Category: Investigations

Interviewing and Evidence Collection Tip: What Evidence Should You Collect First?

June 14th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Today, let’s talk about what evidence to focus on first during the flurry of activity that occurs after an accident.

Always begin with a SnapCharT®

Begin your investigation with a planning SnapCharT® – it takes just a few minutes to create an incident and add a few events that lead up to it into the TapRooT® software or into a paper-based version of SnapCharT®.  The SnapCharT® is a tool that will help you visually organize and prioritize evidence collection.

Pre-collection

So, what evidence should be collected first? Ideally, an investigator can photograph the scene at various angles and distances before carefully collecting the most fragile evidence and before disturbing the scene by removing larger, heavier, or less fragile evidence.  Once things start getting moved, it gets really tricky to remember the initial scene or understand the scene.

Locard’s exchange principle holds that every time a person enters an environment, something is added to and removed. This is sometimes stated as “every contact leaves a trace.” So, depending on the incident, the evidence may have already been altered in some way by first responders, employees or bystanders. It may also be disturbed by an investigator’s attempt to photograph it.  This is why it is so critical to cordon off a path for first responders and employees to minimize contamination (and this also helps first response and others avoid injury).

Take photographs or a video recording of the overall scene first.

After photography, collect fragile evidence

Fragile evidence is evidence that loses its value either because of its particular nature and characteristics, or because of the conditions at the accident scene. For example, blood in rain. Fragile evidence should be collected before it is further contaminated or before it disappears.

When the fragile evidence is removed, an investigator should begin by systematically collecting the “top” layer of evidence.  This may be photographing or collecting what he finds beneath that fragile evidence.  Collecting fragile evidence includes memorializing first impressions and observations in writing, including measurements of the scene that photographs cannot capture or record, including smells, temperature, and humidity.

Every accident and incident is different; however, this is a general guideline of how to get started with evidence collection.  Next week, we’ll discuss the best way to package evidence.

If you’re interested in learning more about Interviewing & Evidence Collection, I hope you will join me in Houston, Texas in November for a 3-day root cause analysis + interviewing and evidence collection course or 1-day  interviewing and evidence collection training.

Interviewing and Evidence Collection Tip: Organize your information with TapRooT® Software

June 7th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents. We’ve talked about the value of a planning SnapCharT® as well as how important it is to uncover facts through evidence collection.

Today, let’s talk about how to keep all of this information organized using TapRooT® Software. Our software is designed to help you track investigations, manage evidence and report on results with ease.

Create a Sequence of Event

The SnapCharT® is a simple method for drawing a sequence of events and is always where an investigator begins evidence collection. Here, you decide many things, including:

  • What information is available
  • What needs to be collected
  • What order the evidence will be collected
  • Who will be interviewed
  • What conflicts exist in the sequence of events and what evidence could help clear them up

Building the SnapCharT® in the TapRooT® software allows you to add all of these notes quickly and efficiently, save them, and edit them as you progress through evidence collection.

Organize digital documents and photos

It doesn’t take long for paper evidence to feel out of control.  Standard operating procedures, work orders, maintenance procedures, company policies and so much more are all collected as you begin uncovering the important facts that will support your conclusions.  Digital photos can easily get lost if they are not stored somewhere immediately.  Storing the digital files in your TapRooT® software catalogs them and keeps them secure.  This also keeps all of these digital items available to pull into the management report feature of the software.  You can easily upload images and documents and add them to your attachment files for each investigation.  Here is a short video to show you how to do just that:  View video.

Use TapRooT® software to create new investigations, manage tasks and analyze the results all in one place.  If you have been trained in TapRooT® and are ready to optimize your investigations, join us for our June 28 webinar!

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

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Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Interviewing & Evidence Collection Tip: You can’t know the “why” before the “what”

May 31st, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Last week we talked about the value of a planning SnapCharT®.  I’d like to take a moment to expand on that thought.

Grasping at the “why” before the “what” is a common mistake that even experienced investigators make.  But you have to understand “what” happened before you can understand why it happened.  The goal of interviewing and evidence collection is to provide facts for the “what” so you can continue with the “why” (identifying causal factors and root causes).

When I worked in the legal field, I felt that most investigations were hypothesis-based.  It seemed that more often than not, we started with several hypotheses and then began a process of elimination until we were left with one we liked.  Instead of collecting evidence before we determined “why” an incident happened, we came up with our guesses and then looked for evidence that supported the guesses.

When an investigator reaches for the “why” before the “what,” this is what occurs:

  1. Tunnel vision.  The investigator only focuses on the hypotheses presented, and none of them may be correct.
  2. Abuse of evidence. The investigator may force the evidence to “fit” the hypothesis he/she feels most strongly about.  Further, any evidence collected that does not fit the hypothesis is ignored or discarded.
  3. Confirmation bias. The investigator only seeks evidence that supports his/her hypothesis.

