Teresa Berry of Arizona Public Service 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 fixed her company’s poorly written reports by finding the root cause of the bad writing:
If you’re at work and don’t have time to watch the video, here’s her tip:
I’m Teresa Berry. I’m from Arizona Public Service and we’ve been using TapRooT® for probably three or three and a half years now on the process side of our industry and what we’ve found is that every now and then we’ll come up with a report that is not written very well. It doesn’t have facts to back up the root causes that were chosen. That is a symptom of a much bigger problem. The problem we found, that we had to go fix, is that people were not using all of the processes that we’re taught to use in TapRooT®; “the rules,” I call them when I teach. These are your rules. You must use the process as it’s laid out or it doesn’t work as well as you’d hoped. And along with that there are also assumptions. Make sure you turn those assumptions into questions so that you know you’ve got to go and answer that question. It’s not a fact until you prove that it’s a fact.
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Are you prepared for a tornado at your facility?
Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …
The picture below is of Mark Paradies helping attendees with their final TapRooT® training exercise. This course was held in beautiful Gatlinburg, TN located in the Great Smokey Mountains.
Sign up for a course today! Just click on the link below to see what courses are available near you. Make sure to check out our discounts that are available when signing up!
What fun story can you tell us about a TapRooT® training course? Please leave a comment below.
I am one of the instructors for the upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Traning in Seattle and I thought I’d pass along some of the great things to do in your spare time (after hours) while attending the course.
Seattle is a great place to eat, shop, and have fun so I’ve listed my favorite places to eat and visit below with links to more information. I’ve also listed a few ideas for the weekend before or after for those who want to get outside of Seattle and see the impressive natural wonders nearby.
Wild Ginger - If you like asian food, try this.
Metropolitan Grill – Best steaks in the USA
The Brooklyn Seafood, Steaks, & Oysters – I recommend getting the oyster sampler.
Ivar’s Acres of Clams – I love their clam chowder and prices are reasonable.
The Cheesecake Factory – Always one of my favorites no matter where I go.
Kells Irish Pub - Love the atmosphere, beer, and the food is good (and a ghost).
Seattle Mariners – In town playing the Toronto Blue Jays on Monday, Tuesday, and Wednesday (night games) of the course.
The Weekend Before/After Ideas
I’m sure the answer to this question varies from company to company. But I also know that the best root cause analysis programs I’ve seen had the most involved managers.
Here are some suggestions to consider…
FIRST, management should be asking for (demanding) root cause analysis. They should insist on it when something bad happens. And they should make sure that there are sufficient trained investigators available and that they have the time they need to actually investigate the problem. But also, management should insist that root cause analysis be used proactively to stop problems before they happen.
SECOND, management needs to set the standard for what is an acceptable root cause analysis. If management accepts substandard reports, presentations, and corrective actions, it will be no wonder that the program fails. But to set the standard, they must know what can be accomplished and what they should look for when they review the results of a root cause analysis.
THIRD, management needs to be self-critical and encourage investigators to look for Management System problems. See the Root Cause Tree® if you don’t understand what a Management System problem is.
FOURTH, management needs to make sure that investigators go beyond specific root causes and look for generic root causes. This should be part of the questions that management asks for every serious incident review.
FIFTH, management should make a special effort to reward good root cause analysis. I didn’t say perfect root cause analysis. Rewards should be for every good root cause analysis.
Do these five points give you any ideas?
See the story at EHS Today.
What could go wrong here?
First, identify all sources of energy nearby.
Next, identify the safeguards for all sources of energy.
Are those safeguards adequate? Do we need more? Are any safeguards being violated (rules broken)?
Leave comments about your Safeguard Analysis.
OGP Safety Alert
WELL CONTROL INCIDENT
While drilling 8″1/2 hole section @ 5052m with 1.51 SG MW, observe well flowing during pipe connection. Shut well in w/ 76 bbls gain. Establish 550psi SIDPP and 970psi SICP.
It took more than 7 minutes for the Driller to shut in after the well flowing situation was recognized (9 minutes 52 seconds total pumps off until well shut in) as follows: “The Mud Logger calls the dog house to inform the Driller that he has seen a gain in the trip tank; the Assistant Driller takes the call and communicates the information to the Driller. As the Driller is in the process of raising the blocks, he waits until the blocks are at 26m and calls the pit room to check that there is nothing that would affect the trip tank volume. He then waited for the return call which confirms nothing would affect the trip tank. The Driller switches over to the flow line as the trip tank is now nearly full and then lowers the TDS and screws back into the string at the rotary table. The string is then picked up and spaced out to close the annular mid joint; the Driller then unlocks the compensator. The annular is then closed by the Assistant Driller who is at the panel and the lower fail safes on the choke line are opened to monitor pressures.
Well was controlled using Drillers Method to circulate/increase MW up to 1.63 SG & decrease gas levels prior to open the well.
What Went Wrong?
Kick zone actual PP exceeds predicted PP range by ~0.07 SG EMW.
But actual PP < ECD (well not flowing while pumping).
76-bbl Kick Volume due to lengthy shut in Vs. ~30-bbl actual Kick Tolerance (KT) calculated from actual ~0.1 SG EMW Kick Intensity (design KT was 80 bbls calculated from maximum predicted PP). Note: There was gas in the influx, but no H2S. According to kick pressure & volume analysis, it is possible that part of the kick was liquid (influx density calculation). Influx density helped evacuating the kick w/out exceeding MAASP & fraccing @ shoe on exceeded KT.
Corrective Actions and Recommendations:
- Flow check each connection prior to starting the physical breaking of the tool joint (rather than flow check during connection).
- Ensure effective monitoring of the Mud Logging fingerprint screen during pumps-off real-time (connection & mid-stand “long connection test”).
- Correct shut-in procedure to be enforced & applied.
- Perform unannounced simulated kicks (kick drills).
- Whenever possible, implement a Well-Full-of-Gas capable casing design so that KT is not limited.
safety alert number: 257
OGP Safety Alerts http://info.ogp.org.uk/safety/
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.
The Val di Stava dam collapsed on July 19, 1985 when two tailings dams used for sedimenting the mud from a nearby mine failed. The subsequent mudflow caused one of Northern Italy’s worst disasters – 268 lives were lost and 63 buildings and eight bridges were destroyed.
According to The History of Geology:
“An investigation into the disaster found that the dams were poorly maintained and the margin of safe operation was very small. As last trigger of the failure is considered a leak of water, caused by a pipe in the upper dam, used to drain water, which had been bent by the weight of sediments. The increasing water pressure of the bunged up dam, in combination with the water saturation weakening the sediments of the dam wall, caused probably the collapse.”
National Hazards and Earth System Sciences published a report indicating that effective regulation may have prevented this disaster.
What do you think? Leave your comments below.
A frequent question that I see in various on-line chat forums is: “Is human error a root cause?” For TapRooT® Users, the answer is obvious. NO! But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.
First, we define a root cause as:
“the absence of a best practice or the failure to apply knowledge that would have prevented a problem.”
But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors.
How does the Root Cause Tree® work?
First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.
The seven Basic Cause Categories are:
- Quality Control,
- Human Engineering,
- Work Direction, and
- Management Systems.
If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.
The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).
The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by clicking here.
If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise.
Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.
How can we make such a risk-free guarantee?
Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance.
Throwback to 2009 in Chile. Chile is just one of the many places where you can receive training and hands on experience with a certified TapRooT® instructor.
Thinking about signing up for a TapRooT® Training class? Click here to find out what courses are available near you.
What was your favorite moment at a TapRooT® course? Please leave comments below.
Devin Johnston of Encana Oil & Gas shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he streamlined the way his facility performed TapRooT® investigations to make each one more efficient than ever:
If you’re at work and don’t have time to watch the video, here’s his tip:
Hi I’m Devin Johnston, with Encana Oil & Gas, from Denver, Colorado. One of the issues with had with TapRooT® is when we would have an incident we would want everyone to be involved. … Everyone would come in the room, we’d lock the doors, we’d run through the whole TapRooT® process, and bang it all out. At the end of the day, everyone was so tired of going through the process and arguing on each little point, that the corrective action part of it at the end was just, they’d take whatever. You’d give them a corrective action and they’d take it, and they weren’t always quality corrective actions. So the thing we fixed at our company is that we made it a more iterate process where we would investigate it, have SnapCharT®s built out already before we went into that meeting, then we selected who actually attended that meeting. If it was contractors, we made sure it wasn’t the whole EHS team, just the guys that things happened to out there. We’d pick the people that were in the investigation at the end to make it simpler, to come to an agreement better, and to improve our process on how we did those TapRooT®s.
Want to learn more about our 2015 TapRooT® Summit in Las Vegas?
Click here: http://www.taproot.com/taproot-summit
The Cristian Science Monitor reported that the spokesperson for the Kermlin’s Investigative Committee (a police body) said:
“As it is a man-caused accident, it is obvious that there are people responsible for it, so soon there will be suspects in the case.“
Later the International Business Times published this headline:
“Moscow Subway Accident: 2 Arrested Metro Workers Failed To Properly Supervise Track Switch Repair, Authorities Say“
It seems the two arrested supervised a job where a track switch was re-wired with the wrong wire.
Twenty-one have died, over a hundred were injured, and over 1000 people had to be evacuated from the subway after the accident.
What do you think? Will discipline solve the problem? Or does a real root cause analysis need to be done?
Thanks to Mhorvan Sherret, the TapRooT® Instructor who sent over these photos from a great course he taught in Warwick England June 12-18, 2014. Enjoy!
Chris Gaborit, Managing Director at The Learning Factor, created this video to inspire us to discover our passion and purpose and to achieve our greatest performance. Invest five minutes of your life to become inspired!
SmartGridNews.com reports “The U.S. grid is the worst in the industrialized world (outages are up 285%!)”Posted: July 15th, 2014 in Current Events, Equipment/Equifactor®
The article starts with …
“Power outages in the United States are up an astonishing 285% since 1984. The U.S. ranks last among the top nine Western industrialized nations in the average length of outages. That dismal performance costs American businesses as much as $150 billion every year according to the EIA.“
It also has a map of power outage by state:
CLICK HERE to see the whole article.
Steve Swarthout and I are teaching the 5 day course this week in Niagara Falls. Here are some pictures of Steve teaching and students working on their first exercise:
Why not join us for a future course? You can see the schedule and register HERE
Monday Accident & Lessons Learned: UK RAIB Accident Report – Locomotive failure near Winchfield, 23 November 2013Posted: July 14th, 2014 in Accidents, Current Events, Equipment/Equifactor®, Investigations, Pictures
The UK RAIB has issued an accident report about the failure of a locomotive near Winchfield, UK. This was a near-miss for a derailment. Here is the Summary:
At about 18:50 hrs on Saturday 23 November 2013, while a steam-hauled passenger train from London Waterloo to Weymouth was approaching Winchfield in Hampshire at about 40 mph (64 km/h), the right-hand connecting rod of the locomotive became detached at its leading end (referred to as the small end), which dropped down onto the track. The driver stopped the train immediately, about one mile (1.6 km) outside Winchfield station. There was some damage to the track, but no-one was hurt. The accident could, in slightly different circumstances, have led to derailment of the train.
The immediate cause of the accident was that the small end assembly came apart, allowing one end of the connecting rod to drop to the ground. The reasons for this could not be established with certainty because some components could not be found after the accident. It is possible that the gudgeon pin securing nut unwound following breakage of the cotter and previous loosening of the nut. A possible factor is that the design of some components had been modified during the restoration of the locomotive some years earlier, without full consideration of the possible effect of these changes. There were deficiencies in the design and manufacture of the cotter. It is also possible, but less likely, that the securing nut split due to an inherent flaw or fatigue cracking.
RAIB has made four recommendations, directed variously to West Coast Railway Company, the Heritage Railway Association, and the Main Line Steam Locomotive Operators Association. They cover the maintenance arrangements for steam locomotives used on the national network, a review of the design of the small end assembly on the type of locomotive involved in the accident, guidance on the design and manufacture of cotters, and assessment of risk arising from changes to the details of the design of locomotives.
For the complete report, see:
We held a great onsite course in Paris, France on June 10-11, 2014. Here are a few photos.