Taproot

Ron Zanoni sent this link to more photos from the Summit …

https://plus.google.com/photos/103976822229396314740/albums/5737724752601518801?authkey=COrjoZWctL2mqgE

Practical Solutions Group instructor Michael Podgomy sent these photos of another class learning to apply TapRooT® to achieve even better performance.

Here is an accident report from the BSEE (Bureau of Safety & Environmental Enforcement of the US Department of the Interior):

http://bsee.gov/uploadedFiles/BSEE/Enforcement/Accidents_and_Incidents/Panel_Investigation_Reports/BSEE%202012-01.pdf
How many times have you seen similar accidents with unprotected holes on construction sites, oil platforms, or in other locations with work that makes “temporary” openings?

It would seem that anyone supervising work should know better.

Yet the report says that the company blamed the roustabout who fell to his death through the hole because he was, “…distracted by concern for a family issue at home.”

The report says:

“This same story that the accident was caused by a lack of concentration by a distracted Roustabout, was repeated in the initial report to BOEMRE, in interviews by Supervisor, Company Man, and by management of Alliance, and was written into the accident investigation report by Contractor and Operator. The only reason given in statements for this conclusion was that the Roustabout had spoken of it at breakfast and had tried to rearrange his shift to accommodate the family issue.”

OK TapRooT® Users, what do you think. Is “lack of concentration” a root cause? Did the company do a thorough investigation? Could they tell everyone to “be more careful” and resume work as usual? Was the BSEE right to question the adequacy of the contractor and the operator?

Read the report and let me know what you think.

Here are the last of the photos from the Summit that I previously didn’t get a chance to post …

I’ve finally finished reading all the critiques from the 2012 TapRooT® Summit and I thought I would share for of the ones that reflect the value and motivation that Summit participants experience …

Great place for networking and exchanging best practices, and a great range of session topics!

As a first time participant I’m taking tons of stuff home. Hope to be back for more next year!

We need to send more front-line leadership to this!

Excellent! There really was value for me in every session each day.

I met improvement professionals from all over the world!

What a diverse group of improvement professionals with great ideas to share.

People were really open and ready to share best practices.

Well done! The Summit is the the BEST conference I’ve attended!

Very motivational and valuable; I would like to have others from our plant attend next time; Great job SI!!

Very impressed!

If 2013 is half as good as 2012, I’ll be looking forward to it!

We need to reach out & involve local site management at this activity – I wish they could see the energy and value gained from the Summit. This is the best event I attend!

Comment on the Planning & Mentoring Session: All conferences should have this type of session.

Now that I’ve finalized the review of the 2012 Summit, we are starting on the planning of the 2013 Global TapRooT® Summit that will be held in Gatlinburg, TN, at the entrance The Great Smokey Mountains National Park. Plan on attending the pre-Summit Courses on March 18-19 and then the TapRooT® Summit on March 20-22.

We’ve had retired Captain George Burk (lone survivor of the crash above) speak at the TapRooT® Summit twice. He also provides us with interesting articles for the TapRooT® Friends and Experts e-Newsletter. Therefore I thought readers might be interested in a story about him meeting the pilots son 40 years later that appeared in the Novoto Patch (a local newspaper). See:

http://novato.patch.com/articles/a-story-of-healing-42-years-after-hamilton-crash

The UK Rail Accident Investigation Branch has published a report with several “learning points.”

Read the report at:

http://www.raib.gov.uk/cms_resources.cfm?file=/120329_R062012_White_House_Farm.pdf

Sanjay Gandhi, our TapRooT® instructor in Africa, sent these pictures from a recent 5-Day TapRooT® Root Cause Analysis Course in Cape Town.

First, the class photo …

Next, people participating in the “House-of-Cards” opening exercise …

Next, people drawing their first SanpCharT® …

Then, people practicing “Cognitive Interviewing” skills …

And finally, the presentations in the final exercise!

People went home with new skills to make them better investigators and that will help their company achieve better performance.