It is a tenet of psychology that the human brain immediately desires a simple pattern that makes sense of a complex situation. So, there is really nothing that the investigator is intentionally doing wrong when he or she falls into that trap. Not to mention, humans simply do not like changing their minds when they become emotionally attached to an idea. And then there is social pressure… when a strong personality on the investigation team thinks he/she knows the “why” – and the rest of the team goes along with it.

TapRooT® helps investigative teams avoid reaching for the “why” before the “what.”  The 7-Step Major Investigation Process taught during our 5-Day training offers a systematic way to move through the investigation and takes the investigator beyond his/her knowledge to determine the “what” first so that the causal factors and root causes identified are accurate. Learn how to collect the evidence you need to understand the “what” in our 1-day Interviewing and Evidence Collection Techniques course on November 8 in Houston, Texas.

Have you fallen into the trap of trying to decide the “why” before the “what”? Do you have something additional to share about this common problem? How has TapRooT® helped you avoid it? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

Interviewing & Evidence Collection Tip: The Value of a Planning SnapCharT®

May 24th, 2017 by

Hello and welcome to our new weekly column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.

If you are a TapRooT® user, you know that the SnapCharT® is the first step in conducting a root cause investigation.  It doesn’t matter if you’re investigating a simple incident or major accident – SnapCharT® is always the starting line.

A SnapCharT® is a simple method for drawing a sequence of events.  It can be drawn on sticky notes or in the TapRooT® software.  Sometimes we refer to the SnapCharT® in it’s initial stages as a “planning” SnapCharT®. So why is a SnapCharT® essential for evidence collection and interviewing?

When you begin an investigation, you are working with suppositions, assumptions and second hand information. The planning SnapCharT® will guide you to who you need to interview and what evidence you need to collect to develop a factual sequence of events and appropriate conditions that explain what happen during the incident. Remember, a fact is not a fact until it is supported by evidence.  

The planning SnapCharT® is used to:

  • develop an initial picture of what happened.
  • decide what information is readily available and what needs to be collected immediately.
  • establish a list of potential witnesses to interview.
  • highlight conflicts that exist in the preliminary information.
  • plan the next steps of interviewing and evidence collection.

The SnapCharT® provides the foundation for solid evidence collection.  Learn how to create a SnapCharT® by reading, “Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents or register for our 1-day Interviewing and Evidence Collection Course in Houston, Texas on November 8, 2017.  We also offer this course as a one or two-day onsite course that can be customized for your investigators.

How has SnapCharT® helped you plan your investigative interviews and evidence collection?  If you’ve never used a SnapCharT®, how do you think a planning SnapCharT® would be helpful to you? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

See you next week!

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

Are You Writing the Same Corrective Actions?

April 17th, 2017 by

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

How to Interpret Body Language In Your Incident Investigation Interviews

April 10th, 2017 by

TapRooT® Instructor and Non-Verbal Communication Expert, Barb Phillips, explains how to interpret common body language cues with an example investigative interview. Watch here for some investigative interviewing tips!

Want to know more? Take a TapRooT® Effective Interviewing and Evidence Collection course.

Root Cause Tip: What is the minimum investigation for a simple incident?

March 20th, 2017 by

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What is the minimum investigation for a simple incident?

Before you can answer this question, you need to decide the outcome you are looking for. For example:

  • Do you just want to document the facts?
  • Would you be happy with a simple corrective action that may (or may not) be effective?
  • Do you need effective corrective actions to prevent repeats of this specific incident?
  • Do you want to prevent similar types of incidents?

The answers to these questions depend on two factors that determine risk:

  1. What were the consequences of this incident and could things have happened slightly differently and had much worse consequences?
  2. What is the likelihood that this type of incident will happen again?

Of course, before you start an investigation, answering these two questions may be difficult. Before you start an investigation, you don’t really know what happened! But in spite of this lack of knowledge, someone must decide if an incident is worth investigating and the resources to dedicate to the investigation.

I’ve seen simple incidents that, when investigated, revealed complex problems that could have caused a serious accident. Therefore, if a thorough investigation is not performed, the investigator may never know what they could have discovered. That’s why I caution management that something that seems simple may not be simple.

However, some incidents ARE simple. I’ve seen many incidents that people were investigating that were similar to this one:

An employee stumbles, falls, and sprains
his wrist while walking down a flat sidewalk.
He had on simple shoes with adequate tread.
He was not particularly preoccupied
nor was he entirely paying attention to each step
(just normal walking).

How much can be learned by investigating this incident? Probably not much. I would suggest that even though the person sprained his wrist, this incident should not be investigated beyond a simple recording of the facts so that the incident could be recorded for safety records (OSHA logs in the USA) and included in future incident trending.

