For the cow…
But imagine the guy who was on the ladder!
Here’s a summary of the report from the UK Rail Accident Investigation Branch about a derailment at Godmersham, UK:
“At around 21:40 hrs on 26 July 2015, a passenger train derailed after striking eight cows that had gained access to the railway at Godmersham in Kent, between Wye and Chilham stations. There had been a report of a cow on the railway an hour earlier, but a subsequent examination by the driver of the next passing train did not find anything. There were no further reports from other trains that passed before the accident occurred.
The train involved in the accident was travelling at 69 mph (111 km/h) at the point of impact. There were 67 passengers on board plus three members of staff; no injuries were reported at the time of the accident. Because the train’s radio had ceased to work during the accident, the driver ran for about three-quarters of a mile towards an oncoming train, which had already been stopped by the signaller, and used its radio to report the accident.
The accident occurred because the fence had not been maintained so as to restrain cows from breaching it, and because the railway’s response to the earlier report of a cow on the railway side of the fence was insufficient to prevent the accident. In addition, the absence of an obstacle deflector on the leading unit of the train made the derailment more likely.
As a result of this accident, RAIB has made five recommendations addressing the fence inspection process, clarification of railway rules in response to reports of large animals within the boundary fence, the fitting of obstacle deflectors to rolling stock (two recommendations), and the reliability of the train radio equipment.
RAIB has also identified two learning points for the railway industry, relating to the railway’s response to emergency situations, including the response to reports of large animals within the boundary fence and the actions to take following an accident.
Here is a link to read the report…
Here’s a partial list …
- New Zealand
- Saudi Arabia
- United Kingdom
That’s why we call the Summit a GLOBAL Summit. Every continent is represented.
Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:
And find out about all the great sessions and keynote speakers by visiting the Summit web site at:
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.
Who would you like to network with if you were going to share best practices and learn how others have solved problems?
The TapRooT® Summit is a great place to meet industry leaders.
Here a partial list of companies that have signed people up for the 2016 Summit:
- Air Liquide
- Arizona Public Service
- Avangrid Renewables
- Balitmore Gas & Electric
- California Resources
- Duke Energy
- Formosa Plastics
- Lawrence Berkeley national Lab
- Liberty Carton Company
- Matrix Services
- Nalco Champion
- National Grid
- Northern Star Generation
- NRG Energy
- Nuclear Fuel Services
- PCS Nitrogen
- Prarie State Generation
- Pratt & Whitney
- PSH JV
- Red Cedar Gathering
- Sacramento Municipal Utility District
- Saudi Aramco
- Teranga Gold
- Tuscon Electric
- US Well Services
- United Technologies
- Vancouver Airport Authority
- Westar Energy
What are some of the job titles of people attending the 2016 Summit?
- Airside Safety Officer
- Area HSE Manager
- Compliance Specialist
- Corporate ESH Director
- Corporate HSE Manager
- Corrective Action Program Manager
- Director of Corporate Safety
- EHS Engineer
- Electrical Engineer
- Emergency Management Manager
- Engineering Superintendant
- Environmental Steward
- Facility Manager
- Global H&S Advidor
- HSE Regional Leader
- HSE Director
- HSE Specialist
- HSE Supervisor
- Human Performance Specialist
- Industrial Hygienist
- Industrial Operations manager
- Issue Management Program Leader
- Lead Production Supervisor
- Loss Prevention System Advisor
- Manager, H&S
- Mechanical Engineer
- Operational Excellence Manager
- Operations Staff
- PDM Coordinator
- Process Safety Manager
- PSM Specialist
- QHSE Leader
- Quality Auditor
- Quality Manager
- Quality Systems Auditor
- RCA Leader
- RCA Manager
- Refining Consultant
- Reliability Specialist
- Results Supervisor
- Risk Manager
- Safety & Training Specialist
- Safety Associate
- Safety Specialist
- SHE Supervisor
- SHEQ Divisional Manager
- Site CAP Manager
- Sr. Director, Serious Injury & Fatality Prevention
- Sr. Safety Analyst
- Staff Compliance Specialist
- Supervisor Training
- Team Leader H&S
- Training Director
- Training Specialist
- Upstream HSE Team Lead
- Vice President, HSE
- VP & Regional Manager
- VP HSE
- WMS Advisor
- Work Week Coordinator
And those are just partial lists!
Imagine the things you could learn and the contacts you could make.
Add your company and your job title to the list by registering at:
The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.
A summary of the report says:
At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.
The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.
As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.
A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.
A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.
For the complete report, see:
Many years ago when I was in the Navy, I was writing an application to become an Assistant Professor at the University of Illinois. My boss was reviewing what I wrote and we got into a long discussion over whether a problem we had had was an event or an incident. A couple of years later, while I was doing my Master’s Degree research, I got into a very similar discussion over whether a significant problem at a nuclear plant was an accident or an incident.
