Category: Current Events

ASSE (Safety 2018) is almost here!

May 22nd, 2018 by

The best safety conference of the year. I can’t wait.

If you are attending the conference, please stop by and see us at booth 843. Barb and I will be there. The first 500 people will get a special gift, so don’t miss out!

See you in San Antonio!

Thanks to all my Linkedin Connections

May 22nd, 2018 by

I have reached 20,000 Linkedin connections! Thank you for your support!

If we are not yet connected, please send me a REQUEST

Newest Aircraft Carrier Breaks Down During Sea Trials

May 8th, 2018 by

USS Ford underway for sea trials …

An article in Popular Mechanics said the the USS Ford had to return early from sea trials because of an overheating thrust bearing on one of the four main engines. Bloomberg reported that:

“inspection of the parts involved in the January 2018 incident revealed improperly machined gears at GE’s facility in Lynn, Massachusetts as the ‘root cause.'”

Is “improperly machined gears” a root cause? That would be a Causal Factor and the start of a root cause analysis in the TapRooT® System. And why wasn’t the “improper” machining detected prior to installation and sea trials?

Here is some footage of sea trials (including a brief glimpse of one main shaft turning).

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

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But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

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 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

Press Release: CSB to Investigate Husky Refinery Fire

April 26th, 2018 by

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Washington, DC, April 26, 2018 –  A four-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that reportedly injured multiple workers this morning at the Husky Energy oil refinery in Superior, Wisconsin. The refinery was shutting down in preparation for a five-week turnaround when an explosion was reported around 10 am CDT.

According to initial reports, several people were transported to area hospitals with injuries. There have been no reports of fatalities. Residents and area schools near the refinery were asked to evacuate due to heavy smoke.

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.

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 the CSB website, www.csb.gov

Here is additional coverage of the fire …

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http://www.kbjr6.com/story/38049655/explosion-injuries-reported-at-husky-energy-superior-refinery?autostart=true

Monday Accidents & Lessons Learned: Putting Yourself on the Right Side of Survival

April 23rd, 2018 by

While building an embankment to circumvent any material from a water supply, a front end loader operator experienced a close call. On March 13, 2018, the operator backed his front end loader over the top of a roadway berm; the loader and operator slipped down the embankment; and the loader landed turning over onto its roof. Fortunately, the operator was wearing his seat belt. He unfastened the seat belt and escaped the upside-down machine through the broken right-side window of the loader door.

Front end loaders are often involved in accidents due to a shift in the machine’s center of gravity. The U.S. Department of Labor Mine Safety and Health Administration (MSHA) documented this incident and issued the statement and best practices below for operating front end loaders.

The size and weight of front end loaders, combined with the limited visibility from the cab, makes the job of backing a front end loader potentially hazardous. To prevent a mishap when operating a front end loader:
• Load the bucket evenly and avoid overloading (refer to the load limits in the operating manual). Keep the bucket low when operating on hills.
• Construct berms or other restraints of adequate height and strength to prevent overtravel and warn operators of hazardous areas.
• Ensure that objects inside of the cab are secured so they don’t become airborne during an accident.
• ALWAYS wear your seatbelt.
• Maintain control of mobile equipment by traveling safe speeds and not
overloading equipment.

We would add the following best practices for loaders:
• Check the manufacturer’s recommendations and supplement appropriate wheel ballast or counterweight.
• Employ maximum stabilizing factors, such as moving the wheels to the widest setting.
• Ensure everyone within range of the loader location is a safe distance away.
• Operate the loader with its load as close to the ground as possible. Should the rear of the tractor tip, its bucket will hit the ground before the tractor tips.

Use the TapRooT® System to put safety first and to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Mark Paradies Speaks about Root Cause Analysis at the Gas Processor’s Association

April 16th, 2018 by

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Attending the GPA Conference in Austin?

Then attend the Safety Committee Meeting on Tuesday (1:30 – 5:30) and hear Mark Paradies talk about common root cause analysis problems and how you can solve them.

