Root Cause Analysis Blog

 

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 abad day look like?

Posted: August 24th, 2016 in Pictures

NewImage

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

Weekly Wisdom: Take risks.

Posted: August 23rd, 2016 in Wisdom Quote

Screen Shot 2016-08-01 at 1.30.16 PM

“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.

shenzhen china3

shenzhen china2

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

Clamp

 

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

johannesburg-1532102_1920

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!

Mark Paradies Receives Ordo Honoris Award

Posted: August 16th, 2016 in Current Events, Pictures

12418608 D30475

The Kappa Delta Rho Fraternity presented Mark Paradies, President of System Improvements with the Ordo Honoris Award for device to his fraternity and the world. Part of this service to the world was Mark’s development and teaching of the TapRooT® Root Cause Analysis System to save lives, improve product quality, and improve workplace productivity by finding and fixing the root causes of accidents and incidents.

Congratulations Mark!

12418608 D30375

12418608 D30386

Weekly Wisdom: Take control of your life.

Posted: August 16th, 2016 in Wisdom Quote

Screen Shot 2016-08-01 at 1.44.12 PM

“You take your life in your own hands, and what happens? A terrible thing, no one to blame.” -Erica Jong

Enter our caption contest!

Posted: August 15th, 2016 in Contest

download (1)
From today through September 16 we are running another fun caption contest!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by September 16.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter.  Only eNewsletter subscribers are eligible.
Our  staff will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on September 20.

Have fun!

Pump Life Cycle Cost Analysis – Numbers Matter!

Posted: August 15th, 2016 in Equipment/Equifactor®

LCC Graphic

When designing spacecraft, there is a humorous (yet amazingly accurate) list of laws to keep in mind to ensure you are not going down the wrong path when developing spacecraft and their associated systems. Akin’s Laws of Spacecraft Design are a set of well-known nuggets that can be adapted to everyday life. But the one that I want to mention here is Akin’s Law #1:

1. Engineering is done with numbers. Analysis without numbers is only an opinion.

When you are looking at your pumping systems, and trying to decide on the best maintenance or repair strategy for a particular pump failure, you may have several options. For example:

– Should I just replace the failed pump with another identical pump?
– Should I replace it with a more efficient design?
– Is the current pump optimized for the system design?
– What other options are available for this repair?
– Why did it fail in the first place?

Iceberg

Life Cycle Cost analysis can be done after almost any failure to help you decide on the best repair strategy.  This analysis includes things like the costs of the initial purchase, installation and commissioning costs, energy and operation costs, and maintenance costs.  You can perform a relatively accurate cost comparison for various repair / replacement options so that you can make an educated decision on the best course of action.  Pump Life Cycle Costs: A Guide to LCC Analysis for Pumping Systems is the result of a collaboration between the Hydraulic Institute, Europump, and the US Department of Energy’s Office of Industrial Technologies (OIT).  It is definitely worth a few minutes to read through this and get a basic understanding of how to calculate the LCC of a particular installation or repair.

There were a couple of take-aways for me, neither of which was particularly surprising, yet both of which are important to keep in mind:

  1.  Energy consumption is often one of the larger cost elements and may dominate the LCC, especially if pumps are run more than 2000 hours per year
  2.  The cost of unexpected downtime and lost production is a very significant item in the total LCC and can rival the energy costs and replacement parts costs in its impact.

Pie Chart

Which drives home the importance of a good root cause analysis to ensure that your failures (and therefore your downtime) are minimized, as the costs of these failures can rapid skew the entire LCC analysis.  Don’t live with repeat or avoidable failures.

 

Monday Accident & Lessons Learned: Five Items To Remember When Using a Checklist

Posted: August 15th, 2016 in Accidents, Current Events, Documents, Investigations

Another great article from NASA’s Aviation Safety Reporting System that applies to a much broader audience than just aviation folks. If you use checklists, there something to be learned from this article. Click on the picture of the article below to read more…

Screen Shot 2016 06 28 at 4 01 44 PM

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed

Equifactor®

Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages…

Bell South

Alaska Airlines adopted System Safety and incorporated TapRooT® into the process to find the root causes…

Alaska Airlines
Contact Us