OK, let’s look at the dictionary definitions… (from the Merriam-Webster on-line Dictionary)
- an unforeseen and unplanned event or circumstance
- lack of intention or necessity : chance <met by accident rather than by design>
- an unfortunate event resulting especially from carelessness or ignorance
- an unexpected and medically important bodily event especially when injurious <a cerebrovascular accident>
- an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought
- used euphemistically to refer to an involuntary act or instance of urination or defecation
- a nonessential property or quality of an entity or circumstance <the accident of nationality>
- something dependent on or subordinate to something else of greater or principal importance
- an occurrence of an action or situation that is a separate unit of experience : happening
- an accompanying minor occurrence or condition : concomitant
- an action likely to lead to grave consequences especially in diplomatic matters <a serious border incident>
- outcomeb : the final outcome or determination of a legal actionc :
- a postulated outcome, condition, or eventuality <in the event that I am not there, call the house>
- something that happens : occurrence
- a noteworthy happeningc : a social occasion or activity
- an adverse or damaging medical occurrence <a heart attack or other cardiac event>
- any of the contests in a program of sports
- the fundamental entity of observed physical reality represented by a point designated by three coordinates of place and one of time in the space-time continuum postulated by the theory of relativity
- a subset of the possible outcomes of an experiment
So let’s make this simple …
In safety terminology, an EVENT is something that happens.
An INCIDENT is a minor accident.
An ACCIDENT is something that has serious human consequences (injury or fatality).
Thus we probably talk about:
- lost time accidents
- near-miss incidents
- events that led to a near-miss
In the TapRooT® System, an Event is an action step in the sequence of events on the SnapCharT®. The Incident is the worst thing that happened in the SnapCharT® sequence of events. Thus, and Incident is a special kind of Event. Plus, if the SnapCharT® is describing a serious injury, the Incident describes the Accident. Thus an Event could be an Incident that describes an Accident!
Do you define these terms at your facility?
If so, please add your definitions as a comment here.
Have you ever had a boss that you needed to fire?
A boss that is:
- hurting your company,
- damaging peoples’ careers, and
- miserable to work for.
I was making a list of the great leaders and mentors that I’ve had and that got me to think of the few really bad people that I’ve worked for.
Unfortunately, I couldn’t fire the bad ones.
In one case, I was in the military. In the military, you have no choice of who you work for. I know that movies make fragging (killing your boss) seem like an option in combat but I never considered that as an option. (Although, my Dad did during WWII. His wing commander was getting multiple pilots killed by bad calls. But he was lucky and didn’t have to choose between his commander and his fellow pilots. The Germans shot him down and the problem went away … although the bad boss survived).
In the second case, the boss was a miserable soul. His only thought was getting himself ahead – he wanted to be a VP (which he eventually accomplished). Luckily, he “traded” me away (think baseball trades) for someone else to advance his agenda. It was great getting out from under his “leadership.”
I guess what really makes these two bad bosses seem even worse are the great leaders that I’ve worked for and known.
Therefore, here is my advice…
If you don’t have a great boss at a great company, fire your boss.
How do you do that?
Find a great boss at a great company that wants you. Get yourself traded.
The other possibility is to make YOU the boss by starting your own company. This has it’s own rewards and problems. (For example, you may not feel comfortable living without the safety net of a big corporation.)
Or you could just wait. (This might be a miserable existence waiting for someone to either fire, transfer, or promote your boss,)
But I’d suggest NOT waiting.
Life is too short to live with a miserable boss.
And for those living under a bad boss, here’s a song for you …
What can you learn about planning a high risk business activity from the planning for a high risk criminal activity?
Probably much more than you might think!
The Global TapRooT® Summit is all about learning from other industries and disciplines and it certainly is different learning from criminal activities and criminal investigations. This talk is based on Alan’s first hand experience with a murder investigation that will keep you riveted to his every word. Don’t miss it.
We have just scheduled a new talk in the Safety Track at the 2016 Global TapRooT® Summit. “Risk Assessing the Perfect Murder” will be held on Thursday, August 4, 2016 from 12:45 p.m. to 1:35 p.m.
Alan Smith, a former Detective Superintendant with the Grampian Police in Scotland, is now a TapRooT® Instructor and a Director of Matrix Risk Control in Aberdeen, Scotland and is leading this intriguing course.
See the complete 2016 Global TapRooT® Summit schedule by CLICKING HERE.
Register for the Safety Track at the 2016 Global TapRooT® Summit (August 1-5 in San Antonio, Texas) by CLICKING HERE. Or add Alan’s talk to another track to customize your Summit experience.
Ever wondered what a TapRooT® Course looks like? Check out these photos of a course in Bogota.
