See, your day seems better already …
On November 17, 2014, TapRooT® will be hosting a 5-Day Advanced Root Cause Analysis Team Leader Training Public Course in Johannesburg, South Africa. Will you be joining us? Johannesburg, or JoBurg as locals call it, has quite interesting and intriguing facts, history and landmarks that pull people in. It is said to be the world’s largest city not located directly on a water source, however, it is located on mineral rich land where the city’s source of gold and diamonds come from. It is known as Africa’s economic powerhouse due to it being the largest economy of any metropolitan area in Sub-Saharan Africa. There is so much offered in this massive city that you’re sure enjoy inside and outside of our course.
Mugg & Bean Cafe: This delicious little cafe offers a little of everything from barbeque and quesadillas to cupcakes and soups.
The GrillHouse Rosebank: Enjoy a fabulous steak dinner in a warm atmosphere with live music here at The GrillHouse.
SalvationCafe: If you love gourmet flavors and branching out from the everyday menu, check out this quaint cafe.
Gold Reef City: Fun on every corner! Theme parks, dining, theaters, etc await you as you stroll through and take it all in.
Apartheid Museum: History museums are always an educational, impacting experience for anyone!
Peacemakers Museum: What an inspirational and interesting exhibit full of the history of all Nobel Peace Laureates. You’re sure to learn something new and leave encouraged by all the incredible men and women all across the globe.
IT DIDN’T HAVE TO HAPPEN
An anesthesia machine cuts off oxygen to a patient causing extensive brain damage. The investigation team finds a mechanical defect that was undetectable without complex testing. They also find that the sentinel event almost happened before.
The baggage door on a 747 opens after takeoff, tearing off part of the plane. Four people are swept out the hole to their death. The investigation uncovers poor, less catastrophic accidents of a similar nature and a history of problems with the door on this particular aircraft.
A plant upset occurs due to corrective maintenance. A relief lifts but fails to shut when pressure decreases. Operators, initially preoccupied with other alarms, misdiagnose the problem and shut off critical safety equipment. The “impossible” accident – a core meltdown – happens at Three Mile Island. The investigation uncovers similar, precursor incidents and a history of relief valve failure at TMI.
These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?
- Suffering for survivors and surviving loved ones.
- Millions – no billions – of Dollars (Yen, Euros, and Pounds).
We could prevent ALL of them. Why don’t we? Don’t we know that:
An ounce of prevention is worth a pound of cure?
Maybe it is:
- Intellectual laziness?
- Just plain bad management?
- A bad system to identify problems?
- Bad investigation techniques?
- Something else?
What would it take to start learning?
STEP 1: MANAGEMENT UNDERSTANDING
Your management – from the CEO down – must understand the problem … People and machines are variable (you might call them unreliable) BY NATURE.
Our job is to reduce the variability and make systems reliable and safe.
In the long run a safe, reliable system will always out perform an unreliable, unsafe systems.
Therefore, improving reliability and safety provides your company with a competitive advantage.
The competitive advantage IS NOT FREE. It requires up front effort and investment in root cause analysis and improvements. It requires persistent attention to detail.
Thus, attaining reliability and safety is the challenge.
STEP 2: GET A PERFORMANCE IMPROVEMENT & ROOT CAUSE ANALYSIS SYSTEM THAT WORKS
Although Ben Franklin’s advice seems simple, consistently identifying the right “ounce of prevention” can be complex.
How dangerous is it to reason from insufficient data.
Improving safety and reliability requires a systematic approach and the use of sophisticated performance improvement techniques. You need a good performance monitoring system.
A good performance monitoring system includes:
- self-reporting of near misses
- reporting and instigation of accidents and incidents
- audits, observations, and self-assessments
- advanced root cause analysis (TapRooT®)
- advanced statistical analysis of trends
- understanding of how to fix human performance problems
- training for those who make the system work
Is putting together this kind of a system a tall order? You bet. Bit it is worth it.
If you need help putting this type of system together, we have the experience to help you and we can provide the training that people need. Call us at 865-539-2139 or drop us a note.
STEP 3: USE THE SYSTEM & FIX PROBLEMS
Get your facts first.
