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.
Could scheduling be a root cause of fatigue related errors? Navy OKs new watch schedule to reduce fatigue on submarines.Posted: April 22nd, 2014 in Human Performance, Root Causes
Finally an attempt to reduce fatigue on submarines. See the story here:
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:
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?
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.
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.
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.
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.
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:
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.
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.
I am in Philadelphia this week teaching the 2 day course. Here are some pictures of day one activities:
Why not join us for the next course? You can see the schedule and register HERE
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:
And the winners:
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!
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.
You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.
Best Summit EVER!
Had a great time and learned great new best practices.
Had people tell me that they often attend conferences and this was the best one they have ever attended BY FAR!
Another person told me that they took away practical things to improve performance from EVERY session and they were so excited that they texted, e-mailed, and called people back at work to get things implemented BEFORE they got back.
I post more next week … stay tuned!
This Summit has been a great one. We’ve enjoyed sunny Texas weather, gorgeous LBJ Lake sunsets, and a truly motivational time of learning root cause best practices and meeting new colleagues.
This morning, our own Barbara Phillips shared interviewing tips for reading non-verbal behavior. I never knew there were so many little body language signals to read and find out what people are really communicating! Baarbara also received an award for being a favorite speaker here at the TapRooT® Summit.
Then we gathered together in groups for our Planning Your Improvements sessions, and discussed the best practices we’ll bring back home to improve our workplaces.
And we ended our day and our 2014 TapRooT® Summit with a keynote address from Rocky Beleier, Vietnam Veteran and former Pittsburgh Steeler. What an honor to meet him and an inspiration to hear his story and what he learned through life’s challenges.
Now that the day’s done, we’re ready for more fun! We’re headed to our annual Summit Charity Golf Tournament. Join us tomorrow for photos of that!
What was your favorite part of the Summit experience? Share in the comments below!