Taproot

I am a sucker for a 1948 Indian Chief motorcycle.  So I  thought … what a great opportunity to talk about Human Factors Design and show off a little nostalgia. The topic of today is the Suicide Shifter.

The Suicide Shifter is located on the left side of the fuel tank and was used to shift gears while riding. Called a Suicide Shifter because you had to take your left hand off the handle bar grip to shift it.

So the question for you today is how many equipment control designs used today at your work area are not placed in the safest area to use while operating?

I almost fell off my chair laughing at this one.

The Supervisor (in Saudi Arabia) said to the employee:

“Make sure that the tanker is labeled Diesel Fuel in Arabic and NO Smoking in Arabic.”

He asked the employee:

“Do you understand?”

The employee said:

“Sure boss … got it. You want the tanker labeled Diesel Fuel in Arabic and No Smoking in Arabic.”

What could go wrong? …

I especially like the spelling. (He must have gone to school at the same place I did!)

In the human factors world there is an acronym, HCI. This stands for Human Computer Interaction. A subset of the human factors field, HCI is where computer software programers meet the computer user’s needs by design BEFORE they sell it. So…… have you seen the marketing and pre-beta download for Windows 8?

• Will the new version frustrate new or experienced window users? or both?
• Will Microsoft help experienced users transition?
• How will Microsoft help experience users transition (if they do) to the new version?
• Will software developers who have software used on Microsoft help transition their existing customers?

Windows 8 Developer Preview is available for you to try now: http://msdn.microsoft.com/en-us/windows/apps/br229516

In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and in our TapRooT® book, TapRooT® Changing the Way the World Solves Problems, we introduce the Critical Human Action Profile (CHAP) tool to help collect more information to analyze any type of problem at the process task level.  I like to call this looking at a problem at the 1 foot level as opposed to many investigations that analyze their problems at the 100,000 mile view only.

The tip here, however, is “why wait for a problem to use CHAP?”

Identify, Evaluate and Improve before it is too late!

Using a very over simplified list of procedure steps on How to Remove a Fuel Pump, found on the internet, I would like to show you how to use CHAP proactively to improve Safety and Quality during a task.

WARNING: The steps listed in the demonstration example below on removing a fuel pump shall not be used. They are incomplete and not necessarily accurate.

Where to start? First off you already perform  JHA, AHA, JSA, Observations…. So Going Out and Looking (GOAL) should not be new or require a lot more additional resources. The difference is that you will be utilizing your resources more efficiently.

1. Start by identifying a task performed by employees that are critical to:

a. Customer/client satisfaction

b. Product Quality

c. Project Timeliness

d. Employee Safety

e. Customer Safety

f. Environmental Exposure

2. Once the task is identified, list the steps to be performed like listed in the image below.
Note: Do not forget to use the Basic Cause Category Procedure in our TapRooT® Root Cause Tree to look for missing best practices as well when listing the steps.

3. Identify each step of the task that is critical to the items listed in step 1 criteria of this article.
Which steps listed above for the fuel pump removal do you think would be listed as critical?

4. For each critical step in the task perform a CHAP Profile.

Note: For each of the items listed below, do not forget to include the Best Practices listed under the Human Engineering Basic Cause Category in our TapRooT® Root Cause Tree.

Last year, a Delta employee lost his leg when it was crushed by the wheel on a jetway in Knoxville, Tennessee.

I had a little extra time waiting for my flight to Atlanta from Knoxville last Friday so I asked the gate agent about the accident and what had been done to prevent a repeat. She said they were now required to have a spotter to make sure that no one got near the wheels while the jetway was moving (the wheels aren’t visible from the jetway controls).

That’s a Human Action Safeguard.

She also said that no one is allowed to use the stairs or get near the wheels while the jetway is in motion. That was already true when the accident happened but it was re-emphasized to everyone after the accident.

That’s a rule “quasi-Safeguard” that requires human action (compliance) to work.

Thus, a near-fatal accident had two human action related Safeguards that are meant to prevent recurrence of the accident.

Here is a graphic from our root cause analysis training…

Now let’s evaluate the corrective actions used to prevent a possible future fatality using the graphic above…

First, we made a rule that required a spotter during moving of the jetway. This is a human action related Safeguard implemented through a rule. That is the second weakest type of corrective action (#5).

Reemphasizing a rule that previously failed (the second corrective action used) is a training related human performance Safeguard and is the weakest corrective action to prevent recurrence of the accident (#6).

What do you think? If you had a serious accident (lost leg due to crushing) and it had the potential to be fatal, would two weak corrective actions be enough?

Maybe we should start at the top of the hierarchy in the figure above and see what is the strongest reasonable Safeguard that we can employ is…

1. REMOVE THE HAZARD

The Hazard in this case is the jetway weight and moving pinch point when the jetway is in motion. This is difficult to remove. (At least I can’t think of a way to do it.)

2. REMOVE THE TARGET

With current aviation operations, people are required to direct the plane while parking, unload baggage, refuel the plane, etc. Perhaps someday this will be done robotically, but for now, removing people from the jetway environment seems unlikely.

3. GUARD THE TARGET

This one is possible. See this photo below from Frankfurt …

They have implemented a guard to keep people away from the wheels.

Is it 100% perfect? No. People can go around the guard (jump over it?).

Is it better than warning people to be careful?

Yes!

So I sent the photo above to the Knoxville airport management. We’ll see if there are changes in the future to implement a stronger Safeguard to the potentially fatal Hazard.

ARE WE DONE?

NO!

This corrective action (if implemented in Knoxville) only fixes one small set of Hazards – jetway pinch-points in Knoxville. This Hazard exists at airports around the world.

For corrective actions to the Generic Root Cause, Delta would need to get airports around the world to guard the Hazard.

Next time you board a plane at your local airport, see what kind of Safeguard is in place. If you don’t see any, send the airport management (you can usually find a “contact us” link at the airport’s web site) a link to this posting.

ONE MORE THING TO LEARN

How do you develop corrective actions? Do you start at the top of the Safeguard hierarchy and work your way down or do you start at the bottom and work your way up?

Your investigators should have their corrective actions evaluated to see how effective they will be. For potentially fatal accidents, I would recommend using the top three strongest on the list and sometimes allow the fourth if somehow the top three aren’t possible.

The bottom two can be allowed in combination with the top 4, but I would never allow them to be the only corrective action if a fatality was possible.

Stop taking the easy way out. Learn a lesson from this accident (and the corrective actions). Improve your corrective action process by using the strongest possible corrective actions.

Watch the chimpanzee vs. human child in a learning experiment.

Here is the video link: http://youtu.be/nHuagL7x5Wc

We are all trained, or learn, by trial and error on how to use equipment or how to use it “properly”. What happens when you get a better “understanding” of how the equipment works? Here are some of the choices that we could make:

1. Ignore the previous training and just get the prize (work done faster, like the chimpanzee)

2. Continue the rules that you learned or were trained to do (at least in front of the bosses like the children).

3. Stop and ask what’s up?

4. Stop using the tool all together and do not tell anyone.

Often the previous training and experience overrides the new operation steps needed … ever been totally frustrated every time someone changes your computer’s Microsoft Windows version? And no, training by itself does not override experience, practice and repetition does!

I had a discussion not too long ago that OSHA forklift training requirements were met when people were retrained after changing forklifts. Unfortunately, the controls worked exactly opposite on the new forklift and the quick review did nothing to override the past knowledge and muscle motor memory.

Just something to think about when you think “Great Human Factors.”

Is the Human Factors Design at it’s best or worst?

However often would you need to change the windshield?

What if you wanted someone else to drive the car?

Should passengers be able to see out the windshield too?

The New York Times reported that Robert LiMandri, the Commissioner of the Buildings Department in New York City, said:

“We know that there was work being done right before the unfortunate event, and we do believe that is a contributing cause, or the cause.”

He also said:

“We know for sure that those events directly before this unfortunate accident clearly are part of our investigation.”

Suzanne Hart was killed while when the elevator suddenly shot upwards as she boarded.

The story also says that the about 60,000 elevators in New York produced 53 accident in the previous year.

Ah, the ever popular safety stand down. If people make mistakes, it must be time to have one.

See the story in the Atlanta Business Journal at this link:

http://www.ajc.com/business/mistakes-idle-workers-at-1310276.html

The article says:

“A TVA spokeswoman told the Chattanooga Times Free Press that the construction ‘stand down’ ordered to start at noon Wednesday was to continue ‘until the errors discovered are clearly communicated to all personnel.’”

