There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.
How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.
Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.
Here are the links:
Mark’s General Session Talk About Fatality Prevention from the 2013 Summit
I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.
For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.
Monday Accident & Lessons Learned: Accidents at Intersections Reduced After Red Light Cameras RemovedPosted: April 29th, 2013 in Accidents, Human Performance, Performance Improvement
Here’s a link to the story in the Houston Chronicle:
The story says that:
“In the five months after Houston voters forced city officials to turn off a camera surveillance system that fined motorists for running red lights, traffic accidents at those 50 intersections with 70 cameras have decreased 16 percent, according to recently released data.”
There were lot’s of reasons given by officials for this unexpected outcome. Everything from the “weather was good” to “the camera’s had trained people to be safer.”
The interesting statistic that no one mentioned was that it is usual for rear-end collision to increase when red light cameras are installed because, to avoid a ticket, people slam on their brakes when a light turns red and they get rear ended.
There are at least two lessons that I think you can learn from this article.
1. People don’t know how to trend infrequently occurring accident statistics.
In this case, no one on either side of the argument used advanced trending techniques to prove their point. Instead, they chose the statistics that best fit their argument and claimed that those stats proved their point.
2. Sometimes corrective actions can have unintended consequences.
Several times in the past we’ve discussed red light cameras as an enforcement tool and the consequences that the tool could have on accident statistics. Our general opinion is that the cameras would be great for raising revenue but would do little to improve safety. For several reasons, rear end collisions were an unintended consequence of red light cameras that tend to increase accident rates at intersections where the devices were installed. So all people looking to improve performance should learn that your corrective actions may have other consequences than the ones you intend them to have!
The story is reported at WorkersCompensation.com that Walter Cardin, Safety Manager for the Shaw Group, was convicted of 8 counts of major fraud. The charges were a result of a six year investigation by the TVA Office of the Inspector General.
Obviously it is better to really improve safety rather than lying about the statistics.
Learn to use advanced root cause analysis to improve your safety record at a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. CLICK HERE for more information about the course and HERE for our public 5-Day TapRooT® Course schedule.
I recently wrote about Cal OSHA spending 20% of its budget investigating a non-fatality fire at Chevron’s Richmond Refinery. See the article HERE.
The article asked the question … “Should regulators focus their efforts on bad actors (actual fatalities), accident investigations, or proactive improvement efforts?”
But this question is applicable well beyond prioritizing the efforts of regulators to improve safety. EVERYONE involved in an improvement effort has a limited budget, limited time, limited “silver bullets” of where management can focus their attention. So the question is equally applicable to everyone involved in improvement. The broader question is …
“How do you prioritize your improvement budget?“
How much effort goes into:
- accident investigation and corrective actions
- incident investigation and corrective actions
- near-miss investigation and corrective actions
- behavior-based safety
- six-sigma/lean improvement efforts
If you measure the effectiveness of the improvements that each improvement initiative produces, you could rationally budget your improvement efforts.
How do you measure trends? Do you have the advanced trending techniques you need to measure improvements in infrequently occurring statistics?
Please leave your ideas as comments here…
Lesson 1: Definiteness of Purpose
Definiteness of purpose is the starting point of all achievement. Without a purpose and a plan, people drift aimlessly through life.
Lesson 2: Mastermind Alliance
The Mastermind principle consists of an alliance of two or more minds working in perfect harmony for the attainment of a common definite objective. Success does not come without the cooperation of others.
Lesson 3: Applied Faith
Faith is a state of mind through which your aims, desires, plans and purposes may be translated into their physical or financial equivalent.
Lesson 4: Going the Extra Mile
Going the extra mile is the action of rendering more and better service than that for which you are presently paid. When you go the extra mile, the Law of Compensation comes into play.
Lesson 5: Pleasing Personality
Personality is the sum total of one’s mental, spiritual and physical traits and habits that distinguish one from all others. It is the factor that determines whether one is liked or disliked by others.
Lesson 6: Personal Initiative
Personal initiative is the power that inspires the completion of that which one begins. It is the power that starts all action. No person is free until he learns to do his own thinking and gains the courage to act on his own.
Lesson 7: Positive Mental Attitude
Positive mental attitude is the right mental attitude in all circumstances. Success attracts more success while failure attracts more failure.
