Category: Video

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Arizona Public Service)

July 24th, 2014 by

Teresa Berry of Arizona Public Service shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch her video below to learn how she fixed her company’s poorly written reports by finding the root cause of the bad writing:

If you’re at work and don’t have time to watch the video, here’s her tip:

I’m Teresa Berry. I’m from Arizona Public Service and we’ve been using TapRooT® for probably three or three and a half years now on the process side of our industry and what we’ve found is that every now and then we’ll come up with a report that is not written very well. It doesn’t have facts to back up the root causes that were chosen. That is a symptom of a much bigger problem. The problem we found, that we had to go fix, is that people were not using all of the processes that we’re taught to use in TapRooT®; “the rules,” I call them when I teach. These are your rules. You must use the process as it’s laid out or it doesn’t work as well as you’d hoped. And along with that there are also assumptions. Make sure you turn those assumptions into questions so that you know you’ve got to go and answer that question. It’s not a fact until you prove that it’s a fact.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Corrective Action for Natural Disaster Category on the Root Cause Tree®

July 24th, 2014 by

Are you prepared for a tornado at your facility?

Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …

Things to Do in Seattle

July 23rd, 2014 by

MarkTeach

I am one of the instructors for the upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Traning in Seattle and I thought I’d pass along some of the great things to do in your spare time (after hours) while attending the course. 

Seattle is a great place to eat, shop, and have fun so I’ve listed my favorite places to eat and visit below with links to more information. I’ve also listed a few ideas for the weekend before or after for those who want to get outside of Seattle and see the impressive natural wonders nearby. 

Food

Wild Ginger - If you like asian food, try this.

Metropolitan Grill – Best steaks in the USA

The Brooklyn Seafood, Steaks, & Oysters – I recommend getting the oyster sampler.

Ivar’s Acres of Clams – I love their clam chowder and prices are reasonable.

The Cheesecake Factory – Always one of my favorites no matter where I go.

Kells Irish Pub - Love the atmosphere, beer, and the food is good (and a ghost).

Fun Activities

Space Needle and World’s Fair Park

Seattle Aquarium

Seattle Mariners – In town playing the Toronto Blue Jays on Monday, Tuesday, and Wednesday (night games) of the course. 

Seattle Art Museaum

Seattle Underground

Seattle Ferries

Tillicum Village Cruise and Samon Dinner

Shopping

REI Co-Op

Nordstroms

Pike Place Market

The Weekend Before/After Ideas

Olympic Peninsula

Mount Raineer

 

 

Remembering an Accident: Val di Stava Dam Collapse

July 19th, 2014 by

The Val di Stava dam collapsed on July 19, 1985 when two tailings dams used for sedimenting the mud from a nearby mine failed. The subsequent mudflow caused one of Northern Italy’s worst disasters – 268 lives were lost and 63 buildings and eight bridges were destroyed.

What happened?

According to The History of Geology:

“An investigation into the disaster found that the dams were poorly maintained and the margin of safe operation was very small. As last trigger of the failure is considered a leak of water, caused by a pipe in the upper dam, used to drain water, which had been bent by the weight of sediments. The increasing water pressure of the bunged up dam, in combination with the water saturation weakening the sediments of the dam wall, caused probably the collapse.”

See more at:  http://historyofgeology.fieldofscience.com/2010/07/july-19-1985-val-di-stava-dam-collapse.html

National Hazards and Earth System Sciences published a report indicating that effective regulation may have prevented this disaster.

Read report:

http://www.nat-hazards-earth-syst-sci.net/12/1029/2012/nhess-12-1029-2012.pdf

What do you think? Leave your comments below.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Encana Oil & Gas)

July 17th, 2014 by

Devin Johnston of Encana Oil & Gas shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he streamlined the way his facility performed TapRooT® investigations to make each one more efficient than ever:

If you’re at work and don’t have time to watch the video, here’s his tip:

