We held an on-site course in Santiago, Chile on July 30-31, 2014, with Piedad Colmenares as the TapRooT® Instructor. She sent us these photos of the class. Enjoy!
Interested in bringing root cause analysis training to your facility?
FATALITY DURING CONFINED SPACE ENTRY
- Two cylindrical foam sponge pads had been inserted in a riser guide tube to form a plug. Argon gas had been pumped into the 60 cm space between the two sponges as shielding gas for welding on the exterior of the riser guide tube.
- After completion of the welding, a worker descended into the riser guide tube by rope access to remove the upper sponge. While inside, communication with the worker ceased.
- A confined space attendant entered the riser guide tube to investigate. Finding his colleague unconscious, he called for rescue and then he too lost consciousness.
- On being brought to the surface, the first worker received CPR; was taken to hospital; but died of suspected cardio-respiratory failure after 2 hours of descent into the space. The co-worker recovered.
What Went Wrong?
- Exposure to an oxygen-deficient atmosphere: The rope access team members (victim and co-worker) were unaware of the asphyxiation risk from the argon gas shielding.
- Gas test: There was no gas test done immediately prior to the confined space entry. The act of removing the upper foam sponge itself could have released (additional) argon, so any prior test would not be meaningful.
- Gas detectors: Portable gas detectors were carried, but inside a canvas bag. The co-worker did not hear any audible alarm from the gas detector when he descended into the space.
- Evacuation time: It took 20 minutes to bring the victim to the deck after communication failed.
Corrective Actions and Recommendations
- As a first step: assess whether the nature of the work absolutely justifies personnel entering the confined space.
- Before confined space entry:
- identify and communicate the risks to personnel carrying out the work
- define requirements, roles and responsibilities to control, monitor and supervise the work
- check gas presence; understand how the work itself may change the atmospheric conditions
- ensure adequate ventilation, lighting, means of communication and escape
- Ensure step by step work permits are issued and displayed for each work phase, together with specific job safety analyses
- During confined space entry:
- station a trained confined space attendant at the entrance to the space at all times
- ensure that communication and rescue equipment and resources are readily available
- carry and use portable/personal gas detectors throughout the activity
Review your yard confined space entry practice, keeping in mind the lessons learned from this incident.
safety alert number: 259
OGP Safety Alerts http://info.ogp.org.uk/safety/
The successful warrior is the average man, with laser-like focus. ~ Bruce Lee
Or do they need better painter quality control?
Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
Just before starting the exercise …
Teams working on their incidents …
Instructions just prior to the presentations …
Teams presenting …
For more information about TapRooT® Root Cause Analysis Courses, see:
The only place where success comes before work is in the dictionary. ~ Vidal Sassoon
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Every company I’ve worked with has an existing improvement program.
Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some still have a long ways to go, but have started their improvement process.
No matter where you are, one question that always seems to come up is …
“What should we improve next?“
The interesting answer to this question is that your plant is telling you if you are listening.
But before I talk about that, let’s look at several other ways to decide what to improve…
1. The Regulator Is Emphasizing This
Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.
2. Management Hot Topic
Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…
- A recent accident (at your facility or someone else’s).
- A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
- That the CEO has a new initiative.
You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.
3. Industry Initiative
Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.
All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.
So how should you decide what to improve next?
By listening to your plant/facility.
What does “listening to you plant” mean?
To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.
Reactively collecting signals comes from your accident, incident, near-miss investigation programs.
It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.
I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.
Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.
Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).
Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.
Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler - see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)
Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.
Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.
Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.
Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…
Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:
TapRooT® Instructor Reb Brickey sent over these photos of our recent onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Lagos, Nigeria. Enjoy!
People often say that motivation doesn’t last.
Well, neither does bathing – that’s why we recommend it daily. ~ Zig Ziglar
Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis CourseAugust 6th, 2014 by Mark Paradies
Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…
Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at:
Pictures from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course at Lake TahoeAugust 5th, 2014 by Mark Paradies
The students below are hard at work reading the Root Cause Tree® Dictionary to discover why someone would break a rule. Ever wonder why people break the rules? Then maybe you should attend one of our 2-Day or 5-Day TapRooT® Courses!
View more photos from Tahoe here: http://www.taproot.com/archives/45935
Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013August 4th, 2014 by Mark Paradies
Here’s the summary of the report from the UK RAIB:
At around 18:35 hrs on Sunday 25 August 2013, a London Underground train departing Holland Park station was brought to a halt by the first of many passenger emergency alarm activations, after smoke and a smell of burning entered the train. During the following four minutes, until the train doors still in the platform were opened by the train operator (driver), around 13 passengers, including some children, climbed out of the train via the doors at the ends of carriages.
The investigation found that rising fear spread through the train when passengers perceived little or no response from the train operator to the activation of the passenger emergency alarms, the train side-doors remained locked and they were unable to open them, and they could not see any staff on the platform to deal with the situation. Believing they were in danger, a number of people in different parts of the train identified that they could climb over the top of safety barriers in the gaps between carriages to reach the platform.