Then you can distort them as much as you please.
Preventing accidents is NOT a quick fix. Something you can do once and forget. Management needs to stay involved. You must be consistently persistent.
Find and fix the root causes of accidents, incidents, near-misses, and audit findings.
The first measure of the effective of the system IS NOT a reduced accident rate (although this will come along quickly enough). The first measure of success is an increased rate of finding and implementing effective corrective actions.
Management needs to demand that people properly using the system to investigate problems, find their root causes, identify effective fixes, and get them implements. If management doesn’t demand this, it won’t happen.
STEP 4: NEVER STOP IMPROVING
If you aren’t better today than you were yesterday, you are falling behind. As my boss once said:
If you’re not peddling, you are going downhill.
Captain William J. Rodriguez, United Staes Navy
Never stop looking for areas that need improvement. This should include improving your improvement system!
We can help. How? Several ways…
- Call us at 865-539-2139 and we can discuss your plans to improve. The call is FREE and we may be able to suggest ways to make your plan even better.
- We can conduct an independent review of your root cause analysis implementation, trending, and performance improvement systems. Although this isn’t free, we guarantee it will be worth the time and money. Just drop us a note to get things started.
- Attend the TapRooT® Summit. Each year we design the Summit to help people learn to solve the toughest problems facing industry. You will network with some of the world’s most knowledgeable performance improvement experts and peers who have faced the same types of problems that you face and found best practices to solve their problems.
Don’t wait for the next “missed opportunity”. Do something to make improvement happen before a major accident takes place.
Save lives – save money – save jobs – improve quality and reliability – that’s what TapRooT® is all about.
(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)
Thank you to Harry Thorburn for sending us these great pictures from the most recent Onsite Course in Athens, Greece.
Visit our website for more information on our Onsite and Public Courses.
What do you have planned to keep walkways clear this winter?
See Andrew G. Rosen’s “7 Ways to Get Motivated” at:
This came to my e-mail account from an on-line retailer …
Maybe it could include an optional Darth Vader voice changer?
Root Cause Tip: Making Team Investigations Work (A Best of Article from the Root Cause Network™ Newsletter)October 9th, 2014 by Mark Paradies
Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.
MAKING TEAM INVESTIGATIONS WORK
WHY USE A TEAM?
First, team investigations are now required for process safety related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?
Quite simply because two heads are better than one! Why? Several reasons:
- A team’s resources can more quickly investigate an incident before the trail goes cold.
- For complex systems, more than one person is usually needed to understand the problem.
- Several organizations that were involved in the incident need to participate in the investigation.
- A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrom.)
MAKING THE TEAM WORK
Investigating an incident using a team is different than performing an individual investigation. To make the team work, you need to consider several factors:
- Who to include on the team.
- The training required for team members.
- Division of work between team members and coordinating the team’s activities.
- Record keeping of the team’s meetings.
- Software to facilitate the team’s work.
- Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.
WHO’S ON THE TEAM?
The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:
- Engineering/technical assistance for hardware expertise.
- Human engineering/ergonomics experts for human performance analysis.
- Operations/maintenance personnel who understand the work practices.
- An investigation coach/facilitator who is experienced in performing investigation.
- A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
- A union rep.
- A safety professional.
TRAINING THE TEAM
A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgement to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. Hopever, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.
What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…
- Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
- Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
- People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness.
KEEPING ON TRACK
One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice.
MORE TO LEARN
This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE. Or contact us to schedule a course at your site.
You think you are having a bad day? Have a look at these pictures of a bad day in the military and you might feel better by comparison…
TapRooT® will be traveling to Krakow, Poland November 3-4 for a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. Will you be joining us? Krakow has so much to offer, as it was named the European Capital of Culture by the European Union in 2000. You will be overwhelmed at the beautiful medieval architecture, world renowned art museums, incredible performing arts, and so much more! Stay a couple extra days after the course to really get the full experience of all Krakow has in store.
Resto Illuminati: A modern, chic restaurant with live music and authentic Polish dishes anyone would love!
Aperitif: This quaint restaurant contains all you need for a relaxing evening, calm atmosphere, excellent wine menu and incredible main course.