Will communicating the “errors” really improve performance?

A TVA spokesperson said:

“TVA had not yet determined if the mistakes were due to carelessness but a ‘root cause analysis’ was being conducted.”

Carelessness as a potential “cause”?

TVA’s top executive, Tom Kilgore, said:

“When workers return to the site on Monday, they will join foremen and supervisors to review an error that occurred in December that had the potential for fatal consequences and that was identified earlier this week at Watts Bar Unit 2. Also to be reviewed is a second incident that occurred this week which could have resulted in a severe injury or worse if it had happened under slightly different circumstances.”

That tool box safety meeting shouldn’t take too long. From the report, they don’t know the root causes yet. All they seem to know is that two mistakes were made. I guess “foremen and supervisors” will just tell employees to “be more careful” and not to make errors. Then everything will be OK.

After that, employees will be willing to cooperate in an open and revealing root cause analysis. Especially when they know that management is looking for those who may have been careless.

We all know that the best way to keep people from being careless is to fire those who are found to be careless. If you fire careless people frequently, everyone will be happy and careful!

Another quote from the article:

“Nuclear Regulatory Commission Region 2 spokesman Roger Hannah said Friday that such work stoppages at nuclear plants are ‘not uncommon’ and probably occur every two or three years. Hannah said they are ‘not exclusive to the nuclear industry.’”

Wonder why they need a stand down every two or three years if they have an effective performance improvement program? I guess people need to be reminded to be more careful every two or three years.

Maybe we should just schedule these stand downs in advance? We could call it  human performance preventive maintenance. Every two years we would give people a day off to think about being more careful and “Presto!” … no more human errors.

Or even better! Rate people on their potential for carelessness on a scale from 1 to 10. Then every year fire the worst 10%-20% of the careless employees! 

Do these actions sound like the Deming Red Bead Experiment to anyone? If you don’t know what the Red Bead Experiment is, see the following videos…

Now read these quotes:

NRC’s “…Hannah declined to speculate about any possible penalty for TVA. He said TVA would assess both nuclear safety and workplace safety issues.”

And …

“The problems were discovered in routine TVA inspections and follow heightened NRC scrutiny on other TVA nuclear plants.”

Ahhh… now we are getting to the “root cause” of the stand downs.

It will look like management is doing something.

Management would hate to look like they are doing nothing.

A stand down makes them look like they are doing something. 

The more people stand down, the more dramatic the effect.

Thus, a stand down may keep the NRC from descending upon a nuclear utility.

If NRC management starts to believe that TVA has multiple troubled plants with multiple reasons for concern about human performance and human reliability, that could result in a special inspection. A special inspection is bad. When multiple regulators descend upon a nuclear utility, they always find things that need to be improved. If too many areas need improvement, the NRC could order reactors shut down until the “culture” is changed.

An NRC ordered shut down is bad news for the utility. “Changing the culture” can take years, cost millions of dollars, and result in many managers being fired. That’s much worse than the impact of a simple stand down for a few days. Thus, a stand down is a cost-effective way to keep the NRC happy – at least for a while – even if the stand down has no lasting impact on human performance.

Is there a better approach?

How about honest recognition of mistakes big and small? Once the mistake is recognized,  management could require a thorough, effective, advanced root cause analysis of any problem that could result in significant impact on plant safety, personnel safety, radiation exposure, environmental performance, or plant performance. Management could then insist upon the development and implementation of effective (SMARTER) corrective actions. Part of those corrective action could include effective communications about what happened and why it happened (the real root causes) to all employees that are impacted by the issue or the corrective actions.

What if you really want to stop having stand downs (and the incidents that cause management to call for stand downs)?

Management needs stop being REACTIVE by being PROACTIVE.

Management needs to shift from reactive root cause analysis to advanced PROACTIVE root cause analysis and stop problems before incidents happen. (We teach how to do this in our 5-Day TapRooT® Course.)

I’d recommend that TVA stop blaming workers (calling them careless) and start finding and fixes the real root causes of problems. Rather than a show stand down for the NRC, use effective advanced root cause analysis – both reactively and proactively – to improve performance and avoid issues that require stand downs every few years.

