Category: Pictures

TapRooT® Public Courses In South America

March 5th, 2015 by


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Bogota, Colombia

Upcoming TapRooT® Public Courses:

Sao Paulo, Brazil 5-Day April 13, 2015 (Language: Portuguese)

Bogota, Colombia 2-Day April 27, 2015 (Language: Spanish)

Bogota, Colombia 3-Day April 27, 2015 (Language: Spanish)

Sao Paulo, Brazil 2-Day May 14, 2015 (Language: Portuguese)

Barrancarbermeja, Colombia 2-Day May 20, 2015 (Language: Spanish)

Barrancarbermeja, Colombia 3-Day May 20, 2015 (Language: Spanish)

 

For more information regarding our public courses around the world, click here.

TapRooT® Public Courses In Oceania and Asia

March 5th, 2015 by

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Adelaide, South, Australia

Upcoming TapRooT® Public Courses:

South Australia: 

Adelaide, Australia 5-Day March 23, 2015 

Adelaide, Australia 2-Day April 28, 2015

Queensland Australia: 

Weipa, Australia 2-Day March 19, 2015 

Brisbane, Australia 2-Day March 30, 2015 

Toowoomba, Australia 2-Day March 30, 2015 

Brisbane, Australia 3-Day March 30, 2015 

Brisbane, Australia 5-Day April 13, 2015

Roma, Australia 2-Day April 21, 2015

Brisbane, Australia 2-Day April 30, 2015

Weipa, Australia 2-Day May 5, 2015

Gladstone, Australia 2-Day May 11, 2015

Brisbane, Australia 5-Day May 18, 2015

Emerald, Australia 5-Day May 25, 2015

Victoria Australia:

Sale, Australia 2-Day May 13, 2015

Sale, Australia 3-Day May 13, 2015

Melbourne, Australia 5-Day May 18, 2015

New South Whales: 

Singleton, Australia 5-Day April 20, 2015

Western Australia:

Perth, Australia 2-Day March 19, 2015

Perth, Australia 2-Day April 13, 2015

Perth, Australia 5-Day April 20, 2015

Perth, Australia 2-Day April 30, 2015

Perth, Australia 2-Day May 14, 2015

Perth, Australia 2-Day May 28, 2015

Northern Territory: 

Darwin, Australia 2-Day March 26, 2015 

 

Singapore: 

Singapore, Singapore 5-Day April 20, 2015

Singapore, Singapore 5-Day May 4, 2015

Singapore, Singapore 2-Day May 11, 2015

Papua New Guinea:

Port Morseby, Papua New Guinea 2-Day April 13, 2015

 

For more information regarding our public courses around the world, click here. 

Upcoming Course in Halifax, Nova Scotia, Canada

March 5th, 2015 by

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Mark your calendars for our 2-Day Incident Investigation and Root Cause Analysis Training Public Course in Halifax, Nova Scotia, Canada April 8-9. TapRooT® courses are a great opportunity to learn root cause analysis skills and work on your investigations. Halifax is a great place to join us! This global city has an impressive economic center, voted second on the list for “Large Cities of the Future” and is home to many of Canada’s major resource industries. Halifax is a powerhouse and will be a great host to TapRooT®, don’t miss it!

Food: 

Stories Casual Fine Dining: Come taste and learn the story behind every flavor of their unique dishes.

2 Doors Down: Fun and exciting describe both their atmosphere and menu. Give it a try!

The Bicycle Thief: Authentic Italian cuisine and wine with a rich historical background. A must visit.

Attractions: 

Halifax Citadel: This National Historic Site is one of the top ranked tourist attractions for Halifax.

Great Escapes Wine Tours: Love wine? Love wine tasting? Take a tour through some of the best.

Local Food Tasting Tour: If you enjoy trying new foods and expanding your palette, take one of these food tours to try all Halifax has to offer.

 

Ready to REGISTER? Click here!

SAVE THE DATE for our annual Global TapRooT® Summit this June 1-5. Click here for more information and registration.

What does a bad day look like?

