For a report from the UK Rail Accident Investigation Branch, see:
If you don’t understand what happened, you will never understand why it happened.
You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?
I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.
Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.
If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?
This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.
The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.
TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.
Foe course information and course dates, see:
The Navy still likes to blame folks as a root cause. At least that’s what I see in this report about a “pilot error” keeping a F/A-18 Hornet making it back to the carrier USS Theodore Roosevelt.
Seems there were lot’s of Causal Factors that contributed to the loss of an $86 million dollar aircraft that are described in this article on Military.com:
I haven’t found the report of the video on line.
What do you think of the report of the investigation?
Beginning your investigation can sometimes be quite a challenge. Deciding on who to talk to, what documents you need, what questions you need to ask, etc. can lead to feeling slightly overwhelmed. As General Creighton Abrams said,
When eating an elephant, take one bite at a time.
In other words, you just need to get started with the first step, and then methodically work your way through to the end.
In TapRooT®, that first bite is the SnapCharT®. The rest of your investigation is going to depend on the data you gather in that SnapCharT®, so it is critical that you begin in a simple, methodical manner.
Let’s say you get that initial notification phone call (usually at 3:00 am). You don’t get much information. Maybe all you know is, “Ken, we had a pipe rupture this morning during a hydrostatic test. Looks like the mechanics didn’t know what they were doing. They had hooked up a test pump to the piping, started the pump, and almost immediately ruptured the piping. We’ve cleaned up the water, and no one was hurt. We need you to investigate this.” This is a pretty common initial report. Not a lot of data, some opinions thrown in, and a request for answers. Without a structured process, most investigations would now start off with some interviews, asking pretty generic questions. It would be really nice if we could start off with some detailed, intelligent questions.
This is where the SnapCharT® comes in. Once you receive that initial phone call, just build your SnapCharT® with the information you have. It honestly won’t have much data, but that’s OK; it’s only your starting point:
However, with this initial SnapCharT®, it is now easier to visualize what you already know, and what you still need to know. For example, I’d have a lot of questions about the pump, the mechanics themselves, recovery actions, etc. I’d use the Root Cause Tree® to help me figure out what questions to ask. I’d take each Event and ask, “What do I already know about this Event, and what questions do I have about it?” These would all be added to the SnapCharT®. It might look more like this:
Keep in mind that these questions were developed before I even went to the scene or questioned anybody about the facts. I still need to interview people, but I now have a much better set of questions to begin my investigations. Many more questions will arise as I ask this initial set of questions, but I’ll feel much better prepared to start talking to people about the issue.
The SnapCharT® is a simple yet effective tool to help the investigator get started with the investigation. It may seem like an inconsequential step, easy to dismiss. However, using the SnapCharT® as your very first tool, before you start gathering data, can greatly speed up the investigation. It allows you to start on the right path, with a set of intelligent questions to ask. Once you have this moving, you’ll find the rest of the investigation falls into place in a logical, easy to follow format. ALWAYS START WITH A SNAPCHART®!
LEARN MORE about TapRooT® essentials in our 2-day course (View schedule and register!)
Lessons learned from six trains passing through an emergency speed restriction at excessive speed. For the complete story. see this post from the UK Rail Accident Investigation Branch:
In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:
“The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.“
Additionally, he said:
“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”
That seems like a “Blame Vision” statement.
That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:
“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”
Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:
We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.
Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:
The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.
To subscribe to the newsletter, provide your contact information at:
Above is the start of an OSHA/EPA Fact Sheet titled: “The Importance of Root Cause Analysis During Incident Investigation.”
OSHA and EPA want companies to go beyond fixing immediate cause (which may eliminate a symptom of a problem) and instead, find and fix the root causes of the problems (the systemic/underlying causes). This is especially important for process safety incidents.
The fact Sheet explains some of the basic of root cause analysis and suggests several tools for root cause analysis.
UNFORTUNATELY, many of the tools suggested by the fact sheet are not really suited to finding and fixing the real root causes of process safety incidents. They don’t help the investigator (or the investigative team) go beyond their current knowledge. Thus, the suggested techniques produce the same ineffective investigations that we have all seen before.
Would you like to learn more about advanced root cause analysis that will help your investigators learn to go beyond their current investigative methods and beyond their current knowledge to discover the real root causes of equipment reliability and human performance related incidents? These are techniques that have been proven to be effective by leading companies around the world.
Yes? Then see: http://www.taproot.com/products-services/about-taproot
And choose one of our upcoming public TapRooT® Courses to learn more about the TapRooT® Root Cause Analysis System. See:
Automation dependency is an interesting topic. Here’s what a recent CALLBACK from the Aviation Safety Reporting System had to say about the topic…
Monday Accident & Lessons Learned: Aviation Safety Reporting System CALLBACK Notice About Ramp SafetyOctober 17th, 2016 by Mark Paradies
Here’s the start of the report …
This month CALLBACK features reports taken from a cross-section of ramp experiences. These excerpts illustrate a variety of ramp hazards that can be present. They describe the incidents that resulted and applaud the “saves” made by the Flight Crews and Ground Personnel involved.
For the complete report, see:
Summary from the UK Rail Accident Investigation Branch …
At 18:12 hrs on Thursday 16 June 2016, a two-car diesel multiple unit train, operated by Great Western Railway (GWR), was driven through open trap points immediately outside Paddington station and derailed. It struck an overhead line equipment (OLE) mast, damaging it severely and causing part of the structure supported by the mast to drop to a position where it was blocking the lines. There were no passengers on the train, and the driver was unhurt. All the the lines at Paddington were closed for the rest of that evening, with some services affected until Sunday 19 June.
For causes and lessons learned, see: https://www.gov.uk/government/publications/paddington-safety-digest/derailment-at-paddington-16-june-2016
Monda Accident & Lessons Learned: US CSB Report on 2014 Freedom Industries Contamination of Charleston, West Virginia Drinking WaterOctober 3rd, 2016 by Mark Paradies
Here is the press release from the US Chemical Safety Board …
CSB Releases Final Report into 2014 Freedom Industries Mass Contamination of Charleston, West Virginia Drinking Water; Final Report notes Shortcomings in Communicating Risks to Public, and Lack of Chemical Tank Maintenance Requirements Report Includes Lessons Learned and Safety Recommendations to Prevent a Similar Incident from Occurring
September 28, 2016, Charleston, WV, — The CSB’s final report into the massive release of chemicals into this valley’s primary source of drinking water in 2014 concludes Freedom Industries failed to inspect or repair corroding tanks, and that as hazardous chemicals flowed into the Elk River, the water company and local authorities were unable to effectively communicate the looming risks to hundreds of thousands of affected residents, who were left without clean water for drinking, cooking and bathing.
On the morning of January 9, 2014, an estimated 10,000 gallons of Crude Methylcyclohexanemethanol (MCHM) mixed with propylene glycol phenyl ethers (PPH Stripped) were released into the Elk River when a 46,000-gallon storage tank located at the Freedom Industries site in Charleston, WV, failed. As the chemical entered the river it flowed towards West Virginia American Water’s intake, which was located approximately 1.5 miles downstream from the Freedom site.
The CSB’s investigation found that Freedom’s inability to immediately provide information about the chemical characteristics and quantity of spilled chemicals resulted in significant delays in the issuance of the “Do Not Use Order” and informing the public about the drinking water contamination. For example, Freedom’s initially reported release quantity was 1,000 gallons of Crude MCHM. Over the following days and weeks, the release quantity increased to 10,000 gallons. Also, the presence of PPH in the released chemical was not made public until 13 days after the initial leak was discovered.
The CSB’s investigation found that no comprehensive aboveground storage tank law existed in West Virginia at the time of the release, and while there were regulations covering industrial facilities that required Freedom to have secondary containment, Freedom ultimately failed to maintain adequate pollution controls and secondary containment as required.
CSB Chairperson Vanessa Allen Sutherland said, “Future incidents can be prevented with proper communication and coordination. Business owners, state regulators and other government officials and public utilities must work together in order to ensure the safety of their residents. The CSB’s investigation found fundamental flaws in the maintenance of the tanks involved, and deficiencies in how the nearby population was told about the risks associated with the chemical release.”