Show stand downs haven’t resulted in improved performance in the Nuclear Navy or the nuclear power industry (as evidence by the fact that they are repeated over and over again) and they should not be accepted by the NRC as effective management action. Rather, knee-jerk use of a stand down should be seen as a sign of weak management. Management that does not know how to improve human performance.

Avoid this scenario at your facility. Make sure that your management understands how to use advanced root cause analysis both reactively and proactively. Get your advanced root cause analysis program effectively implemented and then continue to improve it every year. And this advice is not just for nuclear utilities. Rather, it applies to every industry where mistakes may cause major accidents – oil, refining, chemical plants, aviation, railroads, shipping, pipelines, pharmaceutical manufacturers, mining, hospitals, …

Where can you learn best practices to continuously improve root cause analysis and human performance? Start at the 2012 Global TapRoot® Summit in Las Vegas on February 29 – March 2. See the schedule for all nine Summit Tracks at:

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

Don’t wait to register. The Summit is only a month away. Get registered today.

As an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:

Wrong Tool?

Bad Access by Design?

Mechanic’s Ingenuity?

Or a little bit of them all?

Finally, ever have one of your modified tools bite you back?  Share your stories in the comment section.

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.

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.

The article says:

“Carnival estimated yesterday it would have to pay at least $40 million in insurance deductibles following the wreck. It may also face as much as $95 million in lost voyage earnings this year without the use of Costa Concordia. The company further ‘anticipates other costs to the business that are not possible to determine at this time.‘”

See:

http://www.bloomberg.com/news/2012-01-17/carnival-chief-micky-arison-faces-fallout-from-worst-accident-in-40-years.html

OGP Safety Alert

ELECTRIC LINE FAILURE FROM CORROSION RESULTS IN INJURY

Country: USA – North America

Type of Activity: Construction, Commissioning, Decommissioning

Type of Injury: Struck by

U.S. Department of the Interior Bureau of Safety and Environmental Enforcement (BSEE) Safety Alert Number: 298

During well temporary abandonment operations, electric line (eline) was used to set a 1,000 pound cast iron bridge plug assembly (the assembly). When the assembly was approximately 6 inches from the deck, the eline parted near the rope socket. As the assembly fell, the Injured Person (IP), who was guiding the assembly to the well bore, was struck on the foot as a result of the IP being within the assembly’s potential fall radius.

What Went Wrong?:

A BSEE investigation revealed the following:

After the incident, the eline operator cut 1,500 feet of the eline off the drum and found the eline to be corroded and brittle with 5 out of the 18 wire rope strands broken.

The approved BSEE Permit to Modify stated the assembly would be run with the workstring, but the assembly was actually run with eline.

The Job Safety Analysis (JSA) was performed 9 hours prior to the job and did not identify all risks associated with the specific lifting operation; e.g., the job required a worker to be within the assembly’s 9 feet potential fall radius but risk assessment of the assembly’s potential fall hazard, and the eline’s condition/capability for making the lift were not addressed.

Findings from a third party lab’s visual examination of the eline indicated corrosion and pitting, with the fractured outer wire strands distorted and bent in a way indicative of shear/overload fracturing due to corrosion. A scanning microscope examination also revealed the fractured surfaces were battered, abraded and corroded, also revealing shear/overload due to corrosion.

The eline operator couldn’t provide any standard operating procedures or long term preventative maintenance records for the eline unit.

Corrective Actions and Recommendations:

Therefore, the BSEE recommends:

1. Eline/wireline operators develop and maintain standard operating procedures and records for the eline/wireline units to include preventative maintenance protocol, visual inspection of the wire rope associated with these units and wire rope change-out records (similar to crane wire rope protocols). Lessees should request a copy of these eline/wireline procedures and records.

2. Lessees and its contractors review BSEE Safety Alert No. 282 that discusses the need for workers to understand it is not the JSA Form alone that will keep them safe on the job but rather the process the JSA represents. It is of little value to identify hazards and devise proper controls if the controls are not put in place.

Source Contact:

Glynn T. Breaux
+1 (504) 736-2560

This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and the U.S. Department of the Interior Bureau of Safety and Environmental Enforcement (BSEE) (http://bsee.gov/).

Safety Alert Number: 241

OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP 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.