Category: Pictures

What does a bad day look like?

November 20th, 2014 by

See, your day isn’t so bad…

Screen Shot 2014 09 04 at 12 24 59 PM

TapRooT® Around the World: Course Photos from Birmingham, England

November 19th, 2014 by

Thanks to Harry Thorburn for these pictures of such a great course in Birmingham, England.

unnamed-2

unnamed

unnamed-1

For more information regarding our courses around the world, click here.

TapRooT® Around the World: Canada

November 17th, 2014 by

SJ

St. John’s, Newfoundland

Upcoming TapRooT® Public Courses:

Calgary 2-Day January 14, 2015

Calgary 3-Day January 14, 2015

St. John’s 2-Day January 19, 2015

Edmonton 5-Day January 19, 2015

For more information regarding our public courses around the world, click here.

Monday Accident & Lessons Learned: OPG Safety Alert #261 – WELL CONTROL COMPLICATIONS ON FIRST WELL FOR NEW DRILLSHIP

November 17th, 2014 by

WELL CONTROL COMPLICATIONS ON FIRST WELL FOR NEW DRILLSHIP

This incident occurred whilst drilling the first well following new rig commissioning and start-up. While drilling into suspected sand, the rig experienced a kick. The well was shut in with 180 psi Shut In Drill Pipe Pressure SIDPP), 14 BBLS gained, 270 psi Shut In Casing Pressure (SICP), 12.3 PPG MW (surface) in the hole. Several attempts were made to circulate; pipe was stuck and packed off. A riser mud cap of 13.4 PPG was installed and the well monitored through the choke line (static). The well was opened and monitored to be static. The stuck pipe was freed, circulation re-established and the well was again shut it. The Driller’s Method was then used to displace the influx from the well.

During the first circulation, a high gas alarm, from the shaker exhaust sensor, initiated a rig muster. The well was shut in and monitored. The shaker gas detectors and ventilation were checked and found operable. As the well kill was re-started, mud vented from the Mud Gas Separator (MGS) siphon breaker line, and all the shaker gas sensors alarmed. The rig was called to muster a second time. The well was shut in (indications were that gas had blown through the degasser liquid seal) and monitored. The liquid seal was lost and the well was immediately shut in. The liquid seal was flushed again and well kill started up but again lost the liquid seal and the well was shut in. Further investigation of the MGS identified a blind skillet plate in the spool piece between the MGS and main gas vent line which blocked the normal path for gas flow and misdirected the gas to the shaker room. The skillet plate had been installed during construction to prevent rainwater from entering the MGS.

The blind skillet plate was removed and the well kill re-started without further incident. No injuries were reported.

NewImageFigure 1: Blind flange located on top of vessel near deck ceiling. Not easily detected.

NewImage

Figure 2Removed blind flange from the 12” vent line of the mud gas separator.

What Went Wrong?

  1. Uncertainty about the pore pressure below base of salt resulted in the mud weight being too low to prevent an influx.
  2. Malfunction of the mudlogger gas sampling system during drilling operations led to unrepresentative gas unit data.
  3. A 12-in blind skillet plate installed in the MGS main gas vent line during rig construction was not removed before operations began.
  4. Personnel on the rig did not fully understand the operation of the MGS to prevent subsequent gas releases in the shaker room.

Corrective Actions and Recommendations

  1. Include in rig contractors’ procedures for rig acceptance, flange management procedures to ensure that temporary blanking flanges or skillets, installed during construction or commissioning, are removed prior to hand-over to operations. Verification of rig contractor’s procedures to be in operator’s practices.
  2. Develop detailed instructions and procedures for preventative maintenance and calibration of the surface mud logging gas detection equipment that includes daily visual inspection of the gas trap impeller. Documentation for inspection and maintenance is to be maintained on the rig.
  3. Include critical items provided by Third Parties in the Safety Critical Equipment list and its associated controls.
  4. Implement awareness training for rig crews on the MGS Operating Procedure, LEL readings, mudlog gas detection, and significance and consequence of gas releases.

Source Contact

Safety alert number: 261 OGP
Safety Alerts http://info.ogp.org.uk/safety

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?

November 13th, 2014 by

Is your day really that bad?

Screen Shot 2014 09 04 at 12 22 35 PM

Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)

November 12th, 2014 by

Gatlinburg Sunrise 1

At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:

  1. Management revises the facts. (Or management says “You can’t say that.”)
  2. Assumptions become facts.
  3. Untrained team of investigators. (We assign good people/engineers to find causes.)
  4. Started investigation too late.
  5. Stopped investigation too soon.
  6. No systematic investigation process.
  7. Management can’t be the root cause.
  8. Supervisor performs investigation in their spare time.
  9. Fit the facts to the scenario. (Management tells the investigation team what to find.)
  10. Hidden agendas.

What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.

What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.

TapRooT® Around the World: Course Photos from Copenhagen, Denmark

November 12th, 2014 by

Thanks to one of our Instructors, Ken Reed, for providing these great pictures. Always hard at work at TapRooT® courses.

