Root Cause Analysis Blog

 

WANTED: New Equifactor® Equipment Troubleshooting Tables

Posted: August 29th, 2016 in Equipment/Equifactor®

equipment troubleshooting table

We’re pretty excited about the new TapRooT® VI software service that we released this year. It has some terrific features that are a definite upgrade to the older Version 5 software.

As part of the conversion over to TapRooT® VI, we did an in-depth review of the Equifactor® equipment troubleshooting tables. We found we were able to streamline those tables to make them even easier to use. We dropped some redundant items, standardized some of the terminology, and generally mde them easier to use. Additionally, TapRooT® VI allows you to take the items from the Equifactor® table and drop them right onto your SnapCharT®. It’s a feature we’ve been asked about for quite a while, and the TapRooT® VI architecture finally let us add this enhancement.

I am currently looking for new ideas for tables you would be interested in seeing added to Equifactor®. What general categories of equipment would you like to see developed and added to the system? Some we might be able to do; some aren’t really very conducive to putting into a table format. For example, I was asked to develop tables to troubleshoot PLC problems. While this would be great, there are unfortunately hundreds of different models and types of PLC’s out there, and a simple set of tables would be really tough to do.

Another idea was for hydraulic system troubleshooting. Again, this might be to broad a category. However, I am researching the possibility of doing more specific tables on things like hydraulic cylinders and motors. These might be specific and generic enough that we can put together a useful set of tables.

So what would you like to see? Let me know, and I’ll be happy to take a look.

Monday Accident & Lessons Learned: Passenger Trapped & Dragged by Train

Posted: August 29th, 2016 in Accidents, Current Events, Investigations, Pictures

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From the Rail Accident Investigation Branch …

At around 13:10 hrs on 25 July 2015, a passenger was dragged along the platform at Hayes & Harlington station, London, when the 11:37 hrs First Great Western service from Oxford to London Paddington departed while her hand was trapped in a door. The passenger, who had arrived on the platform as the doors were about to close, had placed her hand between the closing door leaves.

The train driver did not identify that the passenger was trapped and the train moved off, dragging the passenger along the platform. After being dragged for about 19 metres, the passenger lost her footing and fell onto the platform. The passenger suffered head, hand and back injuries.

RAIB’s investigation found that the passenger had deliberately placed her hand in the closing door in the expectation that it would re-open as a consequence. RAIB has concluded that after closing the doors of the train, the driver either did not make a final check that it was safe to depart, or that the check was insufficiently detailed to allow him to identify the trapped passenger. The driver may have been misled into thinking that it was safe to depart because a door interlock light in his cab had illuminated, indicating that the doors were closed and locked and he was able to take power.

Our investigation identified that the train driver and other railway staff held the same misunderstanding: if someone had a hand trapped in a door it would not be possible for the door interlock light to illuminate and a driver to take power. This is not the case, and the door was found to be compliant with all applicable standards after the accident.

As a consequence of this investigation, RAIB has made two recommendations.
The first, addressed to RSSB to review, and if necessary extend, its research into the passenger/train interface to understand passenger behaviour and identify means for deterring members of the public from obstructing train doors.

The second recommendation is addressed to operators and owners of trains similar to the one involved in the accident at Hayes & Harlington, is intended to continue and expand upon a current review into the practicability of fitting sensitive door edge technology to this type of train.
RAIB has also identified three learning points. The first concerns improving awareness among train drivers of the limitations of train door interlocking technology and the importance of the final safety check when dispatching a train.

The second concerns the potential for drivers to be distracted by the use of mobile communication devices while driving.

The third is aimed at train operators to have the necessary processes in place to identify drivers who are showing signs of sub-standard performance or not engaging positively with measures agreed as part of a Competence Development Plan and the provision of briefing and guidance material for driver managers to enable them to identify behaviours and attitudes which are inconsistent with those expected of train drivers.

For the complete report, see:

https://assets.publishing.service.gov.uk/media/577395aded915d622c0000c9/R122016_160630_Hayes_and_Harlington.pdf

Monday Motivation: The right way to the top

Posted: August 29th, 2016 in Career Development, Career Development Tips, Wisdom Quote

pablo (26)

Regardless of where you work or what your title is, everyone must find ways to meet their individual goals and create a path to get there.  Is it easy to move up at your organization? Or will you need to weave around?  Make it a good and honorable journey, contribute where ever you can, and know when you get to the top, you earned the view.

Medical Errors: Are You Preventing Pressure Ulcers?

Posted: August 26th, 2016 in Medical/Healthcare

Medical Error Prevention

My wife was in a cast a few years ago. After about a day, she noticed it was itchy on the bottom of her foot, near her big toe. We didn’t think anything of it (never in a cast before). When we went in for a checkup after a few days, she told the doctor. They pulled off the cast and found a blistery area on the bottom of her foot. It was caused by a slight pressure from a bump in the cast, which cut off blood flow to that small area on the ball of her foot. It ended up being pretty minor (big blister the size of a half dollar), and it healed up just fine.