March 5th, 2015 by

Just like this if you are a bird…

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Upcoming TapRooT® Course in Charleston, South Carolina

February 26th, 2015 by

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Join TapRooT® in Charleston, South Carolina for a 2-Day Incident Investigation and Root Cause Analysis Training Public Course on March 23-24. Charleston is one of the oldest and fastest growing cities in South Carolina. Its historical value brings it alive with monuments, architecture and art. It has also been honored with the award of  “America’s Most Friendly City” by Travel and Leisure in 2011 and 2013. If you haven’t visited here, come take in the American heritage and some TapRooT® knowledge while you’re at it.

Food: 

Circa 1886: Take a trip back in time with this historically inspired restaurant voted as the #12 best restaurant in the U.S. by Trip Advisor.

Charleston Grill: With Charleston being on the ocean, you have to try the best fresh seafood in town right here at the Charleston Grill.

Jeni’s Splendid Ice Creams: This homemade ice cream is hard to come by with it only being sold in seven locations in the U.S. Try it out!

Attractions: 

College of Charleston: Take a tour of the beautiful, historic College of Charleston campus.

Charleston Waterfront Park: Love the outdoors? Take a walk or rent a bike to stroll down this waterfront park and enjoy the view!

Walking Tours: Pick from a variety of walking tours that take you all over Charleston.

 

Ready to REGISTER NOW? Follow the link for information and registration details.

SAVE THE DATE for our Global TapRooT® Summit to be held June 1-5, 2015 in Las Vegas. Click here for information.

What does a bad day look like?

February 26th, 2015 by

Are your spirits sinking?

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We Are Out of the Office Today

February 24th, 2015 by

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For those in the Northeast who have had to deal with so much snow, shutting the office because of 3 inches might sound stupid. But in Knoxville, we aren’t used to snow and the hills make getting around hazardous (especially when so many people never learned to drive on snow and don’t even have all season tires). 

So … SI will be closed today. Hopefully this won’t be like the ice storm last week (three days out with hazardous conditions). 

UK RAIB Investigating Electrical Arcing and Fire Under a Train, Near Windsor, 30 January 2015

February 13th, 2015 by

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RAIB is investigating a train fire that occurred on the evening of Friday 30 January 2015, and which caused serious damage to the structure of the train.

The 19:53 hrs South West Trains service from Windsor & Eton Riverside to London Waterloo had travelled about 400 metres after starting from Windsor station, when a small bang was heard under the sixth carriage of the ten-carriage train, followed by about five seconds of severe sparking and flashing.

The train, which was formed of two class 458/5 electric multiple units and was travelling at about 15 mph at the time, stopped immediately. Some smoke entered the carriages through ventilators. There were two passengers in the sixth carriage, and they moved quickly into another part of the train. The guard of the train moved from the rear to the sixth carriage to investigate, and the driver also moved to the middle of the train. They could see that there was still smoke coming from below the sixth carriage, so the driver returned to the front of the train from where he contacted the signaller by radio to ask for the electric power to be switched off. While he was doing this, the floor of the sixth carriage was penetrated by fire, and smoke rapidly filled the vehicle.

There were eleven passengers on the train. The guard, assisted by the crew of another train that was in Windsor station, evacuated the passengers to the track, and helped them walk back to the station. The fire brigade were called, and confirmed by 20:50 that the fire was out. None of the passengers were hurt, but the guard was taken to hospital and treated for smoke inhalation.

RAIB’s preliminary examination found that the fire had originated in severe arcing in a junction box fixed under the carriage floor, where power cables from the collector shoes on either side on the train are connected to the main power cable (‘bus line’) which runs along the train. The arcing had burnt through the floor of the carriage, and had also destroyed parts of the structural members of the carriage body.

RAIB’s investigation will focus on the cable joint in this junction box, and how this joint was designed and assembled. It will also examine how the train’s structure and equipment, and the people in it, might have been protected from the consequences of a failure of this nature.

RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.

RAIB will publish the findings, including any recommendations to improve safety, at the conclusion of our investigation. This report will be available on their website.

 

 

 

 

 

 

What does a bad day look like?

February 12th, 2015 by

It wasn’t the down ramp…

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Monday Accident & Lessons Learned: Errors Under Pressure – What are the Odds?