An extensive technical analysis conducted by the CSB found that the MCHM tanks were not internally inspected for at least 10 years before the January 2014 incident. However, the CSB report notes, since the incident there have been a number of reforms including passage of the state’s Aboveground Storage Tank Act. Among other requirements, the new regulations would have required the tanks at freedom to be surrounded by an adequate secondary containment structure, and require proper maintenance and corrosion prevention, including internal inspections and a certification process.
The CSB’s investigation determined that nationwide water providers have likely not developed programs to determine the location of potential chemical contamination sources, nor plans to respond to incidents such as the one in Charleston, WV.
Supervisory Investigator Johnnie Banks said, “The public deserves and must demand clean, safe drinking water. We want water systems throughout the country to study the valuable lessons learned from our report and act accordingly. We make specific recommendations to a national association to communicate these findings and lessons.”
Here is a link (click of picture below) to a Callback publication about accidents and Fatigue …
Here is a quote:
“The NTSB 2016 “Most Wanted List” of Transportation Safety Recommendations leads with, ‘Reduce Fatigue-Related Accidents.” It states, “Human fatigue is a serious issue affecting the safety of the traveling public in all modes of transportation.’”
This incident notice is from the UK Rail Investigation Branch about an overspeed incident at Fletton Junction, Peterborough on 11 September 2015.
At around 17:11 hrs on 11 September 2015, the 14:25 hrs Virgin Trains East Coast passenger train service from Newcastle to London King’s Cross passed through Fletton Junction, near Peterborough at 51 mph (82 km/h) around twice the permitted speed of 25 mph (40 km/h). This caused the carriages to lurch sideways resulting in minor injuries to three members of staff and one passenger.
It is likely that the train driver had forgotten about the presence of the speed restriction because he was distracted and fatigued due to issues related to his family. Lineside signs and in-cab warnings may have contributed to him not responding appropriately as he approached the speed restriction and engineering controls did not prevent the overspeeding. Neither Virgin Trains East Coast, nor the driver, had realised that family-related distraction and fatigue were likely to be affecting the safety of his driving. Virgin Trains East Coast route risk assessment had not recognised the overspeeding risks particular to Fletton Junction and Network Rail had not identified that a speed limit sign at the start of the speed restriction was smaller than required by its standards.
The incident could have had more serious consequences if the train had derailed or overturned. The risk of this was present because the track layout was designed for a maximum speed of 27 mph (43 km/h).
As a consequence of this investigation, RAIB has made five recommendations. Two addressed to Virgin Trains East Coast relate to enhancing the management of safety critical staff with problems related to their home life, and considering such issues during the investigation of unsafe events.
A recommendation addressed to Virgin Trains East Coast and an associated recommendation addressed to Network Rail relate to assessing and mitigating risks at speed restrictions.
A further recommendation to Network Rail relates to replacement of operational signage when this is non-compliant with relevant standards.
RAIB report also includes learning points relating to managing personal problems that could affect the safety performance of drivers. A further learning point, arising because of a delay in reporting the incident, stresses the importance of drivers promptly reporting incidents which could have caused track damage. A final learning point encourages a full understanding of the effectiveness of safety mitigation provided by infrastructure and signalling equipment.
For more information see:
Here’s a link to the story: http://www.abc.net.au/news/2016-07-25/baby-dies-at-bankstown-lidcombe-hospital-after-oxygen-mix-up/7659552
An Oxygen line had been improperly installed in 2015. It fed nitrous oxide to a neonatal resuscitation unit rather than oxygen.
The Ministry of Health representative said that all lines in all hospitals in New South Wales installed since the Liberal government took over in 2011 will be checked for correct function.
What can you learn from this?
Think about your installation and testing of new systems. How many Safeguards are in place to protect the targets?
From the UK Rail Accident Investigation Branch…
On 1 August 2015 at about 11:11 hrs, a freight train travelling within a work site collided with the rear of a stationary freight train at 28 mph (45 km/h).