Hi I’m Devin Johnston, with Encana Oil & Gas, from Denver, Colorado. One of the issues with had with TapRooT® is when we would have an incident we would want everyone to be involved. … Everyone would come in the room, we’d lock the doors, we’d run through the whole TapRooT® process, and bang it all out. At the end of the day, everyone was so tired of going through the process and arguing on each little point, that the corrective action part of it at the end was just, they’d take whatever. You’d give them a corrective action and they’d take it, and they weren’t always quality corrective actions. So the thing we fixed at our company is that we made it a more iterate process where we would investigate it, have SnapCharT®s built out already before we went into that meeting, then we selected who actually attended that meeting. If it was contractors, we made sure it wasn’t the whole EHS team, just the guys that things happened to out there. We’d pick the people that were in the investigation at the end to make it simpler, to come to an agreement better, and to improve our process on how we did those TapRooT®s.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (US Army Medical Command)

July 10th, 2014 by

Dana Rocha of US Army Medical Command shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during out Users Share Best Practices session. Watch her video below to learn how she has tailored her TapRooT® investigations so that they are the absolute most thorough they can be:

If you’re at work and don’t have time to watch the video, here’s her tip:

Hello, my name is Dana Rocha, I work for US Army Medical Command. With the help of the navy and the air force we in the army have put together a couple of different documents for people who haven’t been through the training to prepare them for facilitating an RCA as well as sitting on a RCA team. And what we did is we put together a couple of documents for “just in time training” for TapRooT® to help them facilitate and what your roles and responsibilities are on the team. We also put together an RCA trifold and what this is, is a root cause analysis for what event you’re looking at whether its an adverse outcome or sentinel event, near misses or you’re looking at something proactively. It doesn’t matter what you’re looking at, so we use it in different realms. We also put together some checklists. When you do your SnapCharT®, have you considered this? Have you considered that? Check the dates, check the times. Talk to people, and things like that and we found this to be very helpful. And we have done checklists for certain types of events that we find occur more frequently than others. When I say this, don’t freak, but wrong site surgeries do occur, we have retained foreign objects, all kinds of things that do happen, unanticipated deaths, so certain types of events we put together the most common things and asking the questions to make sure that we do a real thorough job when we do the analysis and the investigation so we found that to be very helpful.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Tesco Corp)

July 3rd, 2014 by

At our Users Share Best Practices session at the 2014 Global TapRooT® Summit, Simon Blackwood shared a great tip from his facility. Watch his video below to learn how his company is now “speaking the same language” when it comes to root cause analysis investigations:

Don’t have a minute to watch the video? Here’s his tip:

My name is Simon Blackwood, I work for Tesco Corporation in Houston, Texas and we transferred our terminology of generic causes and root causes over to our compliance report system for HSE and quality incidents so now we’re actually trending for actually all incidents we sill use the TapRooT® software but we have to admit our software is a little bit of work (although in truth it can trend proactively) now we’re getting ahead of the game, we’re using it for project management now but now certainly we’re speaking the same language in our company so it’s been great.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Career Development: A Conference Call in Real Life

July 2nd, 2014 by

This video is a hilarious because it highlights everything that can (and often does) go wrong on a conference call. Are conference calls productive? What do you think?

Congressional Hearings on Whistleblowers and Delayed Investigations at the CSB

June 19th, 2014 by

I received an automated search response today that there were hearings on whistleblower reprisals, and delays in investigations at the Chemical Safety Board. Here are the links to written testimony from the committee’s web site:

http://docs.house.gov/Committee/Calendar/ByEvent.aspx?EventID=102380

Here’s a statement from the committee’s chairman and other committee members:

http://oversight.house.gov/release/hearing-today-report-leadership-failure-chemical-safety-board-jeopardizes-agency-mission-puts-safety-risk/

Here’s the written testimony of the CSB Chairman:

http://oversight.house.gov/wp-content/uploads/2014/06/Moure-Eraso-CSB.pdf

And here are two videos that I found on YouTube of part of the hearing (I wanted to see the whole hearing but this is all I could find):

 

What do you think?

 

How Far Away is Death?

June 17th, 2014 by

Watch the video (.mp4 format) at this link for some train/pedestrian near-misses…

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Chevron Phillips)

June 12th, 2014 by

Kenneth Wilburn of Chevron Phillips shared a great best practice at the 2014 Global TapRooT® Summit. Watch his video below, and learn how Kenneth used TapRooT® to reduce injuries at his facility:

If you’re not able to watch the video right now, below is a transcription of his tip:

“Hello my name is Kenneth Wilburn. I work for Chevron Phillips Chemical Company in Port Arthur, Texas. Through the TapRooT® investigation we conducted as a whole company we realized we were lacking in training our short service worker contractors.

