Category: Current Events
An article in the Aiken Standard got me thinking again about the topic of safety stand-downs (this time called a “safety pause”).
These temporary “stop work” activities where safe work practices are suppose to be reviewed, and where new emphasis is suppose to be applied to ensure safety, are common in government operations (this time a DOE site) and the nuclear industry. I’ve written about them before:
- Monday Accident & Lessons Learned: When is a “Safety Standdown” a “Standdown”
- Monday Accident & Lessons Learned: Mistakes at TVA Reactors Results in Safety Stand Down
- Nuclear Plant “Near-Miss” in Canada Leads to Safety Stand Down
- 22 Near-Fatal Accidents in 12 Months at a UK Steel Mill – Is a Safety Standdown Adequate?
The safety pause at Savannah River Nuclear Solutions is a really long pause. It started on September 11 after a September 3 incident in the H Canyon – HB Line portion of their operations where Plutonium was being handled.
An SRNS spokesperson is quoted by the paper as saying that: “SRNS is a stronger, healthier company as a result of these actions and we are working for sustained improvement.”
Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the “pause” to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.
In 2011 the mining recession started. The price of commodities (iron ore, copper, and other metals) suffered when demand from China dropped. This recession was somewhat independent from the housing crash of 2008.
What is the natural tendency of an industry faced with falling prices and falling demand? To cut costs. And that happened across the mining industry.
The Wall Street Journal is now pointing to the increased number of fatalities at large mining companies “when most are enacting heavy cost cuts as they battle to remain profitable amid a downturn in world commodity prices.” (See articles here and here.)
This negative press coverage by the WSJ resulted from the recent dam failure at a mine co-owned by BHP and Vale (the mine operator is named Samarco) (see article here).
Has cost cutting led to increased mining accidents? Will falling oil prices result in more oil industry fatalities? It is difficult to prove a cause and effect link but statistics point to negative trends.
IOGP SAFETY ALERT
WELL KICK DUE TO LINER TOP SEAL FAILURE
After several attempts and a dedicated leak detection run, the 7” and 5” x 4-1/2” liner were inflow tested successfully to max difference of +10 bar.
Ran completion in heavy brine and displaced well to packer fluid (underbalanced).
Rigged up wireline pressure control equipment to install plug and prong in tubing tailpipe. While RIH with the plug on WL, a sudden pressure increase was observed in the well. Pressure increased to 125 bar on the tubing side.
Attempted to bleed off pressure, but pressure increased to 125 bar immediately.
Continued operation to install plug, pressure up tubing and set production packer.
Performed pump and bleed operation to remove gas from A-annulus. The general gas alarm was triggered during his operation due to losing the liquid seal on the poorboy degasser.
Continued pump and bleed operation until no pressure on tubing and A-annulus side, and the tubing and A-annulus were tested successfully.
What Went Wrong?
Failure of the 5″ liner hanger and 5″ tie-back packer.
Corrective Actions and Recommendations:
Difficult to bleed out gas in a controlled way due to sensitive choke and no pressure readings from poorboy degasser.
When performing pump and bleed operations, line up to pump down one line and take returns in a different line to optimize the operation.
Consider adequacy of the testing of the 5″ liner hanger.
Safety Alert Number: 267
IOGP Safety Alerts http://safetyzone.iogp.org/
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.
This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
The new EPA emission regulation (not yet published in the Federal Register, but available here), requires a root cause analysis and corrective actions for upset emission releases including flare events.
Not only is a root cause analysis with corrective actions required, but a second event from the same equipment for the same root cause would trigger a diviation of the standard (read “fine”). In addition, the same device with more than 3 events per 3 years or the combination of 3 releases becomes a deviation.
This means it is time for effective, advanced root cause analysis of emission events. Time to send your folks to TapRooT® Root Cause Analysis Training!
After an accident, what is the risk that you face if you restart production before you find and fix the root causes of an accident? Starting too soon may risk the chance of another disaster.
Of course, that depends on the risk profile of the accident in question and your operations.
SpaceX is keeping their Falcon 9 rocket grounded for a couple more months after a June explosion of their booster rocket that was carrying supplies to the international space station.
Troubleshooting after the accident points to a failed strut that was holding a bottle of helium in place that, when it failed, caused an over-pressure of the second-stage rocket. See the story here.
Do you analyze the risk of restarting production after an incident or accident? Perhaps this is something your management should consider?
This is not the Friday Joke.
Root cause analysis has become so popular that politicians are now calling for companies to complete a root cause analysis and implement corrective actions.
Massachusetts Governor Charlie Baker wrote a letter to Entergy Nuclear Operations calling on them to “… perform an appropriate root cause analysis …” of safety issues the NRC had announced “… and to complete all necessary repairs and corrective actions.”
The letter was in response to an unplanned shutdown at the Pilgrim nuclear power plant in Plymouth, Massachusetts caused by a malfunctioning main steam stop valve (one of eight valves that is designed to shut off steam from the reactor to the turbine that generates electricity). The valve had failed shut.