Lesson 8: Enthusiasm
Enthusiasm is faith in action. It is the intense emotion known as burning desire. It comes from within, although it radiates outwardly in the expression of one’s voice and countenance.
Lesson 9: Self-Discipline
Self-discipline begins with the mastery of thought. If you do not control your thoughts, you cannot control your needs. Self-discipline calls for a balancing of the emotions of your heart with the reasoning faculty of your head.
Lesson 10: Accurate Thinking
The power of thought is the most dangerous or the most beneficial power available to man, depending on how it is used.
Lesson 11: Controlled Attention
Controlled attention leads to mastery in any type of human endeavor, because it enables one to focus the powers of his mind upon the attainment of a definite objective and to keep it so directed at will.
Lesson 12: Teamwork
Teamwork is harmonious cooperation that is willing, voluntary and free. Whenever the spirit of teamwork is the dominating influence in business or industry, success is inevitable. Harmonious cooperation is a priceless asset that you can acquire in proportion to your giving.
Lesson 13: Adversity & Defeat
Individual success usually is in exact proportion of the scope of the defeat the individual has experienced and mastered. Many so-called failures represent only a temporary defeat that may prove to be a blessing in disguise.
Lesson 14: Creative Vision
Creative vision is developed by the free and fearless use of one’s imagination. It is not a miraculous quality with which one is gifted or is not gifted at birth.
Lesson 15: Health
Sound health begins with a sound health consciousness, just as financial success begins with a prosperity consciousness.
Lesson 16: Budgeting Time & Money
Time and money are precious resources, and few people striving for success ever believe they possess either one in excess.
Lesson 17: Habits
Developing and establishing positive habits leads to peace of mind, health and financial security. You are where you are because of your established habits and thoughts and deeds.
Pictures from one of the many useful Best Practice Breakout Sessions at the 2013 Global TapRooT® Summit.
They are using SnapCharT®, Safeguard Analysis, the Root Cause Tree®, and CHAP to proactively improve a JSA or develop a process improvement.
Do you want to learn creative ways to improve performance? Attend the 2014 TapRooT® Global Summit. Watch for more information on this blog.
Here’s the Meridian-Webster On-line Dictionary definition of “behavior”:
1. a : the manner of conducting oneself
b : anything that an organism does involving action and response to stimulation
c : the response of an individual, group, or species to its environment
2 : the way in which someone behaves; also : an instance of such behavior
3 : the way in which something functions or operates
Another definition that I think that management has in their heads is a “behavior” is:
“Any action or decision that an employee makes that management,
after the fact, decides was wrong.”
Why do I say that mangement uses this definition? Because I often hear about managers blaming the employee’s bad behavior for an accident.
For example, the employee was hurrying to get a job done and makes a mistake. That’s bad behavior!
What if an employee doesn’t hurry? Well, we yell at them to get going!
And what if they hurry and get the job done without an accident? We reward them for being efficient and a “go-getter.”
Management doesn’t usually see their role in making a “behavior” happen.
Behavior should NEVER be the end of a root cause analysis. Behavior is a fact. Just like a failed engine is a fact when a race car “blows it’s engine.”
Of course, a good root cause analysis should look into the causes for a behavior (a mistake) and uncover the reasons for the mistake and, if applicable, the controls that management has over behavior and how those controls failed when an accident occurred.
A bad decision or a human error that we call a “behavior” isn’t the end of the investigation … it is just the beginning!
TapRooT® helps investigator go beyond the symptoms (the behaviors) and find the root causes that management can fix. Some of the most difficult behaviors to fix are those so ingrained in the organization that people can’t see any other way to work.
For example, the culture of cost saving/cutting at BP was so ingrained, that even after the explosions and deaths at the Texas City Refinery, BP didn’t (couldn’t?) change it’s culture – at least not in the Gulf of Mexico exploration division – before they had the Deepwater Horizon accident. At least that is what I see in the reports and testimony that I’ve reviewed after the accident.
And with smaller incidents, it is even harder to get some managers’ attention and show them how they are shaping behavior. But at least in TapRooT® tries by providing guidance in analyzing human errors that leads to true root causes (not just symptoms).