A short term contractor is someone who’s worked less than 6 months in our facilities. In Southeast Texas you have your big Exxonmobils, BASF, Duponts, you have thousands of contract workers. You can’t take for granted that these contract workers and have the same work ethic and same safety aspect at every facility, because some facilities are VPP sites, and some are not. what we did, is we recognized this and we took a proactive approach.

Every contractor at our facilities, if they haven’t been working there for six months, they go through a one-on-one training for an hour before they’re allowed to start working at the facility. Then we hand that training off to the safety representative of the contractor and they continue in this program for 90 days. We’ve seen a large reduction in our reportable injuries because of this.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Press Release from the US CSB: CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

June 5th, 2014 by

 

CSB Draft Report Finds Deepwater Horizon Blowout Preventer Failed Due to Unrecognized Pipe Buckling Phenomenon During Emergency Well-Control Efforts on April 20, 2010, Leading to Environmental Disaster in Gulf of Mexico

 Report Says Similar Accident Could Still Occur, Calls for Better Management
of Safety-Critical Elements by Offshore Industry, Regulators

 Houston, Texas, June 5, 2014— The blowout preventer (BOP) that was intended to shut off the flow of high-pressure oil and gas from the Macondo well in the Gulf of Mexico during the disaster on the Deepwater Horizon drilling rig on April 20, 2010, failed to seal the well because drill pipe buckled for reasons the offshore drilling industry remains largely unaware of, according to a new two-volume draft investigation report released today by the U.S. Chemical Safety Board (CSB).

CLICK HERE to access Overview
CLICK HERE to access Volume 1
CLICK HERE to access Volume 2

The blowout caused explosions and a fire on the Deepwater Horizon rig, leading to the deaths of 11 personnel onboard and serious injuries to 17 others.  Nearly 100 others escaped from the burning rig, which sank two days later, leaving the Macondo well spewing oil and gas into Gulf waters for a total of 87 days. By that time the resulting oil spill was the largest in offshore history.  The failure of the BOP directly led to the oil spill and contributed to the severity of the incident on the rig.

The draft report will be considered for approval by the Board at a public meeting scheduled for 4 p.m. CDT at the Hilton Americas Hotel, 1600 Lamar St., Houston, TX 77010.  The meeting will include a detailed staff presentation, Board questions, and public comments, and will be webcast at:

http://www.csb.gov/investigations/webcast/.

The CSB report concluded that the pipe buckling likely occurred during the first minutes of the blowout, as crews desperately sought to regain control of oil and gas surging up from the Macondo well.  Although other investigations had previously noted that the Macondo drill pipe was found in a bent or buckled state, this was assumed to have occurred days later, after the blowout was well underway.

After testing individual components of the blowout preventer (BOP) and analyzing all the data from post-accident examinations, the CSB draft report concluded that the BOP’s blind shear ram – an emergency hydraulic device with two sharp cutting blades, intended to seal an out-of-control well – likely did activate on the night of the accident, days earlier than other investigations found.  However, the pipe buckling that likely occurred on the night of April 20 prevented the blind shear ram from functioning properly.  Instead of cleanly cutting and sealing the well’s drill pipe, the shear ram actually punctured the buckled, off-center pipe, sending huge additional volumes of oil and gas surging toward the surface and initiating the 87-day-long oil and gas release into the Gulf that defied multiple efforts to bring it under control.

The identification of the new buckling mechanism for the drill pipe ­– called “effective compression” – was a central technical finding of the draft report.  The report concludes that under certain conditions, the “effective compression” phenomenon could compromise the proper functioning of other blowout preventers still deployed around the world at offshore wells.  The complete BOP failure scenario is detailed in a new 11-minute computer video animation the CSB developed and released along with the draft report.

