Sounds like from initial reports that there were no fatalities. If that is true that is good news.
My first reaction when I heard this was: I hope there will be ample time for a thorough investigation before any “knee-jerk” decisions are made to suspend drilling.
Golden Pass LNG Terminal LLC, the owner of the Golden Pass LNG Terminal, is 70 percent owned by an affiliate of Qatar Petroleum, 17.6 percent owned by an affiliate ExxonMobil, and 12.4 percent owned by an affiliate of Conoco Phillips.
Taking the lead before their first shipment of LNG, Golden Pass LNG started the Root Cause Analysis process and training early on. Below are just of few pictures from the first hands-on exercise.
Understanding your process data, filtering the good from the bad and detecting when there are true problems coming to light should not be like hand-sorting grains of rice.
Yet I hear this question frequently, “We have a large database and we would like to ……..?”
When I ask what processes are being measured and what data are tied to the process’ outcome, the answers are often very vague if not delayed with a, “I will get back with you, good question.”
Now most of us our good at tracking outcomes (often because we are required by Regulations) like:
… number of defects
… costumer complaints
… OSHA recordables
… Sentinel Events
With tracking outcomes however, comes the data merging error that hides the fact that all rice does not come from the same fields and cannot always be included in the same analysis. For example:
… we had a wonderful month with lower injuries in July per assigned employees.
Problem: Cannot compare the number of employees assigned in July with the other months because we had a 2 week plant shutdown.
… we count all defect opportunities and perform frequent audits but the leading indicators do not seem to predict the change.
Problem: Not all audits are created equal. Often leading indicator metrics are too global and general. In other words, “just plain rice”. When you see indicators change but there is no correlation to your lagging output metrics, stop and Go Out And Look (GOAL) at the tasks being performed to identify the correct leading metrics.
This is just the tip of the iceberg when looking at wrong data collection thoughts. Just remember just because you collect lots of data does not mean this a good thing…. you just get more grains of salt to sift through.
Below are two presentations to dig a little deeper in this thought process.
Come and learn best practices in Safety & Risk Management at the 2010 TapRooT® Summit. Sign up for this track and be part of these remarkable best practice sessions. (Read bios of the presenters on the Summit website):
How Does Your Corporate Culture Effect Your Investigations? The culture that exists within your company greatly effects the success of any investigation and subsequent corrective actions..
Brian W. Tink and Brian A. Tink will show you some ways to quantify & identify your current corporate culture. The session will conclude by suggesting how you can use this information to strengthen your organizational/safety culture, allowing you to develop and execute more effective corrective actions that will, in turn, lead to desired and significantly improved business results. . Communicating with Management About Risk: Effectively communicating HSE risks to senior management is critical. Their support for resources (time and money) is necessary to implement actions that reduce risk. Strong visual communications and other techniques are needed to get the message across in a way that leads to action and increased credibility for HSE issues. One of the keys is to present HSE information from a business perspective.
In this session, Dennis Osmer, former Worldwide Head of HSE will review development of several risk communication techniques (risk assessment in terms of organizational impact & degree of control vs. probability & severity, use of site risk analysis, score cards, involvement in accident notifications, etc.).
Ahead of the Law: OSHA Enforcement Problems & Solutions: What is the latest in the world of safety compliance? Join Dave Janney and learn what OSHA has been citing, current inspection emphasis programs, the A-Z’s of the Site Specific Target Program, and inspection and citation handling tips..
Using TapRooT® for Regulatory Safety Compliance: Learn how one of the world’s most sucessful airlines is driving safety compliance by using TapRooT®. Dave Janney, System Improvement’s Senior Associate and former FAA Liason at Delta Air Lines will provide framework for the regulatory compliance environment in the industry, and Rick Diamond and Joe Fresquez from Southwest Airlines will discuss how SWA is using TapRooT® in the regulatory oversight function in its aircraft maintenance division.
