Root Cause Analysis Blog

The Canadian Society of Safety Engineering will require one new, additional Instructor for its Applied Risk Communication Skills course beginning in the 2007 CSSE Schedule of Courses.

(more…)

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Releases Trailer Blast Damage Information from BP Texas City Accident

Washington, DC, June 30, 2006 - The U.S. Chemical Safety Board (CSB) announced it is releasing detailed trailer blast damage information developed during the ongoing investigation of the March 23, 2005, explosions at the BP refinery in Texas City, Texas. The information was posted to the agency’s website, CSB.gov, and also provided to the American Petroleum Institute (API), the trade organization that is working to develop new guidance on the safe placement of trailers and similar temporary structures used in the oil and chemical industry.

The accident at BP killed 15 workers and injured about 180 others when flammable liquid and vapor overfilled a blowdown drum during the startup of the refinery’s isomerization unit. All of the fatalities and many of the injuries occurred in and around trailers that had been positioned near the isomerization unit to support maintenance activities on adjacent refinery units.

The data released today include details of the injuries and structural damage that occurred among some 44 different trailers that were located in the vicinity of the isomerization unit. The fifteen fatalities occurred in or near two trailers that were located 121 to 136 feet from the blowdown drum. Occupants were injured in trailers as far away as 479 feet from the drum. Damage was noted in trailers almost 1000 feet away.

(more…)

OK - What is the biggest hazard to the unborn baby?

This is the Friday Joke but … it demonstrates that those closest to the problem sometimes don’t see the problem.

Hello everybody, welcome to another edition of Tech Support Thursday.

Today I’m going to cover a small but important issue for Enterprise or Workgroup clients: What needs to be done to each client machine when the server is being moved? How do you point the existing clients to a new machine?

Read on to find out how!

(more…)

Some would say that fireworks are “unsafe at any speed.”

By if you are planning to use them this 4th of July, see this link:

http://money.cnn.com/2006/06/29/real_estate/tips/willis/index.htm

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

Chicago, Illinois, June 28, 2006 - The U.S. Chemical Safety Board (CSB) today announced it will pursue an investigation of the fatal explosion and fire at Universal Form Clamp Company in Bellwood, Illinois, a Chicago suburb.

(more…)

Watch below as Daniel Gaffney details his favorite aspects of our yearly Summit, courtesy of YouTube.

The June TapRooT(R) Friends/Experts e-Newsletter has been posted at:

http://www.rootcause.net

This months topics are:

- ALWAYS STEP 1: DRAW A SnapCharT®

- QUESTION ON FATALITIES



- PRACTICE YOUR PROACTIVE AUDITING SKILLS

- JUST SCHEDULED! 5-DAY TapRooT® COURSE IN MONTERREY, MEXICO, IN SPANISH. FIRST 5-DAY IN SPANISH WE’VE EVER HELD!



- FIRST 3-DAY EQUIFACTOR IN AUSTRALIA

- HOW LONG DOES IT TAKE TO INVESTIGATE AN INCIDENT?



- MORE SAMPLE “SEVERITY SCALES”

- MAY/JUNE ROOT CAUSE ANALYSIS BLOG TOPICS (Don’t Miss Reading & Replying to These Posts)



- SUCCESS STORIES NEEDED

- MORE NICE THINGS ABOUT TapRooT® COURSES



- PRELIMINARY SUMMIT SCHEDULE IS COMPLETE - ANNOUNCE ONE TRACK PER MONTH - THIS MONTH … PROACTIVE IMPROVEMENT BEST PRACTICES



- WHEN IS A FINE TOO BIG???

- GEORGE BURK PUBLISHES NEW BOOK

- PRE-SUMMIT COURSE SCHEDULE SET

- WHERE IS THE BEST ROOT CAUSE ANALYSIS TRAINING???

- J.O.K.E OF THE MONTH

A hot political issue in the US is the impact of Global Warming and what we should or should not be doing.

This may also be a hot scientific issue, but it is difficult to tell. Why? Because of all the hype (see the article in the Canadian Free Press for an example of some of the discussion/debate in the scientific community).

My point is not to get a political or scientific debate on global warming started on this blog site. Rather, my point is … How do YOU gather and consider evidence when you are analyzing problems?

Al Gore continues to repeat his beliefs about the immanent and devastating impact of global warming. Does repeating the belief make the statements a fact?

At your company, does the fact that someone keeps repeating their version of what happened over and over again make the statement more true because it has been repeated more often?

