Root Cause Analysis Blog

 

Press Release from the US Chemical Safety Board: Chemical Safety Board Ongoing Investigation Emphasizes Lack of Protection for Communities at Risk from Ammonium Nitrate Storage Facilities; Finds Lack of Regulation at All Levels of Government

Posted: April 23rd, 2014 in Accidents, Current Events, Investigations

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Chemical Safety Board Ongoing Investigation Emphasizes Lack of Protection for Communities at Risk from Ammonium Nitrate Storage Facilities; Finds Lack of Regulation at All Levels of Government

 Dallas, TX April 22, 2014 – Today the CSB released preliminary findings into the April 17, 2013, West Fertilizer explosion and fire in West, Texas, which resulted in at least 14 fatalities, 226 injuries, and widespread community damage.  Large quantities of ammonium nitrate (AN) fertilizer exploded after being heated by a fire at the storage and distribution facility.  The CSB’s investigation focuses on shortcomings in existing regulations, standards, and guidance at the federal, state and county level.  

The investigative team’s presentation will occur this evening at a public meeting in West, Texas, at 5:30 pm CDT.
CSB Chairperson Rafael Moure-Eraso said, “The fire and explosion at West Fertilizer was preventable. It should never have occurred. It resulted from the failure of a company to take the necessary steps to avert a preventable fire and explosion and from the inability of federal, state and local regulatory agencies to identify a serious hazard and correct it.”

The CSB’s investigation found that at the state level, there is no fire code and in fact counties under a certain population are prohibited from having them.  “Local authorities and specifically—local fire departments—need fire codes so they can hold industrial operators accountable for safe storage and handling of chemicals,” said Dr. Moure-Eraso. 

CSB Supervisory Investigator Johnnie Banks said “The CSB found at all levels of government a failure to adopt codes to keep populated areas away from hazardous facilities, not just in West, Texas. We found 1,351 facilities across the country that store ammonium nitrate.  Farm communities are just starting to collect data on how close homes or schools are to AN storage, but there can be little doubt that West is not alone and that other communities should act to determine what hazards might exist in proximity.”

The CSB’s preliminary findings follow a yearlong investigation which has focused on learning how to prevent a similar accident from occurring in another community. “It is imperative that people learn from the tragedy at West,” Dr. Moure-Eraso said.

The investigation notes other AN explosions have occurred, causing widespread devastation. A 2001 explosion in France caused 31 fatalities, 2500 injuries and widespread community damage. In the United States, a 1994 incident caused 4 fatalities and eighteen injuries. More recently a July 2009 AN fire in Bryan, Texas, led to an evacuation of tens of thousands of residents. Fortunately no explosion occurred in the Bryan, Texas, incident which highlights the unpredictable nature of AN. 

The CSB’s investigation determined that lessons learned during emergency responses to AN incidents – in which firefighters perished —  have not been effectively disseminated to firefighters and emergency responders in other communities where AN is stored and utilized. 

The CSB has found that on April 17, 2013, West volunteer firefighters were not aware of the explosion hazard from the AN stored at West Fertilizer and were caught in harm’s way when the blast occurred.

Investigators note that the National Fire Protection Association (NFPA) recommends that firefighters evacuate from AN fires of “massive and uncontrollable proportions.” Federal DOT guidance contained in the Emergency Response Guidebook, which is widely used by firefighters, suggests fighting even large ammonium nitrate fertilizer fires by “flood[ing] the area with water from a distance.”  However, the investigation has found,  the response guidance appears to be vague since terms such as “massive,” “uncontrollable,” “large,” and “distance” are not clearly defined. 
Investigator Banks said, “All of these provisions should be reviewed and harmonized in light of the West disaster to ensure that firefighters are adequately protected and are not put into danger protecting property alone.” 

The CSB has previously noted that while U.S. standards for ammonium nitrate have apparently remained static for decades, other countries have more rigorous standards covering both storage and siting of nearby buildings. For example, the U.K.’s Health and Safety Executive states in guidance dating to 1996 that “ammonium nitrate should normally be stored in single story, dedicated, well-ventilated buildings that are constructed from materials that will not burn, such as concrete, bricks or steel.”  The U.K. guidance calls for storage bays “constructed of a material that does not burn, preferably concrete.”

At the county level, McLennan County’s local emergency planning committee did not have an emergency response plan for West Fertilizer as it might have done under the federal Emergency Planning and Community Right to Know Act.  The community clearly was not aware of the potential hazard at West Fertilizer.