Engineering staff had authorised the driver of the moving freight train to enter the work site at New Cumnock station, travel about 3 miles (4.8 km) to the start of a track renewal site, and bring the train to a stand behind the stationary train.
There were no injuries but the locomotive and seven wagons from the moving train and eleven wagons from the stationary train were derailed; the locomotive and derailed wagons were damaged. One wagon came to rest across a minor road. There was also substantial damage to the track on both railway lines.
The immediate cause was that the moving train was travelling too fast to stop short of the rear of the stationary train when its driver first sighted the train ahead. This was due to a combination of the train movement in the work site not taking place at the default speed of 5 mph (8 km/h) or at caution, as required by railway rules, and the driver of the moving train believing that the stationary train was further away than it actually was.
An underlying cause was that drivers often do not comply with the rules that require movements within a work site to be made at a speed of no greater than 5 mph (8 km/h) or at caution.
As a consequence of this investigation, RAIB has made four recommendations addressed to freight operating companies.
One relates to the monitoring of drivers when they are driving trains within possessions and work sites.
Two recommendations relate to implementing a method of formally recording information briefed to drivers about making train movements in possessions and work sites.
A further recommendation relates to investigating the practicalities of driving freight trains in possessions and work sites for long distances at a speed of 5 mph (8 km/h) or at other slow speeds, and taking action to address any identified issues.
RAIB has also identified three learning points including:
the importance of providing drivers with all of the information they need to carry out movements in possessions and work sites safelya reminder to provide drivers (before they start a driving duty) with information about how and when they will be relievedthe importance of engineering staff giving instructions to drivers through a face to face conversation when it is safe and practicable to do so.
From the Rail Accident Investigation Branch …
At around 13:10 hrs on 25 July 2015, a passenger was dragged along the platform at Hayes & Harlington station, London, when the 11:37 hrs First Great Western service from Oxford to London Paddington departed while her hand was trapped in a door. The passenger, who had arrived on the platform as the doors were about to close, had placed her hand between the closing door leaves.
The train driver did not identify that the passenger was trapped and the train moved off, dragging the passenger along the platform. After being dragged for about 19 metres, the passenger lost her footing and fell onto the platform. The passenger suffered head, hand and back injuries.
RAIB’s investigation found that the passenger had deliberately placed her hand in the closing door in the expectation that it would re-open as a consequence. RAIB has concluded that after closing the doors of the train, the driver either did not make a final check that it was safe to depart, or that the check was insufficiently detailed to allow him to identify the trapped passenger. The driver may have been misled into thinking that it was safe to depart because a door interlock light in his cab had illuminated, indicating that the doors were closed and locked and he was able to take power.
Our investigation identified that the train driver and other railway staff held the same misunderstanding: if someone had a hand trapped in a door it would not be possible for the door interlock light to illuminate and a driver to take power. This is not the case, and the door was found to be compliant with all applicable standards after the accident.
As a consequence of this investigation, RAIB has made two recommendations.
The first, addressed to RSSB to review, and if necessary extend, its research into the passenger/train interface to understand passenger behaviour and identify means for deterring members of the public from obstructing train doors.
The second recommendation is addressed to operators and owners of trains similar to the one involved in the accident at Hayes & Harlington, is intended to continue and expand upon a current review into the practicability of fitting sensitive door edge technology to this type of train.
RAIB has also identified three learning points. The first concerns improving awareness among train drivers of the limitations of train door interlocking technology and the importance of the final safety check when dispatching a train.
The second concerns the potential for drivers to be distracted by the use of mobile communication devices while driving.
The third is aimed at train operators to have the necessary processes in place to identify drivers who are showing signs of sub-standard performance or not engaging positively with measures agreed as part of a Competence Development Plan and the provision of briefing and guidance material for driver managers to enable them to identify behaviours and attitudes which are inconsistent with those expected of train drivers.
For the complete report, see:
The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…
IOGP SAFETY ALERT
CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE
Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.
A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.
What Went Wrong?
The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).
- The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
- Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
- The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
- In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
- Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
- In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.
Corrective Actions and Recommendations:
Lessons Learned –
- As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
- The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.