A burning smell from the train had been reported when the train was at the previous station, Notting Hill Gate, and although a request had been made for staff at Holland Park station to investigate the report, the train was not held in the platform for staff to respond. A traction motor on the train was later found to have suffered an electrical fault, known as a ‘flash-over’, which was the main cause of the smoke and smell.
A factor underlying the passengers’ response was the train operator’s lack of training and experience to deal with incidents involving the activation of multiple passenger emergency alarms.
The report observes that London Underground Limited (LUL) commenced an internal investigation of the incident after details appeared in the media.
RAIB has made six recommendations to LUL. These seek to achieve a better ergonomic design of the interface between the train operator and passenger emergency alarm equipment, to improve the ability of train operators to respond appropriately to incidents of this type, and to ensure that train operators carryradios when leaving the cab to go back into the train so that they can maintain communications with line controllers. LUL is also recommended to review the procedures for line controllers to enable a timely response to safety critical conditions on trains and to ensure continuity at shift changeover when dealing with incidents. In addition, LUL is recommended to review the training and competencies of its staff to provide a joined-up response to incidents involving trains in platforms and to reinforce its procedures on the prompt and accurate reporting of incidents so that they may be properly investigated.
If you want to achieve excellence, you can get there today.
As of this second, quit doing less-than-excellent work. ~ Thomas J. Watson
Thanks to TapRooT® Insturctors Piedad Colmenares and Hernando Godoy for teaching this fantastic 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course in Bogota, Colombia July 23-25, 2014! Enjoy their photos of the course:
Ocean Rig recently sponsored their first TapRooT® 5-Day and Train the Trainer Courses, one of many scheduled this year. Here are just a few pictures with our contract instructor, Alan Scott, teaching the onsite courses in Athens, Greece this July. Notice also Ocean Rig’s newly certified trainers getting their certification.
Monday Accident & Lessons Learned: UK RAIB Accident Report – Near-miss at Butterswood level crossing, North Lincolnshire, 25 June 2013July 28th, 2014 by Mark Paradies
The UK Rail Accident Investigation Branch issued a report about a train/car near miss at a crossing. Here is a summary of the report:
At around 07:35 hrs on Tuesday 25 June 2013 a passenger train was involved in a near-miss with a car on a level crossing near Butterswood in North Lincolnshire. The train passed over the level crossing with the barriers in the raised position and the road traffic signals extinguished. No injuries or damage were caused as a result of the incident.
Normally, the approach of the train would have automatically initiated the closure of the crossing. However, the crossing was not working normally because the power supply to the crossing equipment had been interrupted. The crossing was of a type where train drivers are required to check that it is not obstructed as they approach and that it has operated correctly. A flashing light is provided for this purpose, just before the crossing, with a flashing white light displayed if the crossing has correctly closed against road users, and a flashing red light displayed at all other times (including those occasions when the crossing has failed to close on the approach of a train). The driver of the train involved in the near-miss did not notice until it was too late to stop that the flashing light was indicating that the crossing was not working normally, and was still open for road traffic.
The RAIB’s investigation found that the train driver had the expectation that the crossing would operate normally as the train approached and that he had not focused his attention on the flashing light at the point where he needed to confirm that the crossing had operated correctly for the passage of his train. Although the level crossing had probably failed around nine hours before the incident, the fact of its failure was not known to any railway staff.
The investigation also found that the crossing was not protected with automatic warning system equipment and that the maintenance arrangements at the crossing were not effective in ensuring reliable performance of the equipment. In addition, the train operator’s briefing material did not clearly explain to drivers their role in respect of failures at this type of level crossing.
The RAIB has identified four key learning points relating to non-provision of the automatic warning system at locations where it is mandated by standards, recording of the condition of assets during inspection, storage of batteries, and involving people with relevant technical expertise in industry investigations into incidents and accidents.The RAIB has made four recommendations. Three recommendations have been made to Network Rail addressing the indications given to train drivers approaching crossings where they are required to monitor the crossing’s status, improvements to the reliability of power supplies to crossings such as Butterswood and considering remote monitoring of the power supply at similar crossings. One recommendation has been made to First TransPennine Express regarding the briefing that it gives its drivers on this type of level crossing.
For the complete report, see:
Don’t be afraid to give up the good to go for the great. ~ John D. Rockefeller
Ralph Blessing shared this photo of our July 22-23, 2014 class hard at work in Bowling Green, Kentucky. Thanks, all, for a great course!
The picture below is of Mark Paradies helping attendees with their final TapRooT® training exercise. This course was held in beautiful Gatlinburg, TN located in the Great Smokey Mountains.
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What fun story can you tell us about a TapRooT® training course? Please leave a comment below.