Want to find out more about TapRooT® and behavior? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. You’ll see how TapRooT® helps you analyze behavior issues in the exercises on the second day of the training. And you will learn much more. For a public 5-Day Course near you see:
Monday Accident and Lessons Learned: What a Strange Week – BP on Trial and CEO Touts Safety ImprovementPosted: March 11th, 2013 in Accidents, Current Events, Investigations, Performance Improvement
I’ve been trying to keep up with the BP trial. Reading the transcripts of the testimony the day after it happens (although I can’t get time to read a day’s worth of testimony every day).
For me, the testimony of Mark Bly highlighted the restricted scope of BP’s accident investigation which made me think:
“If they didn’t do a thorough investigation
that included looking for management system root causes within BP …
how do they know they are really on the right track when improving safety?“
Yet last week, Hydrocarbon Processing published an article about a speech by Bob Dudley (CEO of BP). Here’s the quotes …
“Two years ago, when I stood here in this very spot, I said I was determined that we would emerge from the Deepwater Horizon accident as a safer, stronger, more sustainable company,” Dudley said.
“We have made good on those promises. We are honoring our commitments. We have set new standards. We continue working very systematically on safety and our record is improving.”
“Among the many responsible parties, we alone stepped up from the outset, acknowledging our role, waving the liability cap and committing ourselves to help restore the environment and economy of the Gulf Coast region,” he said.
“We did not wait for a court to determine fault in order to do what we believed to be the right thing.”
What do you think? Did BP step up to the plate and take responsibility for the spill? Was that what Tony Hayward did in Congressional testimony? And is that what BP did in the lawsuits after the spill to try to void their contracts with Transocean and Halliburton that limited the two contractors’ liability (and were found in court to be valid contracts)?
I really don’t know about BP’s efforts since the Deepwater Horizon blowout and spill to change their culture. But I don’t think they ever admitted (at least not publicly) that there was anything wrong or anything to change in their cost cutting, production over safety culture. The post accident depositions and trial testimony this week by BP employees, including their VP of Safety, never admits that anything was BP’s fault except certain “immediate cause” errors that can’t be denied.
This certainly brings up the question …
“Do you have to admit you were wrong
and find the root causes of failure before you can improve?”
It also makes me wonder …
“Does a company’s actions have to match their speech or
is this the age of the only thing that is important is
what you say and not what you do?“
The Agency for Healthcare Research and Quality did a study looking for proven methods of improving patient safety and healthcare outcomes. In that study, results of root cause analyses were used to find targets for improvement, look for effective techniques (proof of improvement), and provide potential areas for developing corrective actions (improvement initiatives).
The report defined root cause analysis several different ways, including:
Page 290: “Root cause analysis (RCA) is a structured analysis technique originally developed for human factors and systems engineering to retrospectively determine the interrelationship of component elements in causing an observed malfunction or accident. It has been adapted for use in medical and health care systems.”
Page 412: “…an in-depth examination of the data to identify factors in the care process that contribute to the errors…”
One comment in the report was:
“Wu examined the use of RCAs in medicine generally, and noted a very wide range of skill in performing RCAs accurately, a lack of best practices in reporting and followup, and the absence of peer-reviewed evidence of the effectiveness of RCAs or their cost-benefits tradeoffs.”
(Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299(6):685-7. PMID: 18270357)
That made me worry.
Were conclusions drawn in the report that were based on faulty root cause analysis?
After all, we have all seen poor root cause analysis done before. 5-Whys that lead to a preconceived result. Fault Trees built to prove a hypothesis (and missing other possibilities). People jumping to conclusions and not considering causes that they don’t understand.
I wondered … “What if the healthcare industry really adopted an effective root cause tool (TapRooT®) and then actually implemented it effectively? … What would happen?”
There’s more to TapRooT® than just sending people to a 2-Day Course.
To get the full benefits from TapRooT®, management must integrate it into their improvement efforts and manage it’s implementation and use.
That’s why we wrote Chapter 6 of the TapRooT® Book. To guide people to what an effective TapRooT® implementation looks like.
Implementation that includes a vision for improvement with a written plan that includes a sponsor, an improvement leader, and trained facilitators and peer reviewers. A plan that includes effective measurement and continuous improvement. A plan that includes management reviews and rewards for investigations and measured improvement success.