Improving Incident Investigation and Safety in the BW Fleet:BW Fleet Management are responsible for the management of a large fleet of Bulk Carriers, Oil and Gas Tankers. Although they are a recognized leader in the Shipping Industry, in 2008 they decided more needed to be done..
Capt. Vibhas Garg and Malcolm Gresham will present how BW Fleet Management’s search for a better way to analyze incidents resulted in them implementing TapRooT®. This presentation will discuss the challenges overcome when implementing the system. It will also cover how the introduction of a company Risk Management Framework will contribute to future improvements.
Advanced Ideas for Corrective Actions: In this best practice session, Dan Damaan will present how to use risk to rank corrective actions. The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization.
Richard Mesker will also talk about using extent of condition/common cause/generic cause analysis to build complete corrective actions during this session.
Be a Safety STAR: How a VPP Program & TapRooT® Can Be Combined for Excellent Safety Performance: Learn how some leading companies used TapRooT® to improve their OSHA VPP (Voluntary Protection Programs) processes and get some ideas how you can leverage the capabilities of TapRooT® with Melva Luckie-Oni, Dave Janney and Dan Phillippe..
Quality in Life and Work:Quality Improvement can be applied to your personal life and your business. It’s sequential—inside out, not outside in. George Burk was critically burned and severely injured, the sole survivor of 14 passengers in a military plane crash.
Learn how several of W. Edward Deming’s 14 Points for Quality Improvement assisted him in his recovery, rehabilitation and transformation from victim to survivor. Hear and learn how you can apply several of Deming’s points—to help you and help you assist others to achieve success in life and business.
Bloomberg reports that an unreleased internal BP report on the BP Deepwater Horizon accident found that the accident was caused by engineers (commonly called a “company man”) misinterpreting pressure data that indicated a blowout was imminent. The article says that BP plans to release the report in the next 10 days.
Bloomberg says that the report is 200 pages long and details the investigation led by Mark Bly, the head of safety and operations.
Boston, Massachusetts, will be the location for a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course on September 21-22, 2010. In just two days you will learn the basics of the TapRooT® System for finding the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and other types of problems. Once you find the real root causes using this systematic process, learn to develop effective fixes that will keep problems from happening again.
Boston is the capital and largest city of the Commonwealth of Massachusetts and is one of the oldest cities in the United States. The largest city in New England, Boston is considered the economic and cultural center of the region and is sometimes regarded as the unofficial “Capital of New England.” Boston is also the anchor of a substantially larger metropolitan area called Greater Boston, home to 4.5 million people. (Source http://en.wikipedia.org/wiki/Boston,_Massachusetts)
Rich in history, Boston has much to offer visitors. From the Boston Tea Party to the Midnight Ride of Paul Revere, patriotism abounds and the city reflects this in its many sightseeing attractions. Here are just a few options to get you started on your Boston tour:
The Boston Beer Company offers tours of their Sam Adams Brewery. Boston Beer founder Jim Koch is the sixth generation of Koch brewmasters.
Acorn Tours offers private sightseeing tours of Boston and the surrounding areas. See everything from Harvard to the Salem Witch Museum to the Mayflower II and Plymouth Rock.
Boston Sportfishing is located right on Boston Harbor. Enjoy a day of fishing for bluefish and flounder as well as offshore fishing for cod, haddock, pollock, wolffish, shark, and bluefin tuna.
Boston Common is the starting point of the Freedom Trail. The nearly 50-acre Boston Common is one of the oldest parks in the nation.
The Boston Tea Party Ship and Museum offers a multitude of exhibits and memorabilia. It is a full-sized replica of one of three original Boston Tea Party ships.
The Freedom Trail is a 2.5-mile route that passes by some of Boston’s most noteworthy historical sites, including the Paul Revere House and the Old North Church.
Harvard University is the oldest university in the United States. Among its graduates are six U.S. Presidents–John Adams, John Quincy Adams, Theodore and Franklin D. Roosevelt, Rutherford B. Hayes, and John F. Kennedy.
The USS Constitution was launched in 1797, making it the world’s oldest floating commissioned ship.
Dining in Boston:
Cheers/Bull and Finch Pub is a Boston tradition and was the inspiration for Cheers, the long-running TV sitcom. The menu features wings, nachos and burgers along with Cheers memorabilia.
The Bell in Hand Tavern has five bars and lots of live music plus karaoke. They also have your favorite appetizers, burgers, and sandwiches.
33 Restaurant and Lounge offers a wide array of menu options like Potato Ravioli, Spring Salmon, and Sake Miso Black Cod.
Maggiano’s Little Italy features traditional favorites like Baked Ziti & Sausage, Lobster Ravioli, and Fettuccine Alfredo.
Anthony’s Pier 4 overlooks historic Boston Harbor and offers fresh seafood, prime steaks, succulent Maine lobster and more.
For more information or to register for the 2-Day TapRooT® Incident Investigation and Root Cause Analysis in Boston, Massachusetts, visit: http://www.taproot.com/courses.php?d=933&l=1
CSB Conducting Assessment of Ammonia Release
at Millard Refrigerated Services South of Mobile, Alabama
Washington DC, August 27, 2010 – A three-member assessment team led by Mr. Johnnie Banks from the U.S. Chemical Safety Board (CSB) is deploying to the scene of Monday’s anhydrous ammonia release at the Millard Refrigerated Services, a warehouse and distribution center in Theodore, Alabama, 15 miles south of Mobile.
According to media reports, more than 130 members of the public sought medical attention and four people remain hospitalized as a result of the uncontrolled ammonia release.
CSB Chairperson Rafael Moure-Eraso said, “We are seeing too many ammonia releases in our daily incident reviews. Though many are “small” releases, a high consequence accident that causes multiple injuries to members of the public is a serious one that warrants our examination. Our team will be examining the events that led to the release and ways that the community can be better protected in the future.”
Anhydrous ammonia is one of the most commonly used commercial refrigerants; it is a colorless, flammable, toxic gas. For humans, high exposure levels can result in suffocation as well as severe injuries to eyes, lungs and the digestive system.
Based on the CSB’s monitoring of media reports there were four high consequence incidents involving the release of anhydrous ammonia which led to a total of six fatalities in 2009:
· May 14, 2009: American Cold Storage, Louisville, KY – 2 fatalities
· June 20, 2009: Mountaire Farms, Lumber Bridge, NC – 1 fatality
· July 15, 2009: Tanner Industries, Swansea, SC – 1 fatality
· November 16, 2009: CF Industries, Rosemount, MN – 2 fatalities
CNC invited System Improvements, Inc. back to Trinidad to teach a 1-Day Refresher and 2-Day Root Cause Analysis Courses this week. It was pleasure for Mark Olson and I to work with their energetic and passionate team.
Here are a few picture from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis:
The Associated Press reported that Ron Sveden was worried about cancer when he had increased coughing and an x-ray showed a dark spot in his lungs. Then things got strange. The tests came back negative on the cancer. What was in his lung causing problems?
The doctors decided they had to go in for a look. What was the root cause of his problem? A ROOT! (Well … actually a sprout.)
They removed a mass and sent it to pathology. The report was that he had a vegetable – a pea – sprouting in his lungs!
Rafael Moure-Eraso, Chairman of the Chemical Safety Board, sent the letter below to Xcel Energy Inc., a utility with its headquarters in Minnesota. I’ve never seen a letter written so strongly from an investigator about the lack of cooperation about an investigation. Have you?
It would certainly be interesting to know more about what happened to cause the lack of cooperation.
CSB Final Report on Xcel Energy Accident Finds
Company and its Contractor Failed to Adequately Prepare
for Hazardous Work Inside Confined Space of Hydroelectric Plant Tunnel;
Xcel Had No Technically Qualified Responders on Duty
Report Urges OSHA, Colorado Public Utilities Commission to
Strengthen Regulations; CSB Finds 45 Confined Space Fatalities
Have Occurred in 53 Incidents Nationwide Since 1993
Denver, Colorado, August 25, 2010—The tragic accident that took the lives of five industrial painting contractors deep inside an Xcel Energy hydroelectric plant tunnel in Georgetown, Colorado, was the result of several vital safety failures, the U.S. Chemical Safety Board (CSB) determined in a final investigation report issued today in Denver.
Nationally, the investigation identified 53 serious flammable atmosphere confined space accidents that occurred from 1993 to April 2010, causing 45 fatalities and 54 injuries, the majority since 2001.
The CSB also released a 15-minute safety video entitled “No Escape: Dangers of Confined Spaces,” which includes a detailed animation depicting the horrible tragedy that unfolded inside the mountain tunnel at Xcel’s Cabin Creek plant on October 2, 2007.
The accident occurred in the water tunnel, or penstock, of the hydroelectric plant, located 45 miles west of Denver. The penstock carries water from an upper reservoir to a lower one, driving power turbines. The painting contractors, from RPI Coating, Inc., were recoating a 1,530-foot steel portion of the 4,300-foot penstock when a flash fire suddenly erupted as the vapor from flammable solvent, used to clean the epoxy spraying wands, ignited, probably from a static spark in the vicinity of the spraying machine. The initial fire quickly grew, igniting additional buckets of the solvent, methyl ethyl ketone (MEK), and other combustible epoxy materials stored nearby.
The CSB concluded the causes of the accident included (1) a lack of planning and training for hazardous work by Xcel and its contractor, RPI Coating, Inc., (2) Xcel’s selection of RPI despite its h aving the lowest possible safety rating (zero) among competing contractors, and (3) allowing volatile flammable liquids to be introduced into a permit-required confined space without necessary special precautions.
The CSB report found that the permit-required confined space rule set by the U.S. Occupational Health and Safety Administration (OSHA) does not prohibit entry or work in confined spaces where the concentration of flammable vapor exceeds ten percent of the chemical’s lower explosive limit, or LEL. (The LEL is the concentration of vapor in air below which ignition will not occur.)
OSHA’s rule does state that an atmosphere exceeding ten percent of the LEL creates an atmosphere “immediately dangerous to life and health” and that steps should be taken to define safe entry conditions; however, the rule does not define what those safe entry conditions should be or specifically prohibit entry into such hazardous atmospheres, the report notes. The CSB recommended OSHA establish a fixed maximum percentage of the LEL for entry so that work in potentially flammable atmospheres would be prohibited.
Additionally, the Board made recommendations to the company, the governor of Colorado, the Colorado Public Utilities Commission, trade groups, and other organizations.
CSB Board Member William B. Wark said, “This tragedy should never have happened. The companies did not effectively plan for the dangers of bringing significant amounts of flammable liquids into the tunnel, which was a hazardous confined space. Doing so was an unacceptable deviation from good safety practices.”
There were ten workers in the tunnel and one at the entrance at the time of the fire. Five were unable to get around the fire on the painting platform to get to the only available exit – the improvised tunnel entrance. Five workers on the other side of the platform made it to safety, although three of those workers sustained injuries.
The CSB found that Xcel and RPI failed to have technically-qualified confined space rescue crews immediately standing by at the penstock in case of emergency, as required by regulations. Workers called 911 for help but responders entering the penstock had to retreat in the thick smoke, as did workers who had approached the fire with extinguishers.
The closest confined space technical rescue unit – equipped and trained to enter the smoke-filled tunnel – was approximately one hour and 15 minutes away. The trapped workers died about one hour before this response unit arrived, their escape blocked by a steep vertical section of the tunnel deep inside the mountain.
CSB Investigations Supervisor Don Holmstrom, who led the investigation, said, “The five trapped workers communicated with co-workers and emergency responders using handheld radios for approximately 45 minutes, desperately calling for help, before succumbing to smoke inhalation. Their lives likely could have been saved had qualified, company-provided rescuers been in a position to respond immediately to a fire or other emergency.”
Board Member Mark Griffon, joining Mr. Wark and Mr. Holmstrom at the news conference, said, “Even before the operation began, the stage was set for disaster. Xcel not only did not adequately plan for the operation, but it selected the painting contractor with the lowest possible safety rating among the bidders, and it did so mostly on the basis of cost – it was the lowest bid.”
The investigation found that Xcel hoped to compensate for RPI’s safety record by closely supervising the contract work, but did not do so even when the company learned of safety issues during the initial penstock work.
The CSB investigation found Xcel and RPI managers were aware of the plan to operate the epoxy sprayer in the tunnel and to use flammable solvent to clean the sprayer and other equipment.
Mr. Holmstrom said, “As a result of not performing a hazard evaluation of the work to be done, the companies failed to identify serious safety hazards involving use of flammable liquids within the confined space. Use of safer, nonflammable solvents was not evaluated, continuous air monitoring was not required, and key policies and permit forms did not establish a percentage limit for flammable vapor in the tunnel atmosphere.”
Board Member Wark noted the lack of planning for escape in an emergency. “The penstock had only one egress point – the tunnel entrance,” he said. “Xcel and RPI did actually identify this as a major concern in their planning. But despite this, no plans were made for prompt rescue in an emergency, and no rescuers qualified to enter this confined-space environment were standing by.”
The CSB investigation determined that while companies are required to perform a hazard analysis prior to issuing permits for work in confined spaces, regulatory standards pertaining to the use of flammables within confined spaces are inadequate.
Board Member Griffon stated, “Other OSHA regulations on confined and enclosed spaces – for example in the maritime industry and other sectors – prohibit work in such confined spaces above a specific percentage of the LEL, often ten percent. We are recommending that OSHA adopt such enforceable limits for all industry.”
The CSB recommended that OSHA amend its confined space rule to establish a maximum percentage substantially below the lower explosive limit for any given flammable for safe entry and occupancy while working.
The CSB made recommendations to nine other entities. These included that the governor implement an accredited firefighter certification program for technical rescue with specialty areas including confined space rescue; that the Colorado Public Utilities Commission (PUC) require regulated utilities to adopt provisions for selecting contractors based on safety performance measures and qualifications; and that the PUC require utilities to investigate all incidents resulting in death, serious injury or significant property damage and submit and make public written findings and recommendations within one year of the accident.
Numerous recommendations were made to RPI Coating, particularly aimed at revising its confined space entry program and guidance.
CSB investigators and board members cited difficulties encountered in the investigation resulting from efforts by Xcel Energy and RPI Coating to impede the investigation and prevent the release of the investigation report.
Citing a formal Letter of Admonishment sent to the Xcel chief executive officer earlier in the week, Board Member Wark said, “The lack of cooperation and efforts by Xcel to impede our investigation are unprecedented. Mr. Griffon and I join our chairman in criticizing these actions in the strongest terms.”
The letter, signed by CSB Chairperson Rafael Moure-Eraso, states Xcel Energy did not fully comply with CSB requests for documents or answers to questions in formal interrogatories. This required the CSB to seek assistance from the U.S. Attorney’s office in Denver, resulting in delays to the investigation and additional costs to taxpayers. In May, Xcel took the extraordinary and unprecedented step of going to federal court seeking to block release of the CSB report and the safety video. The court sided with the CSB in favor of release.
Xcel was given an advanced draft copy of the report last April for review for accuracy and for confidential business information in accordance with CSB review protocols. Xcel never responded, but in August 2010, contrary to the conditions of confidentiality attached to their receiving this preliminary copy, released it to a news organization.
The letter from Chairperson Moure to Xcel’s CEO concludes, “In light of this disappointing pattern of corporate conduct, I am writing you directly to ensure that you are personally aware of the actions taken by Xcel to delay the CSB investigation, block publication of the CSB final report, and distort the conclusions of the investigation by releasing an unauthorized draft copy of the CSB report. The CSB will issue a formal recommendation that Xcel shareholders be directly notified by management of the significant findings and recommendations of the CSB report, and of the actions Xcel management intends to take to implement needed safety improvements. In the wake of the corporate responsibility concerns raised by the Big Branch Mine accident in West Virginia and the disaster in the Gulf of Mexico, I strongly urge Xcel to renew its focus on safety and to swiftly implement the CSB’s recommendations.”
The RAIB is carrying out an investigation into a collision that occurred at Sewage Works Lane level crossing, 1.5 miles south of Sudbury in Suffolk, on 17 August 2010.
The accident occurred at around 17:35 hrs when train 2T27, the 17:31 hrs service from Sudbury to Marks Tey, struck the trailer of a loaded articulated tanker lorry on the crossing, causing the leading carriage of the two-car class 156 diesel multiple unit to derail.
There were about 19 passengers on the train and two crew members (driver and conductor). It is reported that all persons on the train received injuries as a consequence of the impact with one passenger sustaining critical injuries.
The impact separated the tractor unit of the lorry from the tank causing a major spillage of the tank’s contents. Some diesel fuel was also released during the accident.
Sewage Works Lane crossing is a ‘user worked crossing’, as is often found at the intersections between the railway and minor (usually private) roads. At all such crossings the road user is required to operate gates or barriers when crossing the railway.
No lights or audible alarms were provided at the crossing to warn of the approach of trains. However, the crossing was provided with telephones to enable the drivers of vehicles to call the signaller to confirm if it was safe to cross.
The RAIB’s investigation is independent of any investigations by the British Transport Police and the safety authority (the Office of Rail Regulation).
The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.
I also found it interesting that many of the investigators said that performing a good investigation and seeing people jobs get better (safer) was reward enough.
However, if managers want good investigations, shouldn’t they be rewarding what they want? Isn’t this basic management?
Therefore, one major improvement that management should consider for improving investigations is to start a systematic evaluation of investigations and rewards for good investigations.
Michael Podgomy, one of out TapRooT® Instructors that works for Practical Solutions Group in Australia, send the class photos of a SnapCharT® course exercise held at Rio Tinto’s Tom Price mine.
WASHINGTON, D.C. – Deepwater Horizon Joint Investigation Co-Chairs J. David Dykes (Bureau of Ocean Energy Management, Regulation and Enforcement) and Captain Hung Nguyen (U.S. Coast Guard) today announced that U.S. District Judge (Ret.) Wayne R. Andersen and U.S. Coast Guard Capt. Mark R. Higgins will be joining the Deepwater Horizon Joint Investigation Team. The addition of Judge Andersen and Capt. Higgins will increase the depth and diversity of the team, drawing on their vast expertise in managing and facilitating complex proceedings.
The public hearings in this matter began on May 11, 2010, and have continued during the weeks of May 26 and July 19. The next hearings are scheduled to take place beginning on August 23, 2010, in Houston, Texas.
“The addition of Judge Andersen and Capt. Higgins to the Joint Investigation Team will enhance our work and help us to move expeditiously through the proceedings. They will assist us with some of the legal and procedural issues they are experienced, and allow the other members of the team to continue to focus on gathering the facts,” said Dykes. “They are welcome additions to our team.”
“I look forward to welcoming Judge Andersen and Capt. Higgins into the integrated investigative team, which will benefit from their unique skills and experience as we move into a new phase of the proceedings,” said Nguyen.
