Category: Performance Improvement
If you don’t understand what happened, you will never understand why it happened.
You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?
I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.
Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.
If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?
This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.
The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.
TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.
Foe course information and course dates, see:
I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:
“If people would just try harder, be more careful, or be more alert, the problems would go away.”
This implies bad people (careless, lazy, and/or dullards) are the issues.
Have you ever met one of these people? Do you work in an organization that thinks this way?
I once had a safety manager at a refinery tell me:
“At our refinery, 5% of the people account for 95% of the lost time injuries.”
He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.
Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.
TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.
Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.
And don’t worry about trying something new. Our courses are guaranteed!
Attend our training, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software and
we will refund the entire course fee.
That’s a strong guarantee because we know that TapRooT® will work for your company.
For more information about TapRooT®, watch the video at:
Success teaches us nothing; only failure teaches.
Admiral Hyman Rickover
Every hour has sixty golden minutes,
each studded with sixty diamond seconds.
Admiral Hyman Rickover
I saw this picture today, and I thought about how people often make decisions based entirely on direct cost. For some things, we make a deliberate analysis of the long-range costs, benefits, and applicability of a product. For example, when we buy a new car, we might decide to pass on a particular brand of vehicle based on what we know (or at least, what we have heard) about the quality of that vehicle, its features, its reliability, and the fit to what we need. Remember the Yugo? I don’t see many of them on the road any more!
And yet, when we are making the decision on the best way to improve the health and safety of our coworkers, we seem to jump right on, “What does it cost?” I heard someone in Australia just the other day tell me about an RCA “methodology” that is being evaluated for use in some for their critical improvement programs. I asked why they were considering this other method. Does it work better? The answer made me sad. “Well, no, we don’t think it works as well as TapRooT®. Using [this other system] gives pretty ambiguous results, depending on who is using it. But it’s a little bit cheaper, so my manager wants to go that way.”
This doesn’t seem to make a lot of sense to me. If you can save 10%, but get poor results, what have you actually saved? I encourage you to look at the costs of even a single “simple” incident, and then bounce that against a few percent savings in poor-quality training. I think you’ll find that the initial savings are lost in the noise.
You wouldn’t buy a car based solely on price. I encourage you to take the same due diligence when you are selecting an RCA program that has the potential to save the lives of your teammates.
I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.
How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.
Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances. It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.
When you waste your time remember …
Even God cannot undo the past.
Admiral Hyman Rickover
The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…
IOGP SAFETY ALERT
CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE
Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.
A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.
What Went Wrong?
The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).
- The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
- Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
- The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
- In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
- Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
- In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.
Corrective Actions and Recommendations:
Lessons Learned –
- As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
- The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.
Action taken in originating company –
Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.
- A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
- The temporary suspension does not cover retrieval operations on lines which are depressurised.
* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
Safety Alert Number: 273
IOGP Safety Alerts http://safetyzone.iogp.org
At this school, the smartest work as hard
as those who must struggle to pass.
Admiral Hyman Rickover
The secret of success:
late to bed,
early to rise,
work like hell and you’ll be wise.
Admiral Hyman Rickover
Heaven is blessed with perfect rest.
The blessing of earth is toil.
Admiral Hyman Rickover
Download this Excel® Spreadsheet to your laptop or other device to participate in the exercise in the “Grade Your Investigation” Best Practice Session at the 2016 Global TapRooT® Summit:
This Accident shares a “Call Back” Report from the Aviation Safety Reporting System that is applicable far beyond aviation.
In this case, the pilot was fatigued and just wanted to “get home.” He had a “finish the mission” focus that could have cost him his life. Here’s an excerpt:
I saw nothing of the runway environment…. I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had so many times in past years. The only conscious control input that I can recall is leveling at the MDA [Rather than continuing to the DA? –Ed.] while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at the flight instruments as I began…an uncontrolled, unconscious 90-degree turn to the left, still looking for the runway environment.
To read about this near-miss and the lessons learned, see:
Rickover talking about his famous candidate interviews …
You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?
Is this the best approach to preventing future problems? NO! Not by a long shot.
We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:
- Wacky Willie
- Will Discipline Fix the CTA’s Problems?
- USS Hartford / USS New Orleans Collision & Subsequent Discipline
- Should You Discipline BEFORE an Investigation is Complete?
- What Should Managers Know About Root Cause Analysis?
- Root Cause Analysis – Do it before even thinking about discipline!
Let me sum up what we know …
Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.
In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.
For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses
I just went through the attendance list for the 2016 Global TapRooT® Summit and I was impressed. What a great bunch of people we are having come together in San Antonio!
For me, as President of System Improvements and one of the creators of the TapRooT® Root Cause Analysis System, the Summit always seems like old home week or a high school reunion. I get to see some of our clients that have been working hard to save lives, improve quality, and keep their companies from getting a black eye.
We’ve been doing these Summits since 1994 and you might not believe it but, I’ve been learning new and valuable stuff at the Summit every year.
So for all of you coming to the 2016 Global Summit,
I CAN’T WAIT TO SAY “HOWDY!”
And get caught up on what you have been doing to make the world a better place.
And for those who haven’t signed up yet,
What? You don’t know why you should attend? You need the knowledge shared at the Summit to …
SAVE YOUR COMPANY $$$
Those are business critical topics that you need to make your company best in class.
See the Summit brochure at:
See the Summit agenda at:
If you need more convincing, let me plead with you to attend. Watch this video…
Can command and control improve safety?
According to this ABC article, Chinese government has “ordered” improvements in safety. Yet 11 people died in an accident at an Aluminum Corp. of China aluminum plant when equipment they were dismantling fell on them. The article also mentions the chemical explosion that killed 173 people in the port city of Tianjin last year.
What are you doing to improve safety?
Can you or your management “order” improvements?
Perhaps you need to learn root cause analysis and best practices and skills to make your safety program world class?
If you want next year to be better than this year, sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
Pick the advanced course that will help you learn the skills you need to to improve your company’s performance.
Then pick the best practice sharing sessions at the Summit that will help you meet the biggest challenges that face your company.
Learn from your peers from around the world (see the LIST here).
Learn from people in your industry and other industries (see the LIST here).
And don’t forget our Summit GUARANTEE:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
Have you ever had an accident and someone in management says …
“That looks like a bad trend to me.“
And you didn’t think it was but you couldn’t prove him wrong?
Have you ever had a regulator tell you that you have problems that look like an adverse trend and you didn’t know how to respond?
Have you ever wondered if a slight improvement in safety statistics is really significant?
Have you ever wondered how long it will take without a significant accident until you can say that performance really has improved?
Have you ever presented trend data and hoped that nobody asked any real questions because you were just making stuff up?
IF YOU DON’T LIKE YOUR ANSWERS TO ANY OF THESE QUESTIONS, you need to attend the TapRooT® Advanced Trending Techniques Pre-Summit Course in San Antonio, TX, on August 1-2.
We only offer this course once a year and anyone interested in learning how to trend safety statistics should attend.
Electrical energy helps us in many ways, but when it is misused and an arc flash occurs … perhaps this video will help people get the message that arc flash precautions are important!
WARNING – GRAPHIC CONTENT AT VARIOUS POINTS – DON’T WATCH IF YOU WILL BE UPSET
Want to learn more about arc flash safety? We have a session about it at the 2016 Global TapRooT® Summit. The session titled “Arc Flash Prevention” is from 1:40-2:50 on Thursday in the Safety Best Practices Track.
Scott King and Terry Butler will present Employee and contractor protection utilizing general electrical principles as referenced by OSHA and NFPA 70E 2015 guidelines and qualified low voltage safety training.
Learning Objectives for this session include:
- Provide an overview of the importance of Arc Flash Safety
- Understanding Electrical Hazards
- Safe Work Practices
- Incident Energy Exposure Levels
- Risk Assessment Analysis
- Personal Protective Equipment (PPE)
- Safety Training
See the complete 2106 Global TapRooT® Summit schedule at:
And register for the Summit at: