I have no special talents. I am only passionately curious.
For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.
I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”
The initial Panel Statement at the start of the report includes this quote:
“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”
I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.
What do you think?
Was the report successful? Did it cause change and help BP have an improved process safety culture?
Or did the report fail to cause change across the company?
And if it failed, why did it fail?
Let me know your ideas by leaving your comments by clicking on the comments link below.
You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.
What is a “thought leader”? I wasn’t sure what that meant when I heard the term recently because I wasn’t up-to-date with the latest lingo.
So, I read a Forbes article about thought leaders, (“What is a Thought Leader,” Russ Alan Prince and Bruce Rogers, March 16, 2012). Here’s how the article defined them:
Thought Leader Definition Part 1:
“A thought leader is an individual or firm that prospects, clients, referral sources, intermediaries and even competitors recognize as one of the foremost authorities in selected areas of specialization, resulting in its being the go-to individual or organization for said expertise.”
Thought Leader Definition Part 2:
“A thought leader is an individual or firm that significantly profits from being recognized as such.”
This made me curious, so I dug a little deeper and discovered five unmistakable qualities of a thought leader:
1. Thought leaders are driven by a higher purpose. The reward they seek is more than money; they find reward in a work that is a service to other human beings in some way.
2. Thought leaders implement positive change by first seeing things differently than the rest of the crowd. Their work helps people become unstuck and move forward.
3. Thought leaders are highly motivated and passionate about their missions. This inspires everyone they come into contact with to make a change for the better.
4. Thought leaders focus on their one big thing for decades. They are energized by expansiveness, but have always been driven toward solving one big problem.
5. Thought leaders are interested in creating positive change in the lives of others because they love people. They become students of human behavior, and are more interested in your story than their own.
That got me thinking. People at the Global TapRooT® Summit are thought leaders!
They are individuals and companies that are recognized as leaders in certain specialized areas or industry leaders AND they benefit from the knowledge they learn and take back and apply from the Summit.
Are you a thought leader? Do you want to be a thought leader?
Then you should register NOW for the 2014 Global TapRooT® Summit at Horseshoe Bay near Austin, Texas. The pre-Summit courses are on April 7-8. The Summit is next week – April 9-11.
For more information, see:
I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…
Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.
Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!
Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.
What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.
As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.
The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.
Learn more about TapRooT® Training at: http://www.taproot.com/courses
WHAT ARE HUMAN PERFORMANCE TOOLS?
Over the past decade, best practices and techniques have been developed “stop” or manage human error. They were developed mainly in the US nuclear industry and vary in content/name by the consultant/organization that offers them. Common tools include:
- Procedure Use*
- Place Keeping*
- Pre-Job Brief*
- Post-Job Brief
- Peer Checking*
- Time Out
- Rule of Three
- 3-Way Communication*
- Observation & Coaching*
- Questioning Attitude
- Attention to Detail
- Errors Traps/Precursors
Here are some links to learn more about the tools above:
Also, if you plan on attending the 2014 Global TapRooT® Summit, attend Mark Paradies’ talk on human performance tools to learn more about these tools.
The asterisk (*) techniques above have always been included on the Root Cause Tree® (part of the TapRooT® System) because they are supported by established human factors research. Post-Job Briefs are also a well-established best practice that isn’t included on the Root Cause Tree® because it would occur after an incident or as part of the normal performance improvement program.
WHAT’S WRONG WITH HUMAN PERFORMANCE TOOLS?
Some of the techniques seem like excellent best practices (paying attention, having a questioning attitude, STAR, and Time Out), but I haven’t been able to find scientific human factors research that supports their use. For example, the “Rule of Three” is supposedly supported by research in the aviation industry that three yellow lights (conditions that are worrisome but not enough to prevent a flight) are equal to one red light (a fight no-go indicator – for example weather that doesn’t meet the flight minimums).
Because they seem like good ideas, you may decide to adopt them, but they may not work as intended in all cases. After all, research hasn’t tested their limits.
The final technique, Error Traps/Precursors seems to violate a couple of human factors principles and therefore should only be used with caution.
ERROR TRAPS / PRECURSORS
The concept behind Error Traps/Precursors is that certain human conditions are indicators of impending human error. If a person can self-monitor to detect the “error likely” human condition, he/she can then apply an appro-priate human performance tool to avoid (stop) the impending error. For example, if you notice that you are rushing, you could apply STAR.
What are these human conditions? The selection varies depending on the consultant that presents the technique, but they commonly include:
- High Workload
- New Tasks
- First Time
- New Technique
A problem with this technique is that the person performing work must self-monitor to detect the human condition to self-trigger action. I’ve never seen research that people are particularly good at self-monitoring to detect any human condition. And even if they were, the list seems to indicate that people would be would be constantly self-triggering. By this list, people are always just about to make a mistake. (To err is human?)
Constantly monitoring points to another human factors limitation. The human brain automatically apportions a very limited resource – attention. Your brain continuously, subconsciously decides what to pay attention to and what to ignore. Your brain decides what sounds are important and which ones are noise. Your brain may decide that motion in the visual field deserves more attention than a stationary object. Or that a sharp pain is more important than a faint touch.
In times of crisis or when one is busy, your ability to pay attention is stressed. Imagine yourself driving on ice. You are so focused on the feel of the road and preventing sliding that you don’t have enough attention left over to even have a casual conversation.
Even when you are not stressed, if you self-monitor your state, you stealing attention from some other task. What faint signal might you miss?
All of the Human Performance Tools have a common limitation. They are weak corrective actions. They are 5’s or 6’s on the TapRooT® hierarchy of controls. Rules, procedures, training, are all attempts at improving human performance. And the human may be your weakest safeguard. If your human performance improvement program is based on the weakest safeguards, what should you expect?
This doesn’t mean that you should not try proven human performance tools. It means that you should try to adopt stronger safeguards and understand the limitations of human performance tools and, at a minimum, implement defense in depth to ensure adequate performance.
Maybe it’s time for you to join the 2330 members of the TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn. It’s a great place to network with other TapRooT® Users, ask questions, anmd keep up with the latest TapRooT® Information.
You can set your group profile to receive an e-mail every time something is posted, daily, weekly, or never.
If you are a LinkedIn member, click on the link below to see the group:
One worker was killed and two were injured aboard a nuclear submarine under construction in India.
Was it some high tech nuclear accident? No. I was a simple pressure test of a hydraulic tank.
This accident once again shows that failure to control simple energy is often the cause of fatalities.
See the whole story here: http://www.dawn.com/news/1091836/accident-at-indian-nuclear-submarine-centre-kills-one-worker
Could this accident have been prevented? Yes. How? Find out at the Proactive Use of TapRooT® Course being held on April 7-8.
What if you missed a meeting that could have prevented someone’s death? Or what if you lost your job because you didn’t attend? Or your company lost millions of dollars simply because you didn’t attend a three-day meeting.
Would you make sure that you were there?
Sometimes that what I think about when someone says they just can’t attend this year’s Global TapRooT® Summit. Why? Because people have told me about the improvements in safety practices that they have learned about at the Summit that helped them save lives at their company. They told me how they applied best practices that they learned at the Summit to save their company millions of dollars. And they told me how the ideas they brought back from the Summit helped them looked good in front of their bosses and get promoted.
You might think that missing just one year isn’t that big of a deal … But that would be wrong. Every year the Summit is different. Every year there are different best practices discussed and leading edge practices presented. If you miss a year you might miss the best practice that could have helped you save a life in the following year. And even if that topic was repeated at a future Summit, that chance to save that life has been lost.
But how can you get your boss to approve attending (especially when the Summit is less than a month away)? They need to see the value and see that they too need the ideas that you will bring back. See the Summit brochure attached to the end of this newsletter and find the topics that will help you solve some of the toughest problems at your site. Then show your boss and explain that the company just can’t miss this valuable information. That should make the decision easy.
An intangible that you may not be considering is the motivation that you will get at the Global TapRooT® Summit. Have you thought about how much change you can make happen when you are motivated compared to being de-motivated? The Global TapRooT® Summit will help you revive your spirits and resume the battle to improve performance despite the obstacles. Register today! See:
Can the CEO alone make his company world class? No.
Can a Safety Manager make the safety culture world class all by himself? No.
Can a Maintenance Manager achieve world class equipment reliability without help? No.
It takes a team to make world class performance improvement happen.
Senior management, middle management, supervisors, and shop floor employees all have a role to play to make world class performance a reality.
Would you like to learn more about what it takes to develop a world class performance improvement program? Attend the 2014 Global TapRooT® Summit and hear Mark Paradies, President of System Improvements and co-developer of the TapRooT® System, share what he’s learned from sources around the world about implementing world class performance improvement.
To be even more effective, bring a team to the Summit. Senior managers, the performance improvement sponsor, the performance improvement manager, incident investigators and problem troubleshooters, and shop floor workers that can help lead the charge to making your company’s performance improvement program world class.
Get more Summit info at:
See the complete Summit schedule at:
And register at:
How do you know if your root cause analysis is adequate? Read the article on page 3 of the March Root Cause Network™ Newsletter and find out! Download your copy of the newsletter by clicking on this link: Mar14NL120.pdf
.What else can you learn in this edition?
- What’s Right and What’s Wrong with Human Performance Tools (Page 1)
- Why Do Supervisors Produce Bad Investigations? (Page 2)
- How Should You Target Your Investigations? (Page 2)
- What’s Wrong with Your Trending? (Page 2)
- Admiral Rickover’s Face-the-Facts Philosophy (Page 2)
- Proactive Use of TapRooT® (Page 3)
- Stop Slips, Trips, and Falls (Page 3)
- Risk Management Best Practices (Page 3)
- Upcoming TapRooT® Courses Around the World (Page 4)
- What Can You Learn at the 2014 Global TapRooT® Summit? (Page 5, 6, & 7)
Plus there’s more! An article you really should read and act upon. See the article on Page 3: “Are you Missing an Important Meeting?”
Why should you read that article among all the others? Here’s the first paragraph …
“What if you missed a meeting and it caused someone to die. Or maybe you lost your job if you weren’t there? Or your company lost millions of dollars because you simply didn’t attend a three-day meeting. Would you make sure that you were there?”
If those questions don’t grab your attention, what will?
Go to this link:
Print the March Root Cause Network™ Newsletter and read it from cover to cover!
You’ll be glad you did. (And you’ll find that there are several actions you will be compelled to take.)
If you are a TapRooT® User, you are already have improved your root cause analysis and incident investigation just by attending TapRooT® Training. But what can you do to get even better? To improve beyond your initial TapRooT® Training? To make your company’s incident investigations and root cause analysis world-class?
And choose the Incident Investigation & Root Cause Analysis Best Practices Track. What’s in the track?
- Advanced Causal Factor Development (Ken Turnbull)
- Interviewing: De-Coding Non-Verbal Behavior (Barb Phillips)
- Getting Your Root Cause Analysis PhD (Mark Paradies)
- Expert Facilitation of Investigations Using the TapRooT® Software (Brian Tink)
- Infamous Accident (Alan Smith, Alan Scot, & Harry Thorburn)
- Measure Your RC System: The Good, The Bad, and The Ugly (Ralph Blessing & Brian Dolin)
- Slips, Trips, & Falls: The Science Behind Walking (Robert Shaw)
- The Business End of Equipment Reliability (Heinz Bloch)
Plus you will hear great keynote speakers to give you practical improvement ideas and get you motivated to make change happen.
- Christine Cashen – Why Briansorm When You Can Brain El Niño?
- Carl Dixon – A Strange Way to Live
- Mark Paradies – World Class Performance Improvement
- Edward Foulke – Sweeping Workplace Safety Changes
- Rocky Bleier – Be the Best You Can Be
There’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility. And we know that you learn more when you are having fun so this won’t be a stuffy technical meeting that puts you to sleep. You will be involved and motivated.
Want to get even more out of your Summit experience? Then attend of the advanced pre-Summit Courses. I would recommend one of these if you are interested in making your TapRooT® implementation even better:
- Advanced Trending Techniques
- Advanced Causal Factor Development Course
- TapRooT® Evidence Collection Course
- Getting the Most from Your TapRooT® Software
- Reducing Serious Injuries and Fatalities Using TapRooT®
- Proactive Use of TapRooT®
- TapRooT® Analyzing and Fixing Safety Culture Issues
Here’s a link to the Federal Register request for comments:
Interestingly, OSHA says:
“While the PSM standard has been effective in improving process safety in the United States and protecting workers from many of the hazards associated with uncontrolled releases of highly hazardous chemicals, major incidents have continued to occur.”
It then goes on to list some of the many serious process safety accidents that have occurred after the regulation had plenty of time to be effective.
What does it mean when a regulation is put in place to stop accidents and the accidents continue? Either the regulation is ineffective or the enforcement is ineffective.
In my review of the regulation and comparing it to Admiral Rickover’s successful process (nuclear) safety program, I concluded that there are many gaping holes in the regulation that, even if enforcement was effective, would have allowed the accidents mentioned to occur.
However, I believe that it is doubtful that OSHA will adopt the tough stance that Rickover required to ensure safe operations of the Navy’s nuclear power plants.
To learn more about Admiral Rickover’s approach to process safety, see the links provided here:
Make sure that you scroll down because there are many interesting articles and videos.
Then return here to leave your comments about your concerns/recommendations about the revision of the OSHA Process Safety Management standard.
I was at a meeting last week and the topic came up about how people used their root cause analysis data. To my surprise, about half the companies represented didn’t have a way to produce any type of graphs. The other half could produce pie charts using Microsoft Excel. There were one or two other people who had other ways to look at their data that they manually put into a system of some sort.
That got me thinking:
How do readers of this e-Newsletter use their root cause analysis data?
So I established this poll so that people could respond.
Click on the comments link below (and then scroll down to the comments box) and just let me know what you do.
After a week or two I will compile the data and report it in another e-Newsletter post.
Pass this on to others you know and let’s see how many people we can get to comment.
- – - -
How do you use your root cause analysis data:
1) We don’t have a way to collect our data across the site/company so we don’t use it.
2) We collect the data but don’t have a way to present it graphically.
3) We collect the data and put it in Excel and produce pie charts.
4) We collect the data and put it in Excel and produce Pareto Charts and X mR Charts.
5) We collect the data and put it in Excel and produce other types of charts (please list them).
6) We use TapRooT® Software but I haven’t thought about how to use our data.
7) We use TapRoot® Software and use the charting function in it to analyze our data.
8) We use other software and use it to trend our data using charts (please list software and chart types)
9) Other (tell us what you do)
- – - -
One more note:
a) Read Chapter 5 pf the TapRooT® Book.
b) Attend the 2-Day Advanced Trending Techniques Course on April 7-8 that is being held just before the 2014 Global TapRooT® Summit (just outside Austin, TX).
c) Attend the 2014 Global TapRooT® Summit and see the latest trending features being built into the TapRooT® Software.
We have started a new method of delivering the formerly “paper” Root Cause Network™ Newsletter. In the past you either received it by mail or as a PDF attachment to an e-mail. Now we will be including as one of the items in the TapRooT® Experts & Friends e-Newsletter.
So watch for the special edition of the e-Newsleller that includes a link to the Root Cause Network™ Newsletter every two months. We’ll include a list of the topics in the Root Cause Network™ Newsletter as part of the President’s Note (the first topic in the TapRooT® Experts & Friends e-Newsletter).
The topics in the January Root Cause Network™ Newsletter are:
- What Do You Need to Perfect Your 2014 Improvement Program? (Page 1)
- What Is Your Commitment to Safety? (Page 2)
- Benchmarking Improvement Programs (Page 2)
- Generate Improvement Team Spirit (Page 2)
- Dilbert Cartoon (Page 2)
- 2014 Global TapRooT® Summit Info (Page 3)
- Why Trend? (Page 3)
- Special Pre-Summit Courses (Page 3)
- Why Are Accident Causes the Same Around the World? (Page 4)
- International Networking (Page 4)
- Upcoming International TapRooT® Courses (Page 4)
- Pictures from TapRooT® Courses Around the World (Page 4)
- Upcoming North American TapRooT® Courses (Page 5)
- Pictures from Previous Global TapRooT® Summits (page 5)
Wow! That’s a lot of information. I would especially recommend the first article -
What Do You Need to Perfect Your 2014 Improvement Program?
But there are lot’s of other items that deserve a few minutes of your time.
If you didn’t receive your newsletter, you can download it by clicking on the link below or by going to THIS LINK.
The following is the text of a speech delivered in 1982 by Admiral Hyman G. Rickover – the father of the Nuclear Navy – at Columbia University. Rickover’s accomplishments as the head of the Nuclear Navy are legendary. From developing the first power producing submarine based nuclear reactor from scratch to operations in just three years to creating a program to guarantee process safety (nuclear safety) for over 60 years (zero nuclear accidents).
I am reprinting this speech here because I believe that many do not understand the management concepts needed to guarantee process safety. We teach these concepts in our “Reducing Serious Injuries and Fatalities Using TapRooT®” pre-Summit course. Since many won’t be able to attend this training, I wanted to give all an opportunity to learn these valuable lessons by posting this speech.
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Human experience shows that people, not organizations or management systems, get things done. For this reason, subordinates must be given authority and responsibility early in their careers. In this way they develop quickly and can help the manager do his work. The manager, of course, remains ultimately responsible and must accept the blame if subordinates make mistakes.
As subordinates develop, work should be constantly added so that no one can finish his job. This serves as a prod and a challenge. It brings out their capabilities and frees the manager to assume added responsibilities. As members of the organization become capable of assuming new and more difficult duties, they develop pride in doing the job well. This attitude soon permeates the entire organization.
One must permit his people the freedom to seek added work and greater responsibility. In my organization, there are no formal job descriptions or organizational charts. Responsibilities are defined in a general way, so that people are not circumscribed. All are permitted to do as they think best and to go to anyone and anywhere for help. Each person then is limited only by his own ability.
Complex jobs cannot be accomplished effectively with transients. Therefore, a manager must make the work challenging and rewarding so that his people will remain with the organization for many years. This allows it to benefit fully from their knowledge, experience, and corporate memory.
The Defense Department does not recognize the need for continuity in important jobs. It rotates officer every few years both at headquarters and in the field. The same applies to their civilian superiors.
This system virtually ensures inexperience and nonaccountability. By the time an officer has begun to learn a job, it is time for him to rotate. Under this system, incumbents can blame their problems on predecessors. They are assigned to another job before the results of their work become evident. Subordinates cannot be expected to remain committed to a job and perform effectively when they are continuously adapting to a new job or to a new boss.
When doing a job—any job—one must feel that he owns it, and act as though he will remain in the job forever. He must look after his work just as conscientiously, as though it were his own business and his own money. If he feels he is only a temporary custodian, or that the job is just a stepping stone to a higher position, his actions will not take into account the long-term interests of the organization. His lack of commitment to the present job will be perceived by those who work for him, and they, likewise, will tend not to care. Too many spend their entire working lives looking for their next job. When one feels he owns his present job and acts that way, he need have no concern about his next job.
In accepting responsibility for a job, a person must get directly involved. Every manager has a personal responsibility not only to find problems but to correct them. This responsibility comes before all other obligations, before personal ambition or comfort.
A major flaw in our system of government, and even in industry, is the latitude allowed to do less than is necessary. Too often officials are willing to accept and adapt to situations they know to be wrong. The tendency is to downplay problems instead of actively trying to correct them. Recognizing this, many subordinates give up, contain their views within themselves, and wait for others to take action. When this happens, the manager is deprived of the experience and ideas of subordinates who generally are more knowledgeable than he in their particular areas.
A manager must instill in his people an attitude of personal responsibility for seeing a job properly accomplished. Unfortunately, this seems to be declining, particularly in large organizations where responsibility is broadly distributed. To complaints of a job poorly done, one often hears the excuse, “I am not responsible.” I believe that is literally correct. The man who takes such a stand in fact is not responsible; he is irresponsible. While he may not be legally liable, or the work may not have been specifically assigned to him, no one involved in a job can divest himself of responsibility for its successful completion.
Unless the individual truly responsible can be identified when something goes wrong, no one has really been responsible. With the advent of modern management theories it is becoming common for organizations to deal with problems in a collective manner, by dividing programs into subprograms, with no one left responsible for the entire effort. There is also the tendency to establish more and more levels of management, on the theory that this gives better control. These are but different forms of shared responsibility, which easily lead to no one being responsible—a problems that often inheres in large corporations as well as in the Defense Department.
When I came to Washington before World War II to head the electrical section of the Bureau of Ships, I found that one man was in charge of design, another of production, a third handled maintenance, while a fourth dealt with fiscal matters. The entire bureau operated that way. It didn’t make sense to me. Design problems showed up in production, production errors showed up in maintenance, and financial matters reached into all areas. I changed the system. I made one man responsible for his entire area of equipment—for design, production, maintenance, and contracting. If anything went wrong, I knew exactly at whom to point. I run my present organization on the same principle.
A good manager must have unshakeable determination and tenacity. Deciding what needs to be done is easy, getting it done is more difficult. Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required. Too often, important problems are recognized but no one is willing to sustain the effort needed to solve them.
Nothing worthwhile can be accomplished without determination. In the early days of nuclear power, for example, getting approval to build the first nuclear submarine—the Nautilus—was almost as difficult as designing and building it. Many in the Navy opposed building a nuclear submarine.
In the same way, the Navy once viewed nuclear-powered aircraft carriers and cruisers as too expensive, despite their obvious advantages of unlimited cruising range and ability to remain at sea without vulnerable support ships. Yet today our nuclear submarine fleet is widely recognized as our nation’s most effective deterrent to nuclear war. Our nuclear-powered aircraft carriers and cruisers have proven their worth by defending our interests all over the world—even in remote trouble spots such as the Indian Ocean, where the capability of oil-fired ships would be severely limited by their dependence on fuel supplies.
The man in charge must concern himself with details. If he does not consider them important, neither will his subordinates. Yet “the devil is in the details.” It is hard and monotonous to pay attention to seemingly minor matters. In my work, I probably spend about ninety-nine percent of my time on what others may call petty details. Most managers would rather focus on lofty policy matters. But when the details are ignored, the project fails. No infusion of policy or lofty ideals can then correct the situation.
To maintain proper control one must have simple and direct means to find out what is going on. There are many ways of doing this; all involve constant drudgery. For this reason those in charge often create “management information systems” designed to extract from the operation the details a busy executive needs to know. Often the process is carried too far. The top official then loses touch with his people and with the work that is actually going on.
Attention to detail does not require a manager to do everything himself. No one can work more than twenty-four hours each day. Therefore to multiply his efforts, he must create an environment where his subordinates can work to their maximum ability. Some management experts advocate strict limits to the number of people reporting to a common superior—generally five to seven. But if one has capable people who require but a few moments of his time during the day, there is no reason to set such arbitrary constraints. Some forty key people report frequently and directly to me. This enables me to keep up with what is going on and makes it possible for them to get fast action. The latter aspect is particularly important. Capable people will not work for long where they cannot get prompt decisions and actions from their superior.
I require frequent reports, both oral and written, from many key people in the nuclear program. These include the commanding officers of our nuclear ships, those in charge of our schools and laboratories, and representatives at manufacturers’ plants and commercial shipyards. I insist they report the problems they have found directly to me—and in plain English. This provides them unlimited flexibility in subject matter—something that often is not accommodated in highly structured management systems—and a way to communicate their problems and recommendations to me without having them filtered through others. The Defense Department, with its excessive layers of management, suffers because those at the top who make decisions are generally isolated from their subordinates, who have the first-hand knowledge.
To do a job effectively, one must set priorities. Too many people let their “in” basket set the priorities. On any given day, unimportant but interesting trivia pass through an office; one must not permit these to monopolize his time. The human tendency is to while away time with unimportant matters that do not require mental effort or energy. Since they can be easily resolved, they give a false sense of accomplishment. The manager must exert self-discipline to ensure that his energy is focused where it is truly needed.
All work should be checked through an independent and impartial review. In engineering and manufacturing, industry spends large sums on quality control. But the concept of impartial reviews and oversight is important in other areas also. Even the most dedicated individual makes mistakes—and many workers are less than dedicated. I have seen much poor work and sheer nonsense generated in government and in industry because it was not checked properly.
One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as for their own. Open discussions and disagreements must be encouraged, so that all sides of an issue will be fully explored. Further, important issues should be presented in writing. Nothing so sharpens the thought process as writing down one’s arguments. Weaknesses overlooked in oral discussion become painfully obvious on the written page.
When important decisions are not documented, one becomes dependent on individual memory, which is quickly lost as people leave or move to other jobs. In my work, it is important to be able to go back a number of years to determine the facts that were considered in arriving at a decision. This makes it easier to resolve new problems by putting them into proper perspective. It also minimizes the risk of repeating past mistakes. Moreover if important communications and actions are not documented clearly, one can never be sure they were understood or even executed.
It is a human inclination to hope things will work out, despite evidence or doubt to the contrary. A successful manager must resist this temptation. This is particularly hard if one has invested much time and energy on a project and thus has come to feel possessive about it. Although it is not easy to admit what a person once thought correct now appears to be wrong, one must discipline himself to face the facts objectively and make the necessary changes—regardless of the consequences to himself. The man in charge must personally set the example in this respect. He must be able, in effect, to “kill his own child” if necessary and must require his subordinates to do likewise. I have had to go to Congress and, because of technical problems, recommended terminating a project that had been funded largely on my say-so. It is not a pleasant task, but one must be brutally objective in his work.
No management system can substitute for hard work. A manager who does not work hard or devote extra effort cannot expect his people to do so. He must set the example. The manager may not be the smartest or the most knowledgeable person, but if he dedicates himself to the job and devotes the required effort, his people will follow his lead.
The ideas I have mentioned are not new—previous generations recognized the value of hard work, attention to detail, personal responsibility, and determination. And these, rather than the highly-touted modern management techniques, are still the most important in doing a job. Together they embody a common-sense approach to management, one that cannot be taught by professors of management in a classroom.
I am not against business education. A knowledge of accounting, finance, business law, and the like can be of value in a business environment. What I do believe is harmful is the impression often created by those who teach management that one will be able to manage any job by applying certain management techniques together with some simple academic rules of how to manage people and situations.
Why Are the Major, Steady Declines in Minor and Recordable Injuries Not Seen to the Same Extent in Major Accident (Fatality) Statistics?Posted: December 26th, 2013 in Courses, Human Performance, Performance Improvement
Why are the major, steady declines in minor and recordable injuries not seen to the same extent in major accident (fatality) statistics? Mark Paradies has new insight into the phenomenon and has used it to develop systematic methods to stop major accidents by using TapRooT® both reactively and proactively.
Register for Reducing Serious Injuries & Fatalities Using TapRooT®, a 2-Day Pre-Summit Course scheduled for April 7-8, 2014 in Horseshoe Bay, Texas.
The course highlights three major sources of major accidents:
* industrial hazards
* process safety and
* driving safety.
Learn new ideas to revolutionize your fatality/major accident prevention programs and start you down the road to eliminating major accidents.
Learn more about the Summit: http://www.taproot.com/taproot-summit
Register for this 2-day course and the Summit and save $200!
According to the U.S. Department of Labor, slips, trips and falls make up the majority of general industry accidents. Here are some eye-opening statistics:
- 95 million workdays per year are lost due to slip-and-fall injuries
- 9 million people go to the hospital each year due to slips, trips, and falls.
- Slips, trips, and falls are the number one cause of workers’ compensation claims costing, on average, $20,000 per claim.
- The average time off due to a fall accident is 38 days.
- Occupations with the most slips, trips, and falls are food servive workers, nurses, janitors, and police officers.
- Slips, trips, and falls account for 65% of all work days lost due to injury.
(Source of statistics: EHS Today)
Isn’t it time you did something about slips, trips, and falls at your company? Start planning now to attend the 2014 pre-Summit courses titled “Preventing Slips, Trips, and Falls” (April 7-8, 2014, Horseshoe Bay Texas).
Rob Shaw, expert in preventing slips, trips, and falls from the UK Health & Safety Laboratory, is coming to the US to share the results of his research. This includes practical exercises to reduce the likelihood of slips, trips, and falls at your facility.
For more information, CLICK HERE.
Also, sign up for the 2014 Global TapRooT® Summit. You can learn best practices to improve safety from industry leaders and experts from around the world.
Learn more about the Summit or
Learn more about this course.
The UK Rail Accident Investigation Branch has released their annual report for 2012. CLICK HERE to download the report.
Carolyn Griffiths, the Chief Inspector at the RAIB, starts the report with an interesting observation … that they see some accidents types happen over an over again from one year to the next. She says that this is evidence that the industry needs to do more.
That brings up two important questions …
1) Are you reviewing your accident history on a periodic basis and have you looked for recurring events?
2) If you have noticed recurring events, why are they happening? Why haven’t you be successful in preventing recurrence?
Some serious thought is needed to learn from our past experience and to make sure that we don’t relive history.
We offer advanced trending courses that can help you really understand performance at your facility.
See information about the course here:
Trending is NOT too hard. Watch what these kids are doing…
© Copyright 2013 By System Improvements Inc. Used by Permission.
WHAT IS YOUR PURPOSE?
Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.
For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.
Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.
The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.
This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…
WAITING FOR BIG ACCIDENTS
Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?
I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:
Near-Misses Not Reported
If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.
Hazards Not Recognized
Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).
Shortcuts Become a Way of Life (standards not enforced)
This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.
Process Safety Not Understood
We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.
Ineffective Root Cause Analysis
If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.
Inadequate Corrective Actions
I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?
Corrective Actions Not Implemented
Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.
Trends Not Identified
If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.
INVESTIGATING PAPER CUTS
Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.
Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.
WHAT SHOULD YOU DO?
You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.
“An ounce of prevention is worth a pound of cure.”
If you can’t see yourself ending up in jail because of an accident, how about your attorney’s office?
What’s the point of the headline?
You have a choice. You can either be proactive and prevent accidents or reactive and fight fires after the accidents occur.
What is better … hiring good lawyers to keep you out of jail after a fatal accident or spending time and effort being proactive to prevent the accident from happening?
In both cases, TapRooT® is a great tool for finding and fixing the root causes of problems. But we believe being proactive is much better than being reactive.
Would you like to be proactive in preventing fatalities? Then attend the Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT®.
Whatever you do, DON’T sit by idly waiting for a major accident to occur. Develop you plan to improve performance and prevent fatalities and serious injuries from happening.
Do it today or you may have plenty of time to contemplate your plan while sitting in a jail cell!
New Report: Hospital Errors are the Third Leading Cause of Death in the US and Improvement is Too SlowPosted: October 31st, 2013 in Medical/Healthcare, Performance Improvement
The Leapfrog Group issued a press release about hospital safety scores that once again showed that errors in hospitals are deadly and that improvement of patient safety is occurring too slowly. See the press release at:
Here is more discussion about the most recent rating results:
And here is a site where you can look up the ratings of the hospitals near you:
What can you do to start improving performance at your hospital? Advanced root cause analysis – TapRooT® – can tell you what needs to be fixed.
Learn how TapRooT® can help your hospital improve patient safety by attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Here’s our upcoming worldwide course schedule:
Just click on your continent to see courses closer to you.
And if you are already TapRooT® Trained, attend the Improving Healthcare Quality and Patient Safety Track at the 2014 Global TapRooT® Summit near Austin, Texas. See the track topics by clicking on the fourth button in the left column at:
You will learn best practices from other hospitals and from other industries from around the world.
Found two calculators for the cost of accidents on MSHA’s web site.
The first estimates the annual accident costs at your site when you plug in your annual number of fatalities, your annual number of lost work day cases, and your annual number of reportable cases without a lost workday.
The second calculator estimates the impact of accidents on profits/sales at your company.
Both bof these calculators are generic (not just for mining injuries) based on National Safety Council data.
See both calculators at: