Root Cause Analysis Blog

 

Weekly Wisdom for Overcoming Your Challenges

Posted: January 27th, 2015 in Wisdom Quote

meaningful

“Challenges are what make life interesting and overcoming them is what makes life meaningful.” -Joshua J. Marine

TapRooT® Public Courses In Canada

Posted: January 26th, 2015 in Courses, Pictures

Edmonton

Edmonton, Alberta, Canada

Upcoming TapRooT® Public Courses:

Calgary 5-Day February 23, 2015

Calgary 2-Day March 16, 2015

Edmonton 2-Day March 19, 2015

For more information regarding our public courses around the world, click here.

Risk Assessment and Management Best Practices

Posted: January 26th, 2015 in Courses, Summit, Training

Risk Assessments are necessary in all safety processes, particularly to move programs beyond Behavior Based Safety (BBS).

At least qualitative Risk Assessments (RA) need to be included during any safety-related discussions or interactions, conversations, and meetings. RA are needed every time any safety-related decision needs to be made; and therefore, to move safety programs beyond traditional BBS principles and practices.

RA in safety processes, including BBS – type programs, improve decision-making by making them less subjective, emotional and biased. Safety decision-making needs to be based on the comparative risk levels of the options under consideration. Any chosen safety decision needs to be the option for which the likelihood and quantum of benefit and gain outweighs the likelihood and quantum of loss and harm more than for any other option.

Which option provides the best chance of gain and benefit at both personal and corporate levels?

One such illustrative example is related to un-demonizing the term “shortcut”.

The original, best definition of a shortcut is very simple, positive and with no emotive undertones:

“a smarter, better way of doing a job”

or

“the method, procedure that best reduces the time / $ / energy needed to achieve business objectives.”

Can a shortcut ever be an appropriate, lower risk and authorized job method? And how?

In any safety discussions between managers, supervisors and workers, this definition can help clarify the troublesome distinction between “finding a shortcut,” and “taking a shortcut without an authorized risk assessment.” Finding is undeniably “smart.” Taking without RA is patently “dumb.”

Issues of workplace complexity and relationships between managers, supervisors and workers need to be addressed to be able to move safety programs and cultures beyond BBS principles and practices. Workplace relationships are based on trust, respect, credibility, encouragement, and valued appreciation of jointly-found solutions of challenges and issues. RA provides processes needed in relationship-based safety RBS.

Positive relationships include establishing and holding common beliefs that we want everyone to come to work with their brains as well as their brawn, (and hopefully their hearts), because we all recognize that it is in everyone’s interest for everyone to be always challenged to find smarter better ways of doing our jobs. That is what business is about! It is the never-ending goal of finding smarter, more efficient, more effective, more productive and safer (lower risk) ways of doing our work.

However, too often we tell our people we need and want their “shortcut” ideas for more efficiency and productivity, but as soon as they do give them we jump on them and label their suggestions with negative emotive labels such as “violations” or “breaches” of existing rules and describe them in meaningless, undefined terms such as “unsafe acts” or “at-risk behaviors”. Use of these negative, emotion-loaded terms actually discourages searching for the deep underlying root causes of an apparently stupid, careless, and lazy “violation.”

It is more appropriate to use non-emotive descriptors such as “variations,” “adaptations,” “departures,” or very simply “work-arounds.”

All day-to-day safety meetings, discussions, and personal risk taking behavioral choices involve BBS questions such as:

  • Which procedure or method is safer (lower risk) than another?
  • Which is the safer tool, plant, equipment for this job?
  • Which risk control option is better than the others?
  • Which route should be taken?
  • Which control panel design is less error-provoking than the other?
  • Which roster is best for managing fatigue?
  • What is the appropriate time that we need to allocate to this incident investigation?
  • What to say and how to interact / converse with my peers, supervisors and managers?

These real examples of safety optioneering processes make a compelling argument for doing at least a qualitative (but preferably a Semi – Quantitative) Risk Assessment.

In fact, Risk Assessments will be recognized as definitely needed every time any safety-related decision needs to be made and therefore can move safety programs beyond traditional BBS principles and practices often confused and undermined by subjective beliefs, biases and perceptions.

How can you improve your confidence in the accuracy, reliability, consistency of Risk Assessments?

Learn Best Practices in the training courses being offered as below.

Houston, Texas
May 20-21, (Weds-Thurs)

To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505HOUS20.html

Calgary, Canada
May 27-28, (Wed-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505CALG27.html

Las Vegas, Nevada
June 1-2 (Mon-Tues before the TapRooT® Summit)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1506LASV01-RISKMGMT.html

IN-HOUSE Courses are also available. Contact us for a quote.

Jim WhitWhiting.Jiming, an international expert in risk management and root cause analysis will be conducting the courses detailed above. The courses are the updated versions of a highly successful course that he has been offering for a number of years to over 200 attendees at Pre-Summit courses at past TapRooT® Summits. Due to increasing requests for more offerings of the course, the TapRooT® folks and Jim have decided to offer three RAMBP PUBLIC Courses in North America in 2015.

Jim was on Committees developing the Risk Management Standard AS/ISO 31000 which has been adopted word for word by US standard bodies as ANSI Z690.2 and Canadian bodies as CAN/CSA/ISO 31000. He has developed Risk Assessment unique tools and processes for maximizing the confidence of the results of assessments need to make all safety-related decision-making such as – what is a tolerable risk ?

Monday Accident & Lessons Learned: The US Chemical Safety Board Releases Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

Posted: January 26th, 2015 in Accidents, Current Events, Investigations, Pictures

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CSB Releases Safety Bulletin on Anhydrous Ammonia Incident near Mobile, Alabama

Safety Bulletin Notes Five Key Lessons to Prevent Hydraulic Shock

January 15, 2014, East Rutherford, NJ – Today the U.S. Chemical Safety Board released a safety bulletin intended to inform industries that utilize anhydrous ammonia in bulk refrigeration operations on how to avoid a hazard referred to as hydraulic shock.  The safety lessons were derived from an investigation into a 2010 anhydrous ammonia release that occurred at Millard Refrigerated Services Inc., located in Theodore, 
Alabama.

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The accident occurred before 9:00 am on the morning of August 23, 2010. Two international ships were being loaded when the facility’s refrigeration system experienced “hydraulic shock” which is defined as a sudden, localized pressure surge in piping or equipment resulting from a rapid change in the velocity of a flowing liquid. The highest pressures often occur when vapor and liquid ammonia are present in a single line and are disturbed by a sudden change in volume.

This abnormal transient condition results in a sharp pressure rise with the potential to cause catastrophic failure of piping, valves, and other components – often prior to a hydraulic shock incident there is an audible “hammering” in refrigeration piping. The incident at Millard caused a roof-mounted 12-inch suction pipe to catastrophically fail, resulting in the release of more than 32,000 pounds of anhydrous ammonia.
The release led to one Millard employee sustaining injuries when he fell while attempting to escape from a crane was after it became engulfed in the traveling ammonia cloud.  The large cloud traveled a quarter mile from the facility south toward an area where 800 contractors were working outdoors at a clean-up site for the Deepwater Horizon oil spill. A total of 152 offsite workers and ship crew members reported symptomatic illnesses from ammonia exposure. Thirty two of the offsite workers required hospitalization, four of them in an intensive care unit.

Chairperson Rafael Moure-Eraso said, “The CSB believes that if companies in the ammonia refrigeration industry follow the key lessons from its investigation into the accident at Millard Refrigeration Services, dangerous hydraulic shock events can be avoided – preventing injuries, environmental damage, and potential fatalities.”

Entitled, “Key Lessons for Preventing Hydraulic Shock in Industrial Refrigeration Systems” the bulletin describes that on the day before the incident, on August 22, 2010, the Millard facility experienced a loss of power that lasted over seven hours. During that time the refrigeration system was shut down. The next day the system regained power and was up and running, though operators reported some problems.  While doing some troubleshooting an operator cleared alarms in the control system, which reset the refrigeration cycle on a group of freezer evaporators that were in the process of defrosting. The control system reset caused the freezer evaporator to switch directly from a step in the defrost cycle into refrigeration mode while the evaporator coil still contained hot, high-pressure gas.

The reset triggered a valve to open and low temperature liquid ammonia was fed back into all four evaporator coils before removing the hot ammonia gas. This resulted in both hot, high-pressure gas and extremely low temperature liquid ammonia to be present in the coils and associated piping at the same time. This caused the hot high-pressure ammonia gas to rapidly condense into a liquid.  Because liquid ammonia takes up less volume than ammonia gas – a vacuum was created where the gas had been.  The void sent a wave of liquid ammonia through the piping – causing the “hydraulic shock.”

The pressure surge ruptured the evaporator piping manifold inside one of the freezers and its associated 12-inch piping on the roof of the facility. An estimated 32,100 pounds of ammonia were released into the surrounding environment.

Investigator Lucy Tyler said, “The CSB notes that one key lesson is to avoid the manual interruption of evaporators in defrost and ensure control systems are equipped with password protection to ensure only trained and authorized personnel have the authority to manually override systems.“

The CSB also found that the evaporators at the Millard facility were designed so that one set of valves controlled four separate evaporator coils. As a result, the contents of all four coils connected to that valve group were involved in the hydraulic shock event – leading to a larger, more hazardous pressure surge.

As a result, the CSB notes that when designing ammonia refrigeration systems each evaporator coil should be controlled by a separate set of valves.

The CSB found that immediately after discovering the ammonia release, a decision was made to isolate the source of the leak while the refrigeration system was still operating instead of initiating an emergency shutdown. Shutting down the refrigeration system may have resulted in a smaller release, since all other ammonia-containing equipment associated with the failed rooftop piping continued to operate.

A final key lesson from the CSB’s investigation is that an emergency shutdown should be activated in the event of an ammonia release if a leak cannot be promptly isolated and controlled. Doing so can greatly reduce the amount of ammonia released during an accident.

Last Chance to Double Your Chances to Win an iPad Mini!

Posted: January 26th, 2015 in Summit

We are giving away an iPad Mini to the 2015 Global TapRooT® Summit early bird prize drawing winner, and you still have a chance to get TWO tickets in the drawing.

To enter and receive two tickets, simply submit your paid Summit registration to our office before the end of January, 2015. You can also receive one ticket in the drawing if you submit your paid registration before the end of February.

The early registration drawing will be held at the Kickoff Session, Wednesday, June 3, 2015 at 8:00 a.m. at The Flamingo Las Vegas Hotel (You must be present to win!). This drawing is in addition to the other prize giveaways we have planned for the 2015 Summit.

If you are planning to register for the Summit, don’t delay! Increase your odds of winning an iPad Mini.

REGISTER NOW for the 2015 Global TapRooT® Summit!

Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Houston, TX

Posted: January 23rd, 2015 in Courses, Pictures, TapRooT

Linda Unger, VP at SI, sent these pictures of Ken Turnbull, one of our contract instructors, teaching a bunch of great students.

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Friday Joke: Please Follow the Rules on the Sign

Posted: January 23rd, 2015 in Jokes

Violators will be rewarded! Yes!

areward

And don’t drink and make signs either.

don't drink

 

I know it will be hard, but just please try.

walk without walking

Even in Humor, You can learn about Root Cause and People from Dr. Deming

Posted: January 22nd, 2015 in Accidents, Best Practice Presenters, Human Performance, Performance Improvement, Quality, Root Causes, Summit, TapRooT, Video

Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…

… your own actions.

… your understanding of other peoples actions.

… your past corrective or preventative actions.

Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.

To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance  excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.

To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit

If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw

TapRooT® Around the World: Cape Industries

Posted: January 22nd, 2015 in Courses, Pictures

Thank you to Derek Rutherford for sharing these photos with us from a recent Onsite course at Cape Industries.

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Want more information regarding our Onsite and Public courses? Click Here. 

Will Falling Oil Prices Put the Cost-Cutting Ax to Safety Improvement?

Posted: January 22nd, 2015 in Current Events, Performance Improvement, Pictures, Summit

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It’s easy for a CEO and management to claim to support safety. But the proof comes when times get tough.

The price of oil has declined more that 50% in just six months. That has the oil field in crisis mode. Knee jerk budget cuts, travel restrictions, and layoffs have already started.

What does this mean to safety improvement? Many oil industry safety professionals get ideas about ways to improve by attending the TapRooT® Summit, networking with industry leaders and performance improvement experts, hearing about the latest best practices that will help them solve their toughest problems, and developing plans to take safety to a whole new and better level. But if travel budgets are slashed and conferences are not allowed, these new best practices won’t be learned, safety improvement will stop, and lives that could have been saved will be lost.

Now is the time for management to show their commitment to safety improvement. They can stand up, resist the fear of low oil prices, and demand that safety improvement continues even in times of budget restraint.

After all, safety is not just a priority that can be discarded when times get tough. Safety is a value that must be supported every day, year in and year out, in good times and bad, or people will start to believe that safety is option and the only real value is profit.

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Don’t let safety improvement become an unsupported slogan. Register for the TapRooT® Summit today!

What does a bad day look like?

Posted: January 22nd, 2015 in Pictures

Just like this if you own a Subway …

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Upcoming TapRooT® Public Course in New Plymouth, New Zealand

Posted: January 22nd, 2015 in Courses, Local Attractions, Pictures, TapRooT

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TapRooT® hosts public courses all over the world, including New Zealand. Come out to New Plymouth, New Zealand on February 16, 2015 for a 5-Day Advanced Root Cause Analysis Team Leader Training to learn how you can be proactive and perform better investigations. New Plymouth is a coastal city on the west coast of New Zealand that has been named a “model community” because of its beautiful infrastructure. The small population walks and cycles along the coastal walkway (pictured above) and enjoys the each other’s company and the view. Talk about a great place to visit and take a TapRooT® course!

Food:

Table Restaurant: Placed within the Nice Hotel, this gourmet, award winning restaurant ensures you will enjoy food, wine and friends.

The Mayfair: Want a burger, fries, salads, pizzas or snacks? The Mayfair has it all and some drinks to go with it.

Cow Ree: This small vintage cottage set right on the beach makes for a fun, enjoyable evening out for a great meal.

Attractions:

Pukekura Park:  You’ve never experienced a local park with such beautiful scenery and events-including a lights show you won’t forget!

Coastal Walkway: Enjoy a nice walk along the coast with a perfect view of the mountains.

Taranaki Aviation Transport and Technology Museum: If you’re interested in all things to do with aviation and technological transportation, then this museum is for you.

 

REGISTER HERE for this Public Course today

SAVE THE DATE for the upcoming Global TapRooT® Summit. For more information and registration click on the links.

Find and Fix the Root Causes of Equipment Related Failures

Posted: January 21st, 2015 in Courses, Equipment/Equifactor®

Don’t end up “fixing” the same equipment problems over and over again. Don’t let equipment issues cause quality, operations, and safety issues. Find the real root causes of your equipment reliability issues and develop effective fixes that will keep them from happening again by using this systematic process.

Did you know that we have 3-day and 1-day courses? What’s the difference? 3-Day Courses include the 1-Day Equifactor® Course along with the 2-Day Incident Investigation and Root Cause Analysis Course so you have it all in one. The 1-Day courses are just the separate Equifactor® course that requires a previously taken 2-Day course along with it, not necessarily all in one trip.

Why take an Equifactor® course? You will not only receive invaluable knowledge for your business, but also a Free single-user copy of TapRooT® Software. (A $2890 Value!) You can’t get a better deal than that.

Still deciding? Watch the video below to hear our Equifactor® instructor, Ken Reed, talk about why this course is right for you.

 

Steps to register for the course and Free Software.

1) CLICK HERE

2) Select a 1-Day Equifactor® Course of your choice (Having already taken a 2-Day course or accompanying it with a 2-Day course)

3) Register for the course and add it to your cart

4) Done!

 

Upcoming Equifactor® Public Courses:

Calgary, Alberta | January 16, 2015

Houston, Texas | March 18, 2015

Brisbane, Australia | March 18, 2015

Onsite TapRooT® courses

Posted: January 20th, 2015 in Courses

Thanks to TapRooT® instructor Ralph Blessing for sending this picture of an onsite course being held today for one of my clients in Illinois. In the picture, instructor Ralph Brickey is teaching the students how to find Causal Factors.

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By the way, not all of our instructors are named Ralph, but they are all excellent instructors! We can teach any of our courses at your site (10 or more people), and we have instructors throughout the world. If you are interested in holding a course at your site, just e-mail us at info@taproot.com

How Far Away is Death?

Posted: January 20th, 2015 in Pictures

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Weekly Wisdom for Not Holding Back

Posted: January 20th, 2015 in Wisdom Quote

limitations

“Limitations live only in our minds. But if we use our imaginations, our possibilities become limitless.” -Jamie Paolinetti

Career Development: How to Be a Great Leader

Posted: January 20th, 2015 in Career Development

Who is the happiest man every measured by science? And what was he thinking when he was being measured? And what does any of this have to do with business leadership? View this video and find out!

Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014

Posted: January 19th, 2015 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

UK Rail Accident Investigation Branch Press Release…

The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.

NewImageYellow engineering trolley underneath the train after the collision (image courtesy of Carillion)

The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley. 

The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.

To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.

Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.

RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.

RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.

The RAIB investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

- – – – – 

What can we learn BEFORE the investigation is complete?

First, this “near-miss” was actually a hit.

In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.

Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.

Richard Phillips, Real Life Inspiration for the Movie Captain Phillips, to Speak at 2015 Summit

Posted: January 19th, 2015 in Best Practice Presentations, Best Practice Presenters, Summit

Learn important lessons on leadership at the 2015 Global TapRooT® Summit from Richard Phillips, real life inspiration for the movie, Captain Phillips, who will be the closing keynote speaker on Day 3. The Summit begins on Wednesday, June 3, 2015 right after our 2-day Pre-Summit courses (June 1 and 2, 2015).

Phillips, Richard

Richard Phillips

For five days in April 2009, the world was glued to their TV screens as Captain Richard Phillips became the center of an extraordinary international drama when he was captured by Somali pirates who hijacked his ship, the first hijacking of a US ship in more than 200 years.

Though Captain Phillips describes himself as a “regular guy,” the world knows that his actions were anything but ordinary after the pirate attack. His harrowing and heroic efforts to survive an ordeal that riveted the world were only matched in valor by his decisive actions to save his crew and the ship they sailed. President Obama said, “I share the country’s admiration for the bravery of Captain Phillips and his selfless concern for his crew. His courage is a model for all Americans.”

REGISTER for the 2015 Global TapRooT® Summit, June 1-5, 2015, Las Vegas.

 

 

 

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