IMG_2117-1

IMG_2114

IMG_2116

IMG_2115

IMG_2131

Want more information regarding TapRooT® Public Courses around the world? Click here.

How Far Away is Death?

November 11th, 2014 by

Sent to me by a TapRooT® User…

It all took about 2 minutes. This is a case of 1 photographer photographing a 2nd photographer. The following photos were taken by Hans van de Vorst from the Netherlands at the Grand Canyon, Arizona. The descriptions are his own. The identity of the photographer in the photos is unknown.

ATT00085

I was simply stunned seeing this guy standing on this solitary rock at The Grand Canyon. The canyon’s depth is 900 meters (3000ft) here. The rock on the right is next to the canyon and is safe. Watching this guy wearing flip-flop sandals, with camera and tripod.

I asked myself 3 questions:

  1. How did he get onto that rock?
  2. Why not take that sunset picture from the rock to the right, – which is perfectly safe?
  3. How will he get back?

After the sun set behind the canyon’s horizon, he packed his things (having only one free hand) and prepared himself for the jump. This all took about 2 minutes.

At that point he had the full attention of the crowd of tourists.

ATT00088

He’s now at the point of no return. He jumped in his flip-flops.

ATT00091

Now you can see that the safe rock is higher so he had to land lower, which was quite steep, and tried to use his one free hand to grab the rock.

ATT00094

Look carefully at the photographer. He has a camera, a tripod and also a plastic bag, all on his shoulderbor in his left hand. Only his right hand is available to grab the rock. And the weight of his stuff is a problem. He lands low. Both his right hand and right foot are slipping.

At that very moment, I take this shot. He then pushes his body against the rock, waits for a few seconds,

Throws his stuff up on the flat rock, climbs up and walks away.

Presumably to a bathroom to change his shorts.

I know I had to change mine and I was just watching!

Hans van de Vorst

Monday Accident & Lessons Learned: UK RAIB Report – Freight train derailment near Gloucester

November 10th, 2014 by

Screen Shot 2014 10 10 at 10 02 46 AM

Here’s the summary of the report:

At about 20:15 hrs on 15 October 2013, a freight train operated by Direct Rail Services, which was carrying containers, derailed about 4 miles (6.4 km) south west of Gloucester station on the railway line from Newport via Lydney. It was travelling at 69 mph (111 km/h) when the rear wheelset of the last wagon in the train derailed on track with regularly spaced dips in both rails, a phenomenon known as cyclic top. The train continued to Gloucester station where it was stopped by the signaller, who had become aware of a possible problem with the train through damage to the signalling system. By the time the train stopped, the rear wagon was severely damaged, the empty container it was carrying had fallen off, and there was damage to four miles of track, signalling cables, four level crossings and two bridges.

Screen Shot 2014 10 10 at 9 59 07 AM

The immediate cause of the accident was a cyclic top track defect which caused a wagon that was susceptible to this type of track defect to derail. The dips in the track had formed due to water flowing underneath the track and although the local Network Rail track maintenance team had identified the cyclic top track defect, the repairs it carried out were ineffective. The severity of the dips required immediate action by Network Rail, including the imposition of a speed restriction for the trains passing over it, but no such restriction had been put in place. Speed restrictions had repeatedly been imposed since December 2011 but were removed each time repair work was completed; on each occasion, such work subsequently proved to be ineffective.

The type of wagon that derailed was found to be susceptible to wheel unloading when responding to these dips in the track, especially when loaded with the type of empty container it was carrying. This susceptibility was not identified when the wagon was tested or approved for use on Network Rail’s infrastructure.

The RAIB also observes: the local Network Rail track maintenance team had a shortfall in its manpower resources; and design guidance for the distance between the wheelsets on two-axle wagons could also be applied to the distance between the centres of the bogies on bogie wagons.

The RAIB has made seven recommendations. Four are directed to Network Rail and cover reviewing the drainage in the area where the train derailed, revising processes for managing emergency speed restrictions for cyclic top track defects, providing track maintenance staff with a way of measuring cyclic top after completing repairs, and investigating how cyclic top on steel sleeper track can be effectively repaired. Two are directed to RSSB and cover reviewing how a vehicle’s response to cyclic top is assessed and amending guidance on the design of freight wagons. One is directed to Direct Rail Services and covers mitigating the susceptibility of this type of wagon to cyclic top.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/141009_R202014_Gloucester.pdf

What does a bad day look like?

November 6th, 2014 by

Is your day really that bad?

Screen Shot 2014 09 04 at 12 19 53 PM

TapRooT® Around the World: Monterrey, Mexico

November 6th, 2014 by

Monterrey_skyline

Are you planning to join TapRooT® in Monterrey, Mexico for a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (Spanish) on December 1-5?

