Monthly Archives: May 2010

Top Kills Fails – BP to Try New Plan

Posted: May 31st, 2010 in Accidents, Current Events, Sounds

Various media sources have announced that the “top kill” effort to stop the leaking well in the Gulf has officially failed. Here’s one:

Next step? Looks like BP is planing on trying the remote sub slice and collect approach.

And if that fails? The only answer left is relief wells which probably won’t be completed until August.

Here’s a link to the press conference that declares defeat and discusses options (audio only):

How Safe Is Safe Enough? – The Question Being Analyzed After The BP/Transocean Deepwater Horizon Accident

Posted: May 31st, 2010 in Accidents, Current Events, Investigations

A story in the Houston Chronicle starts out:

BP officials insist safety was a top priority on the Macondo drilling project more than 40 miles off the coast of Louisiana, but there were plenty of reasons for the oil giant to want to cut corners to save time and money.

It’s a good discussion of the shortcuts taken and how perhaps safety was compromised. Read it at:


Posted: May 29th, 2010 in Accidents, Current Events, Investigations


                       NTSB ADVISORY


National Transportation Safety Board

Washington, DC 20594

May 28, 2010




The National Transportation Safety Board has launched an

investigation into the near midair collision of a passenger jetliner and a cargo jumbo jet.

On May 21, 2010, at about 12:10 a.m. Alaska Daylight Savings Time, an Airbus A319, operating as US Airways flight 140, and a Boeing 747-400, operating as Cargolux Airlines International flight 658, came within an estimated 100 feet vertically and a .33 mile lateral separation as the B747 was departing Anchorage International Airport (ANC) and the A319 was executing go-around procedures at ANC.

The A319, with 138 passengers and crew aboard, was inbound from Phoenix (PHX) to runway 14 and the B747, with a crew of 2, was departing Anchorage en route to Chicago (ORD) on runway 25R. The incident occurred in night visual meteorological conditions with 10 miles of visibility.

According to the TCAS report from the A319 crew, that aircraft was approaching ANC when, because of the effects of tailwinds on the aircraft’s approach path, the crew initiated a missed approach and requested new instructions from air traffic control. The tower controller instructed the A319 to turn right heading 300 and report the departing B747 in sight. After the A319 crew reported the B747 in sight, the controller instructed the A319 to maintain visual separation from the B747, climb to 3000 feet, and turn right heading 320. The A319 crew refused the right turn because the turn would have put their flight in direct conflict with the B747. The A319 crew then received a resolution advisory to “monitor vertical speed” and the crew complied with the descent command. During the descent, the A319 crew lost sight of the B747. At about 1700 feet above ground level, the A319 crew received a “clear of conflict” aural command. There were no reported injuries or damage to either aircraft.

NTSB investigator Dan Bartlett, an air traffic control specialist based in Washington, will be traveling to Anchorage to begin the investigation.

A preliminary report of the incident will be available on the Board’s website within 10 business days.

# # #

Media contact:

Bridget Ann Serchak


CNN Reports: BP suspends ‘top kill’ effort

Posted: May 27th, 2010 in Accidents, Current Events, Investigations, Video


Also, the story includes more information about the pre-accident sequence of events.

Picture from an On-Site 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Westex Well Servicing Company

Posted: May 27th, 2010 in Courses, Pictures, TapRooT

That’s Richard (the instructor) on the far left.

tap root.jpg

Need a course at your site? Call us at 865-539-2139. Or click here to e-mail us.

MSNBC Investigates Scandal of BP Deepwater Horizon Incident – Corporate Homicide?

Posted: May 27th, 2010 in Accidents, Current Events, Investigations, Video

Here’s the video:

Visit for breaking news, world news, and news about the economy

What do you think? Press going overboard or a real case of corporate manslaughter?

BP’s Current Plans to Stop the Leak

Posted: May 27th, 2010 in Accidents, Current Events, Video

Interesting video from BP…

Gives you some idea of the technical challenges and the engineering effort going into solving the gulf oil leak at the wellhead.