Hard Rock Café: The familiar restaurant that America knows and loves made its way to Poland. Nestled in the famous Market Square surrounded by historical attractions, it’s bound to be a good time.
Main Market Square: Just taking a stroll through this 10 acre area of Krakow will inspire you and teach you more about the rich culture and medieval history.
Krakow’s Historic Centre: Another area that tourists can stroll through and admire all the 14th century architecture, palaces, synagogues, Gothic cathedrals, etc.
Auschwitz and Salt Mine tours: What an interesting and educational tour this would be. No pictures or articles can do these areas justice.
Have you registered for the course yet? Click here for more info or to register for our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course in Krakow, Poland held November 3-4, 2014.
Monday Accident & Lessons Learned: OPG Safety Alert #260 – Planning & Preparation … Key Elements for Prevention of MPD Well Control AccidentsOctober 6th, 2014 by Mark Paradies
OPG Safety Alert #260
PLANNING AND PREPARATION – KEY ELEMENTS FOR PREVENTION OF MPD WELL CONTROL INCIDENTS
During drilling the 6″ reservoir section in an unconventional well, a kick-loss situation occurred. After opening the circulation port in a drillstring sub-assembly, LCM was pumped to combat losses. When LCM subsequently returned to surface it plugged the choke. Circulation was stopped, the upper auto-Internal BOP (IBOP) was activated, and the choke manifold was lined up for flushing using a mud pump. During the course of this operation mud backflow was observed at the Shaker Box. The Stand Pipe Manifold and mud pumps were isolated to investigate. After a period of monitoring the stand pipe pressure, the upper IBOP, located at the top of the drillpipe, was opened to attempt to bullhead mud into the drillstring. Upon opening, a pressure, above 6500psi and exceeding the surface system safe working pressure, was observed. The upper IBOP was closed immediately and the surface system bled down. An attempt to close the lower manual IBOP as a second barrier was not successful. Due to the presence of high pressure, the Stand Pipe Manifold could not be used as the second barrier, nor could it be used for circulation. Well control experts were mobilised to perform hot tapping and freeze operations which were successfully executed and allowed a high-pressure drillpipe tree to be installed in order to re-instate 2 barriers on the drillpipe.
What Went Wrong?
- With the down-hole circulation sub-assembly open in the drillstring, the upper IBOP was either leaking or remained open due to activation malfunction (this could not be substantiated), and a flow path developed up the drill pipe.
- The line up for flushing the Choke Manifold with the mud pumps did not allow for adequate well monitoring. The set up as used resulted in unexpected flow up the drillstring to go undetected.
- It was incorrectly assumed that monitored volume gains were due only to mud transfer.
- Assessment of flow, volume and pressure risks did not consider in sufficient detail the concurrent operations involving pumping mud off line and a pressurized drill string.
- Operational focus was on choke manifold flushing whereas supervision should have maintained oversight of the broader situation including well monitoring.
Corrective Actions and Recommendations
- Develop a barrier plan for all operational steps; always update the plan as a result of operational changes prior to continuing (ie. ensure a robust Management of Change process).
- Take the time required to verify that intended barriers are in place as per the Barrier Plan and, when activated, have operated properly (eg. IBOP’s).
- Install a landing nipple above the down hole circulation sub-assembly to allow a sealing drop dart to be run if required.
- Always close-in, or line-up, in such a way that allows for monitoring of all the closed-in pressures at all times.
- “Walk the lines” prior to commencing (concurrent) operations involving pressure and flow.
- Develop procedures in advance for flushing of the Well Control system, especially for recognisable potential cases of concurrent operations.
- Develop clear procedures covering all aspects of unconventional operations, including reasonably expected scenarios, and ensure effective communication of these to all relevant staff.
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.
This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
Having a bad day? Look at these pictures and you might feel better by comparison …
We can help you stop bad things from happening.
Is your team trying to prevent fatalities?
Improve your root cause analysis?
Investigate a difficult incident?
Solve equipment reliability issues?
Reduce lost time accidents and workers comp costs?
Stop sentinel events?
Improve process safety?
Meet senior management improvement expectations?