Chairperson Moure-Eraso commended recent action by the Fertilizer Institute in establishing an auditing and outreach program for fertilizer retailers called ResponsibleAg, and for disseminating with the Agricultural Retailers Association a document called “Safety and Security Guidelines for the Storage and Transportation of Fertilizer Grade Ammonium Nitrate at Fertilizer Retail Facilities.” It also contains recommendations for first responders in the event of a fire.  

“We welcome this very positive step,” Dr. Moure-Eraso said, “We hope that the whole industry embraces these voluntary guidelines rather than being accepted only by the companies that choose to volunteer.”

The Chairperson called on states and counties across the country to take action in identifying hazards and requiring the safe storage and handling of ammonium nitrate. “Regulations need to be updated and new ones put in place. The state of Texas, McLennan County, OSHA and the EPA have work to do, because this hazard exists in hundreds of locations across the U.S.  However, it is important to note that there is no substitute for an efficient regulatory system that ensures that all companies are operating to the same high standards. We cannot depend on voluntary compliance.” 

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 Communications Manager Hillary Cohen, cell  202-446-8094  or Sandy Gilmour, Public Affairs, cell  202-251-5496 .

Root Cause Analysis Tip: How to Perform Faster Investigations

Posted: April 23rd, 2014 in Root Cause Analysis Tips

magnifyingglassI was looking through some old blog posts and found one that I thought current readers might find especially helpful. This one is a “blast from the past” – 2005 to be exact and discusses ways to perform faster root cause analysis.

Make sure you read the whole post because some of the best ideas are toward the end. See:

http://www.taproot.com/archives/86

For those who have the 2008 (black) TapRooT® Book, see page 40 for a quick rundown on performing fast, simple investigations using TapRooT®.

Equipment Troubleshooting Training in South America – TapRooT®/Equifactor® Course Photos

Posted: April 22nd, 2014 in Courses, Pictures

TapRooT® Course Planner Diana Munevar shared this photo from our 3-Day TapRooT®/Equifactor® course March 26-28, 2014 in Bogota, Colombia. Our Equifactor® Course is held in limited dates and locations, so it’s special treat to be able to attend one! Click here to learn more about our equipment troubleshooting & root cause analysis course.

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How Far Away is Death?

Posted: April 22nd, 2014 in Pictures

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Root Cause Analysis Training in Chile – TapRooT® Course Photos

Posted: April 22nd, 2014 in Courses, Pictures

Many thanks to Jesus Alonso for these photos of our March 27-28, 2014 onsite course in Punta Arenas, Chile. Enjoy!

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Weekly Wisdom for Root Cause Analysis

Posted: April 22nd, 2014 in Wisdom Quote

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“Quality is never an accident; it is always the result of high intention, sincere effort, intelligent direction, and skillful execution; it represents the wise choice of many alternatives.”

- Will A. Foster

Root Cause Analysis Training in Chile – TapRooT® Course Photos

Posted: April 21st, 2014 in Courses, Pictures

TapRooT® Instructor Jesus Alonso sent over these photos from our March 19-20 and March 20-21, 2014 onsite courses in Chile. Thanks for making these courses great!

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Monday Accident & Lessons Learned: What Can We Do About Unnecessary Deaths by Error at Hospitals?

Posted: April 21st, 2014 in Medical/Healthcare

I just can’t get by the number. Over 400,000 people die each year in US hospitals due to medical errors. That’s over 1,000 per day. Or one or two in the time it takes you to read this article.

This latest estimate came from a study published by Dr. John T. James Ph. D. His estimates are the best numbers we have. Why? Because these deaths aren’t tracked like auto accidents or industrial safety accidents. medical errors are historically under-reported if they are reported at all. That makes it hard to tell if a particular hospital is doing poorly or if we are making improvements across the healthcare system.

As everyone who has read quality guru W. Edwards Deming’s book Out of the Crisis knows, you must have accurate data to guide improvement. Without it, you are shooting in the dark.

What can we do to improve patient safety? It depends on where you are in the system.

Patients can become informed (hard to do) and insist on the best treatment. For some ideas, see:

http://patientsafetyamerica.com

Those in the healthcare system should be striving to improve performance. How? Use TapRooT® to investigate medical errors and develop effective fixes is a start. But you can do more including learning new performance improvement ideas at the TapRooT® Summit.

I’d like to think there was a regulatory or government effort that could work miracles, but I’m afraid that most of the legislation in the healthcare arena has been a failure (and calling it a failure is probably generous).

So as a patient, arm yourself. And if you are a healthcare professional, do what you can with what you have to make progress possible.

What is you are in the government? Would it be too much to ask for accurate, public reporting of these accidents?

 

 

Monday Motivation: Be Curious!

Posted: April 21st, 2014 in Performance Improvement, Pictures

 

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Albert Einstein:

I have no special talents. I am only passionately curious.

Lessons Learned from the South Korean Ferry Disaster

Posted: April 20th, 2014 in Accidents, Current Events

I read an interesting Editorial in the New York Times about the Korean Ferry Accident. The writer urges us to consider 3 possible lessons learned:

1. Few great disasters have one single explanation.

2. Organizations may be more to blame than individuals.

3. Crowds interact unpredictably with technology.

What do you think?

See: http://www.nytimes.com/2014/04/19/opinion/learning-from-koreas-disaster.html?smid=pl-share

Press Release: CSB Announces Upcoming Report on the BP Deepwater Horizon Accident

Posted: April 20th, 2014 in Accidents, Current Events, Investigations

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Statement by CSB Chairperson Rafael Moure-Eraso on Fourth Anniversary
of Deepwater Horizon Tragedy in Gulf of Mexico;
CSB Investigation Reports to be Released at June 5th Public Meeting in Houston, Texas

As we approach the fourth anniversary of the April 20, 2010, Deepwater Horizon tragedy and environmental disaster in the Gulf of Mexico, I would like to announce that the comprehensive Chemical Safety Board investigation of the Macondo well blowout is in the final stages of completion and the first two volumes are planned to be released at a public meeting in Houston on June 5.

The death and destruction of that day are seared in our consciousness. The forthcoming CSB investigation report has a singular focus: preventing such an accident from happening again.

Eleven workers lost their lives, many others were injured, and oil and other hydrocarbons flowed uncontrolled out of the well for months after the explosion on the rig, owned and operated by Transocean under contract with BP. The CSB, at the request of Congress, launched an independent investigation with a broad mandate to examine not only the technical reasons that the incident occurred, but also any possible organizational and cultural causal factors, and opportunities for improving regulatory standards and industry practices to promote safe and reliable offshore energy supplies.

While a number of reports have been published on the incident, and changes made within the U.S. offshore regulatory regime, more can be done. On June 5, the CSB will release the first two volumes of our four-volume investigation report, covering technical, regulatory, and organizational issues.

The CSB examines this event from a process safety perspective, integrating fundamental safety concepts, such as the hierarchy of controls, human factors, and inherent safety into the U.S. offshore vernacular. While these concepts are not new in the petrochemical world or in other offshore regions around the globe, they are not as commonplace in the U.S. outer continental shelf.

At the public meeting, investigators will present for board consideration what I believe is a very comprehensive examination of various aspects of the incident.
Going beyond other previously released reports on the accident, the CSB explores issues not fully covered elsewhere, including:

  • The publication of new findings concerning the failures of a key piece of safety equipment—the blowout preventer—that was, and continues to be, relied upon as a final barrier to loss of well control.
  • A comprehensive examination and comparison of the attributes of  regulatory regimes in other parts of the world to that of the existing framework and the safety regulations established in the US offshore since Macondo.
  • In-depth analysis and discussion of needed safety improvements on a number of organizational factors, such as the industry’s approach to risk management and  corporate governance of safety management for major accident prevention, and  workforce involvement through the lifecycle of hazardous operations.

Recommendations will be included in the various volumes of the CSB’s Macondo investigation report.
Volume 1 will recount a summary of events leading up to the Macondo explosions and fire on the rig, providing descriptive information on drilling and well completion activities.

Volume 2 will present several new critical technical findings, with an emphasis on the functioning of the blowout preventer (BOP), a complex subsea system that was intended to help mitigate and prevent a loss of well control. This volume examines the failures of the BOP as a safety-critical piece of equipment and explores deficiencies in the management systems meant to ensure that the BOP was reliable and available as a barrier on April 20, 2010.

Later in the year, the board will consider report Volume 3 which will delve into the role of the regulator in the oversight of the offshore industry. Finally, Volume 4 will explore several organizational and cultural factors that contributed to the incident.

We look forward to presenting this vital information to the public, industry, Congress, and all others interested in fostering safety in the offshore drilling and production industry. 

END STATEMENT  For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496. 

Friday Joke: Ken Provides Drone Coverage for Summit

Posted: April 18th, 2014 in Jokes, Summit

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Yes, the Global TapRooT® Summit has gone high tech. Here’s a picture of Ken Reed providing arial drone coverage at the 2014 Global TapRooT® Summit. We all felt more secure with Ken keeping an overhead watch!

Root Cause Analysis Tip: TapRooT® is more than a Root Cause Analysis Tool – TapRooT® is Your Performance Improvement Partner!

Posted: April 16th, 2014 in Root Cause Analysis Tips, TapRooT, Video

If you are reading this you probably already know about TapRooT® as a root cause analysis system. If you don’t, watch this:

 

But we want to do more for our clients than helping them fix problems once and for all. We want to help them get a great return on investment from their improvement efforts.