February 9th, 2015 by

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Here’s a description of an car/train accident:

http://www.nytimes.com/2015/02/05/nyregion/on-metro-north-train-in-crash-a-jolt-then-chaos.html?emc=edit_th_20150205&nl=todaysheadlines&nlid=60802201&_r=0

How could things go from a minor error and fender bender to a multi-fatality accident?

It happens when someone makes a bad decision under pressure.

Don’t think it couldn’t happen to you. Even with good training and good human factors design, under high stress, people do things that seem stupid when investigating an accident (looking at what happened in the calm light of the post accident investigation).

Often, the people reacting in a stressful situation aren’t well trained and may have poor displays, poor visibility, or other distractions. Their chance of choosing the right action? About 50/50. That’s right, they could flip a coin and it would be just as effective as their brain in deciding what to do in a high-stress situation.

LESSONS LEARNED

FIRST: Avoid decisions under high stress. In this case, KEEP OFF THE TRACKS!

Never stop on a railroad track even when no trains are coming.

That’s true for all hazards.

Stay out from under loads. Stay away from moving heavy equipment.

You get the idea.

Don’t put yourself in a position where you have to make a split-second decision.

SECOND:  NEVER TRY TO BEAT A TRAIN or PULL IN FRONT OF A TRAIN.

Always back off the tracks if possible. This is true even if you hit the gate and dent your car.

FINALLY: Think about how this train accident could apply to hazards at your facility.

Are people at risk of having to make split-second decisions under stress?

If they do, or if it is possible, a serious accident could be just around the corner.

Try to remove the hazard if possible.

How could have the hazard been removed in this case?

An overpass or underpass for cars is one way.

Other ideas? Leave them below as comments.

TapRooT® Around the World: Houma, LA

February 7th, 2015 by

Thanks to Scott Waddell for sending us these great pictures from a recent onsite course in Houma, LA.

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Want more information regarding our TapRooT® Onsite and Public Courses? Click Here.

Save the Date for our annual Global TapRooT® Summit coming up in June 2015! Click Here for more information.

Upcoming TapRooT® Course in Knoxville, TN

February 5th, 2015 by

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Come to Knoxville, Tennessee, the home of TapRooT®, on March 2, 2015 for a 5-Day Advanced Root Cause Analysis Training Course. Knoxville isn’t only the home of the Tennessee Vols but also headquarters of Tennessee Valley Authority. This large city right in the heart of the Appalachia’s is surrounded by the Great Smoky Mountains giving you an astounding view anywhere you go. Take a trip to Knoxville and join TapRooT® for this local public course.

Food: 

Stock and Barrel: This rustic, fun restaurant offers the best burgers in the area.

Calhoun’s on the River: Enjoy eating with a great view? Calhoun’s serves great barbecue right on the Tennessee River.

Litton’s: A Knoxville favorite! One of the best hometown restaurants with friendly service.

Attractions: 

Market Square: Full of restaurants, bars and boutiques, no better place to enjoy a night out in Knoxville.

Women’s Basketball Hall of Fame: Get to know y0ur history on Women’s basketball and the UT leader of it all- Pat Summit.

World’s Fair Park: Located next to University of Tennessee’s campus, this park was used in 1984 for the World’s Fair.

 

Ready to register for this Knoxville public course? Click Here

SAVE THE DATE for the upcoming Global TapRooT® Summit on June 1-5. Click here for more information.

What does a bad day look like?

February 5th, 2015 by

Is your day worse than this?

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What does a bad day look like?

January 29th, 2015 by

Is you day worse than it was for this pilot?

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Monday Accident & Lessons Learned: The US Chemical Safety Board Releases Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

January 26th, 2015 by

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CSB Releases Safety Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

Safety Bulletin Notes Five Key Lessons to Prevent Hydraulic Shock

January 15, 2014, East Rutherford, NJ – Today the U.S. Chemical Safety Board released a safety bulletin intended to inform industries that utilize anhydrous ammonia in bulk refrigeration operations on how to avoid a hazard referred to as hydraulic shock.  The safety lessons were derived from an investigation into a 2010 anhydrous ammonia release that occurred at Millard Refrigerated Services Inc., located in Theodore, 
Alabama.