Here’s the top kill animation:

Mother Dies at UK NHS Hopital After Injection of Wrong Drug

Posted: May 27th, 2010 in Accidents, Current Events, Investigations, Summit, TapRooT

The story printed in SHP said that:

“HSE investigators discovered that the two drugs were stored in the same racking system, despite having almost identical packaging. They found that no proper management system was in place for the storage of the drugs, and warnings from earlier incidents had not been properly followed up.”

The story said that the mother had died needlessly.

What do you do to make sure that your root cause analysis and corrective actions for incidents are effective?

Would your facility have a “needless” death?

Should you be using TapRooT® and attending the TapRooT® Summit to learn ways to check the effectiveness of your root cause analyses and corrective actions?

Things to think about…

Mark’s LinkedIn Network Grows to >1000

Posted: May 26th, 2010 in Current Events, Meet Our Staff

Mark Paradies, President of System Improvements and co-author of the book, TapRooT® – Changing the Way the World Solves Problems, has surpassed 1000 people that have joined his LinkedIn professional network.

See his LinkedIn profile at:


Send Mark an invitation and you can join his network too!

Use the “Add Mark to your network” link on his profile page.

Using TapRooT® to improve organizational quality….really? Well, yeah!

Posted: May 25th, 2010 in Current Events

Did you know that TapRooT® can fit into any quality or quality improvement program?  Well, think about it.  Is root cause analysis required in your program?  Of course it is!  You can use TapRooT® within the framework of your existing program to perform your root cause analysis, and then make use of our corrective action tools as well.

Do you use PDCA (or PDSA)?  Six Sigma?  Lean?  TQM? Are you ISO certified?  TapRooT® can help with all of these.

Chris Vallee (first picture) and I (second picture) are at the American Society for Quality’s World Conference for Quality and Improvement; we’ve talked to 408 people so far and still have a few hours to go!  The quality managers, auditors, and black belts we have talked to have really been interested in learning more robust techniques.  Thanks to everyone who has visited us this week.

So give us a call to discuss how we can fit into your program and help you improve your analysis; I am an ASQ Certified Manager of Quality and Organizational Excellence, Quality Auditor, and Quality Improvement Associate, and Chris is a Six Sigma Blackbelt.  We can help.

Wisdom Quote

Posted: May 25th, 2010 in Wisdom Quote

“The factory of the future will have only two employees — a man and a dog.  The man will be there to feed the dog.  The dog will be there to keep the man from touching the equipment.” ~ Warren Bennis

TapRooT® Root Cause Analysis Course in Bogotá, Colombia

Posted: May 24th, 2010 in Courses, Pictures

T&PS Certified Training hosted another great 3-Day TapRooT® / Equifactor® course in Bogotá last week.  Marco Flores was the instructor, and it looks like a lot of happy students!

Let us know if you are interested in attending a TapRooT® course in Central or South America!

Monday Accident & Lesson Learned: Either You Are Leading the Solution or You Are Part of the Problem

Posted: May 24th, 2010 in Accidents, Current Events, Human Performance, Performance Improvement

I learned the lesson I am sharing in this article while investigating an oil platform fire back in the mid-90’s. But the recent congressional testimony of executives from BP, Transocean, and Halliburton brought the lesson back to mind.

These lessons are NOT just for people in the petroleum industry. They apply to all industries where a major accident could cause loss of life, damage to the company’s reputation (ie, Toyota’s accelerator problems), or a major financial loss.

After a major accident, there are NO clean hands. There is blame enough for everyone. If you are in the chain of command of the organization that had the accident, you WILL be seen as PART OF THE PROBLEM.


It’s not my fault … YOU are to blame!

Finger pointing is counter productive. Managers may be able to point out others that share the blame, but they won’t be able to get rid of their share of the blame.