For more information on our TapRooT® Courses that are open to the public, see:

http://www.taproot.com/courses

Investigation into a train door incident at Jarrow station on the Tyne and Wear Metro, 12 April 2012

At about 09:55 hrs on 12 April 2012, a person tried to board a train on platform 2 while the doors were closing. The person put their arm between the closing leaves which trapped the arm while the person was still on the platform. Within the next few seconds the train started to move off. The person, whose arm remained trapped, moved with the train for a short distance before falling onto the platform, having released their arm.

Passengers on board the train, who saw the incident, activated the passenger emergency button and the train stopped while it was still partially in the platform. The person whose arm had been trapped left the station immediately after the incident; it is not known whether the incident resulted in any injuries.

Image of Jarrow station, Tyne and Wear Metro

The RAIB’s investigation will look at the operation of the door involved and why the train started to move with the door leaves obstructed by a passenger’s arm. This will include an examination of why the presence of an obstruction, that prevented the doors from closing, was not detected by the driver and the door control systems.

The investigation will also look at similar incidents on the Tyne and Wear Metro system and how the risk of such events is managed.

The RAIB’s investigation is independent of any investigations by the safety authority (the Office of Rail Regulation).

The RAIB will publish a bulletin or report, including any recommendations to improve safety, at the conclusion of its investigation. This will be available on the RAIB website.

How much time does it take to investigate an accident?

The US CSB has announced that they are continuing to investigate the Deepwater Horizon (Macondo Well) Accident and will release a preliminary report in July of 2012 and a final report in 2013.

Today is the two year anniversary of the blowout and explosion that killed 11 aboard the Deepwater Horizon. Of course the resulting oil spill continued for months.

An investigation that concludes more than two years after an accident seems too slow to me … but perhaps the results will be worth the wait?

From the information in the CSB press release, the CSB seems to believe that additional regulation – especially developing a safety case – would have prevented the accident. In their press release (see below), they said:

“Investigation findings to date indicate a need for companies and regulators to institute more rigorous accident prevention programs similar to those in use overseas.”

They also say:

“In December 2010, a CSB public hearing in Washington featured international regulators, companies, trade associations and union representatives discussing the “safety case” regulatory approach for offshore safety, a concept widely used in the North Sea and Australia and supported by a number of the participants.”

To me this seems strange. Transocean had a similar near-miss incident in the North Sea and there have been major spills in exploration covered by Australian regulations (those “overseas” regulations). But people in Washington seem to always believe that more regulation – rather than better management – will keep everyone safe.

I’ve never really believed that regulations are the answer to safe performance. The the press release, CSB says:

“Process safety regulations and standards utilized by oil companies in refineries and process plants in the continental U.S. have a stronger major accident prevention focus, CSB investigators have determined. Unlike the U.S. offshore regulatory system, the “onshore” process safety requirements are more rigorous and apply both to operators and key contractors.”

But refineries and plants covered by the process safety regulations continue to have deadly fires and explosions, showing that adherence to regulations is not enough to prevent accidents. (A subject of my talk at the 2012 TapRooT® Summit – CLICK HERE to watch all three parts of the talk.)

The press release also contains some comments that I believe are right on target from my review of previous Deepwater Horizon accident reports.

First, they say they are looking into the human factors of well control. The release says:

“The issue of human factors in offshore drilling and well completion is particularly important as offshore well control programs currently rely to a large extent on manual control, procedures and human intervention to control hazards…“.

When reviewing the displays available to the operators monitoring the control of the well, I thought – poor human engineering! (See pictures below of what the operators were suppose to catch.)

I haven’t seen pictures of the types of actual instrumentation that was used (all now at the bottom of the sea), but I imagine similar equipment is used throughout the industry. If the drawings of what was supposed to be observed look like real time detection would be error prone, I can only guess that the actual equipment is as hard or harder to use.

The next “human factors” issue that the CSB is investigating is fatigue. The press release says:

“…we are investigating whether fatigue was a factor in this accident. Transocean’s rig workers, originally working 14-day shifts, had been required to go to 21-day shifts on board. CSB is examining whether this decision was assessed for its impact on safe operations.”

Of course, fatigue could be an issue in a 14 day or a 21 day shift. I hope they are using a systematic process like FACTS to evaluate the possibility of fatigue being a potential cause of operator errors.

Here is the entire CSB press release …

CSB Investigation into Macondo Blowout and Explosion in Gulf of Mexico Continues; Two Public Hearings and Interim Reports Scheduled for this Year

April 19, 2012

Washington, DC, April 19, 2012 — The U.S. Chemical Safety Board (CSB) announced today that its investigation into the April 20, 2010 Macondo well blowout, explosion and fire in the Gulf of Mexico is progressing, with two interim reports with findings and recommendations to be released this year. A final report is expected to be completed in early 2013.

Investigation findings to date indicate a need for companies and regulators to institute more rigorous accident prevention programs similar to those in use overseas. The CSB announcement was made approaching the second anniversary of the tragedy, which took eleven lives and caused the worst environmental disaster in U.S. history,

Process safety regulations and standards utilized by oil companies in refineries and process plants in the continental U.S. have a stronger major accident prevention focus, CSB investigators have determined. Unlike the U.S. offshore regulatory system, the “onshore” process safety requirements are more rigorous and apply both to operators and key contractors.

To date, the CSB has conducted numerous interviews, examined tens of thousands of documents from over 15 companies and parties, gathered data from two phases of blowout preventer (BOP) testing, and conducted a public hearing on international regulatory approaches.  Recommendations targeting specific reforms are contemplated for release as early as August of this year.

CSB Chairman Rafael Moure-Eraso said, “Our final report on the tragic accident that occurred two years ago, will, I believe, represent an opportunity to make fundamental safety improvements to offshore oil and gas exploration to prevent future catastrophic accidents.”

Dr. Moure-Eraso continued, “The CSB is not a regulatory agency; our job is to convey information and recommendations to improve safety in the oil and chemical industries and protect workers and the environment. In our view, while previous investigations of the Macondo blowout have produced useful information and recommendations, important opportunities for change have not been fully addressed.  And these are critically important for major accident prevention.” 

Don Holmstrom, manager of the CSB Western Regional Office in Denver, whose team is conducting the investigation, announced a timeline calling for the final report release in early 2013, with the first of several public meetings to be held by the CSB likely in July 2012 in Houston, addressing use of leading and lagging indicators by companies and regulators to improve safety performance.

The CSB anticipates releasing preliminary findings and safety recommendations at the meeting, and to hear experts testify on the need for the offshore drilling industry to utilize safety performance indicators like hydrocarbon leaks and maintenance of safety critical equipment to drive safety improvements and to prevent major accidents.

Dr. Moure-Eraso said the CSB’s investigation is taking a broad look at causal issues of the Macondo blowout and the subsequent massive release of flammable hydrocarbons which resulted in an explosion.  “These issues include the manner in which the industry and the regulating agencies learn or did not learn from previous incidents. They also include a lack of human factors guidance, and organizational issues that impaired effective engineering decisions,” he said.

The issue of human factors in offshore drilling and well completion is particularly important as offshore well control programs currently rely to a large extent on manual control, procedures and human intervention to control hazards, said CSB Investigator Cheryl MacKenzie.  She observed “There are no human factors standards or regulations in U.S. offshore drilling that focus on major accident prevention. As an example, we are investigating whether fatigue was a factor in this accident. Transocean’s rig workers, originally working 14-day shifts, had been required to go to 21-day shifts on board. CSB is examining whether this decision was assessed for its impact on safe operations.” 

The CSB investigation team participated in the examination of the blowout preventer (BOP) in Louisiana last year.  As has been reported, the BOP – a massive device designed to shear off the well pipe and stop the flow of volatile hydrocarbons — failed.  The CSB is currently evaluating BOP deficiencies as reflecting larger needed improvements in offshore risk management.  These include lack of safety barrier reliability/ requirements, inadequate hazard analysis requirements for evaluating BOP equipment design, and insufficient management of change requirements for controlling hazards.

