Root Cause Analysis Blog

 

Monday Accident & Lessons Learned: UK RAIB Accident Report – Near-miss at Butterswood level crossing, North Lincolnshire, 25 June 2013

Posted: July 28th, 2014 in Accidents, Current Events, Investigations, Pictures

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The UK Rail Accident Investigation Branch issued a report about a train/car near miss at a crossing. Here is a summary of the report:

At around 07:35 hrs on Tuesday 25 June 2013 a passenger train was involved in a near-miss with a car on a level crossing near Butterswood in North Lincolnshire. The train passed over the level crossing with the barriers in the raised position and the road traffic signals extinguished. No injuries or damage were caused as a result of the incident.

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Normally, the approach of the train would have automatically initiated the closure of the crossing. However, the crossing was not working normally because the power supply to the crossing equipment had been interrupted. The crossing was of a type where train drivers are required to check that it is not obstructed as they approach and that it has operated correctly. A flashing light is provided for this purpose, just before the crossing, with a flashing white light displayed if the crossing has correctly closed against road users, and a flashing red light displayed at all other times (including those occasions when the crossing has failed to close on the approach of a train). The driver of the train involved in the near-miss did not notice until it was too late to stop that the flashing light was indicating that the crossing was not working normally, and was still open for road traffic.

The RAIB’s investigation found that the train driver had the expectation that the crossing would operate normally as the train approached and that he had not focused his attention on the flashing light at the point where he needed to confirm that the crossing had operated correctly for the passage of his train. Although the level crossing had probably failed around nine hours before the incident, the fact of its failure was not known to any railway staff.

The investigation also found that the crossing was not protected with automatic warning system equipment and that the maintenance arrangements at the crossing were not effective in ensuring reliable performance of the equipment. In addition, the train operator’s briefing material did not clearly explain to drivers their role in respect of failures at this type of level crossing.

The RAIB has identified four key learning points relating to non-provision of the automatic warning system at locations where it is mandated by standards, recording of the condition of assets during inspection, storage of batteries, and involving people with relevant technical expertise in industry investigations into incidents and accidents.The RAIB has made four recommendations. Three recommendations have been made to Network Rail addressing the indications given to train drivers approaching crossings where they are required to monitor the crossing’s status, improvements to the reliability of power supplies to crossings such as Butterswood and considering remote monitoring of the power supply at similar crossings. One recommendation has been made to First TransPennine Express regarding the briefing that it gives its drivers on this type of level crossing.

For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/140616_R122014_Butterswood.pdf

Weekly Wisdom for Root Cause Analysis, Quality, & HSE

Posted: July 28th, 2014 in Wisdom Quote

Lawson

 

“Quality is the degree of excellence with which a product or service fulfills its intended purpose.”

- Edward Lawson

Monday Motivation: John D. Rockefeller

Posted: July 28th, 2014 in Pictures

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Don’t be afraid to give up the good to go for the great. ~ John D. Rockefeller

Root Cause Analysis Training in Kentucky – Course Photo

Posted: July 25th, 2014 in Courses, Pictures

Ralph Blessing shared this photo of our July 22-23, 2014 class hard at work in Bowling Green, Kentucky. Thanks, all, for a great course!

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Click here to contact us and learn more about bringing TapRooT® Training to your facility.

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

Posted: July 24th, 2014 in Summit, Video

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®

Posted: July 24th, 2014 in Current Events, Performance Improvement, Video

Are you prepared for a tornado at your facility?

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

Throwback Thursday: TapRooT® Training

Posted: July 24th, 2014 in Courses, Pictures, TapRooT® Instructor

The picture below is of Mark Paradies helping attendees with their final TapRooT® training exercise. This course was held in beautiful Gatlinburg, TN located in the Great Smokey Mountains.

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Sign up for a course today! Just click on the link below to see what courses are available near you. Make sure to check out our discounts that are available when signing up!

http://www.taproot.com/courses

What fun story can you tell us about a TapRooT® training course? Please leave a comment below.

Things to Do in Seattle

Posted: July 23rd, 2014 in Courses, Video

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

 

 

Root Cause Analysis Tip: How Are Managers Involved in a Root Cause Analysis?

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

I’m sure the answer to this question varies from company to company. But I also know that the best root cause analysis programs I’ve seen had the most involved managers.

Here are some suggestions to consider…

FIRST, management should be asking for (demanding) root cause analysis. They should insist on it when something bad happens. And they should make sure that there are sufficient trained investigators available and that they have the time they need to actually investigate the problem. But also, management should insist that root cause analysis be used proactively to stop problems before they happen.

SECOND, management needs to set the standard for what is an acceptable root cause analysis. If management accepts substandard reports, presentations, and corrective actions, it will be no wonder that the program fails. But to set the standard, they must know what can be accomplished and what they should look for when they review the results of a root cause analysis.

THIRD, management needs to be self-critical and encourage investigators to look for Management System problems. See the Root Cause Tree® if you don’t understand what a Management System problem is.

FOURTH, management needs to make sure that investigators go beyond specific root causes and look for generic root causes. This should be part of the questions that management asks for every serious incident review.

FIFTH, management should make a special effort to reward good root cause analysis. I didn’t say perfect root cause analysis. Rewards should be for every good root cause analysis. 

Do these five points give you any ideas?

How Far Away is Death?

Posted: July 22nd, 2014 in How Far Away Is Death?, Pictures

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What could go wrong here?

 First, identify all sources of energy nearby.

Next, identify the safeguards for all sources of energy.

Are those safeguards adequate? Do we need more? Are any safeguards being violated (rules broken)?

Leave comments about your Safeguard Analysis.