Action taken in originating company –
Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.
- A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
- The temporary suspension does not cover retrieval operations on lines which are depressurised.
* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.
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.
Safety Alert Number: 273
IOGP Safety Alerts http://safetyzone.iogp.org
– Required by regulators or law
– Required by company policy
– Perceived higher return on investment
However, companies often default to less developed (and therefore less accurate) analyses for lower risk, lower consequence problems. For example, almost everyone will perform a TapRooT® investigation when there is a serious injury; this is a high-consequence incident, and preventing it in the future is perceived to have the highest ROI. But what about a near miss? Or maybe someone tripped over an air line on the floor, dropping a repair part and damaging it? Most companies will either not perform any investigation, or they will default to “easy” methods (5-Why’s, etc.). Why spend any time on these “simple” incidents? Let’s just do a quick “analysis” and move on?
While I completely understand this thought process, there are some serious flaws in this thinking.
- Low ROI. While a particular incident may not have caused a large loss, this dos not mean it automatically deserves no attention. Maybe tripping over the air line only caused $800 in damage this time. But what about the other issues that have been caused by poor housekeeping in the past? What if the person had tripped and fallen over the edge of a platform? Making a quick assumption like this can allow you to miss potentially serious issues when taken together. Performing a poor analysis will lead to repeats of the problem.
- Poor results of “quick” RCA methods. Keep in mind that a quick method probably means that you did not gather any information. You are therefore performing an “analysis” without any data to analyze. If your analysis method takes 5 minutes, you have probably just wasted 5 minutes of your time. If you’re going to perform an RCA, make sure it gets to useable and consistent answers.
- TapRooT® is only for the big stuff. This thought often frustrates me. It is true that you will not perform a TapRooT® investigation in 5 minutes. However, any method that purports to give you magic answers in a few minutes is not being honest. See #2 above. However, that does NOT mean that TapRooT® must take days of your time. For simple investigations, the results of a TapRooT® investigation may be found in just an hour or so.
So, how do we use TapRooT® for lower risk or low consequence problems? This year, we have modified the TapRooT® methodology to allow you to use the steps of the process that you need to perform a great investigation on simple problems. This updated process isn’t really new; it just codifies how we’ve taught you to use TapRooT® in the past for these simpler problems. We make the process more efficient and give you the opportunity to optionally skip some of the steps.
Here is the new process flow for low to medium risk incidents:
There are some important points that I wanted to highlight about this new process flow:
- You always start with a SnapCharT®. There is no way to perform any type of analysis unless you first gather some information. Again, any other process that advocates performing an analysis on the information you received in a quick phone call is not a real analysis. The SnapCharT® ensures you have the right information to actually look for root causes.
- There is an off-ramp right at the beginning. Once you’ve gathered information in a SnapCharT®, you can then make an intelligent decision as to whether this problem has the potential to uncover significant problems. You may find, after building your SnapCharT®, that this really was an extremely low potential problem, with minimal consequences. You will then stop the analysis at that point, put simple corrective actions in place to fix what you found, and then document the problem for later trends. That’s it. While most investigations will continue on with the rest of the process, there are some issues that do not require any further analysis and don’t deserve any further resources.
- For most investigations, you will continue by identifying Causal Factors, and run those Causal Factors through the Root Cause Tree®. No different than before.
- For these simpler problems, it probably is not worth the effort of looking for generic causes. We have made this step optional. It you feel the problem has the potential to be more widespread, you can continue to look for generic issues, otherwise, go straight to corrective actions.
- Low to medium risk incidents probably do not need the resources you would normally expend writing full SMARTER corrective actions. We encourage you to write corrective actions based on the guidance in the Corrective Action Helper®, but writing fully SMARTER fixes is probably not necessary.
For more serious incidents, we would still use the full 7-Step TapRooT® Process that you are familiar with. However, for lower risk or lower consequence problems, this abbreviated process flow is much easier to use, allowing you to more quickly work through a TapRooT® investigation. Why use 5-Why’s and get poor results (as expected) just to “save time,” when you can use the simplified TapRooT® process to get MUCH better answers with less effort than before?