Work is required to make root cause analysis successful. If you are in the healthcare industry (or any other industry for that matter) read Chapter 6 and take the challenge to implement TapRooT® effectively at your facility. You’ll then be able to prove that TapRooT® was effective in helping you improve patient safety.
The Agency for Healthcare Research and Quality published a research product that suggested proven ways to improve patient safety. Here were the best methods (strongly encouraged) from the study:
- Preoperative checklists and anesthesia checklists to prevent operative and post-operative events.
- Bundles that include checklists to prevent central line-associated bloodstream infections.
- Interventions to reduce urinary catheter use, including catheter reminders, stop orders, or nurse-initiated removal protocols.
- Bundles that include head-of-bed elevation, sedation vacations, oral care with chlorhexidine, and subglottic-suctioning endotracheal tubes to prevent ventilator-associated pneumonia.
- Hand hygiene.
- “Do Not Use” list for hazardous abbreviations.
- Multicomponent interventions to reduce pressure ulcers.
- Barrier precautions to prevent healthcare-associated infections.
- Use of real-time ultrasound for central line placement.
- Interventions to improve prophylaxis for venous thromboembolisms.
For the complete study, see:
I’ve had so many people ask me, “How can I find the root causes of the problem?” that I’ve decided to put my experience (or at least some of it) and links to others’ suggestions (even though some of the suggestions are bad) in one location – THIS ARTICLE – about how to find root causes.
I’m going to start with a “simple” root cause analysis technique. A technique that I do NOT recommend but that I will share because it is frequently recommended by others. If you choose to use this simple technique, don’t blame me when the “root cause” you find and fix doesn’t seem to improve performance and you keep having the same accidents happen over and over again.
Next, I’ll cover more complex techniques. Some of these are souped-up versions of the simple technique. However, the complex techniques – while being more complex – still have the same inherent problems as the simple technique. Therefore, I can’t recommend these more complex techniques for serious root cause analysis of important safety, quality, maintenance, service, or production issues.
Finally, I’ll talk about the technique you should be using. A technique that was developed to avoid the problems presented by the previously mentioned simple and complex techniques. A technique that was intelligently designed to take you beyond your current knowledge. A technique that users praise for it’s repeatability, thoroughness, and effectiveness.
SIMPLE TECHNIQUE: 5-Whys
I’ve probably heard more “experts” talk about 5-Whys than any other root cause tool. Why? Because it is simple. Simple to teach and simple to use. All you have to do to find root causes is ask “Why?” five times.
Here’s an example of the technique from the technique’s creator, Tailchi Ohno:
1. “Why did the robot stop?”
The circuit has overloaded, causing a fuse to blow.
2. “Why is the circuit overloaded?”
There was insufficient lubrication on the bearings, so they locked up.
3. “Why was there insufficient lubrication on the bearings?”
The oil pump on the robot is not circulating sufficient oil.
4. “Why is the pump not circulating sufficient oil?”
The pump intake is clogged with metal shavings.
5. “Why is the intake clogged with metal shavings?”
Because there is no filter on the pump.
What do you think? Is “NO FILTER ON THE PUMP” a root cause? I think this example is a perfect example of what is WRONG with 5-Whys (and most unguided cause-and-effect analysis).
First, they missed a whole line of questioning. Why didn’t the loss of lube oil pressure trigger an alarm or an automatic shutdown?
Another line of questioning that was missed was “Where did the metal shavings come from?” After all, metal shavings are not normally found in a well-maintained machine.
And finally,”Why was there no filter on the pump?” Did maintenance forget to install it? Did the designer fail to include it? Was it removed because it kept getting clogged?
All of these questions need to be answered but the ultimate expert, Tailchi Ohno, didn’t ask them because he thought he already had the answer.
Watch this 5-Why training video and see if you can poke more holes in their example …
OK, so according to the video, you might need to ask why more or less than five times. And in other 5-Why training they try to teach techniques to determine when you have asked enough “whys” to call the result a “root cause.” So simple might not be so simple after all.
Just watch this 5-Why example and see if you can tell when a root cause has been reached …
Five, six, ten, twenty “Whys”? Or was a root cause ever mentioned in all those why question answers?
MORE COMPLEX TECHNIQUES
Many root cause analysis tools start with the idea of cause and effect. Every effect is caused. If you follow the cause and effect chain back far enough, you will reach the root cause.
Most of the techniques realize that the unguided 5-Why process fails to produce adequate results. Therefore, they modify the process by putting rules or structure around the asking of why (developing the cause and effect chain). They think rules or more extensive training can solve the basic defects inherent in cause and effect.
Here’s an article I wrote for Quality Progress (a quality oriented professional society journal) that outlines most of the problems with cause and effect:
Here’s the root cause analysis example that I criticize in the Quality Progress article “Under Scrutiny” … the bug example.
Here is a You-Tube training video about a common cause-and-effect technique – a Fishbone Diagram …
Here’s what Dilbert has to say about Fishbone Diagrams …
Another technique commonly included as a cause-and-effect analysis tool is Fault Tree Analysis. Here is a presentation oriented toward engineers about Fault Tree Analysis …
Still another version of cause-and-effect mainly used as a design evaluation tool (rather than a root cause analysis tool) is Failure Modes and Effects Analysis (or FMEA). Here is a video about FMEA …
Once again, each example presented in the above references provides proof of why the technique should NOT be used for root cause analysis. All the examples show that the techniques display the analysis teams current knowledge. The technique does NOT get beyond what the team knows. If the team doesn’t know about human factors, they won’t solve human factors problems. And worse yet, the investigators don’t even know that they don’t know. And that’s a real problem when analyzing accidents by finding the accidents’ root causes.
THE ROOT CAUSE ANALYSIS SYSTEM YOU SHOULD BE USING
Back in 1985, I started looking for a way that people in the field could be taught to find the root causes of human error and equipment failure related incidents. Because of my human factors training, I often saw causes that others couldn’t see. I knew the answer wasn’t for me to do every investigation (the ultimate root cause guru) or to put everyone through the same training and experience that I had. Instead, the answer was to develop a system that would help people be able to troubleshoot, understand, and fix problems by leading them to root causes that they previously would have overlooked.
The work over the next six years eventually lead to the development of the TapRooT® Root Cause Analysis System. And that initial development work was just the start. We, with the help of tens of thousands of users, have continuously improved TapRooT® for over 20 years.
How does TapRooT® work? Here are two links that explain the workings of the TapRooT® Root Cause Analysis System:
The first link includes a TV interview I did about root cause analysis. The second link is a white paper that describes how the TapRooT® Root Cause Analysis System works.
For those that lead difficult investigations, I would recommend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
I hope this article helped you understand some of the techniques that are available and the limitations of the common or “simple” techniques.
Please be careful when you decide “How to find root causes.” Picking the wrong technique can lead to poor analysis and corrective actions that don’t solve the real root causes. That’s why we developed TapRooT® and recommend it … because we know you really need to find and fix the root causes of serious safety, quality, production, service, or maintenance issues.
Why Do People Have Problems Finding Root Causes? Read this Article – Under Scrutiny – from Quality Progress…Posted: February 25th, 2013 in Performance Improvement, Quality, Root Cause Analysis Tips, Root Causes
Do you have problems finding the root causes of quality problems, safety incidents, or mechanical failures? It could be becuse of the root cause analysis tools you have chosen to use. Some tools have inherent weaknesses that are “built in.”
The article attached below (as first appeared in Quality Progress, the flagship magazine of the quality professional society ASQ), explains why some techniques commonly recommended for root cause analysis (like 5 Whys) will cause problems when applied by people in the field.
Once you finished reading about the limitations of 5-Whys and Cause-and-Effect, sign up to learn about the advanced root cause analysis system that was intelligently designed to avoid those problems … TapRooT®.
Healthcare Scandal in UK – Calls for Major Improvements in Patient Safety and Criminal Prosecution of “Wrongdoers”Posted: February 24th, 2013 in Current Events, Investigations, Medical/Healthcare, Performance Improvement, Quality
Here’s a link to one of many stories about the “scandal” at UK hospitals in the Midlands:
The story says that “…up to 1,200 patients are believed to have died between January 2005 and March 2009 as a result of poor care at Stafford hospital.”