We would be glad to help.
In helping companies all over the world implement TapRooT® and train their personnel to use advanced root cause analysis, we get involved in all types of performance improvement initiatives. We see what works. We see what doesn’t.
What are some common areas where we can help?
IMPROVE YOUR TapRooT® IMPLEMENTATION
We wrote the book on implementing TapRooT®. We know how it should be used and common ways to improve its use. We see best practices from around the world and we can help you catch up by applying best practices that you haven’t tried.
How do you get started? Call us at 865-539-2139. We’ll be glad to listen to the issues you face, what you’ve done so far to make improvement happen, and explain what you can do to take your program to the next level.
Our instructors are experts in applying TapRooT® to investigate problems. accidents, incidents, quality issues, sentinel events, equipment issues, production problems, and cost overruns. We don’t “do” investigations. But we can supply an an experienced TapRooT® facilitator to help your team with a tough investigation or to review an investigation that is nearing completion. Call us at 865-539-2139 or CLICK HERE to drop us a note to get the process started.
Using TapRooT® to investigate accidents and stop them from happening again is good. But is even better to use TapRooT® to stop accidents from ever occurring by being PROACTIVE.
We can show you how to apply TapRooT® proactively to stop accidents, incidents, quality issues, equipment reliability problems, production problems, or sentinel events. We actually have a specific course to teach the skills you will need to apply (Proactive Use of TapRooT® Course). You can attend the public course (next one is scheduled for June 1-2, 2015 in Las Vegas) which is offered just prior to the TapRooT® Summit. Or you can contact us to have a course at your site. And we would be glad to work with you before the course to get your proactive program set up to take advantage of the tools that TapRooT® offers.
Not only do we teach a course on Advanced Trending Techniques, we can help you apply those techniques to analyze your performance issues and help you present the findings to your management. We’ve found that many TapRooT® Users have never had experience in using trends to target improvement initiatives. So we can give you the training you need to understand trending and help you do your first trend analysis to understand how trending can be applied to prevent problems. Call us at 865-539-2139 or drop us a note to find out what we can do to help you look at your trends.
Many people use TapRooT® Software to analyze incidents. But to get the most from your software, you need to do up front business analysis to properly implement the software. Of course, we offer a course – Getting the Most from Your TapRooT® Software – to help TapRooT® Software Administrators and TapRooT® Software Super-Users learn what is needed to set up their software for best results. But we can also consult with TapRooT® Users and Software Administrators to help them develop a TapRooT® Software implementation plan. Call us at 865-539-2139 or drop us a note for more info about this service,
CREATE AN IMPROVEMENT INITIATIVE
If you are considering starting a new performance improvement initiative, why not get us involved from the ground up? We can use our knowledge of improvement programs from around the world to help you implement a world-class initiative. We can also bring in experts that we have worked with in equipment reliability, aviation safety, construction safety, nuclear safety, human factors, process safety, lean/six sigma, and patient safety to give your program a head start. Don’t try to reinvent the wheel. Let us help you get ahead of the game. Call us at 865-539-2139 to discuss your program and find out how we can help.
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That’s just a few ideas. We have many more. But you will never know how we could have helped you unless you give as a call (865-539-2139) or drop us a note. Our initial advice is FREE and we’ll be happy to provide a quote for any services, training, or software needed to help your program become world-class.
Don’t procrastinate – call today.
This week accident information is from the US Chemical Safety Board …
CSB Chairperson Moure-Eraso Warns About Danger of Hot Work
on Tanks Containing Biological or Organic Material
Earlier this month a team of CSB investigators deployed to the Omega Protein facility in Moss Point, Mississippi, where a tank explosion on July 28, 2014, killed a contract worker and severely injured another. Our team, working alongside federal OSHA inspectors, found that the incident occurred during hot work on or near a tank containing eight inches of a slurry of water and fish matter known as “stickwater.”
The explosion blew the lid off the 30-foot-high tank, fatally injuring a contract worker who was on top of the tank. A second contract worker on the tank was severely injured. CSB investigators commissioned laboratory testing of the stickwater and found telltale signs of microbial activity in the samples, such as the presence of volatile fatty acids in the liquid samples and offgassing of flammable methane and hydrogen sulfide.