The CSB draft report also revealed for the first time that there were two instances of mis-wiring and two backup battery failures affecting the electronic and hydraulic controls for the BOP’s blind shear ram.  One mis-wiring, which led to a battery failure, disabled the BOP’s “blue pod” – a control system designed to activate the blind shear ram in an emergency.  The BOP’s “yellow pod” – an identical, redundant system that could also activate the blind shear ram – had a different miswiring and a different battery failure.  In the case of the yellow pod, however, the two failures fortuitously cancelled each other out, and the pod was likely able to operate the blind shear ram on the night of April 20.

“Although both regulators and the industry itself have made significant progress since the 2010 calamity, more must be done to ensure the correct functioning of blowout preventers and other safety-critical elements that protect workers and the environment from major offshore accidents,” said Dr. Rafael Moure-Eraso, the CSB chairperson. “The two-volume report we are releasing today makes clear why the current offshore safety framework needs to be further strengthened.”

“Our investigation has produced several important findings that were not identified in earlier examinations of the blowout preventer failure,” said CSB Investigator Cheryl MacKenzie, who led the investigative team.  “The CSB team performed a comprehensive examination of the full set of BOP testing data, which were not available to other investigative organizations when their various reports were completed.  From this analysis, we were able to draw new conclusions about how the drill pipe buckled and moved off-center within the BOP, preventing the well from being sealed in an emergency.”

The April 2010 blowout in the Gulf of Mexico occurred during operations to “temporarily abandon” the Macondo oil well, located in approximately 5,000-foot-deep waters some 50 miles off the coast of Louisiana.  Mineral rights to the area were leased to oil major BP, which contracted with Transocean and other companies to drill the exploratory Macondo well under BP’s oversight, using Transocean’s football-field-size Deepwater Horizon drilling rig.

The blowout followed a failure of the cementing job to temporarily seal the well, while a series of pressure tests were misinterpreted to indicate that the well was in fact properly sealed.  The final set of failures on April 20 involved the Deepwater Horizon’s blowout preventer (BOP), a large and complex device on the sea floor that was connected to the rig nearly a mile above on the sea surface.

Effective compression, as described in the draft report, occurs when there is a large pressure difference between the inside and outside of a pipe.  That condition likely occurred during emergency response actions by the Deepwater Horizon crew to the blowout occurring on the night of April 20, when operators closed BOP pipe rams at the wellhead, temporarily sealing the well.  This unfortunately established a large pressure differential that buckled the steel drill pipe inside the BOP, bending it outside the effective reach of the BOP’s last-resort safety device, the blind shear ram.

“The CSB’s model differs from other buckling theories that have been presented over the years but for which insufficient supporting evidence has been produced,” according to CSB Investigator Dr. Mary Beth Mulcahy, who oversaw the technical analysis.  “The CSB’s conclusions are based on real-time pressure data from the Deepwater Horizon and calculations about the behavior of the drill pipe under extreme conditions.  The findings reveal that pipe buckling could occur even when a well is shut-in and apparently in a safe and stable condition.  The pipe buckling – unlikely to be detected by the drilling crew – could render the BOP inoperable in an emergency.  This hazard could impact even the best offshore companies, those who are maintaining their blowout preventers and other equipment to a high standard.  However, there are straightforward methods to avoid pipe buckling if you recognize it as a hazard.”

The CSB investigation found that while Deepwater Horizon personnel performed regular tests and inspections of those BOP components that were necessary for day-to-day drilling operations, neither Transocean nor BP had performed regular inspections or testing to identify latent failures of the BOP’s emergency systems. As a result, the safety-critical BOP systems responsible for shearing drill pipe in emergency situations – and safely sealing an out-of-control well – were compromised before the BOP was even deployed to the Macondo wellhead.  The CSB report pointed to the multiple miswirings and battery failures within the BOP’s subsea control equipment as evidence of the need for more rigorous identification, testing, and management of critical safety devices.  The report also noted that the BOP lacked the capacity to reliably cut and seal the 6-5/8 inch drill pipe that was used during most of the drilling at the Macondo well prior to April 20 – even if the pipe had been properly centered in the blind shear ram’s blades.

Despite the multiple maintenance problems found in the Deepwater Horizon BOP, which could have been detected prior to the accident, CSB investigators ultimately concluded the blind shear ram likely did close on the night of April 20, and the drill pipe could have been successfully sealed but for the buckling of the pipe. 