Here’s a link to the Executive Summary of the report referred to in the article:
Here’s a page where you can download the entire report:
The reports are extensive and I haven’t yet been able to wade through them (many volumes and 290 recommendations).
Here’s a press conference by the Chair of the Inquiry, Robert Francis QC:
The problems reported certainly do seem shocking. The problems are obviously systemic (generic) and seem to be related to the organization. The call for culture change seems obvious, but how to change the culture will be difficult. The problem for patients is the lack of choice (there is only one NHS) so that patients can’t “vote with their feet” when the standards of care become substandard.
The popular press and political outcry is calling for increased regulation and criminal prosecution of those who violate the rules. This seems close to the standard blame game and may succeed temporarily until the increased scrutiny eventually succumbs to complacency. This seems common in organizations with a monopoly on a certain service or product.
It seems to me that competition from hospitals trying to win additional patients would be the ultimate culture change recommendation. However, it is unlikely that this approach could be taken since the UK has had a single national service for so long.
Being in the UK when the story was receiving so much press, I was constantly being asked about how one would find the root causes of patient safety relayed problems. Of course, I described how healthcare organizations in the US use TapRooT® to investigate sentinel events. In the US, patient safety is becoming a competitive advantage – a way that hospitals may compete for patients.
What does your hospital do to ensure the highest standards of patient safety? Does your root cause analysis find and fix the root causes of patient safety problems? Does your management require advanced root cause analysis and insist on the implementation of effective corrective actions to sentinel events? Can you show the improvement in patient safety through the use of advanced trending tools?
Those interested in improving patient safety should consider attending the Improving Healthcare Quality and Patient Safety Track at the 2013 Global TapRooT® Summit in Gatlinburg, TN, on March 20-22. For more Summit information see:
And for the track’s detailed schedule, see:
and click on the button on the left for the track specific schedule.
For those in the UK, changes as great as those described will be difficult and take tremendous effort. I wish you luck but advise you that thorough advanced root cause analysis and effort will be required on a continuing basis if progress is to be made.
Part of the TapRooT® Software is the ability to set up custom categorization fields for incident/accident reports.
Many companies categorize incidents as safety, quality, maintenance, production, environmental, …
The idea I’m going to share here is another way to categorize safety incidents.
In our Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT® Course, we teach that there are three separate pyramids that make up the major accident pyramid – an auto safety pyramid, and industrial/occupational safety pyramid, and a process safety pyramid.
In other words, instead of one pyramid like the one above (from Heinrich’s book, Industrial Accident Prevention, 3rd edition, 1950), there are actually at least three pyramids like the one above – one for auto accidents, one for industrial accidents, and one for process safety accidents.
Each of these separate pyramids are summed up in your “safety” data.
Why is this important? Because each of these pyramids are produced by different systems. When you add them up, you are summing unlike systems and “muddying” your data.
What do I mean by this? A trend in auto and industrial safety getting safer may mask a trend in process safety getting worse. This is especially true because the major accidents in process safety are so few and far between and the “minor injury” and “no-injury incident” equivalents in process safety may seem so minor.
In other words, you should not try to trend all three systems at once. You should trend each system – auto, industrial, and process – separately.
That’s why you need to keep track of these statistics separately by categorizing them separately under your safety data.
By the way, if BP had been doing this before the Texas City accident, they could have detected separate trends in their various systems that result in overall employee safety.
Does this make sense?
Ask questions and leave comments by clicking on the comments button below.
The best way to keep your Valentine’s Day romantic and fun? Make food safety a priority!
A recent article on StateFoodSafety.com notes that the best restaurant to eat in on Valentine’s Day is a clean one. Here are a few of their food safety tips this Valentine’s Day:
- Take note of the dining area and restrooms. If they do not meet cleanliness standards, it’s probably a good sign that the kitchen is also in need of more than just a light dusting. You might consider eating elsewhere for your own safety.
- Only eat foods that are served to you hot. If the food is served to you at a lukewarm temperature, chances are that it was left sitting for too long and has allowed harmful bacteria to multiply.
- Make sure the staff does not touch your food or the tips of your silverware with their bare hands. It’s probably not a good idea to let them sample your drink either.
- Be wary of meat, eggs, oysters, or other raw foods that are undercooked.
- Wash your hands properly before and after eating.
Photo courtesy of NPR.