The 2-Day TapRooT® Root Cause Analysis Course not covers this simpler method of performing TapRooT® investigations. Attendees will still be able to perform investigations on any incident, but we stress this more efficient process flow.
Choose a course and register here!
The errors reported in this Aviation Safety Reporting System “Call Back” article are simple but serious. If you load a plane wrong, it could crash on takeoff. Click on the picture of the article below to read the whole report.
These simple errors seem like they are just an aviation problem. But are there simple errors that your people could make that could cause serious safety, quality, or production issues? maybe a Safeguard Analysis is in order to see if the only Safeguard you are relying on could fail due to a simple human error.
Monday Accident & Lessons Learned: Is the Information Collected as Part of an Accident Investigation “Privileged” – Canadian Court RulesAugust 1st, 2016 by Mark Paradies
The Occupational Health and Safety Act (“OHS Act”) in Canada requires an employer to conduct and investigation and prepare a report following an accident in the workplace. But an Aberta Queens Bench ruled that the obligation does not “foreclose or preclude” the employer’s ability to claim privilege over information collected during an internal investigation into the incident.
Want to learn more? See the article about the Alberta v Suncor Energy case at:
Derailment of freight train near Angerstein Junction, south east London, 3 June 2015
At about 12:10 hrs on 3 June 2015, one wagon of an empty freight train derailed on the approach to Angerstein Junction, near Charlton in south east London. The train continued over the junction, derailing two further wagons, before it stopped on the Blackheath to Charlton line. The three derailed wagons were partly obstructing the line used by trains travelling in the opposite direction. No other trains were involved in the accident and no-one was injured, but there was significant damage to the railway infrastructure.
The wagons derailed because the leading right-hand wheel on one of them was carrying insufficient load to prevent the wheel climbing up the outer rail on a curved section of track. The insufficient load was due to a combination of the suspension on that wheel being locked in one position, a twisted bogie frame and an intended twist in the track.
As a consequence of this investigation, RAIB has made three recommendations.
The first, addressed to VTG (the wagon owner), seeks improvements to its wagon maintenance processes.
The second, also addressed to VTG, seeks liaison with industry to improve understanding of how wagon suspension wear characteristics relate to maintenance processes.
The third, addressed to Network Rail, seeks a review of infrastructure arrangements at the accident location.
The report also includes a learning point reinforcing a previous recommendation intended to encourage use of currently available wheel load data to enable identification of wagons with defects or uneven loads that are running on Network Rail’s infrastructure.
To see the complete report, go to:
The above information and report are from the UK Rail Accident Investigation Branck. See their web site at:
IOGP SAFETY ALERT
WELL CONTROL EVENT WHEN USING AN MPD SYSTEM
A High Pressure exploration gas-condensate bearing reservoir section was being drilled using automated Managed Pressure Drilling (MPD) and Rig Pump Divertor (RPD) equipment. Total gas and Connection Gas (TG/CG) peaks were noted the day before during drilling so the degasser was run. The drilled stand was backreamed at normal drilling flow rate prior to taking a MWD survey, making a connection and then taking Slow Circulating Rates (SCRs) on all 3 mud pumps. During taking SCRs an initial pit gain of 16bbl was noticed and reported.
It was suspected that pit gain was continuing, so a dynamic flow check was carried out in which it was confirmed that the well was flowing. Subsequently the well was shut in on the BOP (SICP=5,800psi, SIDPP=0psi). Dual float valves behind the bit were holding; total pit gain was estimated at 306bbls. Due to high casing pressure/MAASP concerns, an attempt was made to lower the annulus casing pressure by bleeding off gas through the choke and ‘poor boy’ mud-gas separator (MGS). This attempt was quickly aborted due to inadequate choke control leading to loss of the MGS liquid seal (SICP=7,470psi, SIDPP=0psi (floats holding).
After mobilization of high pressure bleed down facilities, the casing pressure was successfully reduced to zero psi through the “Lubricate and Bleed” well control method.
What Went Wrong?