This is true even for the “blessed” level of the corporation. CEOs, Presidents, and Senior Vice Presidents can usually avoid blame for lesser mistakes. But when a major accident – multiple lives lost, extensive environmental damage, and/or a big hit to the company’s reputation and finances – occurs, even the corporate elite can’t escape the blame from the press and politicians.

That’s why the minor amount of finger pointing by executives at the BP / Transocean / Halliburton hearings only seems to make people more upset. They wanted these executives to accept their responsibility for things that have obviously gone wrong.

BP should have lead the way by taking responsibility for the accident. BP should have admitted that their performance was unacceptable. And BP should have then shown that they were ready to lead the way – for the whole industry – when developing solutions to keep this kind of accident from happening ever again anywhere else.

Instead of the statement made by BP’s President (which you can watch on the CSPAN videos posted previously on this blog), they should have said something like the following:

Statement I proposed for Lamar McKay, President of BP Americas…

Chairman Bingaman, ranking member Murkowski, and members of the committee, representatives of the press, and people of American and around the world, I come here today with a heavy and contrite heart for the accident that I have allowed on my watch.

First, let me apologize to the families and loved ones of the 11 workers who were killed in the initial explosion on the Deepwater Horizon. Their loss is tragic and unacceptable and I pledge here that I will do everything in my power to discover the root causes of the fatal blast so that we can learn from it and ensure that it never happens again.

Second, I would like to apologize to the people impacted by the subsequent release of oil from our well. We at BP are responsible for the environmental damage. BP will pay all valid claims without regard to any liability caps. We will do this because we feel it is our responsibility to compensate those who have been harmed.

The extent of this spill is larger than anything we thought possible. The fact that it happened means that our preparations and measures to prevent the accident were insufficient. We should have been better prepared for the unimaginable. We are currently bringing all the resources we can to bear on stopping the spill and mitigating the damage of the oil that is being released.

Furthermore, we pledge to take the lessons we have learned in the spill response and continue to research ways that we can be even more prepared if something of this nature happens again. Our goal is to find the root causes of the spill and prevent it. But we should never again be caught unprepared if the unthinkable happens.

At BP, we believe there will be a need for a reasonably priced source of oil for decades to come. We pledge our best efforts to finding and recovering this oil without loss of life or unacceptable environmental damage. By allowing the current accident to occur, we have failed our shareholders, employees, and the American people. For this we are sorry and we hope to be able to prove to you that we can changed course so that we won’t fail again.

As for plans to prevent future accidents, we have put together a team of experts in deepwater oil exploration and root cause analysis to find the causes of this failure. They will be given complete access to all records and personnel to determine what went wrong, how it went wrong, and why it went wrong. The goal of this investigation is not to point fingers and attribute blame. Rather, the goal is to find out how we can improve our performance so that an accident like this one NEVER happens again. Not at BP. Not at any other exploration site around the world.

It is too early to tell exactly what caused the explosion that killed 11 people and started this environmental accident, but I can say that the fact that it happened means that things went wrong. Somewhere down the well, barriers that we thought were sufficient to prevent the blowout failed. Also, the blowout preventer didn’t prevent a blowout. And our planned emergency response efforts were insufficient to deal with the size and scope of the spill that we now face. I am sure that all of these problems could have been prevented if we had foreseen the outcome. Unfortunately, we didn’t. That is a fact that we wish we could change but we can’t.

What we can do is to understand why bad decisions were made so that we can avoid bad decisions in the future. We want to know any mistakes that were made in sealing the well. If industry practices were followed, why they failed. If industry practices were not followed, why that occurred. If we should have preceded differently, we need to find out what went wrong and how we can do to do it right next time. We need to understand why the blowout preventer didn’t function as intended. We also need to understand what we need to do to be better prepared for a large spill.

What I can pledge to you is that BP wants to redeem our reputation. We pledge to become the safest, most environmentally benign oil producer in the world. We pledge to lead efforts to develop safer methods for deepwater drilling and to share the practices across our industry. We will work with our contractors and suppliers to establish much more reliable blowout preventers. We will lead an industry effort to establish an emergency preparedness and response capability up to the challenge of a spill of this size even though we plan to never have anything like this happen ever again.