You might ask:

“But what if the employee had stumbled and fell in front of an oncoming car and the employee killed?”

In that case, because of the consequences, a detailed major investigation would be required.

In either case, the TapRooT® Root Cause Analysis System could be used to complete the investigation.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix complex accidents, quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and effective corrective actions.

Learn more about when to investigate a simple incident by attending our 2-Day TapRooT® Root Cause Analysis training.  Click here to view the upcoming schedule.

 

Carnival Pride NTSB Allision Report – Causal Factor Challenge

March 7th, 2017 by

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The NTSB released their report on the allision of the Carnival Pride cruise ship with the pier in Baltimore last may. It caused over $2 million in damages to the pier and the ship, and crushed several vehicles when the passenger access gangway collapsed onto them. Luckily, no one was under or on the walkway when it fell.  You can read the report here.

Pride

The report found that the second in command was conning the ship at the time.  He had too much speed and was at the wrong angle when he was approaching the pier.  The report states that the accident occurred because the captain misjudged the power available when shifting to an alternate method of control to stop the ship.  It states there may have been a problem with the controls, or maybe just human error.  It also concluded that the passenger gangway was extended into the path of the ship, and that it did not have to be extended until ready for passengers to debark.

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Gangway collapse after allision

While I’m sure these findings are true, I wonder what the actual root causes would be?  If the findings are read as written, we are really only looking at Causal Factors, and only a few of those to boot.  Based on only this information, I’m not sure what corrective actions could be implemented that would really prevent this in the future.  As I’m reading through the report, I actually see quite a few additional potential Causal Factors that would need to be researched and analyzed in order to find real root causes.

YOUR CHALLENGES:

  1. Identify the Causal Factors you see in this report.  I know you only have this limited information, but try to find the mistakes, errors, or equipment failures that lead directly to this incident (assuming no other information is available)
  2. What additional information would you need to find root causes for the Causal Factors you have identified?
  3. What additional information would you like in order to identify additional Causal Factors?

Reading through this incident, it is apparent to me that there is a lot of missing information.  The problems identified are not related to human performance-based root causes; there are only a few Causal Factors identified.  Unfortunately, I’m also pretty sure that the corrective actions will probably be pretty basic (Train the officer, update procedure, etc.).

BONUS QUESTION:

For those that think I spelled “collision” wrong, what is the meaning of the word “allision”?  How many knew that without using Google?

Remembering an Accident: Montana Coal and Iron Company

February 27th, 2017 by

Two small communities in Montana were tragically touched by a mining accident this day in 1943.

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The Montana Coal and Mine Company employed most men living in Washoe and Bearcreek, Montana. There had never been any major accidents like the one that took place on February 27, 1943. That morning, a massive explosion in mine #3 occurred. It was so powerful that families in both local communities heard and felt it. As the supervisors tried to find the cause of the explosion, they couldn’t find anything. No exact root cause. No evidence to tie together to ensure it doesn’t happen again. Sadly, all they could do was inform the families of their losses and shut down for good. The final fatality count was 74 out of 77 miners. All but 3. It was the largest accident they had ever had.

It’s stories like these that we can learn from. How could they have investigated better to find the root cause? What kind of corrective actions could have been implemented to keep these sort of explosions of happening again?

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.

As Bart Simpson says:

“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”

Blame is so common that people take it for granted.

Somebody makes a mistake and what do we do? Discipline them.

If they are a contractor, we fire them. No questions asked.

And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.

Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?

But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.

Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution. 

How do you stop blame and get people to cooperate with investigations? Here are two best practices.

A. Start Small …

If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous. 

Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.

B. Use a SnapCharT® to facilitate your investigation and report to management.

We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.

Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame. 

What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:

TapRooT® Training

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2. FIRST ASK WHAT NOT WHY

Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.

Why?

Because they should have started by asking what before they asked why.

Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem. 

How do you get people to ask what instead of why?

Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.

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3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE

Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.

What happens when an investigator starts an investigation by jumping to conclusions?

They ignore evidence that is counter to their hypothesis. This problem is called a:

Confirmation Bias

It has been proven in many scientific studies.

But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.

What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?

Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.

How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.

THAT’S IT…

The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.

If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.

If your organization faces:

  • Quality Issues
  • Safety Incidents
  • Repeat Equipment Failures
  • Sentinel Events
  • Environmental Incidents
  • Cost Overruns
  • Missed Schedules
  • Plant Downtime

You need to be apply the best root cause analysis system: TapRooT®.