The CSB is conducting additional computer modeling of the BOP and assessing the capability of the BOP to close and which functions specifically led to its failure. The agency is also exploring new issues and “near miss” deficiencies that did or could have compromised the ability of the BOP to function properly, including the failure of the annular preventer to seal the well, the impact of drill pipe size, and the performance of the BOP hydraulic accumulators.

Finally, the CSB is carefully examining the physical causes of the drill pipe buckling that other investigations previously concluded may have prevented the BOP’s blind shear rams from functioning correctly.  The CSB is evaluating different mechanisms that could have led to the drill pipe buckling.

CSB Chairman Moure-Eraso said the CSB is examining whether further changes to offshore safety regulations and industry standards are needed.  “While important regulatory changes have occurred, we are examining whether these changes that have been made are sufficient for preventing major accidents.  In December 2010, a CSB public hearing in Washington featured international regulators, companies, trade associations and union representatives discussing the “safety case” regulatory approach for offshore safety, a concept widely used in the North Sea and Australia and supported by a number of the participants.

In addition, Chairman Moure-Eraso noted that the CSB investigation is also examining the implementation of effective corporate governance and sustainability standards to address safety and environmental risk, organizational issues that impaired effective engineering decisions, and the consideration of past safety performance in lease allocation decisions and contractor selection.

The CSB investigation into the accident has been delayed on occasion as the Board sought to work out mutually acceptable access and investigation agreements with other investigative groups that had different missions.  The Department of Justice has filed an action against Transocean in federal court and has requested that the Court order Transocean to comply with the CSB subpoenas. Following a hearing last week, the CSB anticipates a decision from the Court in the near future.

Chairman Moure-Eraso said, “The CSB investigation of this tragedy will, we believe, offer unique findings and recommendations that, if adopted, would provide significantly safer operations during vital offshore drilling and production activities.

The CSB is an independent federal agency charged with investigating chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

For more information, contact Communications Manager Hillary Cohen at 202.446.8094 or Sandy Gilmour at 202.251.5496.

CSB Report on Fatal Welding Explosion at DuPont Buffalo Facility Finds Company Overlooked Hazards; Recommendation Calls on Company to Monitor Flammable Vapor Inside Storage Tanks During Hot Work

April 19, 2012

Investigation Details:
E. I. DuPont De Nemours Co. Fatal Hotwork Explosion

Buffalo, NY, April 19, 2012 — In a draft report released today at a news conference in Buffalo, the U.S. Chemical Safety Board (CSB) determined that an explosion that killed one and injured another contract welder on November 9, 2010, was caused by the ignition of flammable vinyl fluoride inside a large process tank, a hazard which had been overlooked by DuPont engineers.

The CSB found that that sparks or heat from the welding, which took place on top of the tank, most likely ignited the vapor. The CSB said a primary cause of the blast was the failure of the company to require that the interior of storage tanks – on which hot work is to be performed ­– be monitored for flammable vapor. A proposed recommendation urges DuPont to require monitoring the inside of storage before performing any hot work, which is defined as welding, cutting, grinding, or other spark-producing activities. 

The Board will vote on the report and its recommendations at a CSB public meeting tonight at 6 pm at the Embassy Suites located at 200 Delaware Avenue in Buffalo. A CSB 11-minute safety video, entitled “Hot Work: Hidden Hazards,” utilizing computer animation to depict the sequence of events leading to the tragedy, will be released at www.CSB.gov, subsequent to the board vote on the report.

Noting the CSB issued a safety bulletin on the dangers of hot work in March 2010, CSB Chairperson Rafael Moure-Eraso said, “I find it tragic that we continue to see lives lost from hot work accidents, which occur all too frequently despite long-known procedures that can prevent them. Facility managers have an obligation to assure the absence of a flammable atmosphere in areas where hot work is to take place. Explosion hazards can be eliminated by testing inside tanks as well as in the areas around them.”

