TapRooT® Instructor Steve Swarthout sent over these photos from our recent onsite TapRooT® couse in Korea! Enjoy!
Remembering an Accident: On December 3, 1984, The Union Carbide Bhopal Chemical Release Kills Over 2,000 – Injuries Over 200,000Posted: December 3rd, 2013 in Accidents, Video
Here is a 10 year anniversary Reuters report …
Here is a video called “The Inside Story” …
There’s lot’s more video out there … some very emotional.
Mark is President of System Improvements in Knoxville, Tennessee. He is co-author of TapRooT® – Changing the Way the World Solves Problems, a contributor to the Root Cause Analysis Blog and the editor of the Root Cause Network newsletter. He is a member of the IEEE Committee writing a root cause analysis standard for the nuclear industry and is a co-author of the book Guidelines for Investigating Chemical Process Incidents published by the Center for Chemical Process Safety.
Mark earned a Master’s Degree in Nuclear Engineering with an emphasis on human factors at the University of Illinois. He was certified by Navsea 08 as an engineer in the Nuclear Navy and is a Certified Professional Ergonomist and a Certified Hazard Control Manager. He is a senior member of the American Society for Quality.
To learn more about the Summit, visit: http://www.taproot.com/taproot-summit
UK Rail Accident Investigation Press Release: Road vehicle incursion onto the railway at Aspatria, Cumbria, 26 October 2013Posted: December 3rd, 2013 in Accidents, Current Events, Investigations, Pictures
The RAIB is investigating the incursion of a road vehicle onto the railway at Aspatria, between Carlisle and Workington, on Saturday 26 October 2013. A train was prevented from colliding with the vehicle and nobody was injured.
Just before 10:03 hrs, a 2.5 tonne builder’s pick up vehicle ran away from the B5299 Brayton Road, broke through the railway boundary fence and fell down the embankment, coming to rest on its roof in the middle of the line used by trains going in the direction of Workington (see figure). The 09:39 hrs train from Carlisle to Lancaster was approaching at the time, but its driver was alerted by an emergency stop call over the train’s radio system and was able to stop 1.5 (2.4 km) miles from the obstruction on the line.
Figure: The builder’s pick up vehicle on the Carlisle – Workington line (by courtesy of Network Rail)
At the accident location, the B5299 joins the main A596 road at a junction adjacent to the railway, and at a point where the A596 runs parallel to the railway, before crossing it over Aspatria Tunnel. Locations where a road is close to a railway are required to be assessed by the local highway authority and/or Network Rail to determine the risk of road vehicle incursion to the operational railway.
The RAIB’s investigation will include a review of how the risk of road vehicle incursion at this site was assessed by both the local highway authority (Cumbria County Council) and Network Rail, and what subsequent actions, if any, were taken to control the risk of such incursions. The investigation will also review the current national policies and processes for the management of road vehicle incursion at locations of this type.
The RAIB’s investigation is independent of any investigation by the safety authority (the Office of Railway Regulation).
The RAIB will publish its findings, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.
Judy Potok, Meeting Planner / Public Course Coordinator for TapRooT®, recently returned from a visit to Horseshoe Bay, Texas to check out the 2014 Global TapRooT® Summit site and finalize some important plans. She is excited to share some new details about next year’s Summit reception below.
“Picture yourself in a place with open skies illuminated with brilliant colors, a soft gentle breeze blowing off the lake, and warm, sunny weather. Does this sound like somewhere you’d like to be? Then come join us for the 2014 Global TapRooT® Summit at the beautiful Horseshoe Bay Marriott Resort, on Lake LBJ in Horseshoe Bay, TX (near Austin).
Anyone who has been to the Summit knows the kind of fun we have at the Wednesday night reception. The reception in 2014 will be no exception. We’re holding the reception at the Yacht Club in 2014. The Yacht Club has been hosting memorable celebrations at Horseshoe Bay for over 30 years. Here is the view of constant-level Lake LBJ from the lawn of the Club. I already feel relaxed!