After my fellow industry colleges have had the chance to share their thoughts about the accident, I would be happy to answer questions about our efforts to discover and eliminate the root causes of this accident and our current efforts to stop the spill and mitigate the environmental damage done.

So to close, thank you for this forum that we can start to express our sincere regret for our past performance and explain how we can start to redeem ourselves with efforts to lead progress in understanding and improving the safety and environmental performance of our company.

At this point, Mr. McKay would have to really have a plan. BP would have to really be performing a thorough, accurate, critical root cause analysis using advanced root cause analysis tools that aren’t looking to place blame. Tools that have advanced human performance, organizational performance, and equipment performance evaluation methods. They would have to really be committed to leading the industry and taking actions to change the culture that has lead to a string of accidents across BP’s business units.

Maybe that is too much to ask. BP management may not be capable of this critical analysis – admitting that they were wrong and need to change BP’s culture.

Also, some of you might think that MARK IS CRAZY. No executive would take this kind of responsibility. Think of future lawsuits. Think of the corporate liability.

But I believe that the company is already guilty by the fact that an “unthinkable” accident has happened. Only if this was a terrorist act or a case of sabotage, could BP escape blame. Since there is no evidence of this, BP will be found to have made mistakes that contributed to the accident. You can count on that.

So my conclusion is that defensive management … management that points fingers at others … management that rejects or doubts their responsibility … can’t successfully lead the change efforts that are needed to improve performance and prevent future accidents of this magnitude.

Eventually these defensive managers WILL lose their jobs because they can’t change something they are defending.

In other words, management all up and down the line – from BP’s CEO to BP’s Company Man on the rig, must recognize their responsibility and their need to lead change or the Management System root causes (which there will be in an accident of this magnitude) will not be fixed.

Thus my conclusion …



Of course, after a major accident it is customary that managers will lose their jobs. The first target are those managers on the rig that made decisions the night of the accident. Next, the next level of management up the chain at BP and Transocean. But more senior management should also be worried. The complete management chain – from the Refinery Business Unit Manager to the CEO – eventually resigned or were let go after the BP Texas City explosion.

I believe the ONLY way that managers in this predicament can save their job is to claim their responsibility and then be seen as STRIDENTLY LEADING the change needed to prevent future accidents.

Now for your ideas and comments …


Should management not only admit errors but actually claim their share of the blame?

Can leading positive change save a corporate manager’s job?

Is pointing fingers and shifting blame a better survival strategy?

Is sincerely apologizing and accepting blame too dangerous?

What do you think?

Leave a comment here.

Cockpit Fire: Equipment Failure Root Cause

Posted: May 24th, 2010 in Uncategorized

A cockpit fire that forced a United Airlines flight to make an emergency landing was located in a piece of window-heating equipment that was the subject of a safety warning three years ago, accident investigators said Friday.  (

According to the article, there have been 29 incidents with this electrical connection over the past 8 years.  Three years ago, in a letter to the FAA, the NTSB recommended that the electrical connection block be replaced.  In 2008, the FAA proposed giving the airlines the option of either inspecting the connections, or replacing the block.  That proposal has still not been approved.

Just a quick calculation shows that, with 29 failures in 8 years, we should expect an average of over 3 failures per year.  This does not take into account a change in the failure rate due to age, inspection results, etc.

Is this really just an equipment failure?  Or is there maybe some human error involved?  It’s a shame to see repeat failures with this much data available.

Root Cause Analysis at the ASQ World Conference on Quality and Improvement

Posted: May 24th, 2010 in Current Events

Chris Vallee and I are in St. Louis this week at the ASQ World Conference on Quality and Improvement.  If you are at the conference and would like to talk about advanced root cause analysis and take a look at our new V5 software, please stop by the TapRooT® Booth (#1122) in the exhibition hall.

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