Learn more at: 

http://www.taproot.com/products-services/about-taproot

And find the dates and locations for our public TapRooT® Training at:

 http://www.taproot.com/store/Courses/

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Monday Accident & Lessons Learned: Railroad Bridge Structural Failure

December 12th, 2016 by

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A Report from the UK Rail Accident Investigation Branch:

Structural failure caused by scour at Lamington viaduct, South Lanarkshire, 31 December 2015

At 08:40 hrs on Thursday 31 December 2015, subsidence of Lamington viaduct resulted in serious deformation of the track as the 05:57 hrs Crewe to Glasgow passenger service passed over at a speed of about 110 mph (177 km/h). The viaduct spans the River Clyde between Lockerbie and Carstairs. Subsequent investigation showed that the viaduct’s central river pier had been partially undermined by scour following high river flow velocity the previous day. The line was closed for over seven weeks until Monday 22 February 2016 while emergency stabilisation works were completed.

The driver of an earlier train had reported a track defect on the viaduct at 07:28 hrs on the same morning, and following trains crossed the viaduct at low speed while a Network Rail track maintenance team was deployed to the site. The team found no significant track defects and normal running was resumed with the 05:57 hrs service being the first train to pass on the down line. Immediately after this occurred at 08:40 hrs, large track movements were noticed by the team, who immediately imposed an emergency speed restriction before closing the line after finding that the central pier was damaged.

The viaduct spans a river bend which causes water to wash against the sides of the piers. It was also known to have shallow foundations. These were among the factors that resulted in it being identified as being at high risk of scour in 2005. A scheme to provide permanent scour protection to the piers and abutments was due to be constructed during 2015, but this project was deferred until mid-2016 because a necessary environmental approval had not been obtained.

To mitigate the risk of scour, the viaduct was included on a list of vulnerable bridges for which special precautions were required during flood conditions. These precautions included monitoring of river levels and closing the line if a pre determined water level was exceeded. However, this process was no longer in use and there was no effective scour risk mitigation for over 100 of the most vulnerable structures across Scotland. This had occurred, in part, because organisational changes within Network Rail had led to the loss of knowledge and ownership of some structures issues.

Although unrelated to the incident, the RAIB found that defects in the central river pier had not been fully addressed by planned maintenance work. There was also no datum level marked on the structure which meant that survey information from different sources could not easily be compared to identify change.

As a result of this investigation, RAIB has made three recommendations to Network Rail relating to:

  • the management of scour risk
  • the response to defect reports affecting structures over water
  • the management of control centre procedures.

Five learning points are also noted relating to effective management of scour risk.

For more information, see:

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Monday Accident & Lessons Learned: Collision at Yafforth, UK, level crossing, 3 August 2016

November 28th, 2016 by

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For a report from the UK Rail Accident Investigation Branch, see:

www.gov.uk

The Blame Culture Hurts Hospital Root Cause Analysis

November 22nd, 2016 by

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.

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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:

http://www.taproot.com/courses

Monday Accident & Lessons Learned: Pilot Error is Root Cause

November 14th, 2016 by

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:

http://www.military.com/daily-news/2016/10/27/debris-pilot-error-caused-2015-jet-crash-persian-gulf-navy.html

I haven’t found the report of the video on line.

What do you think of the report of the investigation?

 

Starting Your Investigations: The Power of the SnapCharT®

November 7th, 2016 by

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:

Initial SnapCharT®

Initial SnapCharT®

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:

Questions to ask

Questions to ask

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!)

 

Monday Accident & Lessons Learned: Lessons Learned from Overspeed Incidents in the UK

November 7th, 2016 by

ExcessSpeed

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:

https://www.gov.uk/government/publications/blatchbridge-safety-digest/overspeed-incidents-somerset-19-july-2016

Navy Root Cause Analysis Focused on Blame Vision, Crisis Vision, or Opportunity to Improve Vision?

November 3rd, 2016 by

NewImage

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:

http://www.taproot.com/contact-us#newsletter

OSHA/EPA “Fact Sheet” About Root Cause Analysis & Incident Investigation

November 1st, 2016 by

Screen Shot 2016 11 01 at 1 49 05 PM

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:

http://www.taproot.com/store/Courses/

 

 

Monday Accident & Lessons Learned: How Can Automation Get You Into Trouble?

October 24th, 2016 by

NewImage

Automation dependency is an interesting topic. Here’s what a recent CALLBACK from the Aviation Safety Reporting System had to say about the topic…

http://asrs.arc.nasa.gov/docs/cb/cb_440.pdf

Monday Accident & Lessons Learned: Aviation Safety Reporting System CALLBACK Notice About Ramp Safety

October 17th, 2016 by

CALLBACK Report Ramp Safety

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:

http://asrs.arc.nasa.gov/docs/cb/cb_439.pdf

Monday Accident & Lessons Learned: UK RAIB Report on Derailment at Paddington Station in London

October 10th, 2016 by

NewImage

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 Water

October 3rd, 2016 by

Here is the press release from the US Chemical Safety Board …

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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.” 

(more…)

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