And to learn to use TapRooT® and Safeguard Analysis, attend out 2-Day or 5-Day TapRooT® Courses.

Monday Accident & Lessons Learned: OPG Safety Alert – WELL CONTROL INCIDENT

Posted: July 21st, 2014 in Accidents, Current Events, Investigations

OGP Safety Alert

WELL CONTROL INCIDENT

While drilling 8″1/2 hole section @ 5052m with 1.51 SG MW, observe well flowing during pipe connection. Shut well in w/ 76 bbls gain. Establish 550psi SIDPP and 970psi SICP.

It took more than 7 minutes for the Driller to shut in after the well flowing situation was recognized (9 minutes 52 seconds total pumps off until well shut in) as follows: “The Mud Logger calls the dog house to inform the Driller that he has seen a gain in the trip tank; the Assistant Driller takes the call and communicates the information to the Driller. As the Driller is in the process of raising the blocks, he waits until the blocks are at 26m and calls the pit room to check that there is nothing that would affect the trip tank volume. He then waited for the return call which confirms nothing would affect the trip tank. The Driller switches over to the flow line as the trip tank is now nearly full and then lowers the TDS and screws back into the string at the rotary table. The string is then picked up and spaced out to close the annular mid joint; the Driller then unlocks the compensator. The annular is then closed by the Assistant Driller who is at the panel and the lower fail safes on the choke line are opened to monitor pressures.

Well was controlled using Drillers Method to circulate/increase MW up to 1.63 SG & decrease gas levels prior to open the well.

What Went Wrong?

Kick zone actual PP exceeds predicted PP range by ~0.07 SG EMW.

But actual PP < ECD (well not flowing while pumping).

76-bbl Kick Volume due to lengthy shut in Vs. ~30-bbl actual Kick Tolerance (KT) calculated from actual ~0.1 SG EMW Kick Intensity (design KT was 80 bbls calculated from maximum predicted PP). Note: There was gas in the influx, but no H2S. According to kick pressure & volume analysis, it is possible that part of the kick was liquid (influx density calculation). Influx density helped evacuating the kick w/out exceeding MAASP & fraccing @ shoe on exceeded KT.

Corrective Actions and Recommendations:

  1. Flow check each connection prior to starting the physical breaking of the tool joint (rather than flow check during connection).
  2. Ensure effective monitoring of the Mud Logging fingerprint screen during pumps-off real-time (connection & mid-stand “long connection test”).
  3. Correct shut-in procedure to be enforced & applied.
  4. Perform unannounced simulated kicks (kick drills).
  5. Whenever possible, implement a Well-Full-of-Gas capable casing design so that KT is not limited.

Source Contact:

safety alert number: 257 

OGP Safety Alerts http://info.ogp.org.uk/safety/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Monday Motivation: Oscar Wilde

Posted: July 21st, 2014 in Pictures

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What seems to us as bitter trials are often blessings in disguise. ~ Oscar Wilde

Weekly Wisdom for Quality, HSE, and Root Cause Analysis

Posted: July 21st, 2014 in Wisdom Quote

Goss

 

“Production is not production without quality.”

- Bill Goss

Remembering an Accident: Val di Stava Dam Collapse

Posted: July 19th, 2014 in Accidents, Video

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 Tip: Is Human Error a Root Cause?

Posted: July 17th, 2014 in Human Performance, Root Cause Analysis Tips, Root Causes

A frequent question that I see in various on-line chat forums is: “Is human error a root cause?” For TapRooT® Users, the answer is obvious. NO! But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.

First, we define a root cause as:

the absence of a best practice or the failure to apply knowledge that would have prevented a problem.”

But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors. 

How does the Root Cause Tree® work?

First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.

The seven Basic Cause Categories are:

  • Procedures, 
  • Training, 
  • Quality Control, 
  • Communications, 
  • Human Engineering, 
  • Work Direction, and 
  • Management Systems.

If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.

The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).

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The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by clicking here.

If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise. 

Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.

How can we make such a risk-free guarantee?

Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance. 

Throwback Thursday: 2009 Chile Course

Posted: July 17th, 2014 in Courses, Pictures, TapRooT

Throwback to 2009 in Chile. Chile is just one of the many places where you can receive training and hands on experience with a certified TapRooT® instructor. 

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Thinking about signing up for a TapRooT® Training class? Click here to find out what courses are available near you.

What was your favorite moment at a TapRooT® course? Please leave comments below.

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

Posted: July 17th, 2014 in Summit, Video

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

Blame Comes Quickly in Moscow Subway Accident – When Will the Root Causes Be Investigated?

Posted: July 16th, 2014 in Accidents, Current Events, Investigations

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The Christian Science Monitor reported that the spokesperson for the Kremlin’s Investigative Committee (a police body) said:

As it is a man-caused accident, it is obvious that there are people responsible for it, so soon there will be suspects in the case.

Later the International Business Times published this headline:

Moscow Subway Accident: 2 Arrested Metro Workers Failed To Properly Supervise Track Switch Repair, Authorities Say

It seems the two arrested supervised a job where a track switch was re-wired with the wrong wire.

Twenty-one have died, over a hundred were injured, and over 1000 people had to be evacuated from the subway after the accident.

What do you think? Will discipline solve the problem? Or does a real root cause analysis need to be done?

Root Cause Analysis Training in the UK – Onsite Course Photos

Posted: July 16th, 2014 in Courses, Pictures

Thanks to Mhorvan Sherret, the TapRooT® Instructor who sent over these photos from a great course he taught in Warwick England June 12-18, 2014. Enjoy!

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Contact us for more info on bringing world-class root cause analysis training to your facility.

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