Interested in TapRooT® Training for you or your colleagues? Click here for more information!
Each year Mark Paradies, President of System Improvements, picks courses to hold prior to the TapRooT® Summit. He chooses the courses to help TapRooT® Users learn even more about root cause analysis and performance improvement… lessons that go beyond the standard 2-Day and 5-Day TapRooT® Courses.
What are the courses scheduled for August 1-2?
- TapRooT® for Audits (New)
- Effective Interviewing and Evidence Collection Techniques (New)
- TapRooT® Quality Process Improvement Facilitator Course (New)
- TapRooT® Advanced Trending Techniques
- Advanced Causal Factor Development Course
- Analyzing and Fixing Safety Culture Issues
- Risk Assessment and Management Best Practices
- Getting the Most from Your TapRooT® VI Software
- Understanding and Stopping Human Error
- 2-Day TapRooT® Root Cause Analysis Training (The revised course)
- TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis
WHICH COURSE IS RIGHT YOU?
I’ll provide some background on each course so that you can choose the course that will provide the knowledge you need to help your facility reach the next level in improving safety, quality, patient safety, root cause analysis, trending, or equipment reliability.
Are you responsible for equipment troubleshooting and root cause analysis?
Do you need to improve your plant’s equipment reliability?
This course has been completely redeveloped and focused on solving equipment problems. Ken Reed, Vice President at System Improvements and lead for Equifactor® will be one of the instructors.
The course is equipment focused, but you don’t have to be an engineer to attend. Anyone who looks into the causes of equipment failures as part of:
- equipment troubleshooting
- safety investigations
- environmental releases
- quality issues
can benefit from this systematic approach to discovering why equipment failures occur.
The course teaches techniques for equipment troubleshooting developed by equipment expert Heinz Bloch. It combines those techniques with the world-renowned TapRooT® Root Cause Analysis System to make a best-of-class system for finding the causes of equipment troubles.
The text for this course is the new book: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
2-Day TapRooT® Root Cause Analysis Training (The revised course)
The 2-day TapRooT® Course has been around for over 20 years. This year we decided to go back to the basics and focus the course on performing investigations of low-to-medium risk incidents. We developed a new 50 page book (Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents) that goes with the course.
The course teaches the essential TapRooT® Techniques in an easy to use new simplified 5-Step Investigation Process. You will learn to:
- Use the SnapCharT® Diagram to collect and organize information and understand what happened.
- Identify Causal Factors using the new, simplified three question method
- Use Safeguard Analysis to help quickly identify Causal Factors.
- Find root causes using the latest TapRooT® Root Cause Tree® and Dictionary.
- Develop effective but simple fixes to improve performance.
- Identify Generic Causes if you want to go beyond the simple process.
You will practice each of these skills to become proficient. In this new course you get more practice than you did in the old course. And each team will take one of their own incidents through the process to find root causes and develop effective fixes.
If you want to learn to use a state-of-the-art root cause analysis process to perform quick investigations of low-to-moderate risk incidents, THIS COURSE IS FOR YOU.
If you are a Certified TapRooT® Instructor, you may want to attend this course to see all the new things you will be teaching (including new animated examples).
Dr. Joel Haight, a TapRooT® User since 1991 and a Professor at the University of Pittsburgh, will teach you to analyze and understand human error. This course teaches many of the techniques covered in a university human factors course in a modified short course format.
Topics covered in the course include:
- Basic understanding of visual, auditory, tactile and vestibular senses.
- Understanding reaction time and decision making.
- Understanding physical human performance (ergonomics).
- Factors that influence human error (stress, fatigue, equipment design,/automation, training, and social factors)
- Nuclear industry human performance tools (attention to detail, questioning attitude, and error traps/precursors, peer checking, 3-way communication, procedure use, peacekeeping, pre-job brief/SAFER, post-job brief, observation/coaching, STAR, and time out)
- Practical questions for incident investigators
- Quantitative/Qualitative methods (THERPS, MAPPS, OAT, and FTA)
If you are interested in an overview of techniques focused on human error to augment your standard incident investigations, this course is for you.
To continue to the other course descriptions click on the link MORE below.
Thanks to Tommy Garnett for sending pictures of the recent Onsite course at Geisinger Medical.
Interested in bringing TapRooT® to your company for an Onsite course? Click here for more details.
TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.
The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.
But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.
One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.
The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.
For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).
For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):
- Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
- Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
- Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?
If you get a “Yes” then you have a problem to solve.
How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.
The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.
The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.
Are you using a tool or a system?
If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:
2-Day TapRooT® Root Cause Analysis Training
2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Training
For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.
To hold a course at your site, contact us by CLICKING HERE.
(Note: Copyrighted material shown above is used by permission of System Improvements.)