In the photo below, we’re checking out the seating at the Yacht Club – there’s plenty of room to move around. Visualize yourself networking with a few colleagues that you only get to see at the Summit or meeting new people at one of the tables below. There will be plenty to talk about after the day’s events, and don’t forget Carl Dixon will be rocking the reception again next year with music and singing.
Here are a couple more photos we brought back from the Yacht Club.
At the Wednesday night reception, you can enjoy good food, delicious drinks and the company of great people courtesy of the 2014 Global TapRooT® Summit. I am very excited about returning to Horseshoe Bay in April. I hope you will join us!”
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LEARN MORE about the Summit.
TapRooT® Instructor Piedad Colmenares sent over these photos from our recent onsite TapRooT® Course in El Salvador last week November 25-29, 2013. Enjoy.
With the New Year on the horizon, it’s time to think about professional goals for 2014. You may already be thinking about additional training that you could attend to enhance your career development (like the 2014 Global TapRooT® Summit!).
The problem with setting goals like these is getting over the obstacles. A common obstacle that causes us to push career development goals aside is that we are just too busy — the demands of the job take precedence.
How can we accomplish our career goals next year if we are weighed down with our day-to-day responsibilities?
Jack Zenger says, “involve your manager in your personal development,” and makes a special point to tell his readers not to inform our managers, but to involve them.
Check out his three tips for getting your manager involved in his Forbe’s article:
The UK Rail Accident Investigation Branch has released their annual report for 2012. CLICK HERE to download the report.
Carolyn Griffiths, the Chief Inspector at the RAIB, starts the report with an interesting observation … that they see some accidents types happen over an over again from one year to the next. She says that this is evidence that the industry needs to do more.
That brings up two important questions …
1) Are you reviewing your accident history on a periodic basis and have you looked for recurring events?
2) If you have noticed recurring events, why are they happening? Why haven’t you be successful in preventing recurrence?
Some serious thought is needed to learn from our past experience and to make sure that we don’t relive history.
Root Cause Analysis Training for Human Error Reduction and Behavior Change – 2014 Global TapRooT® Summit Video InvitationPosted: December 2nd, 2013 in Summit, Video
Would you like to reduce human error in your facility? Take a look at Mark Paradies’ invitation to attend the 2014 Global TapRooT® Summit in the Human Error Reduction & Behavior Change track.
Mark mentioned in the video “the link to the Summit Schedule.” Click here to see our full Summit Schedule, then click the “Human Error Reduction and Behavior Change” option on the left sidebar menu.
At the 2013 Global TapRooT® Summit, we met so many wonderful clients and friends. They couldn’t stop talking about how much they enjoyed the Summit! We got a few of those conversations on camera for you, so you know what you’ll get when you attend the 2014 Global TapRooT® Summit in Horseshoe Bay, Texas!
In this video, we talk with Tom DiGiacomo of Saudi Aramco.
Carl Dixon will be playing & singing at our reception again this year. Click here for more reception information.
For Certified Instructors like Tom, click here to view our Summit Schedule. Choose the Certified instructors track on the left, and learn more about each session.
Tom mentions Process Safety, and our need for increasing it. Click here and choose the Process Quality & Corrective Actions track on the left hand side for more info on our Process Safety session.
Interested in our 2014 Summit? Click here to learn more.
Here is my Thanksgiving posting. I post it every year, lest we forget.
In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!
One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.
During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.
The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.
With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.
Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.
The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.
Is this the root cause of Thanksgiving?
This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:
“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”
William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.
Here are links to more information about the blast and the refinery disruption …
Diana Munevar shared these photos from our Bogota, Colombia course we held November 2-4, 2013. Enjoy!
Marco Flores sent over these photos from the Bogota, Colombia course held October 21-22, 2013. Enjoy!