I was amazed to find out that this can be fairly common after only a few hours in a stationary position, for example, during surgery. They can turn out to be very painful and potentially disfiguring. DO NOT, under any circumstances, Google for pictures of pressure ulcers!

Here is a guide on how the medical community can help prevent pressure ulcers. It is meant to be a proactive means of looking for opportunities to prevent or detect the circumstances and risk factors associated with perioperative pressure injuries.

Employment Opportunity: Director HSE, Matrix Service

Posted: August 25th, 2016 in Career Development, Job Postings

We just received this job posting for a candidate who is interested in providing leadership and direction of the HSE function for the Matrix Service organization, including U.S. and Canadian locations.  This position will manage the HSE organization through HSE professionals in each operating division.

Learn more or apply on-line here.

Technically Speaking – Creating a Custom List

Posted: August 25th, 2016 in Software, Software Updates, Technical Support, Technically Speaking, Video, Video Depot

This week I ‘d like to walk through the quick and easy process to create a new custom list in our TapRooT® VI software.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Hand Hygiene: Patient Safety Through Infection Control

Posted: August 24th, 2016 in Medical/Healthcare, Performance Improvement

Hand Hygiene_Patient Safety Through Infection Control

I remember my mom telling me to “wash my hands before supper”. Something that we all should know how to do, yet vitally important in the medical community.

How hard can it be to wash your hands? If I told you to “Wash your hands before changing that bandage,” how would you do it? What soap would you use? How do you dry your hands afterwards? At what point in the procedure do I actually have to wash your hands? As you can see, there are lots of opportunity to make a mistake and cause a problem, unless you have the answers to these questions.

Hand Hygiene: A Handbook for Medical Professionals is an about-to-be-released book on how to properly hand infection control in a variety of circumstances.  It puts all of these lessons learned into a single reference for a professional to figure out the right way (and the wrong way) to prevent the spread of infections between patients.

Rickover Quote…

Posted: August 24th, 2016 in Performance Improvement, Pictures

When you waste your time remember …
Even God cannot undo the past.

Admiral Hyman Rickover 

RickoverSub

What does a bad day look like?

Posted: August 24th, 2016 in Pictures

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Bet you will be watching trees for porcupines for a while …

Weekly Wisdom: Take risks.

Posted: August 23rd, 2016 in Wisdom Quote

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“You can’t fall if you don’t climb. But there’s no joy in living your whole life on the ground.” -Unknown

TapRooT® Around the World: Shenzhen, China

Posted: August 23rd, 2016 in Courses, Pictures

TapRooT® recently traveled to Shenzhen, China for an Onsite Course.

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shenzhen china

Register for a public course.

Inquire about an onsite course.

The Joint Commission Summary of Sentinel Events – 2Q 2016

Posted: August 22nd, 2016 in Uncategorized

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Here’s a summary for reported sentinel events for the 2nd quarter of this year, compiled by The Joint Commission. It also compares some of the data against previous years.
It is almost impossible to make accurate comparisons on this data, since all reports are voluntary and, as stated in the report:

Data Limitations: The reporting of most sentinel events to The Joint Commission is voluntary and represents only a small proportion of actual events. Therefore, these data are not an epidemiologic data set and no conclusions should be drawn about the actual relative frequency of events or trends in events over time.

Without knowing who is reporting, who is not reporting, how these numbers are compiled or arrived at, how the problem types are assigned, etc., I’m having a tough time viewing the data in an objective light.

While the data is interesting, I’m not sure how this data is used.  Can anyone give me an example of how the data in this summary might be used?

Monday Accident & Lessons Learned: CORROSION COUPON PLUG EJECTED FROM PRESSURIZED PIPELINE

Posted: August 22nd, 2016 in Accidents, Current Events, Investigations, Performance Improvement

The following is a IOPG Safety Alert from the International Association of Oil & Gas Producers…

IOGP SAFETY ALERT

CORROSION COUPON PLUG EJECTED FROM PRESSURISED PIPELINE

Target audience:

Personnel accountable or responsible for pipelines and piping fitted with corrosion coupons.

What happened:

A routine corrosion coupon retrieval operation was being conducted on a 28” crude oil pipeline. Two retrieval technicians were located in a below ground access pit, to perform the operation. The operation involved removal of the corrosion coupon carrier ‘plug’ from its threaded 2” access fitting on the pipeline. The plug was ejected at high velocity from the access fitting (pipeline pressure 103 bar), during the operation to ease the plug using a ring spanner to a maximum of ¼ turn (as per procedure) and before the service valve and retrieval tool were installed. A high volume of crude oil spilled from the pipeline via the access fitting. Fortunately, the two technicians escaped the access pit without injury from the plug projectile or crude oil release.

What Went Wrong?

The Venture is still in the process of conducting the incident investigation. Based on their findings to date, the most probable cause is that the threads of the access fitting were worn down to such an extent, that they were unable to restrain the plug upon minor disturbance (the ¼ turn of the plug).