Therefore, we don’t stop by just making TapRooT® the best root cause analysis system that we can invent. We continuously try to find new ideas, new methods, new ways for our clients to be more effective and efficient in their improvement efforts. And we also try to keep them passionate about their improvement efforts so their work can be sustained through the difficulties that people encounter when they try to may positive change occur.

But how do we get this information to the people who need it? Those out their on the factory floor, the oil rig, or even in the corporate boardroom? By several methods.

BLOG

First, we publish most of what we learn on the Root Cause Analysis Blog.

From these root cause analysis tips, to recent news about accidents, to articles about career development, to course pictures, to Summit information, to TapRooT® software update information, to job openings for TapRooT® users, to our Friday jokes (yes, you can have a sense of humor about improvement), we try to make what we write interesting, short, and to the point so that we communicate things that you may need to know without wasting a bunch of your time.

e-NEWSLETTER

Because many folks don’t have the time to jump on-line and read the blog every day, we take the information shared on the blog and condense it into a weekly newsletter. We are still experimenting to find the best format for this information to make it readable (or maybe “scannable” is a better word) so that you can pick out what is important to you and learn quickly. 

I know that everyone is busy but I think improvement information is important so that I hope you take the few minutes required to skim the weekly e-mail to see if there is anything important that you need to read and, if you can’t get to it right then, that you print it out for your professional reading stack.

SUMMIT

The main way we get the bulk of the details about new improvement ideas out to TapRooT® Users is the annual Global TapRooT® Summit. If you were at the 2014 Summit, you know the value of the best practice sharing and advanced improvement knowledge that goes on at the Summit. You also know that we have excellent keynote speakers to pass along great information and keep you motivated to make improvement happen. To find out more about the Summit, see the Summit web site:

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

We like to think of ourselves as you performance improvement partners. And now you know how we try to get the latest information to you to help you develop the most effective performance improvement program possible.  

How Far Away is Death?

Posted: April 15th, 2014 in Video

Doesn’t take a very big mistake by the excavator operator to make this a fatality…

Weekly Wisdom for Quality & Root Cause Analysis

Posted: April 15th, 2014 in Wisdom Quote

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“One cannot develop taste from what is of average quality but only from the very best.”
- Johann Wolfgang Von Goethe

Root Cause Analysis Training in the United Kingdom – Scotland TapRooT® Course Photos

Posted: April 15th, 2014 in Courses, Pictures

TapRooT® Instructor Harry Thorburn shared these photos from our March 31-April 4, 2014 5-Day TapRooT® Root Cause Analysis Team Leader Training in Aberdeen, Scotland. Enjoy!

Interested in learning more or attending a 5-Day TapRooT® Course? Click here to learn more about our 5-Day Course.

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2 Day TapRooT® Incident Investigation and Root Cause Analysis Course in Philadelphia

Posted: April 14th, 2014 in Courses

I am in Philadelphia this week teaching the 2 day course. Here are some pictures of day one activities:

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Why not join us for the next course? You can see the schedule and register HERE

2014 Global TapRooT® Summit Day 3 – Annual Summit Charity Golf Tournament

Posted: April 14th, 2014 in Courses, Pictures, Summit

We really enjoyed the gorgeous weather and fabulous course at the Horseshoe Bay Resort on Friday April 11th, 2014. Between your generous donations and System Improvements’ matching, we raised over $4,700 for Oasis of Love Women’s Shelter in Clinton, Tennessee. A big thank you to everyone who contributed to this wonderful charity.
Here are a few photos:

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The golf video/photo team.

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And the winners:

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John Malloy – Longest Drive on #4 and Closest to the Pin on #8

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Kim Page – Longest Drive #7

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Robert Pohl – Longest Drive on #10

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Steve Raycraft – Longest Drive on #11

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Michael Podgorny – Closest to the Pin on #3

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Lindsay Kemp – Closest to the Pin on #12

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Scott Robinson – Closest to the Pin on #17

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Ken Scott’s team of Buck Griffith, Loren Stagner, and Paul Larson was the winner again this year. Since this was our last golf tournament for a while, we were glad it was one of the best!

Monday Accident & Lessons Learned: Was the Baker Report a Failure?

Posted: April 14th, 2014 in Accidents, Performance Improvement

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For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.

I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”

The initial Panel Statement at the start of the report includes this quote:

“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”

I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.

What do you think?

Was the report successful? Did it cause change and help BP have an improved process safety culture?

Or did the report fail to cause change across the company?

And if it failed, why did it fail?

Let me know your ideas by leaving your comments by clicking on the comments link below.

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