The accident occurred at the DuPont chemical plant in Tonawanda, a suburb of Buffalo, which employs approximately 600 workers.  The facility produces polymers and surface materials for countertops, sold under the trade names Tedlar® and Corian®. The process for making Tedlar involves transferring polyvinyl fluoride (PVF) slurry from a reactor through a flash tank and then into storage tanks. The tanks were also inter-connected by an overflow line. The CSB found the company erroneously had determined that any vinyl fluoride vapor that might enter the tanks would remain below flammable limits. 

Days before the incident the process had been shut down for tank maintenance due to corrosion on tank agitator supports. The fill lines were locked out for safety. Tanks 2 and 3 were repaired and the process restarted, but work on tank 1 was delayed because the necessary parts were not available. Finally, a contract welder and foreman were engaged to repair the agitator support atop tank 1. Although tank 1 remained locked out from the main process, the overflow line remained open which connected tank 1 to tanks 2 and 3. The CSB determined that flammable vinyl fluoride flowed through the overflow line into tank 1 and accumulated to explosive concentrations. Investigators found that while a facility hot work permit was issued for the task, the DuPont personnel who signed it were not sufficiently knowledgeable about the Tedlar chemical process.

Although DuPont personnel monitored the atmosphere above the tank prior to authorizing hot work, no monitoring was done inside the tank to see if any flammable vapor existed there. The CSB investigation found the hot work ignited the vapor as a result of the increased temperature of the metal tank, sparks falling into the tank, or vapor wafting from the tank into the hot work area.

The explosion blew most of the top off the tank, leaving it and the agitator assembly hanging over the edge. The welder died instantly from blunt force trauma, and the foreman received first-degree burns and minor injuries.

CSB Team Lead Johnnie Banks said, “Our investigation found that DuPont’s process hazard analysis incorrectly assumed that vinyl fluoride in the Tedlar process could not reach flammable levels in the slurry tanks. And, critically, DuPont personnel did not properly isolate and lock out tank 1 from tanks 2 and 3 prior to authorizing the hot work. The flammable vapor was able to pass through the overflow line into the tank the welder was working on, unknown to him or to the operators who signed off the hot work permit.”

The CSB also determined that DuPont should have included the three storage tanks as part of the Tedlar process covered by OSHA Process Safety Management rules. Yet on the day of the accident, a compressor failure led to higher concentrations of vinyl fluoride vapor in the polyvinyl fluoride slurry. Furthermore, a U-shaped seal loop on the flash tank overflow line had a “fishmouth” split in the pipe that could emit vinyl fluoride vapor. Engineers concluded further operation with the broken seal loop presented no hazards, but the CSB determined the pipe split provided a potential pathway for flammable VF gas to enter the tanks.

The Board will consider and vote on several proposed recommendations to DuPont. These include enforcing safety procedures for hot work permits and ensuring explosion hazards associated with hot work activity are recognized and mitigated; revising corporate procedures to require all process piping and vent piping be positively isolated before authorizing any hot work, and to require air monitoring for flammable vapor inside tanks and other containers where hot work is to be performed.

The CSB is an independent federal agency charged with investigating serious chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

For more information, contact CSB Communications Manager Hillary Cohen, cell 202-441-2980 or Sandy Gilmour, cell 202-251.5496

A chemical factory explosion in Germany has the auto industry on edge. The Wall Street Journal reported that a critical component in auto brake and fuel lines, Nylon 12, was only produced by a single plant … the one that blew up. See the story here:

Nylon-12 Haunts Car Makers

In this age of “Just-In-Time” inventory control, an unexpected production outage caused by a serious accident can not only be a serious event to the company involved, but also to the companies they supply.

This, the cost of this accident could be devastating to the auto industry and even the global economy.

Add this accident to the list of reasons why your company needs advanced root cause analysis (TapRooT®) both for reactive and proactive improvement of performance. Companies just can’t afford fires, explosions, and unexpected outages.

Here an article that discusses the details of a settlement of private claims for damage done by the spill:

Judge asked to sign off on $7.8 billion BP oil spill settlement

Count those dollars as 7.8 million reasons to be PROACTIVE in preventing serious accidents!