Monday Accidents & Lessons Learned: When retrofitting does not evaluate risks

April 9th, 2018 by

Bound for London Waterloo, the 2G44 train was about to depart platform 2 at Guildford station. Suddenly, at 2:37 pm, July 7, 2017, an explosion occurred in the train’s underframe equipment case, ejecting debris onto station platforms and into a nearby parking lot. Fortunately, there were no injuries to passengers or staff; damage was contained to the train and station furnishings. It could have been much worse.

The cause of the explosion was an accumulation of flammable gases within the traction equipment case underneath one of the train’s coaches. The gases were generated after the failure of a large electrical capacitor inside the equipment case; the capacitor failure was due to a manufacturing defect.

Recently retrofitted with a modern version of the traction equipment, the train’s replacement equipment also included the failed capacitor. The project team overseeing the design and installation of the new equipment did not consider the risk of an explosion due to a manufacturer’s defect within the capacitor. As a result, there were no preventative engineering safeguards.

The Rail Accident Investigation Branch (RAIB) has recommended a review of the design of UK trains’ electric traction systems to ensure adequate safeguards are in place to offset any identified anomalies and to prevent similar explosions. Learn about the six learning points recommended by the RAIB for this investigation.

Use the TapRooT® System to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

McD’s in UK Fined £200k for Employee Injured While Directing Traffic

March 27th, 2018 by

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An angry motorist hits a 17-year-old employee who is directing traffic and breaks his knee. Normally, you would think the road rage driver would be at fault. But a UK court fined McDonalds $200,000.

Why? It was a repeat incident. Two previous employees had been hurt while directing traffic. And McDonalds didn’t train the employees how to direct traffic.

What do you think? Would a good root cause analysis of the previous injuries and effective corrective actions have prevented this accident?

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

March 6th, 2018 by

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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?

Big Fines for Safety Incidents in the UK

February 27th, 2018 by

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$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.

 

 

 

Nuclear Plant Fined $145,000 for “Gun-Decked Logs”

February 21st, 2018 by

When I was in the Navy, people called it “gun-decking the logs.”

In the Navy this means that you falsify your record keeping … usually by just copying the numbers from the previous hour (maybe with slight changes) without making the rounds and taking the actual measurements. And if you were caught, you were probably going to Captain’s Mast (disciplinary hearing).

The term “gun-decking” has something to do with the “false” gun deck that was built into British sailing ships of war to make them look like they had more guns. Sometimes midshipmen would falsify their navigation training calculations by using dead reckoning to calculate their position rather than using the Sun and the stars. This might have been called “gun-decking” because the gun deck is where they turned their homework over to the ships navigator to be reviewed.

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What happened at the Nuke Plant? A Nuclear Regulatory Commission inspector found that 13 operators had gun-decked their logs. Here’s a quote from the article describing the incident:

“An NRC investigation, completed August 2017, found that on multiple occasions during the three-month period, at least 13 system operators failed to complete their rounds as required by plant procedures, but entered data into an electronic log indicating they had completed equipment status checks and area inspections,” the NRC said in a statement.”

What was the corrective action? The article says:

“The plant operator has already undertaken several corrective actions, the NRC said, including training for employees, changes in the inspection procedures and disciplinary measures for some staff.”

Hmmm … training, procedures, and discipline. That’s the standard three corrective actions. (“Round up the usual suspects!”) Even problems that seem to be HR issues can benefit from advanced root cause analysis. Is this a Standards, Policy, and Administrative Controls Not Used issue? Is there a root cause under that Near Root Cause that needs to be fixed (for example, Enforcement Needs Improvement)? Or is discipline the right answer? It would be interesting to know all the facts.

Want to learn to apply advanced root cause analysis to solve these kinds of problems? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the upcoming public courses by CLICKING HERE. Or CLICK HERE to contact us about having a course at your site.

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.

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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.

New TapRooT® Family Member

February 12th, 2018 by

Sat hello to Lucy Belle … an 8 lb 8 oz girl.

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Pass along congratulations to the proud mom, Amanda Biesbroeck (our Corporate Counsel) by leaving a comment below!

Carl Dixon returns to the 2018 Global TapRooT® Summit!

February 9th, 2018 by

Carl Dixon, who sang and played with Coney Hatch, April Wine, and The Guess Who, is back at the 2018 Global TapRooT® Summit as the entertainment for our reception. Don’t miss the great music and good times!

