Mark Paradies, President of System Improvements and co-creator of the TapRooT® System, will be speaking at the IOSH Conference in Spotlight Theatre 2 on Tuesday, February 26, and Wednesday, February 27.
His topics are:
Tuesday: 13:20 – 13:50 – Spotlight Theatre 2
BP Deepwater Horizon & BP Texas City Accidents: Two Lessons That You May NOT Have Learned
Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into two lessons learned that have not received much attention yet are important to safety improvement.
Wednesday: 11:20-11:50 – Spotlight Theatre 2
Fixing The Safety Pyramid & Stopping Major Accidents
Several articles have been published criticizing Heinrich’s Safety Pyramid and blaming it’s weaknesses for the gap between the decline in safety statistics and the continuing level rate of serious injuries, including fatalities. Mark Paradies will share insight into the Safety Pyramid and explain why fatality prevention needs a revised model and new approaches to achieve across the board safety performance improvements.
Hope to see you there!
This lesson learned is from a regulatory incident.
I remember talking to a nuclear industry VP who had a troubled plant (NRC regulatory issues). He said that he was blindsided by their problems. It was as if the day before he was walking along on a beautiful day and the next morning he woke up at the bottom of a deep dark hole. The change seemed almost instantaneous … without warning.
How does a leading company go from excellence to disaster? It isn’t that there weren’t warning signs. The signs were there but management missed them.
The fastest way to get in trouble is to start thinking that you are so good that you don’t need to pay attention to small problems. That you can economize on improvement without experiencing performance improve-ment declines. That your cost saving efforts will NOT lead to field personnel placing more emphasis on production and less on safety and quality.
The switch from a performance improvement focus to a cost-cutting focus can seem like a small change – a minor variation. But when the problems start – when you wake up at the bottom of the deep dark hole – you will say the same thing that the nuclear VP said:
If I’d known how bad
this was going to be,
I would have paid any
amount of money to avoid it.
Don’t find yourself at the bottom of the deep dark hole.
Keep your focus on performance improvement.
Learn best practices that others use to make their programs better every year.
Where can you learn these practices? At the 2013 Global TapRooT® Summit in Gatlinburg, TN!
Summit week is March 18-22. Register now to ensure your choice of the pre-Summit Courses.
Get complete Summit info including the complete Summit schedule at:
Remember, there is no time like the present to avoid a disaster!
He says you will “Jump out of your chair!”…
He’s a Tony Robbins Fan.
Last week we shared some quick tips and staggering stats on Fall Safety and Electrical Safety during the holiday season. Here are a few tips from The Electrical Safety Foundation International to keep you and your children safe when displaying your decorations.
- Make sure your Christmas tree is fresh, and keep it hydrated by refilling the stand. It will pose less of a fire hazard this way.
- With artificial trees, look for a fire resistant one.
- Don’t use electrical ornaments or lights on trees with metallic leaves or tinsel in them.
- Place your tree at least 3 feet away form heat sources, including fireplaces, radiators, and heaters.
- 45% of home décor fires start with candles.
- An average of 260 homes fires begin with Christmas trees each year, resulting in 12 deaths, 24 injuries, and $16.4 million in damage.
Check out this Fire safety video comparing the flammability of a poorly watered tree and properly watered tree: Click Here
- Keep children supervised around candles and electrical lights.
- Never allow them to use garlands, tree lights, and cords as playthings – they pose a strangulation hazard.
- All small, fragile ornaments and decorations should be placed out of children’s reach, as children may break them and get hurt, or simply put them in their mouth.
- Cover all unused outlet with electrical tape or plastic covers.
Happy Holidays and stay safe, from all of us at TapRooT®!
Inc.com listed links to what they think are the best tips for motivating employees. The article asserts:
” … success of any facet of your business can almost always be traced back to motivated employees. From productivity and profitability to recruiting and retention, hardworking and happy employees lead to triumph.”
Links to articles on motivation Inc.com listed fall into categories ranging from changing corporate culture to non-cash incentives to creating a fun workplace and more.
