Root Cause Analysis Blog

 

Root Cause Analysis Training in Ohio – Dayton’s Local Attractions

Posted: August 21st, 2014 in Courses, Local Attractions

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Dayton, Ohio may seem like your average midwestern town, but look a little closer and you’ll find a life and personality all its own. Dayton is the home of the Wright Brothers, so the history of aviation permeates the town. It’s also got a strong arts, dining, and craft beer scene, with Warped Wing brewery located in Oregon Historic District. While you’re in town attending our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course this September 15-16, 2014, stop by a few of these restaurants and take a little bit of time to enjoy the fun Dayton has to offer:

 

Food

Voltzy’s Weiner World - Hot dogs, root beer, coneys, and burgers are the casual fare of this hometown joint.

The Paragon Supper Club - A great place to sit down for a nice steak dinner after the course.

Lucky’s Taproom - A fantastic selection of craft beer, including the local Warped Wing brand.

Slyder’s Tavern - Hailed as “the best burger in town” by locals.

Marion’s Piazza - Voted Dayton’s #1 pizza, this place has been around since 1965.

 

Activities

National Museum of the US Air Force - America’s oldest and largest military aviation museum in the world, with over 100 aircrafts to see and 11 exhibits separated by era.

Warped Wing Brewery - Stop by for a tasting at Dayton’s local brewery.

The Neon - Enjoy independent movies with a beer or cocktail at this eclectic movie theatre.

America’s Packard Museum - Located in the former Packard auto factory, this museum holds over 50 beautifully restored historical cars.

Riverscape MetroPark - Relax and unwind after the TapRooT® course with a stroll in the park along the Miami River.

Would you like to learn to find and fix the real root causes of problems in your workplace? Click here to register or find out more information: 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OH.

Throwback Thursday: Scotland

Posted: August 21st, 2014 in Pictures, Root Causes, TapRooT, Training

Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!

Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!

SnapChartExercise2

Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.

Root Cause Analysis Tips – Doing Better Investigations (Part 1)

Posted: August 20th, 2014 in Root Cause Analysis Tips, Video

Hello and welcome to this week’s root cause analysis tip. This week the topic is doing better investigations.

The most important thing you can do for better investigations is to use TapRooT®! But assuming you already do that, here are some more tips that I hope will help.

The first thing to think about is preparation – does your company have an investigation policy and does everyone know their roles and responsibilities? In other words, do you have a plan? The time to develop your plan is not after you have had a major incident! You can refer to Appendix A of the TapRooT® book for a sample plan; however, I would imagine most of you already have a plan at your company, so your preparation is simple – read the plan and understand it.

Think about Notification – Who, and under what circumstances? Let senior management know someone’s working on the investigation.  You can share the preliminary information as well. Set expectation that it may take some time. They’ll often back off and let you do your job if you tell them these things.

Plan your investigation – what kind of photos, documents, equipment reliability data do you need? Plan what data to collect and how you’re going to collect that data.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart. Interviewing is and important part of evidence collection. Follow our 14-Step interview process, it’s in the book. The best way to interview is to let the person tell their story, they may answer your questions without you even needing to ask. If you only ask questions, you’ll only get the answers to your questions and nothing else.

Join us next week for Part 2 of Dave’s tip on Performing Better Investigations!

 

TapRooT® Around the World: Europe, India, and Africa

Posted: August 20th, 2014 in Courses
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A Nigeria class smiles after completing their SnapCharT®.

Click any of the dates & locations to learn more about the course and its details.

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Stavanger, Norway September 2-3, 2014

Aberdeen, Scotland | September 4-5, 2014

Johannesburg, South Africa | September 4-5, 2014

 

3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Stavanger, Norway | September 2-4, 2014

Aberdeen, Scotland | September 4-6, 2014

 

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Manchester, England | September 29-October 3, 2014

Final Exercise at the 5-Day TapRooT® Advanced Root Cause Analysis Course in Seattle

Posted: August 19th, 2014 in Courses, Pictures, TapRooT

Just before starting the exercise …

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Teams working on their incidents …

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Instructions just prior to the presentations …

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Teams presenting …

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For more information about TapRooT® Root Cause Analysis Courses, see:

http://www.taproot.com/courses

How Far Away is Death?

Posted: August 19th, 2014 in How Far Away Is Death?, Video

Don’t stand under a load (or nearly under a load)! Click this video link below to watch…

WatchtheLoad.mp4

Weekly Wisdom for Root Cause Analysis & HSEQ

Posted: August 19th, 2014 in Wisdom Quote

Seng

 

“If you have no time for quality, then why do you have time for rework?”