How do you verify a statement - be it Al Gore’s or someone at your plant?

What do you consider as evidence?

At your plant site, you would probably get some independent facts and expert opinions to help verify or disprove the story that is being told.

But many don’t have the scientific background to evaluate the statements made by Al Gore or to evaluate the global warming research being published. Thus the statements can’t be independently verified.

Politics is an interesting arena where facts sometimes seem to be irrelevant.

Problem solving is a completely different animal.

Facts - independently verified facts - are the driving force behind finding root causes and really fixing problems. No matter what problem solving technique you use, your process MUST be driven by facts, or it won’t work.

So the next time you are investigating an incident, reading a newspaper, or watching a movie, THINK … how can I verify the statements … what are the FACTS. The simple process of verifying statements with other sources of evidence will make you a much better investigator and problem solver.

(CSB Chairman Carolyn Merritt testifies

about agency recommendations on

community emergency response

procedures. - from CSB web site)

The US Chemical Safety Board has issues 28 reports with recommendations to improve safety. These recommendations are based on the CSB’s root cause analysis of major chemical accidents (almost all involving fatalities).

Do you know what those recommendations are?

Do they include lessons learned that should be applied at your facility?

And what if you aren’t in the chemical industry … Could you learn generic lessons that could still be applied at your facility?

To see the reports’ recommendations go to:

http://www.csb.gov/index.cfm?folder=recommendations&page=index

If you would like to see the CSB’s statistics on the response to their recommendations, see:

http://www.csb.gov/index.cfm?folder=recommendations&page=rec_stats

Interested in troubleshooting equipment failures and analyzing their root causes?

Live in Europe?

Then you should start planning to attend the special 2-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting & Root Cause Analysis Course that is being sponsored by SKF (and held at their facilities) in Utrecht City, The Netherlands on September 14-15, 2006.

This course isn’t on our registration pages yet, so if you want to register now you will have to call our offices in the US at 865-539-2139 or use the e-mail link.

The cost for this 2-Day Equifactor(R) Course is $1690 US Dollars.

This price includes:

1. An individual user version of the TapRooT(R) Software (priced at $1495 without the course).
2. Heinz Bloch’s book - Machinery Failure Analysis and Troubleshooting (a $115 value) - and
3. The TapRooT(R) Book (a $195 value) by Mark Paradies & Linda Unger.

That’s $1805 of software and books in a course that only costs $1690. What a deal!

Space in the course is limited so register by phone or e-mail today.

Bad day for the pilot. And everyone else didn’t have much fun.

Whenever I see a video of a crash I wonder … Did they find the root causes?

(Click on box to play video)

I thought the bucket brigade was obsolete until Ken Reed, one of our TapRooT(R) Instructors, sent me this picture.

(Click on picture to expand.)

Seems to me that evacuation would be the best idea….

I often get questions that sound something like this…
“I’ve been trying to sift through the bewildering amount of information out there on equipment reliability. Is there a
“relatively simple” method that lends itself toward machine reliability issues?”
In other words, is there a simple method available that will make my machinery more reliable?

That’s a pretty tall order. There are many directions you can go, and you really need to narrow down your area of concern. Are you looking for:
- Predictive Maintenance capabilities
- Theory behind equipment failures (Weibull curves, etc)
- Equipment Troubleshooting aids
- Root Cause Analysis
- Etc, etc, etc

I can definitely help with the root cause analysis problems prevalent in industry today. I facilitate companies throughout the country on accident root cause analysis, and I see equipment reliability and failure issues all the time. More often than not I see companies that do an adequate job of applying predictive maintenance techniques to track when a piece of gear is failing, but they rarely try to find out why it is failing. That is, until a catastrophic failure forces them to perform a root cause analysis of the incident.

I do not feel that equipment troubleshooting and root cause analysis should be separated. If you are troubleshooting your equipment, it means you had a failure of some type. Are you satisfied with repairing the symptom and putting it back in service, or do you want to find out why you are troubleshooting in the first place? The same problem is almost guaranteed to happen again, unless the actual cause of the failure is discovered and corrected. This goes to the heart of equipment reliability issues seen in almost every industry segment.

Using Equifactor(R) in combination with the rest of the TapRooT(R) system will provide you with a method of looking beyond mere symptom correction. The combination of a systematic troubleshooting tool with a world-class root cause analysis system provides an extremely effective yet easy-to-use tool for finding out why your equipment fails.

Don’t be satisfied with finding and correcting symptoms. Use Equifactor(R) to define the problems with your equipment, then apply TapRooT(R) to find out why you have the problem in the first place.

