Mark Paradies, President of System Improvements, Inc./TapRooT®, presents a view of lessons *not* learned according previous reports related to Deepwater Horizon & Texas City. In this 2013 Global TapRooT® Summit presentation he critiques the failure to learn and prevent accident recurrence, and offers suggestions to improve investigations.
View four-part video of this presentation:
Watch two children explain their morning routine using a process flow chart and a control chart.
If you do not have a knowledgeable kindergartner hanging around to help you, I would recommend attending the following this April during our TapRooT® Summit Week:
Advanced Trending Techniques
TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training http://www.taproot.com/taproot-summit/pre-summit-courses#TapRooTSixSigma
Process Quality and Corrective Action Programs
There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.
How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.
Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.
Here are the links:
Mark’s General Session Talk About Fatality Prevention from the 2013 Summit
I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.
For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.
I promised people at the 2013 Global TapRooT® Summit that I would post links to last year’s talk about Admiral Rickover and process safety and a link to his testimony to Congress about nuclear safety and the Nuclear Navy. Here they are…
And here are the slides from the Nuclear Navy and Process Safety talk mentioned above…
Mark Paradies, President of System Improvements and co-creator of the TapRooT® System, will be speaking at the IOSH Conference in Spotlight Theatre 2 on Tuesday, February 26, and Wednesday, February 27.
His topics are:
Tuesday: 13:20 – 13:50 – Spotlight Theatre 2
BP Deepwater Horizon & BP Texas City Accidents: Two Lessons That You May NOT Have Learned
Much has been published about the BP Deepwater Horizon and Texas City Refinery accidents. But there are still some important lessons learned that people may be overlooking. Mark Paradies, root cause analysis expert, will share insights into two lessons learned that have not received much attention yet are important to safety improvement.
Wednesday: 11:20-11:50 – Spotlight Theatre 2
Fixing The Safety Pyramid & Stopping Major Accidents
Several articles have been published criticizing Heinrich’s Safety Pyramid and blaming it’s weaknesses for the gap between the decline in safety statistics and the continuing level rate of serious injuries, including fatalities. Mark Paradies will share insight into the Safety Pyramid and explain why fatality prevention needs a revised model and new approaches to achieve across the board safety performance improvements.
Hope to see you there!
Mark Paradies and Linda Unger attended the Budapest Conference on EHS in Emerging Markets.
Mark gave a talk: Solving Root Cause Analysis Problems by Using Advanced Root Cause Analysis. Here’s some pictures of Mark Speaking …
Linda talked to prospective TapRooT® Root Cause Analysis System users and explained how they could learn about and implement TapRooT® at their sites across Europe.
This week is our third and final installment of Mark Paradies’ Summit talk on process safety in the Nuclear Navy.
In this 35-minute clip, you’ll learn how Admiral Rickover’s process safety standards compare to OSHA and CCPS standards, and what that means for your safety program.
Note: We are trying a new video hosting service. Please let us know in the comments if you have trouble viewing this.
Next week, we’ll begin our 13-week series sharing best practices from users like you at our 2012 Global TapRooT® Summit.
You won’t want to miss these innovative tips!
Last week, we shared Part 1 of Mark Paradies’ Summit talk on Process Safety.
He shared some of his experience in the Nuclear Navy and discussed the fact that large accidents like Deepwater Horizon could be prevented by following important process safety regulations.
This week, in Part 2, Mark discusses Admiral Rickover’s process safety principles and why they matter to your process safety improvement.
Come back next week for the third and final part of this series!
Update: Click here for Part 3.
This week’s Root Cause Analysis Tip comes straight from our 2012 Global TapRooT® Summit.
If you missed Mark Paradies’ session on “What Does Management Need to Know About Improving Process Safety?” don’t worry. We will be sharing it on the blog over the next three weeks.
Today is Part 1.
Mark began by showing this comedy clip on Deepwater Horizon:
(If you can’t see YouTube videos at work, click here.)
And continued on with his discussion on Process Safety:
(Having trouble seeing the videos? Refresh your browser page.)
Come back next Wednesday for Part 2 of his Process Safety Talk, in which he discusses Admiral Rickover’s “Big Three” nuclear navy safety regulations and more from his congressional testimony after the accident at Three Mile Island.
Update: Parts 2 and 3 have been posted!
Alan Smith (one of our UK Instructors) Presents at the IOSH Conference: “How a Fatal Accident Could Have Been Prevented Proactively By Use of TapRooT®”March 7th, 2012 by Mark Paradies
What Management Needs to Know About Process Safety Improvement (or Why We Continue To Have Process Safety Accidents)May 16th, 2011 by Mark Paradies
I’m giving this talk in Bruges, Belgium for Total today and posted a PDF of the talk here so people who attended could get copies of the slides.
Click on the object below to download it…
As usual, the slides don’t tell the whole story. So if you would rather hear this talk, plan to attend the TapRooT® Summit on February 29 – March 2, 2012, in Las Vegas.
Success Story Contest: Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being InvestigatedFebruary 21st, 2011 by Barb Phillips
There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.
Entry #2: Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated
Submitted by: James Watson, Regional Specialist, System Safety Branch
TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors to cause a future accident.