Here’s a video from back in the day – Carl and Coney Hatch …

and April Wine …

And here is Carl in 2010 with the Guess Who …

And finally CARL SINGING “No Sugar” with The Guess Who in 2016 …

Monday accidents & lessons learned

February 5th, 2018 by

Packed with 250 commuters and heading to Milan’s Porta Garibaldi station, the Italian Trenord-operated train derailed January 25, 2018, killing three people and seriously injuring dozens. The train was said to have been traveling at normal speed but was described by witnesses as “trembling for a few minutes before the accident.” A collapse of the track is under investigation. Why is early information-gathering important?

Carl Dixon at the 2018 Global TapRooT® Summit Reception

February 1st, 2018 by

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

January 29th, 2018 by

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On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

January 27th, 2018 by

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

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CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

Have FUN at the 2018 Global TapRooT® Summit!

January 25th, 2018 by

We don’t want the 2018 Global TapRooT® Summit to be boring. We want you to meet smart industry leaders, learn amazing best practices, and have fun!

Learning while having fun is much more effective that trying to stay awake during boring presentations. That’s why we organize the Global TapRooT® Summit to have activities, Keynote Speakers, and sessions that are active and entertaining.

Plus we start with the Name Game and have an excellent Reception on Wednesday.

This year we will again have rock star Carl Dixon as our entertainment at the reception where you can network with the new friends and important contacts that you have established.

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Here’s Carl back in the day playing with April Wine …

And more classic rock from Carl and April Wine …

And just one more …

I think he is even better today. Don’t miss the 2018 Global TapRooT® Summit reception!

Interesting Article in “Stars & Strips” About Navy Court-Martials for COs Involved in Collisions

January 22nd, 2018 by

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The article starts with:

The Navy’s decision to pursue charges of negligent homicide against the former commanders of the USS Fitzgerald and USS John McCain has little precedent, according to a Navy scholar who has extensively scrutinized cases of command failure.”

See the whole article at:

https://www.stripes.com/news/navy/few-navy-commanders-face-court-martial-for-operational-failures-1.507226

The article implies that blame and shame is the normal process for COs whose ships are involved in accidents.

Isn’t it time for the US Navy to learn real advanced root cause analysis that can teach them to find and fix the causes of problems at cause collisions at sea?

Safety Fines Double in One Year in UK

January 18th, 2018 by

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

Ready for a road trip? Then wrap up your travel planning for the 2018 Global TapRooT® Summit in Knoxville, Tennessee!

January 18th, 2018 by

 


When some people think of Knoxville, Tennessee they often think of the regional attractions such as the Smoky Mountains and the area’s large, picturesque lakes. However, this city has plenty to offer without ever leaving town. Knoxville’s Urban Wilderness is just three miles from the Knoxville Convention Center where the 2018 Global TapRooT® Summit will be held. It includes 50 miles of natural surface for hikers, mountain bikers and trail runners. The city also has a rich musical heritage, which includes stars like Dolly Parton, the Everly Brothers and Roy Acuff. Popular music venues today include the historic Tennessee Theatre, Bijou Theatre, the Square Room and a host of clubs that present live music every night of the week. Dining options are numerous . . . you’ll find a heavy focus on farm-to-table fare during your visit downtown. In addition to hiking, biking, music, history and arts, the city has an exciting craft beer scene and the opportunity to relax with some of the country’s finest beers and people.

Have you taken the steps to a memorable road trip? It’s simple!

Step 1: REGISTER for the 2018 Global TapRooT® Summit.

Step 2: Do your travel planning and get a hotel booked.

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And don’t miss the activities the week of the Summit.

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Miranda Lambert is performing at Thompson-Boling Arena on Thursday, March 1, 2018.

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Tape Face, the Comedian, is performing at the Bijou Theatre on Sunday, February 25, 2018.

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Jonny Lang with Tony Lucca Solo is performing at the Bijou Theatre on Tuesday, February 27, 2018.

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Beth Hart is performing at the Bijou Theatre on Thursday, March 1, 2018.

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The Wizard of Oz national tour will be starring at The Tennessee Theatre on Friday, Saturday and Sunday, March 1, 2 and 3, 2018.

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

January 17th, 2018 by

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Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.

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Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

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