Category: Documents

CSB Asks for Comments on Their 2012-2016 Strategic Plan

March 29th, 2012 by

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The CSB has asked for comments on their 2012-2016 Strategic Plan by April 12, 2012. You can see the plan at:

http://www.csb.gov/assets/news/document/CSB_Strat_Plan_Web_Posting_(3-26-2012).pdf

You can send your comments by email to strategicplan@csb.gov.

My thought was that the strategic plan needed more specifics as far as the strategies to be adopted. For example, there were five sub-goals under “Goal 3: Preserve the public trust by maintaining and improving organizational excellence.” One of these was “Maintain effective human capital management by promoting development in leadership, technical, and analytical competencies.

The document referred to several other plans, (the “CSB Human Capital Plan for Fiscal Years 2011 – 2015,” the “Office of Personnel Management (OPM) Workforce Planning Model,” and the “OPM Strategic Leadership Management Model”), that were not readily available on the CSB web site or by a link in the Strategic Plan. Thus, the specifics of the plan are largely unknown and unknowable.

For example, I would like to see an easy link to the qualification requirements and training program for CSB investigators. This could be helpful so that others could see what the CSB considers an adequately qualified investigator.

It would also be interesting for the CSB to detail what they are doing to learn industry best practices for root cause analysis, interviewing, corrective action development, and accident prevention. But these details are not easily available.

Also, I would think that many TapRooT® Users would suggest that the CSB have a core of investigators familiar with the TapRooT® System that is used extensively across the chemical, petrochemical, and oil industry. This would help them interface with industry personnel and provide them the knowledge they need to evaluate industry incident reports produced using TapRooT®.

Finally, I would also think that TapRooT® Users would like to see continued participation of the CSB in ongoing TapRooT® Summits where industry best practices about root cause analysis and accident prevention are shared. Participation in the TapRooT® Summit and other industry conferences should be spelled out as part of the strategy to keep up with the state-of-the-art in the chemical industry.

One other item that deserves comments is the timeliness of CSB accident reports. Frequently, these reports are more than a year after the accident. Important investigations, (for example, BP Texas City, and the still unreleased BP Deepwater Horizon investigations), take more than two years. By the time the investigations are released, the industry has already implemented corrective actions and moved along. I would like to see a specific strategy/plan to improve the timeliness of investigations to avoid late investigations that have limited industry impact because of their tardiness.

One final thought … because having an effective independent evaluation of major accidents is so important, I highly recommend that readers in the chemical industry take the time to read the CSB Strategic Plan and provide your comments before April 12. You can’t complain about the outcome if you don’t comment when asked.

T-48 Hours and Counting! Welcome to the TapRooT® Summit!

February 27th, 2012 by

Just 48 hours until the start of the 2012 Global TapRooT® Summit.

Here’s the welcome talk in a PDF format …

Welcome2012

Monday Accident & NOT Lessons Learned: Under-Reporting of Sentinel Events May Be One More Cause of Failure to Prevent Human Errors in the Healthcare Setting

February 20th, 2012 by

A new investigation by the Inspector General of the Department of Health and Human Services says that:

Hospital employees recognize and report only one out of seven errors, accidents and other events that harm Medicare patients while they are hospitalized.

The report also says that:

…even after hospitals investigate preventable injuries and infections that have been reported, they rarely change their practices to prevent repetition of the ‘adverse events.’

For the whole report, see:

http://oig.hhs.gov/oei/reports/oei-06-09-00091.pdf

So, only a small fraction of sentinel events are investigated and most of those don’t cause permanent, effective change to prevent future errors.

Sometimes it can be frustrating to be a prophet when those that could make change happen just don’t listen. We’ve been suggesting proven ways to improve sentinel event investigation and performance improvement that could be applied by medical facilities ever sine the 1994 TapRooT® Summit. But only a limited number of healthcare facilities have taken advantage of the lessons they could learn.

The TapRooT® Summit is coming up on February 29 – March 2 and we have a full track devoted to improving performance in the healthcare industry. This isn’t just lessons from inside the industry. Rather, this is a place where healthcare folks can learn from a wide variety of industries and facilities with best practices from around-the-world.

If you are from a healthcare facility that needs to improve (and from the Inspector General’s report, that’s just about every facility) there’s still just enough time to sign up. See:

http://www.taproot.com/summit.php

PowerPoint of Pictures of the Costa Concordia

January 24th, 2012 by

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Click on the .ppt file below to download.

COSTA_CONCORDIA.ppt

Root Cause Tip: Sources of Root Cause Analysis Failure – A Paper By Mark Paradies

January 18th, 2012 by

I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.

Mark Paradies Article Quasar 118-3

The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.

Sources of Root Cause Analysis Failures by Mark Paradies is published by:

Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.

Used by Permission.

How Many Days Until the 2012 GLOBAL TapRooT® SUMMIT? Just 42!

January 17th, 2012 by

If you have already signed up for the TapRooT® Summit, have you made sure that others in your company who should be there have signed up?

Here’s a link to the TapRooT® Summit Brochure that you can pass along to them as a reminder …

2012 TapRooT Global Summit

Press Release from the US Chemical Safety Board: CSB Report Finds that Oil and Gas Exploration and Production Facilities Present Hazards to Members of the Public, Especially Children

October 27th, 2011 by

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CSB Issues Recommendations to EPA, State Regulators, NFPA, and API Aimed at Increasing Oil Site Safety and Security

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Hattiesburg, MS, October 27, 2011 – The U.S. Chemical Safety Board (CSB) today released a new study of explosions at oil and gas production sites across the U.S., identifying 26 incidents since 1983 that killed 44 members of the public and injured 25 others under the age of 25, and is calling for new public protection measures at the sites.

The report examined in detail three explosions that occurred at oil and gas production facilities in Mississippi, Oklahoma, and Texas, that killed and injured members of the public between October 2009 and April 2010.

The CSB report found that children and young adults frequently socialize at oil sites in rural areas, unaware of the explosion hazards from storage tanks that contain flammable hydrocarbons like crude oil and natural gas condensate.  The unintentional introduction of an ignition source (such as a match, lighter, cigarette, or static electricity) near tank hatches or vents can trigger an internal tank explosion, often launching the tank into the air and killing or injuring people nearby. The report identified regulatory gaps at the federal and state levels and called on the U.S. Environmental Protection Agency (EPA) and state regulatory bodies to improve current safety and security measures at exploration and production sites such as warning signs, full fencing, locked gates, locks on tank hatches, and other physical barriers. The report also called on state regulators in Mississippi, Oklahoma, and Texas to require safer, modern tank designs that reduce the likelihood of an internal tank explosion if an ignition source is inadvertently introduced nearby.

On October 31, 2009, two teenagers, aged 16 and 18, were killed when a storage tank containing natural gas condensate exploded at a rural gas production site in Carnes, Mississippi. Six months later a group of youths were exploring a similar tank site in Weleetka, Oklahoma, when an explosion and fire fatally injured one individual. Two weeks later, a 25-year-old man and a 24-year-old woman were on top of an oil tank in rural New London, Texas, when the tank exploded, killing the woman and seriously injuring the man. The CSB deployed investigators to all three sites to collect information on the incidents.

Investigators found that the three accidents occurred in isolated, rural wooded areas at production sites that were unfenced, did not have clear or legible warning signs and did not have hatch locks to prevent access to the flammable hydrocarbons inside the tanks.

CSB Chairman Rafael Moure-Eraso said, “After reviewing the work of our investigators I believe that these incidents were entirely preventable. Basic security measures and warning signs – as well as more safely designed storage tanks – will essentially prevent kids from being killed in tank explosions at these sites.”

The CSB’s investigation found a few major cities and some states, such as California and Ohio, already require varying levels of security for oil and gas production sites, such as fencing, locked or sealed tank hatches, and warning signs. As a result, California did not appear to have any fatal tank explosions between 1983 and 2011. However, many other large oil and gas producing states have no such requirements. The major oil producing states Texas and Oklahoma require fencing and warning signs for certain sites that have toxic gas hazards but not for all sites with flammable storage tanks.

“Oil and gas storage sites are part of the landscape in many rural American communities; hundreds of thousands of similar sites are located across the country,” said CSB Lead Investigator Vidisha Parasram. “It was a concern to discover that issues related to public safety are rarely considered prior to placement and design of these sites. In many cases sites can be as close as 150 to 300 feet from existing buildings such as residences, schools, and churches, and still lack any meaningful warnings or barriers to prevent public access.”

Among the six formal safety recommendations in the report, the Board urged that state regulators require the use of inherently safety tank design features such as flame arrestors, pressure-vacuum vents, floating roofs, and vapor recovery systems. The safety measures, which are similar to those already in use in refineries and other downstream storage tanks, reduce the emissions of flammable vapor from the tanks or otherwise prevent an external flame from igniting vapor inside tanks.

“The goal of this investigative study is to issue recommendations that will effectively address the current gaps that exist at the state and federal level, said Dr. Moure-Eraso. “As I have seen firsthand, these sites can be dangerous to the people who live and work in these communities and should be properly designed and protected.”

The Board recommended that EPA issue a safety bulletin warning of the explosion hazards of storage tanks, describe the importance of increased security measures such as fencing, gates and signs, and recommend the use of inherently safer storage tank design.  Similarly, the CSB’s recommendations seek to address the current gaps in regulations and codes in Mississippi, Oklahoma and Texas.

The CSB’s investigation also examined industry codes and standards, such as those from the American Petroleum Institute (API) and the National Fire Protection Association (NFPA). The final report recommends that both organizations adequately address the hazards that these sites present to members of the public through amendments to their existing codes or creation of additional guidance.

As a result of the investigation’s findings the CSB recommended that API warn of the explosion hazards presented by exploration and production sites, including requirements for security measures such as fencing gates and signs, recommendations for inherently safer storage tank design and acknowledgment of the public safety issue presented by these sites. Similarly the CSB recommended that NFPA amend NFPA 30 “Storage of Liquids in Tanks – Requirements for all Storage Tanks” to adequately describe unmanned extraction and production sites and include information in a relevant security standard that offers specifications on fencing and locks.

Chairman Moure-Eraso said, “As the demand for domestic energy resources continues to grow and the number of active extraction and production sites continues to rise steadily, it is important to ensure that these sites have the appropriate safeguards to save young people’s lives.”

On April 13, 2011, the CSB held a news conference and public meeting in Hattiesburg to release the safety video “No Place to Hang Out: The Danger of Oil Well Sites.”The video is aimed at educating young people about the hazards associated with oil storage tanks. In the video the CSB interviewed teenagers and adults who stated that it is a common practice in rural areas for young people to hang out and socialize at oil production sites.

To view the CSB’s final report click here.

To view the CSB’s safety video “No Place to Hang Out: The Danger of Oil Well Sitesclick here.

The CSB is an independent 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 safety management systems. The Board does not issue citations or fines but does make safety recommendations to companies, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Please visit our website, www.CSB.gov.

Contact: For more information, contact Communications Manager Hillary Cohen at 202-446-8094 or via email at Hillary.Cohen@csb.gov or Sandy Gilmour at 202-261-7614 or cell 202-251-5496 or via email at Sandy.Gilmour@csb.gov.

Monday Accident & Lessons Learned: Derailment in Summit Tunnel, Near Todmorden, West Yorkshire, UK

October 24th, 2011 by

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The UK Rail Accident Investigation Branch has published a report about a train derailment in Summit Tunnel, near Todmorden, West Yorkshire, UK.

Here’s the summary from their press release:

In the early hours of 28 December 2010, a passenger train was travelling from Manchester to Leeds when it struck a large amount of ice that had fallen onto the tracks from a ventilation shaft in Summit tunnel.  All wheels of the front bogie were derailed to the left in the direction of travel causing the front driving cab of the train to strike the tunnel wall.  The train remained upright and once it had stopped, the train crew took action to protect the train and raise the alarm.  About three hours later, the passengers and train crew had been led out of the tunnel by the emergency services.  No injuries were reported, while the train suffered damage to its cab windscreen, a coupler, bodywork and underframe. There was minor damage to the track.

The ice formed as water, seeping through the lining of a ventilation shaft, froze during a long period of freezing temperatures.  This ice fell onto the track after a thaw which started on 27 December 2010.  The train, which was the first to pass through the tunnel in over three days due to the Christmas holiday period, then collided with it.  A combination of factors led to this accident:

  • the risk of ice, particularly ice falls onto the track, was not identified before the train service resumed so the train was allowed to enter Summit tunnel while running at its maximum permitted speed; and
  • the routine maintenance regime did not identify excessive ice in the tunnel and no additional inspections were carried out.

The RAIB has made five recommendations, all directed to Network Rail.

The first recommendation relates to how water in Summit tunnel is managed.

The second is about identifying those structures which are at risk from extreme weather and then checking they are safe to use after periods when no trains have been running.

The third calls for the potential hazards due to extreme weather and thaw conditions to be taken into account in Network Rail’s weather management processes.

The fourth calls for training and information to be given to staff who need to carry out the additional inspection of structures that are at risk in extreme cold weather.

The fifth relates to the management of safety related information (and details of actions taken) that is passed from Network Rail’s buildings and civils – asset management function to other parts of the company.

For the complete report and lessons learned, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/110929_R162011_Summit_Tunnel.pdf

NTSB Releases Accident Report on California Pipeline Explosion

September 27th, 2011 by

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Here’s a link to a summary on the NTSB web site:

http://www.ntsb.gov/investigations/summary/PAR1101.html

Here’s the report:

http://www.ntsb.gov/doclib/reports/2011/PAR1101.pdf

Here is a CBS story about the report:

http://www.cbsnews.com/stories/2011/09/26/ap/cabstatepent/main20111675.shtml

Here’s video of the NTSB press conference:

White Paper Available: "The Advantages & Disadvantages of 12-Hour Shifts: A Balanced Perspective"

September 15th, 2011 by

Circadian Technologies has published a white paper titled:

The Advantages & Disadvantages of 12-Hour Shifts:
A Balanced Perspective

Their press release states:

12-hour shifts remain a much-debated topic in 24-hour operations. Do they cost more than 8-hour shifts? Are they safe? What impact do they have on alertness, health and productivity?

CIRCADIAN®, the global leader in providing 24/7 workforce performance and safety solutions for businesses that operate around the clock, has collected considerable data on the benefits and complications of 12-hour shifts. The goal of this white paper is to provide you with a balanced perspective of 12-hour shifts – one that will examine the pros and cons from both a management and shiftworker perspective.

Here’s the link to register to receive this report:

http://www.circadianinfo.com/landing/The_Advantages_Disadvantages_of_12_Hour_Shifts.htm

If you are interested in preventing fatigue and developing a fatigue risk management program, sign up for the:

Fatigue Risk Management Training

being held on February 27-28, 2012, in Las Vegas just prior to the TapRooT® Summit.

This training, being provided by Circadian Technologies, will help you:

• Design and implement a cost-effective Fatigue-Risk Management System

• Assess the risks and costs of fatigue in your business

• Determine safe staffing levels and optimal shift/duty patterns for your operation

• Train employees and supervisors to mitigate fatigue risk

• Improve employee health, safety, and quality of life

Also, the Summit (February 29 – March 2 in Las Vegas) has two sessions on fatigue as well as other sessions on improving human performance. Don’t miss it!

BOEMRE Releases Deepwater Horizon Report

September 14th, 2011 by

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Here’s a link to the report:

http://www.boemre.gov/pdfs/maps/DWHFINAL.pdf

Here’s a link to The Wall Street Journal article about the report:

http://online.wsj.com/article/SB10001424053111904060604576570600492781420.html?mod=rss_US_News

I’ve just started reading the report so … no comments for now.

How much does an Accident cost? See OSHA's "$afety Pays" calculation.

September 6th, 2011 by

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OSHA has an on-line calculator to help you find the total cost of an accident. See it at:

http://www.osha.gov/dcsp/smallbusiness/safetypays/estimator.html?

This calculator is very similar to the rough estimate provided in the TapRooT® Book.

For more information on the basis for this calculator, see:

http://www.osha.gov/dcsp/smallbusiness/safetypays/background.html

Monday Accident & Lessons Learned: UK RAIB investigation report on the safety of automatic open level crossings

September 5th, 2011 by

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From the report:

Summary

Following the fatal accident at Halkirk automatic open level crossing, Caithness, on 29 September 2009, the RAIB decided to carry out two separate investigations. The first of these was into the Halkirk accident1, while the second was to investigate the more general safety issues associated with automatic open level crossings installed on Network Rail’s managed infrastructure. This report addresses the more general safety issues.

The RAIB’s investigation confirmed that automatic open level crossings, which are protected only by road traffic light signals, and have no barriers, are the highest risk form of level crossing for vehicle drivers on public roads, and some of them have a significant history of incidents and accidents.

The investigation found that the lack of barriers at automatic open level crossings is the most significant factor contributing to vehicle drivers passing the road traffic light signals when they are operating, either deliberately or as a genuine error. The RAIB considers that the crossings with the highest risk of collision between trains and road vehicles should be upgraded, probably by fitting half barriers, but there may be other means which deliver an equivalent or better level of safety (eg closure).

The high cost of new level crossings is a reason why it can be difficult to justify upgrading existing crossings based on a cost benefit analysis. However, a system is being developed to retro-fit half barriers to existing automatic open crossings at a much lower cost than that of a new crossing. If this initiative is successful, it will be easier to justify the upgrade of existing crossings. The RAIB believes that this work should be prioritised accordingly.

The safety of level crossings can be improved by taking action against vehicle drivers who deliberately pass the flashing red lights. Where this behaviour is prevalent, red light enforcement equipment is a deterrent. The RAIB believes that the development of fixed digital cameras and their installation at selected level crossings, particularly in combination with greater penalties, would be beneficial in improving safety and should be prioritised.

The identification of factors at each crossing that lead to deliberate risk taking behaviour or genuine errors would enable appropriate risk reduction measures to be implemented. The RAIB believes that the existing risk assessments of automatic open level crossings should be reviewed to check whether all the relevant factors have been identified, and to determine whether additional mitigation measures are required.

Finally, the RAIB believes that Network Rail’s process covering the risk assessment of level crossings should include guidance to its staff on how to identify the relevant human factors, and take account of the associated risk, at specific level crossings in order to determine the adequacy of existing mitigation measures and the need for additional measures. This builds upon a similar recommendation the RAIB made following its investigation of the Halkirk accident.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/110728_R122011_AOCLs%20Class%20Inv.pdf

New White Paper Available from Circadian Technologies: "The Evolution of Fatigue Risk Management Systems"

August 24th, 2011 by

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Circadian Technologies has published a new white paper titled:

The Evolution of Fatigue Risk Management Systems

Just click on the link above to go to their web site to register to receive the paper.

If you want even more information, consider attending the course being provided by Circadian Technologies prior to the TapRooT® Summit:

Fatigue Risk Management Training

Just click on the course link above to get more information and to register.

Also, Bill Sirois, COO at Circadian Technologies, will be providing two talks about fatigue and fatigue risk management at the TapRooT® Summit. For complete Summit info, see:

http://www.taproot.com/summit.php

Monday Accident & Lessons Learned: UK RAIB Report on Accident at Falls of Cruachan, Argyll 6 June 2010

August 22nd, 2011 by

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Summary

At 20:55 hrs on Sunday 6 June 2010, the 18:20 hrs train from Glasgow Queen Street to Oban struck a boulder that had fallen onto the track just west of the station at Falls of Cruachan, in the Pass of Brander, on the line from Crianlarich to Oban. The boulder lifted up the front coach of the two-coach train and derailed it to the left and down an embankment. The leading bogie of the rear coach came to a stand supported by the boulder with the rear bogie still on the track.

Of the 64 passengers and three crew on the train, eight of the passengers were taken to hospital with minor injuries.

The boulder had fallen down the cutting slope onto the railway from within the railway boundary. It had become insecure due to the growth of tree roots around it, which gradually prised it from its stable position, and soil erosion from normal rainfall. Network Rail’s earthworks management system applied to cutting slopes had not identified the hazard of loose boulders in the area that the accident occurred.

The RAIB has made five recommendations to Network Rail relating to the management of earthworks. These include:

• improving the clearance of vegetation growing on earthworks so that hazards to the safety of railway operation can be identified;

• improvements to the collection of slope data so that a full appreciation of the condition of slopes is obtained; and

• improvements to the process for the implementation of remediation works to prevent future earthworks failures.

A further recommendation has been made relating to the prevention of lighting diffusers and other saloon panels on rolling stock becoming displaced during accidents.

For the whole report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/110714_R112011_Falls%20of%20Cruachan.pdf

Mark Publish an Article in The Compass – "Root Cause Analysis & I2P2"

July 11th, 2011 by

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Read the article (pages 6 and 7) in The Compass at:

http://viewer.zmags.com/publication/846aabfd#/846aabfd/1

The Compass is a technical publication of ASSE’s Management Practice Specialty.

7 Tips for Enhancing Alertness at Work – From Circadian Technologies

June 28th, 2011 by

Circadian Technologies will be presenting a pre-Summit course on Fatigue Risk Management and two breakout sessions in different tracks at the Global TapRooT® Summit. But before you can attend these sessions, I thought that readers might want to learn just a little about the knowledge available from Circadian Technologies. Therefore, I’ve posted this link to a recent article they published titled:

7 Tips for Enhancing Alertness at Work

Just click on the title to read their advice.

NRC Issues "FINAL SAFETY CULTURE POLICY STATEMENT" ,,, Can You Show That You Are Compliant?

June 21st, 2011 by

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The NRC has issued what they are calling a “final safety culture policy statement.”  See:

http://www.nrc.gov/reading-rm/doc-collections/news/2011/11-104.pdf

I’m sure that it isn’t really final. (Aren’t we always learning and improving?) But I guess that they are saying they are done with the initial development and will now be starting to look at nuclear utilities to see that they have a positive safety culture.

What is a safety culture? The NRC says it is:

… an organization’s collective commitment, by leaders and individuals, to emphasize safety as an overriding priority to competing goals and other considerations to ensure protection of people and the environment.

The go on to define nine traits that nuclear plants should foster. They are:

1.Leadership Safety Values and Actions – Leaders demonstrate a commitment to safety in their decisions and behaviors;

2. Problem Identification and Resolution – Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance;

3. Personal Accountability – All individuals take personal responsibility for safety;

4. Work Processes – The process of planning and controlling work activities is implemented so that safety is maintained;

5. Continuous Learning – Opportunities to learn about ways to ensure safety are sought out and implemented;

6. Environment for Raising Concerns – A safety-conscious work environment is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination;

7. Effective Safety Communication – Communications maintain a focus on safety;

8. Respectful Work Environment – Trust and respect permeate the organization;

9. Questioning Attitude – Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action.

As I read more, I started thinking … As a utility, how do you measure your culture, diagnose opportunities for improvement, and demonstrate efforts to improve the safety culture at your plant?

Fortunately, we’ve been interested in safety culture for a long time and TapRooT® is able to help you diagnose safety culture issues.

But where to start? Safety culture is a tough subject. Many find it hard to be specific about culture issues. Even TapRooT® users sometimes don’t understand how TapRooT® can help them understand their safety culture and improve it.

So, we decided to build a course to help TapRooT® Users understand safety culture issues and then fix them.

This new course was built on a solid foundation of culture research and the bedrock of the TapRooT® System.

The FIRST public TapRooT® Analyzing and Fixing Safety Culture Issues will be held in Las Vegas on February 27-28, 2012. We will be putting out more information in future updates here on the Root Cause Analysis Blog, but, if you are interested in safety culture, you should plan to attend the course.

But the course isn’t all we are doing.

The TapRooT® Summit is also a great way for your company to demonstrate a commitment to improving your safety culture.

First, since problem identification and resolution is a major part of a positive safety culture, the Summit helps Summit participants by keeping them up-to-date on the latest incident investigation, troubleshooting, and root cause analysis technology. That way they can go back to their companies and make sure that issues really are fully evaluated and promptly addressed.

Second, another major trait that nuclear plants are suppose to foster is “continuous learning”. And continuous learning is what the Global TapRooT® Summit is all about. Learning best practices and new techniques from industry leaders from around the world. What better way to demonstrate your companies commitment to continuous learning than to send a team to the Summit and have them return to work with a custom plan to continuously improve performance.

Finally, the first trait mentioned by the NRC is that “Leaders demonstrate a commitment to safety in their decisions and behaviors.” But how can you demonstrate a leaders commitment? Participating in the Summit and making sure that your nuclear sites are well represented is an excellent way to demonstrate commitment. This is especially true because there is a best practice track for managers, the – “Leading Performance Improvement Track.”

The Leading Performance Improvement track includes these breakout sessions:

TapRooT® Implementation Success Stories (Leaders hear how others improved performance.)

What is Culture and How Do You Identify and Solve Culture Problems Using TapRooT® (Highlights from the 2-day course plus communication ideas to have effective safety communications.)

What Does Management Need to Know About Process Safety Improvement (Mark Paradies shares management lessons from Admiral Rickover and how missing elements of process safety management have contributed to major accidents.)

Deepwater Horizon: A Dramatic Portrayal (A dramatic presentation that can capture management’s attention and help them see the management roots of a major accident.)

Criminal Prosecution of Accidents (What happens to those involved when accidents become crimes. Two reports from people who experienced post-accident criminal investigations.)

Investigation & Root Cause Analysis Insights (Insights into root cause analysis from two perspectives – Mark Paradies, creator of TapRooT®, and a government regulator.)

Designing Your Continuous Improvement Program (Kevin McManus – the Systems Guy – shares practical lessons he has learned from industrial experience and his experience as a Malcolm Baldridge Award Senior Examiner.)

How Pfizer Achieves Operational Excellence (Hear Pfizer’s operational excellence story.)

In addition to these breakout sessions, all Summit participants hear from the excellent Keynote Speakers. Two of particular interest to senior management are:

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Ken Mattingly speaking about “Lessons Learned from Apollo 13 and Space Shuttle Operations.”

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Dr. Beverly Chiodo speaking about “Character Driven Success.”

So start planning for your management and all your improvement team members to be at the Global TapRooT® Summit in Las Vegas from February 27 – March 2, 2012, and attending a special 2-day course and the 3-day Summit to help you achieve – and demonstrate – a positive safety culture.

Checklist for Checklists

June 21st, 2011 by

Dr. Atul Gawande at Brigham and Women’s Hospital and several associates developed this “Checklist for Checklists” for use at hospitals…

Checklist For Checklists Group Draft 5

Great stuff. Check out his web site at:

http://gawande.com/

Root Cause Analysis Tip: Improving the Use of TapRooT® through Knowledge

June 15th, 2011 by

If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.

To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:

  • Specifically designed on-site training for gaps identified as additional needs in your trending and proactive assessments.
  • Feedback for our investigators through our Advisory Board and one-on-one.
  • A Summit for system experts, which include our clients, to share best practices from multiple industries.

The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:

1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)

Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.

Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:

Task Performance Levels

1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
Proficient)
3. Can do all parts of the task. Needs only a spot check of completed work.
(Competent)
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)

Task Knowledge Levels

a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)

Subject Knowledge Levels

A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
(Analysis)
D. Can evaluate conditions and make proper decisions about the subject.
(Evaluation)

By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).

Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:

1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.

2-Day TapRooT® Incident Investigation and Root Cause Analysis
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis

2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.

3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.

4. Develop in-house group sessions to discuss lessons learned.

5. Schedule refresher training to give competency levels high.

Good luck on your quest for knowledge!

Second Fatality this Year at Henley Street Bridge Construction Site

May 24th, 2011 by

 Images 640 360 2 Assetpool Images 110524040642 Bridge

This job is in Knoxville – the home of System Improvements and TapRooT®. But just because it is down the road from our offices doesn’t mean that they learn from their incidents to prevent major accidents. Here’s the story that we know so far from the web:

http://www.wbir.com/news/article/170682/29/Developing-Worker-killed-on-barge-under-Henley-Bridge

Some construction companies run extremely safe sites. At others, the fatalities persist. Perhaps the “bad” companies should read the article below from a 2003 Root Cause Network™ Newsletter (click on the document below to open the PDF):

Stopsacrifices

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