These factors that the thorough analysis of TapRooT® helped identify are included in the presentation to management at the end of the talk (after the root cause analysis and corrective actions have been reviewed). This review includes explaining and discussing each of these potentially adverse factors with management. At a minimum, management is aware of these potentially adverse factors and the review often leads to discussion of additional corrective actions to address these issues.
Accidents that might have happened are avoided by implementing corrective actions for problems identified during a root cause analysis that didn’t cause that accident but could have cause additional accident and were corrected by proactive corrective actions.
Often people have the right ideas, the right plans and a need to get it done. Problem is that it is not always you who can drive the change. During the Summit we held a session that generated discussion on Stakeholders and Influence Centers.
Check out the multiple active group discussions during this workshop. Click on the Image to play the Video.
For the link to the slides that generated these active discussions and a link to more formal analysis go here: http://www.taproot.com/content/archives/17099
The people below in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training held in Philadelphia got to talk about this one.
I have received several requests from our San Antonio Summit attendees for a copy of our ‘What’s New In The TapRooT® Software?” breakout session. So without further ado, here it is…Click Here
I just got off the phone with Jeff Skiles who was the co-pilot of the US Airways flight that made an emergency landing in the Hudson River. It was a flight that could have had a tragic end but instead, everyone made it off the plane. After the conversation, I know we are going to have another great Keynote Speaker at the Summit.
Jeff said that he tells his story but provides some of the behind the scenes information that most people don’t know about. Information that helped them be successful that day but also might help you at your facility. The lessons aren’t just about aviation. They can be applied in any industry where things can go wrong and consequences can be severe.
So make sure that when you plan your trip, you plan to stay until the end of the Summit to hear Jeff’s talk. He’ll be speaking from 10:35-11:55 (followed by the TapRooT® Summit Charity Golf Tournament).
For the complete Summit schedule, see:
Mark’s Talk About the Heinrich Pyramid (Safety Pyramid) at the European Safety Committee of the Conference BoardJune 1st, 2010 by Mark Paradies
That’s me and the interested participants at the Conference Board…
Below is a copy of a PDF of the PowerPoint that I used.
Little is known (or at least has been released) about the actual failure of the Blowout Preventer on the Deepwater Horizon. However, a technical paper (2003) has surfaced that may be a “smoking gun” if it is found that maintenance was deferred on the BOP to reduce costs of drilling.
Here’s a link to the paper (Earl Shanks, Transocean, presented at the Offshore Technology Conference, 2003):
Here’s one of the “smoking gun” quotes:
“Because of the pressure on getting the equipment back to work, root cause analysis of the failure is generally not performed.”
Ah … a failure to perform root cause analysis to save time (and big bucks) during drilling.
“In general, operating reliability (of the BOP) is maintained on rigs mostly through regular maintenance intervals rather than specifying a reliability of a system or a component to minimize maintenance.”
The article also said:
“… this is a very expensive approach, and it is also an opportunity to introduce human error into the system.”
Most of the paper is about ways to improve the design and reliability of Blowout Preventers. But the vultures are circling. And the smoking gun quotes above will mean trouble if it is found that any maintenance was skipped or if the BOP had a poor reliability record.
If maintenance was skipped and/or if the BOP had a poor reliability record, you will hear the cry that BP is once again trading lives (as at the BP Texas City explosion) and the environment (as at the corrosion related oil leaks in their pipeline at Prudhoe Bay). Actually, many don’t need evidence. They will start saying it already!
This is a link to an April 26 chat session with OSHA. Interesting answers.
Here is just one question and answer:
[Comment From Greg Hellman, BNAGreg Hellman, BNA: ]
OSHA has placed an injury and illness prevention program rule on its agenda for the first time. Could such a rule address musculoskeletal disorders in some way?
Monday April 26, 2010 1:27 Greg Hellman, BNA
The i2p2 standard is not a substitute for other OSHA standards. It provides a mechanism to achieve the culture change needed in this country to effectively address workplace safety and health issues. It will be the employer’s responsibility to identify all hazards in their workplace, which may include ergonomics, falls, amputations, electrocutions, work-related respiratory disease (such as occupational asthma), etc. The i2p2 standard simply provides a mechanism for employers to identify hazards; however, the control of those hazards will be required by existing OSHA standards and the general duty clause, as is currently the case.
Quality Progress Magazine published a new article written by System Improvements’ President, Mark Paradies which can be read on the Quality Progress website: http://www.asq.org/quality-progress/2010/04/quality-tools/under-scrutiny.html
You don’t have to be a member to access the article — free registration allows you access to ASQ’s “open-access” articles and case studies.
You can also find this article on page 32 of the April edition of Quality Progress magazine.
• Cause and effect analysis has inherent limitations that may result in root cause analysis misconceptions and hinder problem-solving efforts.
• Problem solvers need help analyzing human performance issues.
• A new definition of root cause could help people realize a systematic process beyond cause and effect is needed for root cause analysis.
“Lessons from TN OSHA Fatality Investigations” was a best practice session presented by Steve Hawkins at the 2009 TapRooT® Summit.