Category: Documents

Monday Accident & Lessons Learned: UK RAIB Has 8 Recommendations for Track Maintenance Issue

April 4th, 2011 by

The report from the UK Rail Accident Investigation Branch is titled:

Derailment of an engineering train between Gloucester Road and Earl’s Court stations on London Underground 12 May 2010

To read the report that includes eight recommendations, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/110321_R052011_Earls_Court.pdf

Potential Human Factors Root Cause of the Deepwater Horizon Accident

March 31st, 2011 by

One of the interesting avenues of questioning that TapRooT® would lead investigators to is the human factors involved in detecting that a blowout was starting while the well displacement was in progress.

Two people had indications that could have detected the blowout starting and could have helped those in control of the well maintain control of the well or shut the well in before a blowout occurred.

Therefore, investigators should be looking at the human factors of the detection of a well blowout.

I was reviewing information on the Deepwater Horizon Joint Investigation site and found these pictures …

April20Normalabnormalflow

April20Flowinflowout

April20Drillpipepressure

Screen Shot 2011-03-31 At 12.02.44 Pm

The first three graphs are fairly easy to interpret. Especially with the clearly marked notes with arrows pointing to the applicable trends. The last one is a typical multiple pen strip chart that is difficult to interpret.

So my question would be … “What do the real indicators look like?”

The displays and alarms are a big deal for this accident. This could be a major reason why the crew didn’t detect the blow out starting when they could have taken action.

Does anyone have actual pictures of the type of indicators they would be using? I’d love to have a look at them. If you have them, contact me by clicking here.

Deepwater Horizon – Macondo Well Blowout – Chief Counsel's Report

February 22nd, 2011 by

The Chief Counsel has released a more detailed report about the Deepwater Horizon blowout. See it at:

http://www.oilspillcommission.gov/chief-counsels-report

So far I can’t get the whole report to download, but I can download the separate chapters. Once again, a massive report … This time over 350 pages with animation of certain key technical issues.

A Note in Portuguese from our Brazilian Instructor Boris Risnic

February 2nd, 2011 by

Here’s a note about the upcoming course in Brazil from Boris Risnic …

Taproot Visao Geral 2D

Mark’s Initial Comments on the President’s Commission Report on the BP Deepwater Horizon Accident

January 18th, 2011 by

I didn’t make it very far into the report before the political tone became apparent.

In the second paragraph of the first section (the Forward), the report says:

A treasured American landscape, already battered and degraded from years of mismanagement, faced yet another blow as the oil spread and washed ashore.

These type of political statements and adjectives that can easily agitate public opinion are common throughout the first three chapters that I read this weekend. My opinion is that an accident report should stand on the facts. Perhaps Chapter 4 will present them – I’m still reading.

However, the Editors of The Wall Street Journal were not convinced. In an article in the “Review & Outlook” of the editorial page titled: “Gulf Political Spill”, they said:

Unable to name what difinitively caused the well failure, the commission resorts to a hodgepodge of speculation.”

It also says:

Its [the report’s] section ‘The Root Causes: Failures in Industry and Government’ uses questionable decisions made by the Macondo players to suggest, with no evidence, that such behavior is the industry norm.”

Toward the end of the editorial, it says:

The unbalanced, tendentious nature of the commission report vindicates those who suspected from the start that this was all a political exercise.

They conclude the WSJ editorial with:

The BP spill was a tragedy that should be diagnosed with a goal of preventing a repeat, not in order to all but shut down an industry that is vital to U.S. energy supplies and the livelihood of millions on the Gulf Coast.”

What I’d suggest is that you read the 398 page report for yourself and leave your comments here based on your own observations. Let me know what you think.

To download the report, go to:

http://templatelab.com/deepwater-report-to-the-president-final-report/

President's Commission Releases Report on BP Deepwater Horizon Oil Spill

January 18th, 2011 by

Here are the important links to download the report …
First, download the report at:

Full Report Download Page

Staff Working Papers Page

But the report cites another report still to be written – The Chief Counsel’s Report. The final report references this report for more about the facts of the investigation. There is a place to request notification when the Chief Counsel’s Report is completed on the full report download page.

Friday Joke: The Blame Oriented Alternative to TapRooT®

January 14th, 2011 by

Sometimes people ask me what the most popular problem solving system (besides TapRooT®) is. That easy! Blame.

Here’s a self-executing PowerPoint to help you understand the concept …

ProbSolvingFlowchart.pps

Screen Shot 2011-01-07 At 3.23.24 Pm

Is this the way  your employees view your root cause analysis?

Environmental Groups Blast Louisiana Refineries for “Accidents” Reported to the LA Dept of Environmental Quality

December 14th, 2010 by

Here’s the story from the New Orleans Times-Picayune:

http://www.nola.com/business/index.ssf/2010/12/louisiana_oil_refineries_accid.html

While the groups complain about under-reporting, they then turn around to say that the numbers reported show that a BP Texas City type accident could threaten workers and local residents.

What do you think? A fair use of data or a political hit job?

Safe Holiday Wish PowerPoint

December 2nd, 2010 by

I post several Holiday Safety PowerPoints that were given to me by TapRooT® Users. They are yours for toolbox holiday safety meetings.

Here is the first:

SafeHolidayWish-1.ppt

Monday Accident & Lessons Learned: Technical Investigation Report concerning the Fire on Eurotunnel Freight Shuttle 7412 on 11 September 2008

November 22nd, 2010 by

See the joint report by the French Bureau d’enquêtes sur les Accidents de transport terrestre and the UK Rail Accident Investigation Branch at:

http://www.raib.gov.uk/cms_resources.cfm?file=/101122_ReportET2010_eurotunnel_eng.pdf

Taking Improvement to the Next Level

October 27th, 2010 by

You really need to be at this talk to hear what I have to say. This PowerPoint is for the attendees to remind them of what they heard…

Takingimprovementnextlevelprint2

Lessons Learned from Rickover About Process Safety/Nuclear Safety

October 22nd, 2010 by

Rickover’s ideas are still applicable and controversial today. Here’s the slides from the talk I’m giving at the Summit…

Rickoverprint2

Prioritizing Improvements

October 21st, 2010 by

Here’s the “kick off” slides from a discussion we will be having at the Summit…

Prioritizingimprovementsprint

Welcome to the TapRooT® Summit

October 21st, 2010 by

The Summit starts next Wednesday, but I’ll be posting some of the talks so that people attending the Sumnmit can print them to take notes and preview what they will hear.

Caution: A PowerPoint of a talk isn’t the same as a talk. I know in my talks, there are things that are said that make the slides “come alive.” Also, some of the bullets on the slides are “for discussion.” They aren’t meant as a final conclusion, but rather as a starting point. Therefore, these talks should be observed and participated in at the Summit rather than being read as a final statement.

here is the Summit intro talk that will be delivered by Mark Paradies, Linda Unger, Ed Skompski, Ken Reed, Chris Vallee, and David Janney.

Welcome10Print

UK Rail Accident Investigation Branch Publishes a Report on the Derailment at Dingwall, Scotland, 22 January 2010

September 30th, 2010 by

See:

http://www.raib.gov.uk/cms_resources.cfm?file=/Bulletin%20(Dingwall)%2011-2010.pdf

Blame Culture and Deepwater Horizon Accident

September 23rd, 2010 by

Safety & Health Practitioner (the official magazine of the Institute of Occupational Safety & Health) published an article titled: “Blame culture prominent on Transocean rigs“.

The first paragraph said:

A culture of fear and blame is rife across the operations of offshore drilling contractor Transocean, according to a leaked HSE inspection report.

Wow! That’s certainly an “explosive” claim. Especially with the weight of the UK Health and Safety Executive behind it.