- Sng Yang Seng

Career Development: Traits of Exceptional Employees

Posted: August 19th, 2014 in Career Development, Career Development Tips

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Have you ever wondered can make your work (and yourself) stand out from the crowd? Ever thought about what got your buddy that promotion, or how you can make the most of the position you’re in? Forbes.com shared 18 traits of exceptional employees on their blog this week, and we think these are great ways to amp up your professional game. Enjoy the first four traits below:

1. They rewrite their internal monologues. A strong will to win knows how to push out the negative voices bantering back and forth inside one’s head and instead create a voice that challenges such negativity. In so doing, they answer their newly formed questions and turn the self-limiting “Why can’t I do [task]?” question into the exploratory “How can I do [task]?”

2. They have a healthy disregard for authority. Employees with a strong will to win consider the rulebook as more of a guide while still working within the confines of what’s “right.” In other words, exceptional employees know how to solve problems creatively while not breaking the rules.

3. They don’t wallow in regret. Exceptional employees feel good about their performance because they know they gave it their all. If a big fat “L” (for “Loser”) is the takeaway for the day, they will learn, adapt and move on.

4. They display grit. In my BUD/S (Basic Underwater Demolition/SEAL Training) class we started with 174 students who wanted to be Navy SEALs, but only 32 of us truly desired it. Why? Because the latter group chose to enact the defining quality that bridges the gap between want and wish, purpose and passion. What I’m talking about is grit.”

Click here to read the rest of the article:

http://www.forbes.com/sites/jeffboss/2014/08/11/18-characteristics-of-exceptional-employees/

 

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Monday Accident & Lessons Learned: OPG Safety Alert – Well Control Incident – Managing Gas Breakout in SOBM

Posted: August 18th, 2014 in Accidents, Investigations

Safety Alert Number: 258 

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

While drilling at a depth of 4747m, the well was shut-in due to an increase in returns with a total gain of 17bbls recorded. The well kill needed an increase in density from 1.40sg to 1.61sg to achieve a stable situation. With the well open the BHA was pumped out to the shoe and tripped 400m to pick up a BOP test tool to perform the post-kill BOP test.

The BOP and choke manifold test were performed as well as some rig maintenance. The BHA was then tripped into the hole and the last 2 stands were washed to bottom. Total pumps-off time without circulation was 44 hours.

Gas levels during the bottoms-up initially peaked at around 14% and then dropped steadily to around 5%. HPHT procedures were being followed and this operation required circulation through the choke for the last 1/3 of the bottoms up. This corresponds to taking returns through the choke after 162m3 is circulated.

After 124 cubic metres of the bottoms-up had been pumped the gas detector at the bell nipple was triggered. Simultaneously, mud started to be pushed up out of the hole, reaching a height of around 1 joint above the drill floor. The flow continued for around 30 seconds corresponding to a bubble of gas exiting the riser. The pumps and rotation were shut down, followed by closure of the diverter, annular and upper pipe rams. Approximately 2bbls of SBM were lost over-board through the diverter line. The flow stopped by itself after just a few seconds and casing pressure was recorded as zero. No-one was on the drill floor at the time and no movement, damage or displacement of equipment occurred.

After verifying that there was no flow (monitored on the stripping tank) the diverter was opened and 10 cubic metres of mud used to refill the riser, equal to a drop in height of 56m.

The riser was circulated to fresh mud with maximum gas levels recorded at 54%. This was followed by a full bottoms up through the choke.

A full muster of POB was conducted due to the gas alarms being triggered.

What Went Wrong?

Conclusion – An undetected influx was swabbed into the well during the BOP test which was then circulated up inadvertently though a non-closed system breaking out in the riser.

  1. Stroke counter was reset to zero after washing 3 stands to bottom (this resulted in 136 cubic metres of circulation not being accounted for in the bottoms up monitoring).
  2. Review of Monitoring While Drilling Annular Pressure memory logs identified several swabbing events identified – main event was when the BOP test tool was POOH from the wellhead – ESD as measured by APWD dropped to 1.59sg on 10 or 11 occasions.
  3. Swabbing was exacerbated by Kill Weight Mud not having sufficient margin above PP.

Corrective Actions and Recommendations:

  • Take into account all washing to bottom for any circulation where bottoms up is to be via choke.
  • Tool Pushers shall cross check the bottoms up calculation and joint agreement on reset of the stroke counter.
  • All BHA tripping speeds to be modeled so that potential swabbing operations are identified and so that tripping speed limits can be specified.
  • Verify, when possible, actual swabbing magnitude using PWD memory logs (ie after a trip out of the hole).
  • Pumping out (even inside liner/casing) shall be considered in tight tolerance liner/drilling BHA. Modeling shall be used to underpin the decision.

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: Vidal Sassoon

Posted: August 18th, 2014 in Pictures

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The only place where success comes before work is in the dictionary. ~ Vidal Sassoon

Things to Do: Nashville, TN TapRooT® Root Cause Analysis Course

Posted: August 14th, 2014 in Courses, Local Attractions

On August 2oth System Improvements will be in Nashville, TN hosting a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. There will be plenty of opportunity to get out and explore the city after each day of the course, or you may want to spend a few extra days after the course to really go out and experience all Nashville has to offer.

Nashville is full of culture and entertainment, after all it’s nickname is Music City. Nashville has great food, shopping, music, kid activities, and all around fun for all ages. Below I have listed some of my favorite things to do when visiting. Just click on the links to learn more information about each activity.

Food:

The Pharmacy Burger Parlor and Beer Garden – The Pharmacy is a one of a kind burger joint and a must have while visiting Nashville. They have great bratwurst as well and their sweet potato fries are to die for. 

Capitol Grille – Looking for something with southern flare? Look no further, Capitol Grille takes traditional southern dishes and adds a twist. They uses home grown vegetables and all the meat is farm raised just miles from the restaurant. 

Margot Café and Bar – If you enjoy French and Italian cuisine Margot Café is the place for you. Margot Café has a great atmosphere and wonderful food.

Patterson House – If you are looking for a more intimate dining experience Patterson’s is the place for you. They have fantastic bar drinks and amazing food. The atmosphere in Patterson’s is truly unique. Probably one of my favorite spots in Nashville.

Activities:

Parthenon – You won’t want to miss this full-scale replica of the Athenian Parthenon located in Nashville’s Centennial Park. The Parthenon also serves as Nashville’s Art Museum.

Belle Meade Plantation – The Belle Meade is a beautiful historic plantation that now serves as a museum. It also offers free wine tasting when you visit.

Broadway Street – A trip to Nashville wouldn’t be complete without visiting the infamous Broadway St. Broadway is full of shopping, restaurants, and it has a happening night life.

The Hermitage – The Hermitage is a plantation that was home to President Andrew Jackson and is open to the public for historic tours. Located just 10 miles outside of Nashville.

Music:

Country Music Hall of Fame – A place where you can learn about the origins of country music and its’ Hall of Fame inductees, such as Hank Williams.

Grand Ole Opry The Opry holds weekly performances of country music legends and chart-toppers performing country, bluegrassfolkgospel, and comedic performances and skits

General Jackson Showboat - Take a sight seeing cruise down the Cumberland River where you can enjoy dinner and show.

For the Kids:

Adventure Science Center – This massive center offers fun for the whole family. With nearly 44,000 square feet the Center offers 200 hands on activities that will educate and inspire your children.

Nashville Zoo – The Nashville Zoo is a unique zoo with a historic plantation house attached to it called Grassmere.

Want to join in on the fun? It is easy, just click here and register today!

What is your favorite thing to do in Nashville, TN? Please leave comments below.

Food Industry Related OSHA General Duty Clause Citations: Did you make the list? Now what?

Posted: August 13th, 2014 in Accidents, Current Events, Equipment/Equifactor®, Investigations, Pictures, Quality, Root Cause Analysis Tips, Root Causes, TapRooT, Training

OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities

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Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.

Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……

Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:

The hazard referenced in Inspection Number [insert 9-digit #]

for violation identified as:

 Citation [insert #] and item [insert #] was corrected on [insert

date] by:

 

Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..

….are the findings correct?

….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?

….is the finding a generic/systemic issue?

As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:

 

o   SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.

o   Root Cause Tree®: an easy-to-use resource to determine root causes of problems.

o   Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.

In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments

Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review

http://www.taproot.com/archives/43841

If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:

BENCHMARKING ROOT CAUSE ANALYSIS

http://www.taproot.com/archives/45408

 

TapRooT® Software Version 5.3.2 Release Announcement

Posted: August 13th, 2014 in Software Updates

We are very pleased to announce the release of our Version 5.3.2  TapRooT® Single User Software.

The majority of the enhancements in the Version 5.3.2 TapRooT® Software were to repair minor bugs or known issues.  A detailed list of these enhancements is found below.

TAPROOT® 5.3.2 ENHANCEMENTS

  • Investigation Reports display issues were resolved for those who had non-standard SQL Collation installations.
  • Custom Details fields are now visible on the display list, even when they are inactive.
  • Custom Details Currency fields are displaying the label and currency symbol properly in all cases.
  • Corrective Action Priority field is restored.
  • Corrective Action Editor now validates and prompts if you want to save your work when selecting CLOSE.
  • Root Cause Tree® validates and displays all changes when switching between front and back page.
  • Root Cause Tree® displays all Red X’s in print mode.
  • Root Cause Tree® documents can be deleted from the 7 Step Process page.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Entergy Services)

Posted: August 13th, 2014 in Root Cause Analysis Tips, Summit, Video

Darlene Normand of Entergy Services 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 got everyone engaged and having fun while teaching them TapRooT®:

If you’re at work and don’t have time to watch the video, here’s her tip:

“Hello my name is Darlene Normand. I’m with Entergy Services, fossil section. We’re building a new plant. We had a conference last year and I was tasked with teaching everyone a little bit about TapRooT®. We cover four states and they heard about TapRooT® because they were getting these corrective actions to put in place, but they didn’t know what it was. So how do you teach 1000 people about TapRooT® and make it fun? Well, I came up with a game, and called it the TapRooT® scramble. (I think I called Ken Reed and said “Hey, you got anything for me?”) I made a SnapCharT®. I used the pothole story from the 5-day class and I made puzzle pieces from the SnapCharT®. I had them all scrambled. I think I did 20 groups. I would give them the story, put them in teams, and their goal was to put the SnapCharT® in the sequence that it went. It went over well; the VPs and the directors got a little taste of it, and some people even took it back to their plants and started changed some of their ways with TapRooT®. It got the message across. It was fun.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

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

Root Cause Tip: What Should We Improve Next?

Posted: August 13th, 2014 in Performance Improvement, Pictures, Root Cause Analysis Tips

Every company I’ve worked with has an existing improvement program.

Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some  still have a long ways to go, but have started their improvement process.

No matter where you are, one question that always seems to come up is …

What should we improve next?

The interesting answer to this question is that your plant is telling you if you are listening.

But before I talk about that, let’s look at several other ways to decide what to improve…

1. The Regulator Is Emphasizing This

Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.

2. Management Hot Topic

Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…

  • A recent accident (at your facility or someone else’s).
  • A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
  • That the CEO has a new initiative.

You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.

3. Industry Initiative

Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.

All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.

So how should you decide what to improve next?

By listening to your plant/facility.

What does “listening to you plant” mean?

To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.

Reactively collecting signals comes from your accident, incident, near-miss investigation programs.

It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.

I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.

Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.

Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).

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Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.

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Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler - see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)

Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.

Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.

 

 

 

TapRooT® Around the World: Europe, India, and Africa

Posted: August 13th, 2014 in Courses
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A Paris, France class discusses their SnapCharT®.

Click any of the dates & locations to learn more about the course and its details.

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Stavanger, Norway September 2-3, 2014

Aberdeen, Scotland | September 4-5, 2014

Johannesburg, South Africa | September 4-5, 2014

 

3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Stavanger, Norway | September 2-4, 2014

Aberdeen, Scotland | September 4-6, 2014

 

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Manchester, England | September 29-October 3, 2014

Mumbai, India | September 22-26, 2014

Hydrocarbon Process Reports: “Pemex Blast at Ciudad Madero Refinery Kills Four Workers, Injures More”

Posted: August 12th, 2014 in Accidents, Current Events

An oil refinery in Ciudad Madero burst into flames earlier this week killing four workers. After evaluating the situation, officials determined that the refinery was under maintenance and not operating at the time of the fire. What caught fire? How did this happen? Reports indicated that this particular refinery, being the smallest of six in the company, may not have been producing it’s quota for daily production due to refining inefficiencies and infrastructure that went ignored for too long.

Fortunately, this accident forced the government to pass a law for private investments for the National Energy Industry. Consequently, they waited too long to invest in this maintenance and inefficiencies which lead to destruction.

See:

http://www.hydrocarbonprocessing.com/Article/3370103/Latest-News/Pemex-blast-at-Ciudad-Madero-refinery-kills-four-workers-injures-more.html

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