Monterrey is one of the largest cities in Mexico, and is home to many important industries and businesses such as CEMEX and Mercedez-Benz Mexico. This amazing city is also surrounded by the Sierra Madre Oriental mountains which are filled with public trails and canyons for anyone to admire the natural beauty that Monterrey has to offer. We still have a few spots left, you won’t want to miss this opportunity to travel and gain knowledge to benefit your company.

Food:

El Gaucho: This warm, friendly restaurant offers classic Mexican cuisine that can cater to all pallets.

Sante Fe: In the mood for a little fine dining? Sante Fe offers all the best gourmet dishes, wines and desserts.

Bread Panaderos: Everyone loves a fresh bread bakery that also serves freshly ground coffee. Order a snack or a whole loaf to take home with you.

Attractions:

Horno 3: A museum of technological history, innovations and interactive exhibits must be interesting. Check out this museo del acero to find out for yourself.

Parque Fundidora: This large municipal park is always hosting activities for all ages and is a great place for site seeing the beautiful city.

Planetario Alfa: Museums and an IMAX Theater all in one. Take a tour through Mexican history or watch the latest educational movie in the state of the art IMAX Theater.

To register, click here.

For more information regarding our other courses, click here.

For information on the 2015 Global TapRooT® Summit, click here.

TapRooT® Around the World: Course Photos from Reykjavik, Iceland

November 5th, 2014 by

Working hard at a recent TapRooT® course in Reykjavik, Iceland.

IMG_2101

IMG_2102

For more information on our Public Courses all over the world, click here.

San Antonio 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

November 4th, 2014 by

Students presenting their final case studies on day 5 of the course. Students always learn something new in the case that they brought to be reviewed.

Image Image 1 Image 3Image 2

For more information on our public courses click here or to book your own onsite course click here.

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by

plane-crash-julie-click-kester1

Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

Washington Post reports: “Commercial spaceship suffers catastrophic failure, at least 1 dead”

October 31st, 2014 by

Screen Shot 2014 10 31 at 4 44 17 PM

The suborbital commercial flights give passengers a small taste of space travel by piloting international flights 62 miles above the Earth’s atmosphere for about $250,000 per seat.

So far, more than 700 prospective passengers have paid for tickets.

See:

http://www.washingtontimes.com/news/2014/oct/31/commercial-spaceship-suffers-catastrophic-failure-/

Friday Joke: Oh Nooo….

October 31st, 2014 by

Here I thought coffee was supposed to help with the Mondays.

Oh, dear...

TapRooT® Around the World: Course Photos from onsite course in Macae, Brazil

October 31st, 2014 by

 

 

 

Thank you to Boris Risnic for the wonderful pictures of two of our onsite TapRooT® course held in Macae, Brazil.

2014-10-23 10.44.56

2014-10-27 08.53.08

2014-10-24 15.03.47

2014-10-24 14.39.41

2014-10-28 09.58.02

2014-10-28 15.11.14

2014-10-23 10.45.02

2014-10-24 15.24.59

2014-10-23 10.45.10

For more information on our onsite courses and how to register for them, click here.

Forbes Reports: “… Nuclear Navy has the best safety record of any industry.”

October 30th, 2014 by

NewImage

Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:

America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.

And no one ever discusses it.

Well, not exactly. We’ve been discussing it for years! And the philosophy that keeps the Nuclear Navy safe is outlined in our Fatality Prevention Course and at the TapRooT® Summit.

See the article at:

http://www.forbes.com/sites/jamesconca/2014/10/28/americas-navy-the-unsung-heroes-of-nuclear-energy/

The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos.

Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?

Stupid indeed.

Did Retiring Warthogs to “Save Money” Lead to The Recent Friendly Fire Accident In Afganistan?

October 30th, 2014 by

NewImage

And interesting article in the Washing Post suggests that using a B-1B for night time close air support and insufficient training led to the death of 7 Americans and 3 allies in a friendly fire accident.

See the story at THIS LINK and see what you think.

What does a bad day look like?

October 30th, 2014 by

When you are having a bad day, sometimes others misfortune can make it seem not so bad by comparison…

NewImage

TapRooT® Around the World: Onsite Course in Argentina

October 28th, 2014 by

Thanks to Piedad Colmenares for sending us these great pictures from some recent onsite courses at ENAP and SIPETROL in Argentina.

Foto ENAP - Sipetrol Argentina Comodoro Rivadavia - 1 Foto ENAP - Sipetrol Argentina Rio Gallegos - 3 unnamed Foto ENAP - Sipetrol  Argentina Comodoro Rivadavia -2 Foto ENAP - Sipetrol Argentina Rio Gallegos - 2

Want more information regarding onsite courses or public courses? Click Here.

How Far Away Is Death?

October 28th, 2014 by

Who would think this was safe?

Who would think this was safe?

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
Information Technology
Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
Equifactor®
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
Technical Support

Success Stories

Our challenge was to further improve the medication administration process at our facility by proactively…

Jackson County Memorial Hospital

In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages…

Bell South
Contact Us