  • The access fitting was installed during pipeline construction in 1987. It is estimated to have been subject to over 140 coupon retrieval and installation cycles.
  • Bottom-of-pipeline debris can cause galling of threads on stainless steel plugs, which in turn can damage the threads of carbon steel access fittings.
  • The repair (chasing) of worn threads on access fittings is performed using an original equipment manufacturer supplied thread tap assembly service tool.
  • In the presence of bottom-of-pipeline debris and thread damage, the repetitive removal of internal thread material, can lead to ever smaller contact surfaces, increasing contact stress, increasing wear rates and/or galling.
  • Smaller thread contact surfaces reduce the ability of the access fittings to restrain plugs.
  • In this incident, the original equipment manufacturer supplied thread tap assembly service tool had been used routinely for every plug coupon retrieval and installation cycle without the use of flushing oil to remove debris from the threads.

Corrective Actions and Recommendations:

Lessons Learned –

  • As yet, there is no standard method to determine internal thread condition of on-line corrosion probe/coupon original equipment manufacturer access fittings. Thread condition is not easily inspected.
  • The risk posed by long term use of thread tap assembly service tools on access fittings, has not been previously identified.

Action taken in originating company –

Temporarily suspend all corrosion coupon retrieval operations on pressurised lines furnished with threaded access fittings in the 6 o’clock position (bottom of pipeline). This provides time to complete the investigation and complete work with the original equipment manufacturer to develop clear guidance on the maximum number of retrieval cycles.

  • A subsequent notification will be issued based on the completed investigation and original equipment manufacturer tests*. In this alert any changes to guidance or maintenance routines (i.e. how and when these type operations can be recommenced) will be advised.
  • The temporary suspension does not cover retrieval operations on lines which are depressurised.

* the use of ‘no go’ gauges for checking access fittings after every use of a thread tap assembly service tool or access fitting body seat reamer, is being explored.

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP 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.

Safety Alert Number: 273 

IOGP Safety Alerts http://safetyzone.iogp.org

Severe Pump Damage Due To Inadequate Analysis

Posted: August 22nd, 2016 in Equipment/Equifactor®

Cavitation

Here is a great example of damage to large pumps resulting from a poor understanding of the operating environment. When coupled with inferior manufacturing techniques, rapid failure of critical equipment can occur.

TapRooT® Around the World: Monterrey, Mexico

Posted: August 22nd, 2016 in Courses, Pictures

Just last week TapRooT® held a 2-Day public course in Monterrey. What a great class!

Register for a TapRooT® Public Course today!

Inquire about an Onsite Course for your company!

Monday Motivation: Failure is Better than “What if”

Posted: August 22nd, 2016 in Career Development, Career Development Tips, Wisdom Quote

pablo (25)

It’s a funny thing about life. You never know until you try, but to try is to risk failure. If you don’t try. you’re stuck in the “what if” your entire life. Try and know. Even if you fall, you’ll learn some things on the way down to help you rise a better person.

Things to do in Johannesburg, South Africa

Posted: August 18th, 2016 in Courses, Local Attractions

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September 12-16 |  TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Training | Are you coming?

Johannesburg, or Joburg as the locals call it, is an amazingly diverse city that goes unnoticed. It is said to be the world’s largest city not located directly on a water source, however, it is located on mineral rich land where the city’s source of gold and diamonds come from. It is also known as Africa’s economic powerhouse due to it being the largest economy of any metropolitan area in Sub-Saharan Africa. Not only that, it’s rich history with Apartheid and Nelson Mandela are what really make the country of South Africa an historical landmark. Visit Joburg and see what this massive city has to offer, including our TapRooT® 5-Day course.

Food:

Mugg & Bean Cafe: This delicious little cafe offers a little of everything from barbeque and quesadillas to cupcakes and soups.

Lucky Bean Guesthouse: Enjoy a contemporary restaurant serving traditional African foods with a modern twist.

SalvationCafe: If you love gourmet flavors and branching out from the everyday menu, check out this quaint cafe.

Attractions:

Gold Reef City: Fun on every corner! Theme parks, dining, theaters, etc await you as you stroll through and take it all in.

Apartheid Museum: This highly-rated, very well-done history museums is an educational, impacting experience for anyone!

Liliesleaf Farm: If you like museums, this one will definitely catch your eye. Through interactive exhibits, learn about the deep history and struggle of South African liberation in the secret headquarters of the African National Congress.

Ready to register? Click Here.

Interested in other TapRooT® Public Courses? Click Here.

Inquire about a TapRooT® Onsite Course: Click Here.

Rickover Quote…

Posted: August 18th, 2016 in Performance Improvement, Pictures

At this school, the smartest work as hard
as those who must struggle to pass.

Admiral Hyman Rickover 

RickoverTraining

Technically Speaking – Helpdesk Humor

Posted: August 18th, 2016 in Software, Technical Support, Technically Speaking

Human errors happen! Help stop future accidents by signing up for a TapRooT® training course today! Click this link to view all the upcoming courses.

Technically Speaking is a weekly series that highlights our TapRooT® VI software and occasionally includes a little Help Desk humor.
Remember, just because it’s technical, doesn’t mean it has to be complicated!

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