Root Cause Analysis Blog

 

Tappan Zee Crane Collapse: What We Know

Posted: July 25th, 2016 in Accidents, Equipment/Equifactor®

Crane boom collapse

Last week’s collapse of the 235 foot boom on a crane building the new Tappan Zee bridge is still under investigation. There are apparently 3 separate investigations in progress, and as expected, not much information has been released.

The boom came down across all lanes of traffic on the old (still active) portion of the bridge. Amazingly enough, there were only 4 minor injuries, and it cause direct damage to a single vehicle. If you’ve ever driven across that bridge (I was on it just 30 days before the incident), you understand how lucky we were not to have any fatalities.

What we know so far:

– There was almost no wind, and this has been eliminated as a cause.
– The crane was being used to drive piles into the river bottom using a 60 ton vibratory hammer.
– There is a “black box” on the crane which will supply data on the boom angle, weight, etc.
– The operator says he knows what caused it (it wasn’t him).
– This is a new model crane with several safety features designed to eliminate human error.
– This is the only crane of this model being used on the project.
– The crane operator is licensed, with over 30 years of experience.

Tappan Zee Before

This seems to be a good start to an investigation. And as expected, there are a lot of questions (and “expert” opinions) about what happened.  Some of the questions that might be asked:

  • Was the crane properly inspected and certified?
  • What was the condition of the vibratory hammer?
  • Was there any sense of urgency that may have caused someone to make a mistake?  The contract specified $120,000 per day fine of the project finished late.
  • Was there an adequate review and approval of the safe zone around the crane operation?

It’s important not to just ask the hard questions, but also to give the hard answers.  For example, one option that could have been in place (20/20 hindsight) would be to close the operating section of the bridge during construction.  While this would definitely have been 100% safer, does it actually make sense to do this?  Were there adequate safeguards in place to allow continued use of the old span?  The answers here might be yes, and it was perfectly appropriate to operate the old bridge during contruction.  I’ve seen hundreds of construction projects that have cranes in near proximity to the public.  In fact, almost every downtown construction project has the potential to cause injury to the public if a crane collapses.  Some of the criticism I’ve seen written about this accident (“Why wasn’t the old span closed during this constructiuon project?”) is too simplistic for the real world.  The real question should be, “Were there adequate safeguards put in place for the level of risk imposed by this projct?”  We don’t know the answers yet, but just asking these questions in an unbiased investigation can provide useful information.

Crane Collapse

It appears that there is plenty of information available to the investigators. I’m very interested to see the results after the investigations are complete.

Monday Accident & Lessons Learned: Human Error That Should Not Occur

Posted: July 25th, 2016 in Accidents, Current Events, Documents, Human Performance, Performance Improvement

This Accident shares a “Call Back” Report from the Aviation Safety Reporting System that is applicable far beyond aviation.

In this case, the pilot was fatigued and just wanted to “get home.” He had a “finish the mission” focus that could have cost him his life. Here’s an excerpt:

I saw nothing of the runway environment…. I had made no mental accommodation to do a missed approach as I just knew that my skills would allow me to land as they had so many times in past years. The only conscious control input that I can recall is leveling at the MDA [Rather than continuing to the DA? –Ed.] while continuing to focus outside the cockpit for the runway environment. It just had to be there! I do not consciously remember looking at the flight instruments as I began…an uncontrolled, unconscious 90-degree turn to the left, still looking for the runway environment.

To read about this near-miss and the lessons learned, see:

http://asrs.arc.nasa.gov/docs/cb/cb_436.pdf

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Monday Motivation: How to win after a fall

Posted: July 25th, 2016 in Career Development, Career Development Tips, Wisdom Quote

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It’s easy to stand up after a win to applause and admiration. It’s not so easy after a knock down. Encountering defeat and becoming defeated are two different things. Standing up after a fall requires deep character, courage, tenacity … it’s how to turn a tough situation into a personal WIN!

Technically Speaking – TapRooT® Support at the 2016 Summit

Posted: July 21st, 2016 in Summit, Technical Support, Technically Speaking

Hello TapRooT® users! It’s the TapRooT® Tech Guy here letting you know that we will have several members of our team available during both the Pre-Summit and the Summit which is August 1st – 5th, 2016 in San Antonio, TX. We will be located right outside the Navarro Ballroom on the Ballroom Level.

Navarro Location

Come over to our desk and say hello. We will be glad to answer your TapRooT® software questions. If you haven’t yet registered for the 2016 TapRooT® Global Summit, you can register here. We look forward to meeting you!

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!

Water Hammer – What is it, and how we can prevent equipment damage?

Posted: July 20th, 2016 in Equipment/Equifactor®

water_hammer

If you’ve ever heard your pipes rattle in your house after flushing the toilet, you’ve experienced water hammer. While this is just a noisy occurrence in your home, it can cause major damage in industrial situations.
We talk about water hammer during our 5-Day TapRooT® course as a great root cause analysis example. It’s a fairly easy concept on the surface, but it’s actually a fascinating phenomenon. I found this great article that discusses the causes of water hammer and describes some ideas to keep in mind that can prevent or at least mitigate the consequences.

How Far Away is Death?

Posted: July 20th, 2016 in How Far Away Is Death?, Video

Don’t threaten a hippo to find out!

Weekly Wisdom: Human Problems

Posted: July 19th, 2016 in Wisdom Quote

easy solution

 

“There is always an easy solution to every human problem- neat, plausible, and wrong.” -H. L. Mencken

Monday Accident & Lessons Learned: Freight Train Derailment in the UK – Three New Recommendations

Posted: July 18th, 2016 in Accidents, Current Events, Investigations, Pictures

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Derailment of freight train near Angerstein Junction, south east London, 3 June 2015

At about 12:10 hrs on 3 June 2015, one wagon of an empty freight train derailed on the approach to Angerstein Junction, near Charlton in south east London. The train continued over the junction, derailing two further wagons, before it stopped on the Blackheath to Charlton line. The three derailed wagons were partly obstructing the line used by trains travelling in the opposite direction. No other trains were involved in the accident and no-one was injured, but there was significant damage to the railway infrastructure.

The wagons derailed because the leading right-hand wheel on one of them was carrying insufficient load to prevent the wheel climbing up the outer rail on a curved section of track. The insufficient load was due to a combination of the suspension on that wheel being locked in one position, a twisted bogie frame and an intended twist in the track.

As a consequence of this investigation, RAIB has made three recommendations.

The first, addressed to VTG (the wagon owner), seeks improvements to its wagon maintenance processes.

The second, also addressed to VTG, seeks liaison with industry to improve understanding of how wagon suspension wear characteristics relate to maintenance processes.

The third, addressed to Network Rail, seeks a review of infrastructure arrangements at the accident location.

The report also includes a learning point reinforcing a previous recommendation intended to encourage use of currently available wheel load data to enable identification of wagons with defects or uneven loads that are running on Network Rail’s infrastructure.

To see the complete report, go to:

https://assets.digital.cabinet-office.gov.uk/media/5748532b40f0b60366000016/R102016_160601_Angerstein_Junction.pdf

The above information and report are from the UK Rail Accident Investigation Branck. See their web site at:

https://www.gov.uk/government/organisations/rail-accident-investigation-branch

Monday Motivation: Choose your heroes wisely

Posted: July 18th, 2016 in Career Development, Career Development Tips, Wisdom Quote

pablo (20)

Our culture celebrates people who make little to no meaningful contributions to others. When we make heroes of people who can act, play a sport, or sing we are placing value on activities they perform well. Do the people you honor have the personal qualities you’d like to emulate in business and life? Think of those who have made a direct impact on your life. These people are likely those you see every week, who have overcome the odds to be successful. They are the people who will walk with you during tough times.  Do one thing to honor your hero today!

Technically Speaking – The Root Cause Tree®

Posted: July 15th, 2016 in Software, Software Updates, Technical Support, Technically Speaking

The Root Cause Tree® is undeniably an essential tool used in the TapRooT® process.

With the new TapRooT® VI software, we’ve preserved our roots, with an eye on the future in regards to the Root Cause Tree® and Root Cause Tree® Dictionary.

What does this mean exactly? It means you have options! Let me show you.

rct toggle pic

When you open a Root Cause Tree® in the new software, you will find a “toggle” button in the upper right hand corner that presents you with two options: Question View and Tree View.

The Tree View is the “visual” Root Cause Tree® that you’re probably used to.

rct tree view1

And now we also offer the Question View which presents ALL of the same Root Cause Tree® and Root Cause Tree® Dictionary information as the Tree View but in a new and easy to use format.

rct question view

CLICK THE ABOVE IMAGE TO VIEW A LARGER COPY IN A NEW WINDOW

You will see a drop down list of questions that are expandable at the Basic Cause Category, Near Root Cause and Root Cause level. This sleek design allows you to view as much or as little information at a time while you work through the Basic Cause Categories.

Both views offer a new enhancement to the tree that allows you to select YES or NO to the individual Root Cause Tree® Dictionary questions contained within each individual Basic Cause Category, Near Root Cause and Root Cause. Did you ever go back to a Root Cause Tree® and not be able to recall WHY you chose a specific Root Cause? This new feature will make it much easier to track the decisions that were made while analyzing your Causal Factors.

In Question View, these questions are found by clicking on the expandable Basic Cause Category, Near Root Cause or Root Cause sections. In the Tree View, they are accessed by clicking the question mark icon on the hover menu that appears when you place your mouse over each section.

visual hover

Another new feature to the tree are Instruction Banners. You will find these yellow Instruction Banners anywhere there is work direction or instruction that should be considered BEFORE proceeding to the YES/NO questions. By prominently displaying these instructions, it can help reduce the amount of time spent on a given Basic Cause, Near Root Cause or Root Cause by clearly providing important information beforehand.

instruction banner

CLICK THE ABOVE IMAGE TO VIEW A LARGER COPY IN A NEW WINDOW

Still need some help? You will also find additional guidance and notes (when applicable) in a pop up display that is accessed by clicking on a light bulb icon.

guidance light bulb

CLICK THE ABOVE IMAGE TO VIEW A LARGER COPY IN A NEW WINDOW

And of course the basic functions are still found on the tree including Analysis Comments where you can enter and save any relevant data for reference at a later time.

analysis comments blog

CLICK THE ABOVE IMAGE TO VIEW A LARGER COPY IN A NEW WINDOW

Whether you prefer the Question View or Tree View, TapRooT® VI Root Cause Tree® has it all. Get yours HERE today!

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!

July Trivia Contest

Posted: July 14th, 2016 in Contest

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With the 2016 TapRooT® Summit right around the corner, this month’s contest is a trivia question about the Summit! Follow the link to the trivia, answer and enter to win. You could be the lucky winner of a Big Texas prize.

TRIVIA QUESTION

And remember, there is still time to register for the 2016 Summit. We want you to join us in San Antonio to improve your investigations, network across various industries and learn from some amazing Keynote speakers.

 

 

TapRooT® Around the World: Summit Refresher Course in Santiago

Posted: July 13th, 2016 in Courses, Pictures

Another successful Onsite Course in Santiago at ENAP.

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Interested in an Onsite Course for your company? Inquire today!

Technically Speaking – June Customer Satisfaction Survey Prize Winner

Posted: July 13th, 2016 in Software, Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner.

This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.

Everyone, congratulate Kim Taylor from WILLBROS Canada as the polo shirt winner for the month of June!

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