During “pump off” events the Bottom Hole Pressure (BHP) dropped below Pore Pressure (Po) which resulted in initial small influxes into the wellbore. These were not recognized and therefore not reported as and when they occurred.
In MPD-RPD mode, fluid density dropped below the setpoint of 16.6 ppg (0.86 psi/ft) during pump off events (first and second survey and connections) due to a ‘sluggish’ RPD auto-choke. The RPD system had not been properly calibrated and the choke not run in the optimum position for effective control.
The formation pressure gradient of the gas-condensate bearing reservoir was evaluated to be 0.84psi/ft (Po~13,950psi).
Corrective Actions and Recommendations:
- Comprehensive and clear communication and action protocols (eg. close-in) should be tested, and verified as effective, across all Crews and Shifts.
- Drillers must be clear that immediately on detecting an influx, they need to shut-in the well (applies for both MPD and non-MPD operations). The deployment of MPD does not change this basic principle.
- Choke drills (A/B Crews and Day/Night shifts), including operation of remote choke(s) through a remote choke control panel, are critical to verifying that the total system (equipment, procedures, people including actions and communication protocols) are effective to operate the chokes against the maximum anticipated casing pressure.
Safety Alert Number: 272
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Here’s a summary of the report from the UK Rail Accident Investigation Branch about a derailment at Godmersham, UK:
“At around 21:40 hrs on 26 July 2015, a passenger train derailed after striking eight cows that had gained access to the railway at Godmersham in Kent, between Wye and Chilham stations. There had been a report of a cow on the railway an hour earlier, but a subsequent examination by the driver of the next passing train did not find anything. There were no further reports from other trains that passed before the accident occurred.
The train involved in the accident was travelling at 69 mph (111 km/h) at the point of impact. There were 67 passengers on board plus three members of staff; no injuries were reported at the time of the accident. Because the train’s radio had ceased to work during the accident, the driver ran for about three-quarters of a mile towards an oncoming train, which had already been stopped by the signaller, and used its radio to report the accident.
The accident occurred because the fence had not been maintained so as to restrain cows from breaching it, and because the railway’s response to the earlier report of a cow on the railway side of the fence was insufficient to prevent the accident. In addition, the absence of an obstacle deflector on the leading unit of the train made the derailment more likely.
As a result of this accident, RAIB has made five recommendations addressing the fence inspection process, clarification of railway rules in response to reports of large animals within the boundary fence, the fitting of obstacle deflectors to rolling stock (two recommendations), and the reliability of the train radio equipment.
RAIB has also identified two learning points for the railway industry, relating to the railway’s response to emergency situations, including the response to reports of large animals within the boundary fence and the actions to take following an accident.
Here is a link to read the report…
Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?
Unfortunately, most systems kind of leave you hanging. They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt. Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!
Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process. We have recently tweaked this guidance to make it even easier to quickly progress through the investigation. Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.
Some of these tools are required for every investigation; some are optional data-gathering tools. Let’s first take a look at the required tools.
One of the first things you need to do is get a good understanding of exactly what happened. Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred. By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out. It helps you figure out what questions to ask and who to ask. Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason. There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask. It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.
Root Cause Tree®:
Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process. However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®. In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation. You’ll need the answers to these questions once you get to the root cause analysis phase. Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?
The tools I listed above are used during EVERY investigation. However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®. Let’s look at the non-required tools.
Change Analysis: This is a great tool to use to help you ask thought-provoking questions. It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances. The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident. It is actually an extremely easy tool to use, and yet it is very powerful. I find this to be my most-used optional tool. The results of this analysis are now added to your SnapCharT® for later root cause analysis.
Critical Human Action Profile (CHAP): Sometimes, you need help understanding those “dumb” mistakes. How can someone be walking down the stairs and just plain fall down? The person must just be clumsy! This is a great time to use CHAP. It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task. What tools were they using (and supposed to be using)? How did we expect them to perform the individual steps in the task? This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing. The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.
Equifactor®: If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure. You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem. For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring. Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration. The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure. These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure. Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.
The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with. The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations. If you need some help getting started, the TapRooT® tools will get you going! Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.