For all those not in the nuclear industry, note that in the nuclear industry, a failure of one of eight valves that failed in the safe direction (shut) and that has backup safety systems (both manual and automatic) can get a public letter from the Governor and attention from a federal regulator. Imagine if you had this level of safety oversight of your systems. Would your equipment reliability programs pass muster?
The response from Entergy to the Governor noted that, “We have made changes and equipment upgrades that have already resulted in positive enhancements to operational reliability.” (Note that these fixes occurred in less than a week after the original mechanical failure.)
For more about the story, see: http://www.wbur.org/2015/09/03/baker-pilgrim-nuclear
Note the local NPR story at the link above is inaccurate in its description of the problem and the mechanical systems.
For those interested in improving equipment reliability and root cause analysis, consider attending one of our 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Courses. See the upcoming course list at:
Now for the biggest question …
When will government authorities start applying root cause analysis
to the myriad of problems we face as a nation and start implementing appropriate corrective actions?
Click here to view the video and read story.
Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness? How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post. But the real question is, do you want MORE than all of the useful information we provide on this blog? That’s okay – we’ll allow you to be greedy!
A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more. Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”
We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses. If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”
Thank you for being part of the global TapRooT® community!
Initial reports are that it was at a terminal facility: Here a news story …
When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?July 29th, 2015 by Mark Paradies
I think we all agree that a fatality is a very unfortunate event. But it may not be a criminal act.
When one asks after an accident if a crime has been committed, the answer depends on the country where the accident occurred. A crime in China may not be a crime in the UK. A crime in the UK may not be a crime in the USA. And a crime in the USA may not be a crime in China.
Even experts may disagree on what constitutes a crime. For example, University of Maryland Law Professor Rena Steinzor wrote an article on her blog titled: “Kill a Worker? You’re Not a Criminal. Steal a Worker’s Pay? You Are One.” Her belief is that Du Pont and Du Pont’s managers should have faced criminal prosecution after an accident at their LaPorte, Texas, facility. She cited behavior by Du Pont’s management as “extraordinarily reckless.”
OSHA Chief David Michaels disagrees with Professor Steinzor. He is quoted in a different article as saying during a press conference that Professor Steinzor’s conclusions and article are, “… simply wrong.”
The debate should raise a significant question: Is making an accident – especially a fatal accident – a corporate crime a good way to change corporate/management behavior and improve worker safety?
Having worked for Du Pont back in the late 1980’s, I know that management was very concerned about safety. They really took safety to heart. I don’t know if that attitude changed as Du Pont transformed itself to increase return on equity … Perhaps they lost their way. But would making poor management decisions a crime make Du Pont a safer place to work?
Making accidents a crime would definitely making performing an accident investigation more difficult. Would employees and managers cooperate with ANY investigation (internal, OSHA, or criminal) IF the outcome could be a jail sentence? I can picture every interviewee consulting with their attorney prior to answering an investigator’s question.
I believe the lack of cooperation would make finding and fixing root causes much more difficult. And finding and fixing the root causes of accidents is extremely important when trying to improve safety. Thus, I believe increased criminalization of accidents would actually work against improving safety.
I believe that Du Pont will take action to turn around safety performance after a series of serious and sometimes fatal accidents. I think they will do this out of concern for their employees. I don’t think the potential for managers going to jail would improve the odds that this improvement will occur.
What do you think? Do you agree or disagree. Or better yet, do you have evidence of criminal proceedings improving or hindering safety improvement?
Let me know by leaving a comment below.
I overheard a senior executive talking about the problems his company was facing:
- Prices for their commodity were down, yet costs for production were up.
- Cost overruns and schedule slippages were too common.
- HSE performance was stagnant despite improvement goals.
- They had several recent quality issues that had caused customer complaints.
- They were cutting “unnecessary” spending like training and travel to make up for revenue shortfalls.
I thought to myself …
“How many times have I heard this story?”
I felt like interrupting him and explaining how he could stop at least some of his PAIN.
I can’t do anything about low commodity prices. The price of oil, copper, gold, coal, or iron ore is beyond my control. And he can’t control these either.
But he was doing things that were making his problems (pain) worse.
For example, if you want to stop cost overruns, you need to analyze and fix the root causes of cost overruns.
How do you do that? With TapRooT®.
And how would people learn about TapRooT®? By going to training.
And what had he eliminated? The training budget!
How about the stagnant HSE performance?
To improve performance his company needs to do something different. They need to learn best practices from other industry leaders from their industry AND from other industries.
Where could his folks learn this stuff? At the TapRooT® Summit.
His folks didn’t attend because they didn’t have a training or travel budget!
And the quality issues? He could have his people use the same advanced root cause analysis tools (TapRooT®) to attack them that they were already using for cost, schedule, and HSE incidents. Oh, wait. His people don’t know about TapRooT®. They didn’t attend training.