The stickwater inside of the storage tank had been thought to be nonhazardous. No combustible gas testing was done on the contents of the tank before the hot work commenced.
This tragedy underscores the extreme importance of careful hot work planning, hazard evaluation, and procedures for all storage tanks, whether or not flammable material is expected to be present. Hot work dangers are not limited to the oil, gas, and chemical sectors where flammability hazards are commonplace.
The CSB has now examined three serious hot work incidents—all with fatalities—involving hot work on tanks of biological or organic matter. At the Packaging Corporation of America (PCA), three workers were killed on July 29, 2008, as they were performing hot work on a catwalk above an 80-foot-tall tank of “white water,” a slurry of pulp fiber waste and water. CSB laboratory testing identified anaerobic, hydrogen-producing bacteria in the tank. The hydrogen gas ignited, ripping open the tank lid and sending workers tumbling to their deaths.
On February 16, 2009, a welding contractor was killed while repairing a water clarifier tank at the ConAgra Foods facility in Boardman, Oregon. The tank held water and waste from potato washing; the CSB investigation found that water and organic material had built up beneath the base of the tank and decayed through microbial action, producing flammable gas that exploded.
Mixtures of water with fish, potatoes, or cardboard waste could understandably be assumed to be benign and pose little safety risk to workers. It is vital that companies, contract firms, and maintenance personnel recognize that in the confines of a storage tank, seemingly non-hazardous organic substances can release flammable gases at levels that cause the vapor space to exceed the lower flammability limit. Under those conditions, a simple spark or even conducted heat from hot work can prove disastrous.
I urge all companies to follow the positive example set by the DuPont Corporation, after a fatal hot work tragedy occurred at a DuPont chemical site near Buffalo, New York. Following CSB recommendations from 2012, DuPont instituted a series of reforms to hot work safety practices on a global basis, including requirements for combustible gas monitoring when planning for welding or other hot work on or near storage tanks or adjacent spaces.
Combustible gas testing is simple, safe, and affordable. It is a recommended practice of the National Fire Protection Association, The American Petroleum Institute, FM Global, and other safety organizations that produce hot work guidance. Combustible gas testing is important on tanks that hold or have held flammables, but it is equally important—if not more so—for tanks where flammables are not understood to be present. It will save lives.
If you are having a bad day, have a look at these pictures and it might not seem so bad by comparison…
Enjoy the artistic and historic culture of Tulsa with TapRooT® at our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course on October 20th. Tulsa is filled with American Indian and Western heritage that will take you back in time. All the cultural attractions and food that you can venture out into are sure to be educational and fun. Come join us and explore deeper into root cause analysis training and Tulsa’s rich heritage.
Burn Co. Barbecue: When’s the last time you had perfectly smoked, delicious BBQ? Burn Co. Barbecue is one of the most popular restaurants in town with the best BBQ!
Savastanos Pizzeria: Authentic Chicago style pizza is the only way to go in Tulsa! Treat yourself to a thick, original Chicago style pizza and a beer!
Kilkenny’s Irish Pub and Eatery: Irish pubs always have a fun atmosphere, great beer and delicious food! Bring your friends to Kilkenny’s and enjoy a night out!
Native American Art Museum: A specialized, intriguing art museum containing only artifacts and archives from Native American history.
Tulsa Air and Space Museum and Planetarium: This museum is fun for all ages! Enjoy learning about the vintage airplanes used in the 1930’s and experience the interactive exhibits.
Marshall Brewing Co.: Come tour this unique, local brewery and taste their authentic ales and lager!
Have you registered for the course yet? Click here for more info or to register for our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course in Tulsa, Oklahoma held October 20-24, 2014.
Thanks to TapRooT® Instructor Marco Flores for these great photos of our September 8-12, 2014 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
Monday Accident & Lesson Learned: Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottingham, 26 October 2013September 22nd, 2014 by Mark Paradies
The UK Rail Accident Investigation Branch issued a report about the fatal accident of a train striking a pedestrian at a footpath crossing near Nottingham, UK. See the entire report and the one lesson learned at: