The Delta Mariner struck the Eggner Ferry Bridge in southwest Kentucky, knocking down 2 spans of the bridge. Motorists almost didn’t notice the missing spans as they came up to it in the dark. Link
The barge is designed to carry Delta 4 and Atlas V rocket stages from the assembly plant in Decatur, Alabama. No word if there were any rocket components on board.
A later report indicates that the barge took the wrong channel. It apparently attempted to use the recreational channel (for small private boats), instead of using the main navigational channel. Link
Often people participating in the TapRooT® Summit THINK they know what will be their favorite session, but are surprised when one of the sessions they attend BLOWS THEIR SOCKS OFF.
For example, all of the Keynote Speakers (CLICK HERE to review them) have the potential to be the best talk at the Summit.
But there are some Best Practice Session presenters who also have the potential to be your favorite session. Here are just a few of the ones that I’m looking forward to …
Lori Reineke-Avant and Eric Cropp
They will discuss their personal experience being prosecuted for an accident.
Linda Unger and Michele Lindsay
One of the most highly praised sessions at past Summits has been the “TapRooT® Users Share Root Cause Best Practices” session facilitated by Linda and Michele.
Richard Mesker
Richard gives interesting, interactive talks. What I’ve heard about his “Risk Management and Safety: Safety Third” session leads me to believe it will surprise you.
I always like Bill’s talks about fatigue and he has two at the Summit that you should consider attending. The first is about a new federal requirement for airlines – developing a fatigue risk management plan. These plans really should be implemented everywhere that fatigue could be an issue.
Second, is “Using FACT to Measure & Analyze Fatigue (Both Reactive and Proactive)”. If you’ve ever wondered how you can prove that fatigue was an issue in an accident, Bill has the answer and will share it at the Summit.
- – -
Well, I said I’d share a few … so I better stop now. And I haven’t even mentioned the talks I’ll be presenting!
Make sure you attend the Summit so that you can learn all the valuable information that will help you take performance at your facility to the next level.
With just 34 days until the 2012 Global TapRooT® Summit, some people already planning on participating may be wondering …
What kind of people will I be networking with?
I like Wayne’s quote from the following video:
“… the most highly skilled safety professionals in industry.”
(.wmv format – click to play)
We aren’t quite ready to send out the attendance list (you will get it the first day of the Summit), but we do know the types of people that participated in previous Summits …
Sample list of companies:
Alaska Airlines
Alcoa
Ameren
Ashland
Barrick
Bayer
Bell South
Boart Longyear
BUMED
Cameco
Champion Technologies
Chevron
Christus Health
Ciba Vison
CNSC
Cogentrix
ConocoPhillips
Continental Airlines
EnCana
ENSCO
EPA
Exelon
ExxonMobil
FAA
First Energy
Flint Hills Refining
Fluor
GE
General Dynamics
Genetech
Good Samaritan Hospital
Greater Cleveland Regional Transit Authority
Halliburton
Hess
Hydro One
Integris Health
Intel
Irving Oil
Jackson County Memorial Hospital
KBR
Marathon Oil
MI-SWACO
Military Healthcare System
Monsanto
MSHA
Norsk Hydro
Novartis
NRC
NTSB
ORNL
OSHA
OXY
PCS
Petro-Canada
Petrobras
Pfizer
Potash
Pracxair
Pratt & Whitney
Qantus
Rhom & Haas
Rio Tinto
Rust-Oleum
Sandia National Labs
Sasol
Savanah River
Southern California Edison
Southwest Airlines
Saudi Aramco
Shell
SKF
Total
TN OSHA
TVA
United Technologies
Wakenhut
Westar
Willbros
What countries did they come from? Here’s a sample …
Australia
Brazil
Canada
Columbia
Denmark
France
Germany
Indonesia
Kenya
Malaysia
Mexico
New Zealand
Nigeria
Norway
Qatar
Saudi Arabia
Singapore
South Africa
South Korea
Tanzania
Thailand
The Netherlands
Trinidad
UK
USA
What type of job titles? Here’s a sample …
Aviation Maintenance Manager
Aviation Safety Manager
Captain (maritime)
COO
Construction Safety Manager
Corporate Counsel
Director of HSE
Director of Nuclear Safety and Licensing
Doctor (MD)
EHS Specialist
Healthcare Quality Specialist
Human Performance Specialist
Industrial Health & Safety Manager
Investigator
Maintenance Manager
Maintenance Technician
Manager of Engineering
Manager of Safety
Mine Safety Manager
Network Reliability Engineer
Network Security Engineer
Nuclear Safety Engineer
Operations Manager
Operator
Patient Safety Manager
Patient Safety Representative
Process Safety Engineer
Process Safety Manager
QC Engineer
Quality Auditor
Quality Director
Quality Engineer
Refinery Safety Manager
Reliability Engineer
Risk Manager
Safety Committee Representative
Safety Manager
Security Manager
Tool Pusher
Trending Technician
Vice President, QSHE
Vice President, Risk Management and Patient Safety
Vice President, Safety, Health and Environment
This mixture of participants makes for great networking within industries/disciplines and across industries/disciplines.
Don’t miss this great chance to learn by networking with improvement professionals from around the world. If you have not registered already, register by going to:
As you have probably heard, on the two days before the summit we have special pre-summit courses we only teach publicly at the summit (we can do any of them onsite). The course I teach is called the Advanced TapRooT® techniques course. In this course we cover best practices for each of the steps of our seven step process. A big focus of the course is identifying causal factors, and I will give you some insight into some of that in the root cause tips on February 15. Today I wanted to talk about something from the course that is extremely important. Take a look at this analogy:
Have you ever wondered why sometimes you do an investigation, things get better, but there are still some of the same problems present – maybe they are not as frequent or serious, but they still occur. Why is that? A great deal of the time, I would say because you found some of the causal factors and their root causes, but you may have missed one. In order to make sure problems do not reoccur, you have to find ALL of the causal factors, and therefore, all of the root causes. And it all starts with a good SnapCharT®. You see, it is much easier to find the causal factors if your chart is very clear, is not missing important details, and is well worded. Most of the time you spend in your investigation should be on this front end of the process – the investment in collecting good information and assembling it on your chart will make finding the causal factors easier, and taking them through the Root Cause Tree® faster.
Hopefully this discussion helps. If you want to hear more, consider joining us in Las Vegas for the course. And stay for the summit.
Thanks for visiting the blog and happy investigating.
Don’t have time to go out at night and see a fun Vegas show during our 2012 Global TapRooT® Summit? Don’t worry; we’re staying at the Flamingo Hotel, which offers you fun, music, and a whole lot of laughs without having to leave the building! Take a look at these shows and their descriptions, all located at the Flamingo Las Vegas!
DIRK ARTHUR
O’Sheas Theatre
Price $22.95, $33.95
7:30 PM
Dirk Arthur’s high-energy Wild Magic show combines comedy, dance, magic, and large uncaged exotic cats at 10-40 feet away.
DONNY & MARIE IN LAS VEGAS AT THE FLAMINGO
The Flamingo Showroom
Price $260; $125; $109; $95 (plus taxes and fees)
7:30 PM
Donny and Marie Osmond rock this 90-minute show with their greatest hits and a multimedia production.
GEORGE WALLACE LIVE AT THE FLAMINGO LAS VEGAS
The Flamingo Showroom
Price $49.95 plus tax & fees
10:00 PM
Wallace is the winner out of 150 competitors of the stand-up comedy TV special “The Big Laugh-Off,” reading audiences like a book and cracking them up with his humor drawn from everyday life.
NATHAN BURTON
The Flamingo Showroom
Price $34.00 General Admission, $44.00 VIP + taxes/fees
4:00 PM
Relax after the Summit on Friday afternoon with Burton’s fast-paced comedy and magic show.
Vinnie Favorito is an infamous “roaster”with no pre-planned skits or notes. He wins audiences over with his off-the-cuff quips and hilarious digs on his audience members.
“…your jaw aches from laughter…your side hurts…devastatingly funny!” Jerry Fink, Las Vegas Sun
“Rickles with venom” Milton Berle Best Comedian in Las Vegas – Guest Pick, Las Vegas Review Journal
The Sun reported that damage to the Costa Fortuna, previously blamed on a collision with a whale, may have been caused by the vessel hitting rocks (running aground) in May of 2005 near Sorrento, Italy.
I don’t think that I’ve ever seen a major accident with fatalities that didn’t have a previous incident that could have been investigated, learned from, and thereby prevent the follow on accident IF they had applied advanced root cause analysis and implemented SMARTER corrective actions.
“A TVA spokeswoman told the Chattanooga Times Free Press that the construction ‘stand down’ ordered to start at noon Wednesday was to continue ‘until the errors discovered are clearly communicated to all personnel.’”
Will communicating the “errors” really improve performance?
A TVA spokesperson said:
“TVA had not yet determined if the mistakes were due to carelessness but a ‘root cause analysis’ was being conducted.”
Carelessness as a potential “cause”?
TVA’s top executive, Tom Kilgore, said:
“When workers return to the site on Monday, they will join foremen and supervisors to review an error that occurred in December that had the potential for fatal consequences and that was identified earlier this week at Watts Bar Unit 2. Also to be reviewed is a second incident that occurred this week which could have resulted in a severe injury or worse if it had happened under slightly different circumstances.”
That tool box safety meeting shouldn’t take too long. From the report, they don’t know the root causes yet. All they seem to know is that two mistakes were made. I guess “foremen and supervisors” will just tell employees to “be more careful” and not to make errors. Then everything will be OK.
After that, employees will be willing to cooperate in an open and revealing root cause analysis. Especially when they know that management is looking for those who may have been careless.
We all know that the best way to keep people from being careless is to fire those who are found to be careless. If you fire careless people frequently, everyone will be happy and careful!
Another quote from the article:
“Nuclear Regulatory Commission Region 2 spokesman Roger Hannah said Friday that such work stoppages at nuclear plants are ‘not uncommon’ and probably occur every two or three years. Hannah said they are ‘not exclusive to the nuclear industry.’”
Wonder why they need a stand down every two or three years if they have an effective performance improvement program? I guess people need to be reminded to be more careful every two or three years.
Maybe we should just schedule these stand downs in advance? We could call it human performance preventive maintenance. Every two years we would give people a day off to think about being more careful and “Presto!” … no more human errors.
Or even better! Rate people on their potential for carelessness on a scale from 1 to 10. Then every year fire the worst 10%-20% of the careless employees!
Do these actions sound like the Deming Red Bead Experiment to anyone? If you don’t know what the Red Bead Experiment is, see the following videos…
Now read these quotes:
NRC’s “…Hannah declined to speculate about any possible penalty for TVA. He said TVA would assess both nuclear safety and workplace safety issues.”
And …
“The problems were discovered in routine TVA inspections and follow heightened NRC scrutiny on other TVA nuclear plants.”
Ahhh… now we are getting to the “root cause” of the stand downs.
It will look like management is doing something.
Management would hate to look like they are doing nothing.
A stand down makes them look like they are doing something.
The more people stand down, the more dramatic the effect.
Thus, a stand down may keep the NRC from descending upon a nuclear utility.
If NRC management starts to believe that TVA has multiple troubled plants with multiple reasons for concern about human performance and human reliability, that could result in a special inspection. A special inspection is bad. When multiple regulators descend upon a nuclear utility, they always find things that need to be improved. If too many areas need improvement, the NRC could order reactors shut down until the “culture” is changed.
An NRC ordered shut down is bad news for the utility. “Changing the culture” can take years, cost millions of dollars, and result in many managers being fired. That’s much worse than the impact of a simple stand down for a few days. Thus, a stand down is a cost-effective way to keep the NRC happy – at least for a while – even if the stand down has no lasting impact on human performance.
Is there a better approach?
How about honest recognition of mistakes big and small? Once the mistake is recognized, management could require a thorough, effective, advanced root cause analysis of any problem that could result in significant impact on plant safety, personnel safety, radiation exposure, environmental performance, or plant performance. Management could then insist upon the development and implementation of effective (SMARTER) corrective actions. Part of those corrective action could include effective communications about what happened and why it happened (the real root causes) to all employees that are impacted by the issue or the corrective actions.
What if you really want to stop having stand downs (and the incidents that cause management to call for stand downs)?
Management needs stop being REACTIVE by being PROACTIVE.
Management needs to shift from reactive root cause analysis to advanced PROACTIVE root cause analysis and stop problems before incidents happen. (We teach how to do this in our 5-Day TapRooT® Course.)
I’d recommend that TVA stop blaming workers (calling them careless) and start finding and fixes the real root causes of problems. Rather than a show stand down for the NRC, use effective advanced root cause analysis – both reactively and proactively – to improve performance and avoid issues that require stand downs every few years.
Show stand downs haven’t resulted in improved performance in the Nuclear Navy or the nuclear power industry (as evidence by the fact that they are repeated over and over again) and they should not be accepted by the NRC as effective management action. Rather, knee-jerk use of a stand down should be seen as a sign of weak management. Management that does not know how to improve human performance.
Avoid this scenario at your facility. Make sure that your management understands how to use advanced root cause analysis both reactively and proactively. Get your advanced root cause analysis program effectively implemented and then continue to improve it every year. And this advice is not just for nuclear utilities. Rather, it applies to every industry where mistakes may cause major accidents – oil, refining, chemical plants, aviation, railroads, shipping, pipelines, pharmaceutical manufacturers, mining, hospitals, …
Where can you learn best practices to continuously improve root cause analysis and human performance? Start at the 2012 Global TapRoot® Summit in Las Vegas on February 29 – March 2. See the schedule for all nine Summit Tracks at:
Anybody can make a mistake. Few of us (so far) go to jail for making one.
Eric Cropp made a mistake when reviewing a technician’s work. He didn’t catch the technician’s mistake. He was convicted of breaking a state law and went to jail for that mistake.
See the links below and then attend the TapRooT® Summit to hear Eric Cropp talk about his experience.
ARP Colpatria hosted a 3-Day TapRooT® and Equifactor® Root Cause Analysis and Equipment Troubleshooting course this week. They had a great class with lots of learning, with some fun thrown in for good measure.
Here’s some creative solutions during the Marble Drop game:
At a recent training, I was curious as to why there were a dozen colorful “fidget” toys strewn around the tables. To me, they seemed like a distraction. Later I learned that people focus better and absorb information faster if they have something to do with their hands.
If you are having a hard time focusing on a task at work, fidgeting with a desk toy may provide stimulation your mind is craving, calming your brain and helping you get the task finished.
Stress balls may also ease office stress. The simple process of acute muscle tension and relaxation as you squeeze and release the ball flushes out muscle tension and, thus, helps you feel calmer.
There is stimulation of nerves in the hands. These nerves carry the signal to different areas in brain especially the limbic area which is linked with emotions. This mechanism is similar to the popular Chinese method of ‘Acu pressure’ for treating health problems. Moreover stimulation of brain also results in the production of endorphins which act as natural pain relievers and as sedatives.
Fidget toys may also be used to help when creative solutions are needed. Office brainstorming sessions are typically very “left-brained” and creative solutions require using the whole brain and the whole person … so fidgeting with desk toys can invite the creative right brain into the solution.
You may notice you tap your finger, shuffle paperwork or doodle when you are talking on the phone at work or are in a meeting. A fidget toy provides the same relief and may be less distracting to others.
Not all fidget toys work the same for all people. People who enjoy tactile input will prefer a bumpy fidget, while others will prefer a smooth stress ball they can squeeze. If you decide to try it, you may need to try various types to see which helps you play attention the best.
As an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:
Wrong Tool?
Bad Access by Design?
Mechanic’s Ingenuity?
Or a little bit of them all?
Finally, ever have one of your modified tools bite you back? Share your stories in the comment section.
I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.
The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.
Sources of Root Cause Analysis Failures by Mark Paradies is published by:
Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.
41 days is enough time to get approval, register, and make travel plans to attend the 2012 Global TapRooT® Summit (February 29 – March 2 in Las Vegas).
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