The Financial Times article starts out saying:
The company has set out for the first time details of how it has restructured its operations and invested in new technology in an attempt to show that the mistakes that led to the fatal explosion and huge oil spill in the Gulf of Mexico will not be repeated.”
As with all culture change efforts, the real results won’t completely take effect for 5-7 years. Therefore, performance between now and 2021 will tell the story if the claimed efforts really take effect and are more effective than the last “focus on safety like a laser” efforts during Tony Hayward’s leadership.
For readers, please note that Mark Paradies is presenting a lessons learned session at the TapRooT® Summit titled:
“Deepwater Horizon and Texas City: What Should We Learn About Accident Investigation & Process Safety?”
The synopsis of the session says:
“Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into lessons learned that have gone unnoticed or may have been misinterpreted that shed light on accident investigation and process safety.”
To register for the 2013 TapRooT® Summit in Gatlinburg, TN, on March 18-22, see:
Mark Paradies, President of System Improvements and co-creator of the TapRooT® System, will be speaking at the IOSH Conference in Spotlight Theatre 2 on Tuesday, February 26, and Wednesday, February 27.
His topics are:
Tuesday: 13:20 – 13:50 – Spotlight Theatre 2
BP Deepwater Horizon & BP Texas City Accidents: Two Lessons That You May NOT Have Learned
Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into two lessons learned that have not received much attention yet are important to safety improvement.
Wednesday: 11:20-11:50 – Spotlight Theatre 2
Fixing The Safety Pyramid & Stopping Major Accidents
Several articles have been published criticizing Heinrich’s Safety Pyramid and blaming it’s weaknesses for the gap between the decline in safety statistics and the continuing level rate of serious injuries, including fatalities. Mark Paradies will share insight into the Safety Pyramid and explain why fatality prevention needs a revised model and new approaches to achieve across the board safety performance improvements.
Hope to see you there!
Need help developing your incident investigation and corrective action program? We can help.
Need help facilitating a difficult investigation? We can help.
Need help analyzing the trends in your accident data? We can help.
Our TapRooT® Instructors are all experienced improvement professionals (many retired from senior leadership positions before they started a second career helping others improve).
You can get their advice by hiring them to provide TapRooT® Consulting Services.
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This lesson learned is from a regulatory incident.
I remember talking to a nuclear industry VP who had a troubled plant (NRC regulatory issues). He said that he was blindsided by their problems. It was as if the day before he was walking along on a beautiful day and the next morning he woke up at the bottom of a deep dark hole. The change seemed almost instantaneous … without warning.
How does a leading company go from excellence to disaster? It isn’t that there weren’t warning signs. The signs were there but management missed them.
The fastest way to get in trouble is to start thinking that you are so good that you don’t need to pay attention to small problems. That you can economize on improvement without experiencing performance improve-ment declines. That your cost saving efforts will NOT lead to field personnel placing more emphasis on production and less on safety and quality.
The switch from a performance improvement focus to a cost-cutting focus can seem like a small change – a minor variation. But when the problems start – when you wake up at the bottom of the deep dark hole – you will say the same thing that the nuclear VP said:
If I’d known how bad
this was going to be,
I would have paid any
amount of money to avoid it.
Don’t find yourself at the bottom of the deep dark hole.
Keep your focus on performance improvement.
Learn best practices that others use to make their programs better every year.
Where can you learn these practices? At the 2013 Global TapRooT® Summit in Gatlinburg, TN!
Summit week is March 18-22. Register now to ensure your choice of the pre-Summit Courses.
Get complete Summit info including the complete Summit schedule at:
Remember, there is no time like the present to avoid a disaster!
When I talk to people about the Global TapRooT® Summit, people sometimes say they can’t come because it is too far away. But that’s one of the great things about the Summit … If you are on this planet, it’s NOT too far away.
How do I know? Because we already have people registered from 20 countries from every continent.
Here the country list…
And I know with a couple of months of registration left to go, the list will continue to grow.
If you are interested in performance improvement and you are on this planet … get registered for the 2013 Global TapRooT® Summit on March 18-22 in Gatlinburg, Tennessee, USA. See the complete Summit information at:
Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.
He says you will “Jump out of your chair!”…
He’s a Tony Robbins Fan.