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The accident occurred before 9:00 am on the morning of August 23, 2010. Two international ships were being loaded when the facility’s refrigeration system experienced “hydraulic shock” which is defined as a sudden, localized pressure surge in piping or equipment resulting from a rapid change in the velocity of a flowing liquid. The highest pressures often occur when vapor and liquid ammonia are present in a single line and are disturbed by a sudden change in volume.

This abnormal transient condition results in a sharp pressure rise with the potential to cause catastrophic failure of piping, valves, and other components – often prior to a hydraulic shock incident there is an audible “hammering” in refrigeration piping. The incident at Millard caused a roof-mounted 12-inch suction pipe to catastrophically fail, resulting in the release of more than 32,000 pounds of anhydrous ammonia.
The release led to one Millard employee sustaining injuries when he fell while attempting to escape from a crane was after it became engulfed in the traveling ammonia cloud.  The large cloud traveled a quarter mile from the facility south toward an area where 800 contractors were working outdoors at a clean-up site for the Deepwater Horizon oil spill. A total of 152 offsite workers and ship crew members reported symptomatic illnesses from ammonia exposure. Thirty two of the offsite workers required hospitalization, four of them in an intensive care unit.

Chairperson Rafael Moure-Eraso said, “The CSB believes that if companies in the ammonia refrigeration industry follow the key lessons from its investigation into the accident at Millard Refrigeration Services, dangerous hydraulic shock events can be avoided – preventing injuries, environmental damage, and potential fatalities.”

Entitled, “Key Lessons for Preventing Hydraulic Shock in Industrial Refrigeration Systems” the bulletin describes that on the day before the incident, on August 22, 2010, the Millard facility experienced a loss of power that lasted over seven hours. During that time the refrigeration system was shut down. The next day the system regained power and was up and running, though operators reported some problems.  While doing some troubleshooting an operator cleared alarms in the control system, which reset the refrigeration cycle on a group of freezer evaporators that were in the process of defrosting. The control system reset caused the freezer evaporator to switch directly from a step in the defrost cycle into refrigeration mode while the evaporator coil still contained hot, high-pressure gas.

The reset triggered a valve to open and low temperature liquid ammonia was fed back into all four evaporator coils before removing the hot ammonia gas. This resulted in both hot, high-pressure gas and extremely low temperature liquid ammonia to be present in the coils and associated piping at the same time. This caused the hot high-pressure ammonia gas to rapidly condense into a liquid.  Because liquid ammonia takes up less volume than ammonia gas – a vacuum was created where the gas had been.  The void sent a wave of liquid ammonia through the piping – causing the “hydraulic shock.”

The pressure surge ruptured the evaporator piping manifold inside one of the freezers and its associated 12-inch piping on the roof of the facility. An estimated 32,100 pounds of ammonia were released into the surrounding environment.

Investigator Lucy Tyler said, “The CSB notes that one key lesson is to avoid the manual interruption of evaporators in defrost and ensure control systems are equipped with password protection to ensure only trained and authorized personnel have the authority to manually override systems.“

The CSB also found that the evaporators at the Millard facility were designed so that one set of valves controlled four separate evaporator coils. As a result, the contents of all four coils connected to that valve group were involved in the hydraulic shock event – leading to a larger, more hazardous pressure surge.

As a result, the CSB notes that when designing ammonia refrigeration systems each evaporator coil should be controlled by a separate set of valves.

The CSB found that immediately after discovering the ammonia release, a decision was made to isolate the source of the leak while the refrigeration system was still operating instead of initiating an emergency shutdown. Shutting down the refrigeration system may have resulted in a smaller release, since all other ammonia-containing equipment associated with the failed rooftop piping continued to operate.

A final key lesson from the CSB’s investigation is that an emergency shutdown should be activated in the event of an ammonia release if a leak cannot be promptly isolated and controlled. Doing so can greatly reduce the amount of ammonia released during an accident.

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Barb PhillipsBarb Phillips
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Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
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Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
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Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
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