Category: Pictures

Missed Opportunities (A Best Of Article from the Root Cause Network™ Newsletter)

October 22nd, 2014 by


MISSED OPPORTUNITIES

IT DIDN’T HAVE TO HAPPEN

An anesthesia machine cuts off oxygen to a patient causing extensive brian 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.

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These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?

  • Lives. 
  • 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?
Benjamin Franklin 

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Maybe it is:

  • Intellectual laziness? 
  • Shortsightedness? 
  • 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.
Sherlock Holmes 

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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.
Mark Twain 

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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 

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Never stop looking for areas that need improvement. This should include improving your improvement system!

We can help. How? Several ways…

  1. 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.
  2. 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. 
  3. 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.

TapRooTWorld

(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)

TapRooT® Around the World: Onsite Course in Makae, Brazil

October 21st, 2014 by

Thank you to Marco Flores-Verdugo from one of our recent onsite courses in Makae, Brazil for these great pictures.

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Join us for a Public Course near your or inquire about our Onsite Courses.

TapRooT® Around the World: Athens, Greece Onsite Course

October 20th, 2014 by

Thank you to Harry Thorburn for sending us these great pictures from the most recent Onsite Course in Athens, Greece.

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Visit our website for more information on our Onsite and Public Courses.

What does a bad day look like?

October 16th, 2014 by

Your day isn’t so bad after all…

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Monday Accident & Lessons Learned: Remove the Hazard – Snow & Ice Removal

October 13th, 2014 by

What do you have planned to keep walkways clear this winter?

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Monday Motivation: Make Things Happen!

October 13th, 2014 by

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See Andrew G. Rosen’s  “7 Ways to Get Motivated” at:

http://www.drewrosen.com/7-ways-i-get-motivated/

Friday Joke: Don’t We All Need One of These?

October 10th, 2014 by

This came to my e-mail account from an on-line retailer …

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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

Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.

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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.)

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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.

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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

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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. 

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 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.

What does a bad day look like?

October 9th, 2014 by

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…

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Root Cause Analysis Training in Poland: Krakow’s Local Attractions

October 9th, 2014 by

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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.

Food:

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.

Attractions:

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 Accidents

October 6th, 2014 by

OPG Safety Alert #260

PLANNING AND PREPARATION – KEY ELEMENTS FOR PREVENTION OF MPD WELL CONTROL INCIDENTS

Summary

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?

  1. 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.
  2. 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.
  3. It was incorrectly assumed that monitored volume gains were due only to mud transfer.
  4. 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.
  5. Operational focus was on choke manifold flushing whereas supervision should have maintained oversight of the broader situation including well monitoring.

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Corrective Actions and Recommendations

  1. 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).
  2. 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).
  3. Install a landing nipple above the down hole circulation sub-assembly to allow a sealing drop dart to be run if required.
  4. Always close-in, or line-up, in such a way that allows for monitoring of all the closed-in pressures at all times.
  5. “Walk the lines” prior to commencing (concurrent) operations involving pressure and flow.
  6. Develop procedures in advance for flushing of the Well Control system, especially for recognisable potential cases of concurrent operations.
  7. Develop clear procedures covering all aspects of unconventional operations, including reasonably expected scenarios, and ensure effective communication of these to all relevant staff.

Disclaimer

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.

What does a bad day look like?

October 2nd, 2014 by

Having a bad day? Look at these pictures and you might feel better by comparison …

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How Can We Help You? (More ways than you might think!)

October 1st, 2014 by

We can help you stop bad things from happening.

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Is your team trying to prevent fatalities?

Improve quality?

Improve your root cause analysis?

Investigate a difficult incident?

Solve equipment reliability issues?

Improve profitability?

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.

INVESTIGATION FACILITATION

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. 

BECOMING PROACTIVE

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.

ANALYZE TRENDS

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.

SOFTWARE IMPLEMENTATION

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.

Monday Accident & Lessons Learned: Hot Work on Tanks Containing Biological or Organic Material

September 29th, 2014 by

This week accident information is from the US Chemical Safety Board …

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CSB Chairperson Moure-Eraso Warns About Danger of Hot Work
on Tanks Containing Biological or Organic Material

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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.”

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 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.

END STATEMENT

More resources:

http://www.csb.gov/e-i-dupont-de-nemours-co-fatal-hotwork-explosion/

http://www.csb.gov/packaging-corporation-storage-tank-explosion/

http://www.csb.gov/seven-key-lessons-to-prevent-worker-deaths-during-hot-work-in-and-around-tanks/

http://www.csb.gov/motiva-enterprises-sulfuric-acid-tank-explosion/

http://www.csb.gov/partridge-raleigh-oilfield-explosion-and-fire/&?nbsp;

 

What does a bad day look like?

September 25th, 2014 by

If you are having a bad day, have a look at these pictures and it might not seem so bad by comparison…

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Root Cause Analysis Training in Tulsa: Local Attractions

September 25th, 2014 by

 

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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.

Food:

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!

Attractions:

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.

Monday Accident & Lesson Learned: Fatal accident at Barratt’s Lane No.2 footpath crossing, Attenborough, Nottingham, 26 October 2013

September 22nd, 2014 by

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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:

http://www.raib.gov.uk/cms_resources.cfm?file=/140821_R182014_Barratts_Lane.pdf

Best of The Root Cause Network™ Newsletter – Beat ‘Em or Lead ‘Em … A Tale of Two Plants

September 18th, 2014 by

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.

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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 matters 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:

  1. 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.
  2. 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.”
  3. 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.
  4. 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.
  5. 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:

  1. 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.
  2. 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.
  3. “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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.

DIFFERENCES

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.

What does a bad day look like?

September 18th, 2014 by

Having a bad day? look at these pictures and your day might not seem so bad…

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