recruiting, has said, “When things come back online, there’s going to be an enormous talent shortage of epic proportions.”

So, once you start hiring, who will you hire? Unfortunately, much of the 170,000 oil workers laid off over the past couple of years are no longer available. That experience gap is going to be keenly felt as you try to bring on new people. In fact, you’re probably going to be hiring many people with little to no experience in safe operation of your systems.

Are you prepared for this? How will you ensure your HSE, Quality, and Equipment Reliability programs are set up to handle this young, eager, inexperienced workforce? What you certainly do NOT want to see are your new hires getting hurt, breaking equipment, or causing environmental releases. Here are some things you should think about:

– Review old incidents and look for recurring mistakes (Causal Factors). Analyze for generic root causes. Conduct a TapRooT® analysis of any recurring issues to help eliminate those root causes.
– Update on-boarding processes to ensure your new hires are receiving the proper training.
– Ensure your HSE staff are prepared to perform more frequent audits and subsequent root cause analysis.
– Ensure your HSE staff are fully trained to investigate problems as they arise.
– Train your supervisors to conduct audits and detailed RCA.
– Conduct human factors audits of your processes. You can use the TapRooT® Root Cause Tree® to help you look for potential issues.
– Take a look at your corrective action program. Are you closing out actions? Are you satisfied with the types of actions that are in there?
– Your HSE team may also be new. Make sure they’ve attended a recent TapRooT® course to make sure they are proficient in using TapRooT®.

Don’t wait until you have these new hires on board before you start thinking about these items. Your team is going to be excited and enthusiastic, trying to do their best to meet your goals. You need to be ready to give them the support and tools they need to be successful for themselves and for your company.

TapRooT® training may be part of your preparation.  You can see a list of upcoming courses HERE.

How can TapRooT® help with your ISO programs (or other management system issues)?

January 25th, 2017 by

Happy Wednesday and welcome to this week’s root cause analysis tips.

Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.

Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.

While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.

PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.

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As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.

Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.

Audits Kit

Thanks for reading the blog, and best of luck with your improvement efforts.

Monday Accident & Lessons Learned: Railroad Bridge Structural Failure

December 12th, 2016 by

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A Report from the UK Rail Accident Investigation Branch:

Structural failure caused by scour at Lamington viaduct, South Lanarkshire, 31 December 2015

At 08:40 hrs on Thursday 31 December 2015, subsidence of Lamington viaduct resulted in serious deformation of the track as the 05:57 hrs Crewe to Glasgow passenger service passed over at a speed of about 110 mph (177 km/h). The viaduct spans the River Clyde between Lockerbie and Carstairs. Subsequent investigation showed that the viaduct’s central river pier had been partially undermined by scour following high river flow velocity the previous day. The line was closed for over seven weeks until Monday 22 February 2016 while emergency stabilisation works were completed.

The driver of an earlier train had reported a track defect on the viaduct at 07:28 hrs on the same morning, and following trains crossed the viaduct at low speed while a Network Rail track maintenance team was deployed to the site. The team found no significant track defects and normal running was resumed with the 05:57 hrs service being the first train to pass on the down line. Immediately after this occurred at 08:40 hrs, large track movements were noticed by the team, who immediately imposed an emergency speed restriction before closing the line after finding that the central pier was damaged.

The viaduct spans a river bend which causes water to wash against the sides of the piers. It was also known to have shallow foundations. These were among the factors that resulted in it being identified as being at high risk of scour in 2005. A scheme to provide permanent scour protection to the piers and abutments was due to be constructed during 2015, but this project was deferred until mid-2016 because a necessary environmental approval had not been obtained.

To mitigate the risk of scour, the viaduct was included on a list of vulnerable bridges for which special precautions were required during flood conditions. These precautions included monitoring of river levels and closing the line if a pre determined water level was exceeded. However, this process was no longer in use and there was no effective scour risk mitigation for over 100 of the most vulnerable structures across Scotland. This had occurred, in part, because organisational changes within Network Rail had led to the loss of knowledge and ownership of some structures issues.

Although unrelated to the incident, the RAIB found that defects in the central river pier had not been fully addressed by planned maintenance work. There was also no datum level marked on the structure which meant that survey information from different sources could not easily be compared to identify change.

As a result of this investigation, RAIB has made three recommendations to Network Rail relating to:

  • the management of scour risk
  • the response to defect reports affecting structures over water
  • the management of control centre procedures.

Five learning points are also noted relating to effective management of scour risk.

For more information, see:

R222016_161114_Lamington_viaduct

Monday Accident & Lessons Learned: Ammonia leak kills 1 at Carlsberg brewery in UK

December 5th, 2016 by

SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.

Are you using advanced root cause analysis to investigate near-misses and stop major accidents? Major accidents can be avoided.  That’s a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:

Upcoming TapRooT® Public Courses

TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.

For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.

Don’t wait! If you have attended TapRooT® Training, get signed up today!

Monday Accident & Lessons Learned: Collision at Yafforth, UK, level crossing, 3 August 2016

November 28th, 2016 by

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For a report from the UK Rail Accident Investigation Branch, see:

www.gov.uk

The Blame Culture Hurts Hospital Root Cause Analysis

November 22nd, 2016 by

If you don’t understand what happened, you will never understand why it happened.

You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?

I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.

Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.

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If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?

This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.

The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.

TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.

Foe course information and course dates, see:

http://www.taproot.com/courses

Monday Accident & Lessons Learned: Pilot Error is Root Cause

November 14th, 2016 by

The Navy still likes to blame folks as a root cause. At least that’s what I see in this report about a “pilot error” keeping a F/A-18 Hornet making it back to the carrier USS Theodore Roosevelt.

Seems there were lot’s of Causal Factors that contributed to the loss of an $86 million dollar aircraft that are described in this article on Military.com:

http://www.military.com/daily-news/2016/10/27/debris-pilot-error-caused-2015-jet-crash-persian-gulf-navy.html

I haven’t found the report of the video on line.

What do you think of the report of the investigation?

 

Monday Accident & Lessons Learned: Lessons Learned from Overspeed Incidents in the UK

November 7th, 2016 by

ExcessSpeed

Lessons learned from six trains passing through an emergency speed restriction at excessive speed. For the complete story. see this post from the UK Rail Accident Investigation Branch:

https://www.gov.uk/government/publications/blatchbridge-safety-digest/overspeed-incidents-somerset-19-july-2016

Arturo de la Garza Guajardo, Safety Guru and TapRooT® Instructor

November 5th, 2016 by

Arturo de la Garza died last July after a long career improving safety and many years teaching TapRooT®.

Arturo was one of our first clients outside the US. Linda and I taught a course for him for the safety people at Cydsa in Monterrey, Mexico. 

Arturo was a Chemical Engineer and had lost of chemical plant experience including plant management before joint Cydsa’s corporate staff.

When Arturo retired from Cydsa, he went to work for Cemex and then left Cemex to become one of out contract TapRooT® Instructors. For over a decade he taught courses for SI in Mexico and South America until he was 80 years old.

We will miss his good humor and knowledge and we know that all the instructors who taught with him and clients with whom he shared his knowledge will miss him as well.

ArturoTeaching

Navy Root Cause Analysis Focused on Blame Vision, Crisis Vision, or Opportunity to Improve Vision?

November 3rd, 2016 by

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In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:

The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.

Additionally, he said:

“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”

That seems like a “Blame Vision” statement.

That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:

“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”

Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:

We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.

Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:

The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems

It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.

To subscribe to the newsletter, provide your contact information at:

http://www.taproot.com/contact-us#newsletter

Fatal Theme Park Ride in Australia

November 2nd, 2016 by

Here’s the press report.

A similar ride in the US has been closed while the investigation is ongoing. 

Monday Accident & Lessons Learned: CSB Report on the Williams Olefins Plant Explosion and Fire

October 31st, 2016 by

Pres release from the US Chemical Safety Board…

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CSB Releases Final Case Study into 2013 Explosion and Fire at Williams Olefins Plant
in Geismar, Louisiana; Case Study Concludes that Process Safety Management Deficiencies
During 12 Years Prior to the Incident Led to the Explosion

October 19, 2016, Baton Rouge, LA — Today the CSB released its final report into the June 13, 2013, explosion and fire at the Williams Olefins Plant in Geismar, Louisiana, which killed two employees. The report concludes that process safety management program deficiencies at the Williams Geismar facility during the 12 years leading to the incident allowed a type of heat exchanger called a “reboiler” to be unprotected from overpressure, and ultimately rupture, causing the explosion.

The Williams Geismar facility produces ethylene and propylene for the petrochemical industry and employs approximately 110 people. At the time of the incident, approximately 800 contractors worked at the plant on an expansion project aimed at increasing the production of ethylene.

The incident occurred during non-routine operational activities that introduced heat to the reboiler, which was offline and isolated from its pressure relief device. The heat increased the temperature of a liquid propane mixture confined within the reboiler, resulting in a dramatic pressure rise within the vessel. The reboiler shell catastrophically ruptured, causing a boiling liquid expanding vapor explosion (BLEVE) and fire, which killed two workers; 167 others reported injuries, the majority of which were contractors.

The CSB investigation revealed a poor process safety culture at the Williams Geismar facility, resulting in a number of process safety management program weaknesses. These include deficiencies in implementing Management of Change (MOC), Pre-Startup Safety Review (PSSR), Process Hazard Analysis (PHA) programs, and procedure programs causal to the incident:

  • Failure to appropriately manage or effectively review two significant changes that introduced new hazards involving the reboiler that ruptured—(1) the installation of block valves that could isolate the reboiler from its protective pressure relief device and (2) the administrative controls Williams relied on to control the position (open or closed) of these block valves. 
  • Failure to effectively complete a key hazard analysis recommendation intended to protect the reboiler that ultimately ruptured.
  • Failure to perform a hazard analysis and develop a procedure for the operations activities conducted on the day of the incident that could have addressed overpressure protection. 

CSB Chairperson Vanessa Allen Sutherland said, “The tragic accident at Williams was preventable and therefore unacceptable. This report provides important safety lessons that we urge other companies to review and incorporate within their own facilities.”

The CSB case study on the accident at Williams notes the importance of:

  • Using a risk-reduction strategy known as the “hierarchy of controls” to effectively evaluate and select safeguards to control process hazards.  This strategy could have resulted in Williams choosing to install a pressure relief valve on the reboiler that ultimately ruptured instead of relying on a locked open block valve to provide an open path to pressure relief, which is less reliable due to the possibility of human implementation errors;
  • Establishing a strong organizational process safety culture.  A weak process safety culture contributed to the performance and approval of a delayed MOC that did not identify a major overpressure hazard and an incomplete PSSR;
  • Developing robust process safety management programs, which could have helped to ensure PHA action items were implemented effectively; and
  • Ensuring continual vigilance in implementing process safety management programs to prevent major process safety incidents. 

Following the incident, Williams implemented improvements in managing process safety at the Geismar facility. These include, among others, redesigning the reboilers to prevent isolation from their pressure relief valves, improving its management of change process to be more collaborative, and updating its process hazard analysis procedure.

Investigator Lauren Grim said, “Williams made positive safety management changes at the Geismar facility following the accident, but more should be done to improve process safety and strengthen the plant’s process safety culture. Our report details important safety recommendations to protect workers at the Williams Geismar facility.”

To prevent future incidents and further improve process safety at the Geismar plant, the CSB recommended that Williams strengthen existing safety management systems and adopt additional safety programs. These strategies include conducting safety culture assessments, developing a robust safety indicators tracking program, and conducting detailed process safety program assessments.

The CSB also identified gaps in a key industry standard by the American Petroleum Institute (API) and issued recommendations to API to strengthen its “Pressure-relieving and Depressuring Systems” requirements to help prevent future similar incidents industry-wide.

Chairperson Sutherland said, “Most of the accidents the CSB investigates could have been prevented had process safety culture been a top priority at the facility where the incident occurred. These changes must be encouraged from the top with managers implementing effective process safety management programs.” 

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.  For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov.

Defense Argues Jail Time is Wrong

October 28th, 2016 by

The Associate Press reported that attorneys for Don Blankenship, the imprisoned former CEO of Massey Energy, should not have been sentenced to go to jail for the 2010 coal mine explosion that killed 29 people.

Read more here:

http://www.pennenergy.com/articles/pennenergy/2016/10/coal-news-ex-coal-ceo-argues-he-s-wrongly-imprisoned-after-29-deaths.html?cmpid=EnlDailyPowerOctober272016&eid=294706529&bid=1569999

Note that I found this “wanted poster” on line at http://mountainkeeper.blogspot.com.

NewImage

Monday Accident & Lessons Learned: How Can Automation Get You Into Trouble?

October 24th, 2016 by

NewImage

Automation dependency is an interesting topic. Here’s what a recent CALLBACK from the Aviation Safety Reporting System had to say about the topic…

http://asrs.arc.nasa.gov/docs/cb/cb_440.pdf

Monday Accident & Lessons Learned: Aviation Safety Reporting System CALLBACK Notice About Ramp Safety

October 17th, 2016 by

CALLBACK Report Ramp Safety

Here’s the start of the report …

This month CALLBACK features reports taken from a cross-section of ramp experiences. These excerpts illustrate a variety of ramp hazards that can be present. They describe the incidents that resulted and applaud the “saves” made by the Flight Crews and Ground Personnel involved.

For the complete report, see:

http://asrs.arc.nasa.gov/docs/cb/cb_439.pdf

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