See the link below and make some positive resolutions for enhancing motivation in your workplace:
To find out more about the Summit, see:
Monday Motivation: The Motivated Student – Do You Think This Would Motivate Any Student To Do Better?Posted: October 29th, 2012 in Human Performance, Performance Improvement, Video
R.R. Donnelley & Sons Co. prematurely filed Google Inc.’s earnings report with the Securities and Exchange Commission on Thursday. Google’s earnings were supposed to be released after the stock markets closed at 3 p.m. Instead, they showed up on the SEC’s Edgar website about 11:30 a.m. Google’s stock dropped as much as 11 percent, to $676 a share, before trading was halted about 20 minutes later at the company’s request.
About an hour after the earnings release, Google issued a statement blaming Chicago-based R.R. Donnelley for the blunder.
(“Glitch on Google Earnings Report under Investigation,” Chicago Tribune, October 19, 2012.)
Why do people think that blame will stop incidents? Haven’t we tried that already? Don’t the incidents just continue? Share your comments below.
Inc. Magazine published a story about the “9 Things That Motivate Employees More Than Money”. Here’s the list:
1. Be generous with praise.
2. Get rid of the managers.
3. Make your ideas theirs.
4. Never criticize or correct.
5. Make everyone a leader.
6. Take an employee to lunch once a week.
7. Give recognition and small rewards.
8. Throw company parties.
9. Share the rewards—and the pain.
See the complete story at:
What do you think? Good ideas?
One of the things that was discussed at the 2012 Global TapRooT® Summit was fatigue risk management programs. Just thought I’d pass along to readers that Circadian Technologies is having a public course titled:
Developing & Implementing an Effective Fatigue Risk Management System
on November 7-8, 2012, in New Orleans. See the brochure below or click on this link for more info …
The Definition of Human Fatigue
by Martin Moore-Ede, M.D., Ph.D.
Everyone these days is talking about employee fatigue, driver fatigue and fatigue risk management systems. But what exactly is the definition of “fatigue”?
While engineers use the term to describe the irreversible failure of materials as a result of stresses over an extended period of time, the term is also used to describe human impairment in the workplace or on the highway.
In The Definition of Human Fatigue, Dr. Moore-Ede, one of the world’s leading experts on human fatigue, explains the meaning of fatigue and its causes, including extended wakefulness, heavy work, excessive stimulation, illness or stress. Knowing what exactly is meant by human fatigue is critical to reversing it.
CIRCADIAN offers its white papers for free to shift work managers and others interested in improving the health, safety and productivity of the 24/7 workforce.
Throughout our 29 years of working with shiftwork and extended hours operations, CIRCADIAN has written many white papers in response to our clients questions and interests. If you have a question for us, please contact us.
Two Main Street, Suite 310
Stoneham, MA 02180 USA
When was the last time you saved a life?
I remember the first time I saw my daughter, who had a summer job as a lifeguard, save a man and a boy from drowning in a lake. Afterwards I talked to her. She didn’t see it as a big deal. She said she did rescues every week. She didn’t consider it heroic. It was just part of her job.
Several years ago at the TapRooT® Summit, a TapRooT® User approached me to thank me. He said that they had stopped fatalities at their site after learning to apply TapRooT®. He told me that improved performance meant that, over a period of several years, they had saved about five lives at their refinery. He then said …
“Imagine how many TapRooT® Users there are applying TapRooT® around the world …
Easily there are hundreds of lives saved every year!”
Have you found and fixed the root causes of potentially fatal accidents at your site? Then you too have saved a life – or maybe more than one life.
Try not to become complacent about the lives you are saving. Celebrate your success. Tell others about the good job they are doing. Make sure that management knows about the lives saved.
And never stop improving.
As my boss in the Navy, Captain Willian J. Rodriguez, told me:
“If you’re not pedaling, you’re going downhill.”
Don’t become complacent about saving lives.
Keep up the good work.
And when you can, enlist others in this great cause.