Andersen is a retired U.S. District Judge for the Northern District of Illinois, where he served from 1991- July 2010. He is currently a mediator and arbitrator for JAMS, a national alternative dispute resolution provider. He previously served as Judge of the Circuit Court of Cook County and Deputy Secretary of State of Illinois. He received his law degree from the University of Illinois College of Law in 1970 and an undergraduate degree in government, cum laude, from Harvard University in 1967. He is donating his time and will not receive compensation for his service on the team.
Higgins is currently serving as the Staff Judge Advocate for the U.S. Coast Guard Atlantic Area. He serves as regional counsel for all legal issues within the Atlantic Area, including operations and international maritime issues involving five Coast Guard Districts and Coast Guard operations in Europe, Africa, and the Middle East. He also serves as a military judge. He received his law degree, cum laude, from the University of Miami in 1989 and an undergraduate degree in civil engineering, with honors, from the U.S. Coast Guard Academy in 1983.
In response to the April 20, 2010, explosion of the Deepwater Horizon, Secretary of the Interior Ken Salazar and Department of Homeland Security Secretary Janet Napolitano directed the Minerals Management Service, now the Bureau of Ocean Energy Management, Regulation and Enforcement (BOEM), and the U.S. Coast Guard to conduct a joint investigation in accordance with a pre-existing Memorandum of Agreement. The facts collected at the hearings, along with the lead investigators’ conclusions and recommendations, will be presented in a final investigative report.
The Joint Investigation Team is comprised of both BOEM and Coast Guard personnel exercising both agencies’ authorities. In addition to the co-chairs, members include: Lt. Robert Butts, Coast Guard; Jason Mathews, BOEM; John McCarroll, BOEM; and Ross Wheatley, Coast Guard.
Attend the Improvement Program track at the 2010 TapRooT® Summit (learn more about the presenters on the Summit website). The specific sessions for this track include:
Self Improvement for Your Future: In response to a declining job market in 2009, we offered a Career Development Track at the Summit in Nashville, Tennessee. It was so well received, we decided to offer a best practice “mini course” in career development for 2010. Register for this session and join Dave Janney, Brad Towe and Barb Phillips as they present not only how to end 2010 on a professional high note, but also how to make 2011 the best professional year ever!
Dr. Beverly Chiodo is returning to the Summit to speak about Character Driven Success and how to change behavior by praising the 49 character traits:
Character Driven Success: You will learn to:
* Motivate people to respond nobly to life’s challenges.
* Express specific ways others have benefited your life and the life of your organization.
* Discover the secret of “going the second mile.”
* Create an environment which builds rapport and team spirit.
The purpose of this session is to broaden your understanding of what makes communication powerful and effective. Dr. Chiodo will challenge you with a new perspective on how to motivate others to excellence.
Changing Behavior By Praising the 49 Character Traits
The purpose of Dr. Chiodo’s presentation is to enlarge your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
As you participate, laugh, and refine your ability to speak and write, you will learn to influence and motivate others. Your life will be changed as Dr. Chiodo teaches you how to empower others.
How To Set-Up and Sustain a Continuous Improvement System
How do high performing organizations design their continuous improvement systems?
How do these organizations use and improve their continuous improvement systems over time?
What options exist for setting up a high impact continuous improvement system?
What types of teams do you need?
Kevin McManus will answer these questions, while also providing an overview of the tools and processes necessary to implement and sustain a continuous improvement system that meets your needs in a value added manner.
Mark Paradies will be presenting Lessons Learned about Excellence & Safety from Admiral Rickover on this track.
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In the best practice session, “What are Your Proactive Performance Indicators?” the difference between reactive and proactive measures will be explained with examples. Attendees will also have the opportunity to share the proactive measures that they have found useful.
“How TapRooT® Fits into ISO” is also a best practice session on this track, as well as “Using Training Simulation to Improve Performance” presented by Mario Paquette and Gerald Perrier.
Here’s Roland Reid teaching his first TapRooT® Class at Subsea 7 in the UK with Mhorvan Sherret. Subsea 7 is a licensed TapRooT® User and they do their own 2-Day classes with Certified TapRooT® Instructors that work for Subsea 7.