This reminds me of a VP at a company that at the end of a presentation about a major accident that cost his company big $$$$ and could have caused multiple fatalities (but they were lucky that day). The accident had causes that were directly linked to a cost cutting/downsizing initiative that the VP had initiated for his division. The cost cutting initiative had been suggested by consultants to make the company more competitive in a down economy with low commodity prices. At the end of the presentation he said:
“If anybody would have told me the impacts of these cuts, I wouldn’t have made them!”
Yup. Imaging that. Those bad people didn’t tell him he was causing bad performance by cutting the people and budget they needed to make the place work.
That accident and quote occurred almost 20 years ago.
Yes, this isn’t the first time we have faced a poor economy, dropping commodity prices, or performance issues. The more things change, the more they stay the same!
But what can you do?
Share this story!
And let your management know how TapRooT® Root Cause Analysis can help them alleviate their PAIN!
Once they understand how TapRooT®’s systematic problem solving can help them improve performance even in a down economy, they will realize that the small investment required is well worth it compared to the headaches they will avoid and the performance improvement they can achieve.
Because in bad times it is especially true that:
“You can stop spending bad money
or start spending good money
When it comes to root cause analysis, more people (over 14,000) are linked to Mark Paradies than anyone else on the internet.
Mark also has thousands of colleges that have endorsed him for the skill “root cause analysis”.
See his LinkedIn profile at:
If you would like to link up with Mark on LinkedIn, click on the link above and send him an invitation to connect. Also, please feel free to recognize Mark for his root cause analysis skills by recommending him for his work on root cause analysis.
The Associated Press reported that the US Department of Justice is warning food companies that they could face civil and criminal charges if they poison their customers.
POISON THEIR CUSTOMERS!
Yes, you read it right.
We are again testing the fine line between accidents and criminal behavior.
How does a company know that they have gone over the line? The FDA stops showing up and the FBI puts boundary tape around your facilities.
Are you in the food business? Think it is time to start taking root cause analysis of food safety incidents seriously? You betcha!
Your company can’t afford a Blue Bell Ice Cream incident. You need to effectively analyze and learn from smaller incidents to stop the big accidents from happening.
What tool should you use for effective root cause analysis? The TapRooT® Root Cause Analysis System.
Why choose TapRooT® Root Cause Analysis?
Because it has proven itself effective in a wide number of industries around the world. That’s why industry leaders use it and recommend it to their suppliers.
Find out more about the TapRooT® System at:
And then attend one of our public courses held around the world.
You can attend at no risk because of our iron-clad guarantee:
Attend a TapRooT® 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.
Get started NOW because you can’t afford to wait for the FBI to knock on your door with a warrant in their hand.
I love to use Safeguard Analysis to examine incidents and determine Causal Factors.
What were the Safeguards keeping this officer safe and how did they fail? (A failed Safeguard is usually a Causal Factor.)
Watch and leave a comment about your ideas …
United grounds all of their flights for two hours due to “computer problems” (see the CNBC story).
The NYSE stops trading for over three hours due to an “internal technical issue” (see the CNBC story).
Computer issues can cost companies big bucks and cause public relations headaches. Do you think they should be applying state of the art root cause analysis tools both reactively and proactively to prevent and avoid future problems?
TapRooT® has been used to improve computer reliability and security by performing root cause analysis of computer/IT related events and developing effective corrective actions. The first TapRooT® uses for computer/high reliability network problems where banking and communication service providers that started using TapRooT® in the late 1990’s. The first computer security application of TapRooT® that we knew about was in the early 2000s.
Need to improve your root cause analysis of computer and IT issues? Attend one of our TapRooT® Root Cause Analysis Courses. See the upcoming course schedule at:
The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.
A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.
Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?
For those outside the USA, on the 4th of July we are off celebrating our God given freedoms that are guaranteed in the US Constitution that resulted from declaring our independence from the British crown. On July 4, 1776, the Continental Congress approved the final wording of the Declaration of Independence. That act continued the progress of the revolt that had started back in April of 1775 and resulted in the founding of the United States and the US Constitution.
For more information about the US Constitution, see: http://www.constitutionfacts.com
See you next week!
It is the largest environmental settlement ever.
BP will pay the US Government,Alabama, Florida, Louisiana,Mississippi, and Texas $18.7 billion to compensate for environmental damage done by the Deepwater Horizon spill.
The Chicago Tribune reported “Fall from ladder nets Merrillville man $2.4 million jury verdict.”
Part of the reason that the company was found liable is that the ladder was “out of code.” It had been produced before standards for ladders were developed.
Have any old ladders out there that need to be replaced?
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
John Lehman, the youngest Secretary of the Navy who fired the oldest admiral ever, says that Obama’s decision to promote the head of the Nuclear Navy after just two years will put the best safety record in the world at risk.
Here’s a link to the article: http://www.wsj.com/articles/obama-torpedoes-the-nuclear-navy-1432591747
What do you think?