Category: Current Events

Will They Really Find the Root Causes?

February 3rd, 2016 by

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

Monday Accident & Lessons Learned: UK RAIB Report – Collision at Froxfield

January 25th, 2016 by

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Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)

 

RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015

 

At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.

The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.

The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.

Recommendations

RAIB has made four recommendations relating to the following:

  • installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
  • enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
  • introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.

RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles

Notes to editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
  2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
  3. For media enquiries, please call 020 7944 3108.

For the complete report, see:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493315/R022016_160120_Froxfield.pdf

SpaceX Rocket ALMOST Lands – Equipment Failure?

January 18th, 2016 by

So close!

SpaceX attempted to land the first stage of their Jason 3 launch vehicle on their Autonomous Spaceport Drone Ship this weekend. The video shows the stage softly touching down, and then toppling over. Elon Musk tweeted that the leg did not fully latch prior to touchdown, and folded up when the stage weight was applied. He said it looks like the collet between the leg extension tube segments did not hold due to icing prior to launch.

While this is a cool video, it got me thinking about using the correct type of equipment for the application. for example, Musk said they use a “collet” between the leg segments. A collet is a friction device that holds 2 tubes together. Not necessarily a positive locking device. It appears that ice prevented full extension and therefore full friction from being applied, and the leg collapsed.

What do you think? Is a collet the correct type of device to hold a static load like this in place? My thoughts: I think a more simple locking pin that drops into place, or a circumferential collar that drops into a slot, would be a much more reliable locking device, rather than something that depends on friction for support.

Still, what an awesome landing attempt!

What Does an Accident Cost? After $1.6 Billion in Sanctions, PG&E Faces More Fines.

December 28th, 2015 by

A Judge in California has ruled that PG&E must face charges that it knowingly and willfully violated minimum pipeline standards in the 2010 explosion that killed 8 people. 

State regulators have already imposed $1.6 billion in civil sanctions. PG&E faces and additional $565 million in penalties as part of these charges. 

For more information, see: http://www.gasprocessingnews.com/news/pge-to-face-most-charges-over-deadly-california-gas-pipeline-blast.aspx

Monday Accident & Lessons Learned: REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS MEASURED IN THE RESERVOIR LEADING TO KICK

December 21st, 2015 by

IOGP SAFETY ALERT

REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS
MEASURED IN THE RESERVOIR LEADING TO KICK

Course of events:

  • Drilled 6×7″ hole section, ran screens and set hanger.
  • Displaced from 1.18 SG drilling fluids to 1.05 SG brine.
  • Closed in based on 600 l influx (PP estimated to be 1.09 SG)
  • Circulated out gas and displaced to 1.15 SG brine (using drillers method)

What Went Wrong?

Factors which contributed to the incident:

  • Brine weight reduction
  • Pore pressure prognosis
  • Lack of pressure point coverage of all sands during drilling

Corrective Actions and Recommendations:

  • Several pressure points where taken in the reservoir and these were used to reduce to mud weight from 1,08 sg to 1,05 sg brine. This reduction turned out to result in too great a weight decrease, since there were two small sand zones exposed that where not picked up on the log. It is important not to place to great a reliance on pressure points taken during the section, since there can be small zones that have not been caught on the log that may have a different pressure.
  • Instead of displacing the well to kill mud during the second circulation of the drillers method, the team decided to displace to a higher weight brine. This meant that they would continue operations faster, after the kill, than would have been the case if they displaced to drilling mud.

Source Contact:

safety alert number: 269
IOGP Safety Alerts http://safetyzone.iogp.org

Disclaimer

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. 

 

Monday Accident & Lessons Learned: FATALITY WHILE TRIPPING PIPE

December 14th, 2015 by

IOGP SAFETY ALERT

FATALITY WHILE TRIPPING PIPE

Country: USA – North America
Location: OFFSHORE : Mobile Drilling Unit
Incident Date: 20 October 2015   
Type of Activity: Drilling, workover, well services
Type of Injury: Struck by
Function: Drilling

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View of pipe stand in lower fingerboard

 A Deepwater drill crew was tripping in the hole with drill pipe.

As they were transferring a stand of pipe out of the setback area with a hydraracker, the stand caught on a finger at the 51′ lower fingerboard.

As the hydraracker continued to move, tension caused the pipe to bow and the pipe was released from the lower tailing arm with significant force toward the setback area striking and fatally injuring the employee.

What Went Wrong?

This investigation for this event is ongoing.

Corrective Actions and Recommendations:

While this incident is still under investigation, drilling rig operators using fingerboards with latches are recommended to:

  • Review and assess applicability of NOV Product Information Bulletin 85766409 and NOV Safety Alert Product Bulletin 95249112
  • Verify a system is in place to confirm the opening and closing of fingerboard latches (by way of CCTV or spotter)
  • Ensure personnel are kept clear of the setback area 

Safety Alert Nnumber: 268 
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer

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.

 

 

Reuters Reports: “BP spill manslaughter charges dropped, one guilty of environmental crime”

December 3rd, 2015 by

Manslaughter charges were dropped against the two BP Engineers in-charge on the ill-fated Deepwater Horizon. Donald Vidrine did plead guilty to one misdemeanor violation of the Clean Water Act.

For more info, see: http://uk.reuters.com/article/2015/12/02/uk-bp-spill-charges-idUKKBN0TL26M20151202 

Monday Accident & Lessons Learned: Is Training the Right Corrective Action for this Fatal Accident?

November 30th, 2015 by

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Here is a link to the significant incident report:

http://www.dmp.wa.gov.au/Documents/Safety/MSH_SIR_230.pdf

It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:

Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.” 

In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause. 

What do you think? Was this a training root cause that needs a training corrective action?

Leave your comments below…

Monday Accident & Lessons Learned: “Safety Pause” – Does It Work?

November 16th, 2015 by

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:

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.

WSJ: “Dam Failure Points to Rise in Mine Woes”

November 9th, 2015 by

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.

Monday Accident & Lessons Learned: Well Kick Due to Liner Top Seal Failure

November 9th, 2015 by

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.
NewImageWhat 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/

Disclaimer:

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.

New EPA Refinery Regulation Requires Root Cause Analysis of Upset Emission Events

November 5th, 2015 by

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!

Will you be at the NISO Conference tomorrow?

October 1st, 2015 by

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Mark Paradies, President of System Improvements, is am invited speaker at the National Irish Safety Organization Annual Conference being held in Galway, Ireland, tomorrow. His talk is about achieving safety excellence using lessons learned from Admiral Rickover. He hopes to see you there!

Monday Accident & Lessons Learned: Restart Risk After an Accident

September 7th, 2015 by

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?

Politician Calls for Root Cause Analysis

September 4th, 2015 by

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.

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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:

 http://www.taproot.com/store/3-Day-Courses/

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?

Dramatic Cell Phone Video Shows Accident at Construction Site

September 2nd, 2015 by

adamr2Worker starts to climb into underground vault but when popping noises are heard, the worker is pulled out by co-workers, and saved from being scalded.

Click here to view the video and read story.

Get More from TapRooT®: Follow our Pages on LinkedIn

August 13th, 2015 by

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.”

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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.”

training page

Thank you for being part of the global TapRooT® community!

When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?

July 29th, 2015 by

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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.

 

The more things change the more they stay the same…

July 21st, 2015 by

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
fast enough!”

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Mark Paradies Now Has Over 14,000 Connections on LinkedIn

July 20th, 2015 by

Screen Shot 2015 07 20 at 5 44 29 PM

 

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:

https://www.linkedin.com/in/markparadies

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.

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Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

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