Want to find out what it takes to be a Certified TapRooT® Instructor at your company? See:
Press release from the UK Rail Accident Investigation Branch:
The RAIB is carrying out an investigation into the runaway of an engineering train which occurred on the Northern Line of London Underground (LUL) on Friday 13th August 2010.
The train consisted of a self-propelled diesel-powered unit designed for re-profiling worn rails. It had been working between Highgate and Archway stations on the southbound line during the night of 12/13 August. At the end of grinding operations that night, the crew of the unit found that they were unable to restart its engine to travel away from the site of work.
An assisting train, consisting of a six-car train of the 1995 stock used for passenger services on the Northern line, was sent to the rescue of the grinding unit. The assisting train was coupled to the grinding unit by means of an emergency coupling device, and the braking system of the grinding unit was de-activated to allow it to be towed. The combined trains then set out to run to East Finchley station. At about 06:44 hrs, after passing through Highgate station, the coupling device failed and the grinding unit began to run back down the gradient towards central London. The crew of the grinding unit, who had no means of re-applying the brake, jumped off the unit as it passed through Highgate station. It then ran unattended for about four miles, passing through a further six stations, and came to rest near Warren Street station about thirteen minutes later. No-one was hurt.
There was some damage to the grinding unit, and points at Mornington Crescent station were damaged when the unit ran through them.
LUL control room staff took action to clear trains away from the path of the runaway unit. The RAIB’s investigation will seek to identify the position of these trains in relation to the runaway. It will also consider the reasons for the failure of the coupling, and the rules and procedures applicable to the rescue of failed engineering trains.
The RAIB’s preliminary examination has identified no evidence that the condition of the track or the signalling system contributed to the incident.
The RAIB’s investigation is independent of any investigations by the safety authority.
The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website.
The Associated Press reported that MSHA cited Massey Energy for failing to report 20 accidents at the Upper Big Branch Mine. These violations were found as part of the investigation into the accident earlier this year that killed 29 workers.
The story also says:
“Separately, MSHA said Tuesday it is fining a Massey Energy subsidiary more than $542,000 for violations that contributed to a fatal accident at a Virginia mine in 2009.
The accident occurred Aug. 20, 2009, when the mine was owned by Cumberland Resources, which Massey acquired in April.”
. . . . .
Once again, finding and fixing the causes of accidents before a major accident happens could have saved lives and big bucks!
$2.4 million is a considerable fine. But one wonders if a fine 3 years after an accident will really help improve safety.
The 2007 accident was a result of poor maintenance and repair activities, says a report by the Pipelines and Hazardous materials Safety Administration. The report took a year to complete and was reported on in part of an article in the Kalamazoo Gazette.
The article said:
“In addition to the $2,405,000 fine, Enbridge must also revise and implement certain pipeline maintenance and repair procedures, as well as train and re-qualify its employees.”
The fine comes after a accident in Michigan that happened on July 26 that resulted in more than 1 million gallons of oil spilling into the Kalamazoo River. Enbridge has released estimates of the cost of the cleanup of that spill: $300 to $400 million. Some of those costs will be covered by insurance. After insurance, Enbridge expects the costs to be $35-45 million.
. . . . . .
Wow! The fine is a pittance compared to the accident costs of the recent spill. It seems as if a great deal of money could be saved by implementing proactive maintenance programs to improve pipeline/equipment reliability. Perhaps Enbridge should be looking into using Equifactor® and attend the Heinz Bloch session at the TapRooT® Summit to learn the latest ideas for equipment reliability improvement.
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Boston, Massachusetts, will be the location for a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course on September 21-22, 2010. In just two days you will learn the basics of the TapRooT® System for finding the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and other types of problems. Once you find the real root causes using this systematic process, learn to develop effective fixes that will keep problems from happening again.