Consumer Reports published an article about teenage and older person fatality rates. They had this graph…
Here is something interesting that you can learn …
Did you know that the human brain doesn’t fully develop the ability to assess risk until about age 25? Now look at the graph above. Look at the fatality reduction post age 25.
Now think … what are you doing to keep your (<25) year old workers safe in all situations where they make make poor risk decisions?
In our family we did what the article recommended – a graduated driving program.
First, kids weren’t allowed to obtain their full licenses until they were 17.
Next, we talked to them extensively about the risk of driving before we let them start driving independently and kept that as limited as possible (no friends in the car – only family for the first year). We did a lot of “critiqued” driving with them even after they had their full license. We also had them take advanced (beyond high school drivers ed) classes put on by our local police.
And we didn’t get them high powered vehicles.
How could you take the same approach with young employees?
Monday Accident & Lessons Learned: UK RAIB Report on a Track Worker Struck by a Train at Stoats Nest Junction, 12 June 2011Posted: August 27th, 2012 in Accidents, Current Events, Human Performance, Investigations
Here’s a link to a report by the UK Rail Accident Investigation Branch about a train that struck a worker near the tracks:
How do you keep your workers safe from moving vehicles?
One interesting point in this report was that the train’s horn probably could not be heard by the track workers because of the noise generated by the equipment they were using.
Recent press coverage of fatal accidents …
The Associated Press: Kraft Food employee killed in fork lift accident
The Associated Press: Man electrocuted in constrution accident
The Southern Illinoisan: Illinois man, 70, dies in accident at Iowa auction
The Marin Independent: Report: Lack of ‘prudent seamanship’ led to fatal Farallones yacht accident
In a recent article by Circadian Technologies, they suggested that the idea temperature to maintain alertness in 24 hour (shift work) environments was between 66º to 68º F.
Wow! That seems cool! See the whole article here …
How do you keep people alert? What influences your alertness? Find out about the nine switches that Dr. Martin Moore-Ede has described in his book, The 24 Hour Society. Here’s the link …
I recently received an inquiry asking me, “What is the test to assure true root cause is found? We use the “Why-Why” Analysis.”
Using one of the “why” methods (“Why-Why”, 5-Why’s, etc) unfortunately leads many investigators to question their methodology. That’s because, after using it once or twice, it becomes pretty obvious that these methods are 100% dependent on the experience and biases of the investigator. If you’re a training person, amazingly enough, your “why” analysis leads you to training problems. If you’re a quality person, you end up with quality-related issues.
That’s because these methods do not give you any expert guidance to get beyond the investigator’s current level of knowledge. For example, if you don’t know anything about “human engineering” (what color should an alarm light be? what shape valve hand wheel should be used?), you will never look for these problems. You will only find problems you’re already familiar with, and therefore you will only put corrective actions in place that you have probably already tried in the past.
The question posed is exactly the right question. “How do I know I’ve found the real root cause?” The bad news is that only a highly-trained human performance expert can answer that without some type of expert guidance. The good news is, TapRooT® was designed to give you exactly that expert guidance.
TapRooT® was designed by human performance experts to guide the normal investigator toward the true root causes that a highly-trained expert would find. It does this by supplying a series of simple “yes/no” questions that you answer in the course of your investigation. The answers to those question will quickly narrow you down to the true root causes of human performance or equipment failures that actually led to the accident. Once you have these root causes, you can then apply effective corrective actions to eliminate them, preventing similar human performance mistakes in the future.
Now, instead of ending up with corrective actions like, “Counseled the operator on the importance of opening the correct valve” (like he doesn’t already know that!), you can now find out why he opened the wrong valve. You can be confident that the root causes you have found are real, proven root causes… the real reasons good people make mistakes.
To directly answer the question, “why” methodologies will not consistently get you to true root causes. There is no test built into those methods to verify root causes are found. There’s no electronic “magic bullet” that can work around the weaknesses in those systems. You’ll have to go outside those methodologies to get there. Give TapRooT® a try! We guarantee you’ll be satisfied with the results.