“Although there have been regulatory improvements since the accident, the effective management of safety critical elements has yet to be established,” Investigator MacKenzie said.  “This results in potential safety gaps in U.S. offshore operations and leaves open the possibility of another similar catastrophic accident.”

The draft report, subject to Board approval, makes a number of recommendations to the U.S. Department of Interior’s Bureau of Safety and Environmental Enforcement (BSEE), the federal organization established following the Macondo accident to oversee U.S. offshore safety. These recommendations call on BSEE to require drilling operators to effectively manage technical, operational, and organizational safety-critical elements in order to reduce major accident risk to an acceptably low level, known as “as low as reasonably practicable.”

“Although blowout preventers are just one of the important barriers for avoiding a major offshore accident, the specific findings from the investigation about this BOP’s unreliability illustrate how the current system of regulations and standards can be improved to make offshore operations safer,” Investigator MacKenzie said.  “Ultimately the barriers against a blowout or other offshore disaster include not only equipment like the BOP, but also operational and organizational factors.  And all of these need to be rigorously defined, actively monitored, and verified through an effective management system if safety is to be assured.”  Companies should be required to identify these safety-critical elements in advance, define their performance requirements, and prove to the regulator and outside auditors that these elements will perform reliably when called upon, according to the draft report.

The report also proposes recommendations to the American Petroleum Institute (API), the U.S. trade association for both upstream and downstream petroleum industry. The first recommendation is to revise API Standard 53, Blowout Prevention Equipment Systems for Drilling Wells, calling for critical testing of the redundant control systems within BOP’s, and another for new guidance for the effective management of safety-critical elements in general.

CSB Chairperson Rafael Moure-Eraso said, “Drilling continues to extend to new depths, and operations in increasingly challenging environments, such as the Arctic, are being planned.  The CSB report and its key findings and recommendations are intended to put the United States in a leading role for improving well-control procedures and practices.  To maintain a leadership position, the U.S. should adopt rigorous management methods that go beyond current industry best practices.”

Two forthcoming volumes of the CSB’s Macondo investigation report are planned to address additional regulatory matters as well as organizational and human factors safety issues raised by the accident.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Trojan Battery)

June 5th, 2014 by

Kim Aul of Trojan Battery shared a great best practice at the 2014 Global TapRooT® Summit. Watch his video below, and learn how Kim used TapRooT® for proactive analysis:

If you’re not able to watch the video right now, below is a transcription of his tip:

“Hi, my name is Kim Aul. I currently work for Trojan Battery Company but I have to speak to a previous life for mine. I worked for a company that had a union environment and our best practice was that we trained union employees in TapRooT® and made it mandatory that every TapRooT® investigation had union employees as part of the team. It built trust between union and salaried workforce. In fact, I got word that this was a negotiation year and for the first time ever safety was not on the board. So it really worked out for us. Paid off well. Thank you.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

“Normalization of Deviance” – The Cause of Accidents in a Complex Era?

June 2nd, 2014 by

A quote from the New York Times article:

“Another sociologist, Diane Vaughan, has written extensively about Challenger and served on the commission that investigated the Columbia horror. She has advanced the theory of ‘normalization of deviance,’ meaning that in many organizations — NASA certainly being no exception — some problems and risks are understood to be acceptable — part of doing business, if you will. Take those problematic O rings on Challenger. Their erosion had been evident on earlier launchings, but flying with them became routine. To Ms. Vaughan, NASA’s decision to forge ahead on that fateful January day in 1986, despite new concerns about the O rings that were raised, did not reflect cold, bottom-line thinking or an amoral bending of rules. ‘They applied all the usual rules,’ she told Retro Report. Regrettably, they did so ‘in a situation where the usual rules didn’t apply.’”

The video presents Interesting concepts about accident causes. Mark Paradies, President of System Improvements, will present a talk about Normalization of Deviance at the 2015 Global TapRooT® Summit. Watch for more information as Summit planning progresses. The 2015 Global TapRooT® Summit will be held on June 1-5, 2015 in Las Vegas, NV.

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