Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.
BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS
You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.
The turbine trips.
The plant trips.
If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) good-bye.
To make matter worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator – the NRC) is sending a special inspection team to look at the plant’s culture. That could mean days, weeks or even months of down time due to regulatory startup delays.
What do you do???
PLANT 1 – RAPID ACTION
He who hesitates is lost!
Corporate expects heads to roll!
You don’t want to be the first, so you:
- Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
- Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
- Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale.
- Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us any more.
- Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs and a quick start-up will keep the PUC happy.
PLANT 2 – ALTERNATIVE ACTION
No one likes these types of situations, but you are prepared, so you:
- Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify.
- Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts sharing your root cause analyses means that they have confidence that you will do a thorough investigation.
- “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault finding, and results in future lies and cover-ups.
- Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems to avoid the big ones.
- Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
- Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to show off your team’s capabilities while in the heat of battle. Reward them while the sweat is still on their brow.
- Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.
Which culture is more common in your industry?
Which plant would you rather manage?
Where would you rather work?
What makes Plant 1 and Plant 2 so different? It is really quite simple…
- Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose that to help then succeed by giving them the tools they need to get the job done right.
- Trust: Everyone trusts everyone on this team. This starts with good face to face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
- Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.
Which plant exhibited these characteristics?
HOW TO CHANGE
Can you change from Plant 1 to Plant 2? YES! But how???
The first step has to be made by senior managers. The right attitude must be adopted before trust can be developed and a systematic approach can succeed.
Part of exhibiting the belief in your people is making sure that they have the tools they need. This includes:
- Choosing an advanced, systematic root cause analysis tool (TapRooT®).
- Adopting a written accident/incident investigation policy that shows managements commitment to thorough investigations and detailed root cause analysis.
- Creating a database to trend incident causes and track corrective actions to completion.
- Training people to use the root cause analysis tool and the databases that go with them.
- Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
- Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.
Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implement and experienced by folks in the field, trust in management will become a forgone conclusion.
YOU CAN CHANGE
Have faith that your plant can change. If you are senior management, take the first step: Trust your people.
Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world class.
_ _ _
Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting.
Having a bad day? look at these pictures and your day might not seem so bad…
Thanks to Diana Munevar for these great photos of our August 27-29, 2014 course in Bogota, Colombia.
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 16th, 2014 by Mark Paradies
Final presentations by the teams after performing a root cause analysis on their incident that they brought to the course…
He didn’t die … but his boss was fined £5,000 by the HSE.
Linda Unger Teaching the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
Need root cause analysis training at your site? Contact us to set up a TapRooT® Course by CLICKING HERE.
Teams Working on Their SnapCharT®s at the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
You have to understand what happened before you can understand why it happened. The SnapChart helps you do just that. These folks at the 2-Day class in Dayton are practicing their newly learned skills…
For the next public TapRooT® Course near you, click on your continent at:
The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.
To see the report and the one lesson learned, CLICK HERE.
A man can be as great as he wants to be.
If you believe in yourself and have the courage,
the determination, the dedication, the competitive drive and
if you are willing to sacrifice the little things in life and
pay the price for the things that are worthwhile,
it can be done. ~ Vince Lombardi
Mark Paradies Teaching a Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
Want to find out more about TapRooT® Root Cause Analysis Training? Then visit our web site:
On August 21-22, we held a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Bogota, Colombia. Course Planner Diana Munevar shared these photos of the Marble Game, SnapCharT® creating, and interviewing during the course. Enjoy!
Are you interested in learning to find and fix the real root causes of problems in your workplace? Click here to learn more about our South America TapRooT® Courses.
Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil held August 4-8, 2014 went fantastically! Thanks to TapRooT® Instructor Boris Risnic for these photos and a great course.
I heard an interesting speaker last week talk about technology adoption. He spoke about how valued brands developed a “tribe” of users who often networked and shared best practices. This often made the technology (the brand) better and more valuable.
That’s when I realized that TapRooT® Users were a tribe that constantly made TapRooT® a more valuable technology/brand.
And once a year, the tribe gets together at The Global TapRooT® Summit.
Think of this like the tribal meetings of old. Or mountain men getting together at the rendezvous. Or, if you are from a Norse heritage, a þing (things).
If you’ve never been to the Summit, now is the time to start planning to attend. Mark out the dates (June 1-5, 2015) on your calendar. Get any budget requests to travel authorizations started (or at least planned for). See if you can get a team of your best performance improvement experts to register as a group.
You’ll return to work from the Summit energized to make improvement happen with great ideas and best practices from around the world. General Summit information is available HERE. The Summit schedule of events will be posted shortly.
Looking forward to seeing you and the rest of the tribe next June.
President, System Improvements
The TapRooT® Folks
Monday Accident & Lessons Learned: NTSB Investigation – Grounding and Sinking of Towing Vessel Stephen L. Colby”September 8th, 2014 by Mark Paradies
Below is the NTSB investigation PDF. Read it and see what you think of the “probable cause” of the accident … “The National Transportation Safety Board determines that the probable cause of the grounding and sinking of the Stephen L. Colby was the failure of the master and mate to ensure sufficient underkeel clearance for the intended transit through the accident area.“
See the whole report here:
You measure the size of the accomplishment
by the obstacles you had to overcome to reach your goals. ~ Booker T. Washington
We recently held an onsite TapRooT® course in Villahermosa, Mexico. Our August 6-8 course went great, and we have TapRooT® Instructor Marco Flores to thank for that and for these photos. Enjoy!
Want to learn how TapRooT® can teach you to find and fix root causes?
What happens after hours at the TapRooT® Summit? People relax and share their experiences. In the picture below, TapRooT® VP Linda Unger is having dinner with three TapRooT® Users at the 2003 TapRooT® Summit.
When and where is the next TapRooT® Summit that you can network, share best practices, and learn the latest new ideas? June 1-5 in Las Vegas. Click here for more information.
Did this post bring back any favorite memories from a Global TapRooT® Summit you have attended? Tell your story by leaving a comment below!
Root Cause Analysis Tip: Rate Your Root Cause Analysis / Incident Investigation System – The Good, The Bad, and The UglySeptember 3rd, 2014 by Mark Paradies
Over a decade ago, I developed a rating sheet for root cause analysis implementation. We had several sessions at the TapRooT® Summit about it and it was posted on our web site (and then our blog). But in the last web site crash, it was lost. Therefore, I’m reposting it here for those who would like to download it. (Just click on the link below.)
Instructions for using the sheet are on the sheet.
I’m working on a new rating system for evaluation of individual incident investigations and corrective actions. Anyone have any ideas they would like to share?
Monday Accident & Lessons Learned: RAIB Investigation Report – Road Rail Vehicle Runs Away, Strikes ScaffoldSeptember 1st, 2014 by Mark Paradies
Here is the summary of the report from the UK Rail Accident Investigation Branch:
At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.
The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.
The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.
The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.
To read the whole report, see:
Develop success from failures.
Discouragement and failure are two of the surest stepping stones to success. ~ Dale Carnegie
UK Rail Accident Investigation Branch investigates electrical arcing and fire on a Metro train and parting of the overhead line at Walkergate station, Newcastle upon Tyne, on 11 August 2014August 29th, 2014 by Mark Paradies
Here’s the press release …
Electrical arcing and fire on a Metro train and parting of the overhead line
at Walkergate station, Newcastle upon Tyne, on 11 August 2014
RAIB is investigating an accident which occurred on the Tyne and Wear Metro system at Walkergate station on Monday 11 August 2014.
At 18:56 hrs a two-car Metro train, travelling from South Shields to St James, arrived at Walkergate station. While standing in the station an electrical fault occurred to a line breaker mounted on the underside of the train, which produced some smoke. It also caused the circuit breakers at the sub-stations supplying the train with electricity, via the overhead line, to trip (open). About one minute later power was restored to the train. There followed a brief fire in the area of the initial electrical fault and further smoke. Shortly afterwards, the overhead line above the train parted and the flailing ends of the wire fell on the train roof and one then fell on to the platform, producing significant arcing and sparks for around 14 seconds. Fortunately, there was no-one on the platform at the time. However, there were at least 30 passengers on the train who self-evacuated on to the platform using the train doors’ emergency release handles. The fire service attended but the fire was no longer burning. No-one was reported to be injured in the accident and there was no significant damage to the interior of the train.
Image courtesy of Tyne and Wear Metro
RAIB’s investigation will consider the sequence of events and factors that led to the accident, and identify any safety lessons. In particular, it will examine:
- the reasons for the electrical fault;
- the response of the staff involved, including the driver and controllers;
- the adequacy of the electrical protection arrangements; and
- actions taken since a previous accident of a similar type that occurred at South Gosforth in January 2013 (RAIB report 18/2013).
RAIB’s investigation is independent of any investigations by the safety authority. RAIB will publish its findings at the conclusion of the investigation. The report will be available on the RAIB’s website.
You can subscribe to automated emails notifying you when the RAIB publishes its report and bulletins.
RAIB would like to hear from any passengers who were on the train. Any information provided to assist our safety investigation will be treated in strict confidence. If you are able to help the RAIB please contact us by email on firstname.lastname@example.org or by telephoning 01332 253300