For the complete story, see:

http://www.shponline.co.uk/news-content/full/blame-culture-prominent-on-transocean-rigs

Are 12 Hour Shifts Safe?

September 22nd, 2010 by

Teaching root cause analysis, I have lots of people ask me about 12 hours shifts, fatigue, and safety. If this is a question you are interested in, I have a free publication that might interest you …

 Landing 12Hrcover

It is written by the experts in fatigue and shift scheduling, Circadian Technologies. Get your copy at:

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

ANSI/API Fatigue Risk Management System Recommended Practice

September 7th, 2010 by

The American Petroleum Institute and the American National Standards Institute have published a recommended practice titled: Fatigue Risk Management Systems for Personnel in the Refining and Petrochemical Industries (ANSI/API Recommended Practice 775, First Edition, April 2010).

You can download the standard at this site:

http://www.api.org/Standards/new/api-rp-755.cfm

Now, what do incident investigators need to know about this standard when performing a root cause analysis? If you are at a refinery or petrochemical plant, you are required to consider fatigue when doing your investigation. The standard says:

4.7 Incident/Near Miss Investigation

The investigation of incidents should be conducted in a manner that facilitates the determination of the role, if any, of fatigue as a root cause or contributing cause to the incident. Information collected should include the time of the incident, the shift pattern, including the number of consecutive shifts worked, the number of hours awake, the number of hours of sleep in the past 24 hours by the individuals involved; the shift duration (and any overtime worked); whether the incident occured under normal operations or an extended shift; whether an outage was occurring; and, other fatigue factors. It should be noted that for individual incidents, often no definitive conclusion regarding the role of fatigue may be possible. However, aggregate analysis of incidents may reveal patterns suggestive of the role of fatigue that is not apparent by evaluating incidents individually.

When using TapRooT®, fatigue has always been considered as part of the “15 Questions” asked for every Human Performance Difficulty. The first question asks:

Was the person excessively fatigues, impaired, upset, distracted, or overwhelmed?

This question is expanded on in the Root Cause Tree® Dictionary. These questions were developed with the help of Circadian Technologies. We also worked with them to develop a free internet based fatigue evaluation tool called FACTS (Fatigue Accident/Incident Causation Testing System). You can try it for free at:

http://facts.circadian.com/facts/

Want to find out more about fatigue and FACTS? The attend the TapRooT® Summit. Rainer Gutkuhn (one of the designers of FACTS) will show attendees in the Behavior Change & Stopping Human Error Track how to use FACTS in an investigation.

That’s just one of the many great sessions at the Summit. See:

http://www.taproot.com/summit.php?t=schedule

for the complete Summit Schedule.

Process Safety and Operational Excellence Were Invented By Admiral Rickover

September 6th, 2010 by

Here’s an old document (1979 – in pdf format) where Admiral Rickover set out his tenets that assured reactor safety in the Nuclear Navy.

Click link below…

Download (PDF, 3.28MB)

We will be discussing his philosophy at the TapRooT® Summit in the “Lessons Learned About Excellence and Safety From Admiral Rickover” session in the Improvement Program Best Practices Track on Thursday from 10:40-12.

Don’t miss this session where where you can learn how Process Safety Management and Operational Excellence originated.

To register for the Summit, go to:

https://taproot.com/summit.php?t=register

And if your were a Navy Nuc … leave your comments here about your experience in the Nuclear navy and how it changed your approach to operations, maintenance, or life.

Safety Culture Components

August 29th, 2010 by

The Nuclear Regulatory Commission has developed 13 safety culture components that were updated and released earlier this year. They are:

  1. Decision-making
  2. Resources
  3. Work Control
  4. Work Practices
  5. Corrective action program
  6. Operating experience
  7. Self and independent assessments
  8. Environment for raising safety concerns
  9. Preventing, detecting, and mitigating perceptions of retaliation
  10. Accountability
  11. Continuous learning environment
  12. Organizational change management
  13. Safety policies

To read more about these safety culture components, see this NRC document:

Safetyculture13Components

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