Hello again everybody, welcome to another edition of Tech Support Thursday.

Today I’m going to cover comments on the Root Cause Tree—how to add one, what they look like, and the report you can run to view them all.

All of that and more inside!

(more…)

Reports to: Director, Health, Safety Environment Strategy

Summary of Position:

This position is responsible for helping to shape the corporation’s global safety culture.

Responsibilities:

Oversees the establishment, implementation, and maintenance of the corporate EHS management system, standards, policies, and procedures to protect the corporation and its employees from losses due to accident or fire.

Prepares meaningful and insightful analyses of internal and benchmark data for department and corporation management reports on a monthly, quarterly, and ad hoc basis.

Provides advice and counsel to executive and business unit management to improve safe working conditions and facilities in offices, exploration, production, refineries, terminals, pipelines, retail outlets, and other company locations.

Assists business units, facilities and operations in developing meaningful programs to improve employee safety performance.

Manage multi-discipline teams comprised of Hess personnel and/or external contractors/consultants on topics pertaining to Safety.

(more…)

Yesterday, the White House announced the president’s intention to nominate William B. Wark and William E. Wright to serve five-year terms as board members of the U.S. Chemical Safety Board (CSB). There are currently two vacancies on the five-member board. Both nominations are subject to Senate confirmation.

Mr. Wark currently serves as Executive Vice President for LGH, Incorporated. Prior to this, he served as Project Manager for The Marasco Newton Group. Earlier in his career, he served as Deputy Director for the Technological Hazards Division at the Federal Emergency Management Agency. Mr. Wark has served as a Lieutenant in the United States Navy. He received his bachelor’s degree from the University of Maine at Fort Kent and his master’s degree at The George Washington University.

Mr. Wright currently serves as Chairman of the Department of Defense Explosives Safety Board. Prior to this, he served as Commander of Explosive Ordnance Disposal Group ONE. Earlier in his career, he served as Head of the Ordnance Branch for the Chief of Naval Operations. He has served as Captain in the United States Navy for 30 years. Mr. Wright received his bachelor’s degree and a master’s degree from the University of Puget Sound. He went on to receive a second master’s degree from the Naval War College.

These two nominations would bring the board up to their full five members as authorized by Congress.

The auto industry is aligning to a single, worldwide quality standard.

That “standard” is not technically a standard. Rather it is called a Technical Specification.

Its numerical title is TS 16949.

My goal isn’t to discuss the differences between standards and specifications or to outline all the ways that QS 9000, ISO 9000, AVSQ94, EAQF94, and VDA6.1 have been combined. Rather - because this blog is focussed on root cause analysis - I would like to highlight one item that I’ve heard… that is that third party auditors (registrars) are now putting more emphasis on the following requirements:

1) A continuous process for monitoring customer perception of whether their contractual requirements have been met exactly or not;

2) A continuous evaluation and analysis of technical, manufacturing, and testing data; and

3) Demonstration with evidence of compliance with customer requirements and efficiency of processes.

But the third party auditors are not just focusing on process auditing of these three requirements. They want suppliers to meet and exceed customer expectations and customer-specific requirements.

What happens when a supplier has less than 100% compliance?

The auditors expect a reaction plan (immediate actions in TapRooT(R) terminology) to be in place to contain OEM risk.

In addition, on the longer term side, the auditors expect root cause analysis with effective corrective action that prevent future problems (the same problem happening over and over again).

Strategies to prevent problems should include error proofing/defect prevention.

An example of this can be found in the DaimlerCrysler customer requirements. Section 4.2.9.1 says:

“The organization shall show evidence of immediate corrective actions, containment (as required), and root cause analysis (as required).”



That section also states that:

“Communication Procedure is required to address reoccurring non-conformances. Specific areas of focus shall include the following:

- Resolution of non-conformamnces

- Escalation of issues for management review

- Lessons learned.”



The key, therefore, to avoid reoccurring non-conformances is effective corrective actions.

That is where TapRooT(R) can help automotive suppliers go beyond the simple but ineffective techniques of fishbone diagrams (Ishikawa Diagrams) and 5-Whys. (For an analysis of the problems with 5-Whys and fishbone diagrams, see: http://www.taproot.com/blog/2005/10/whats_wrong_with_5whys_complet.html )

Not only does TapRooT(R) lead investigators beyond their current knowledge by an advanced human performance troubleshooting tool and another advanced equipment performance troubleshooting tool, but TapRooT(R) also has the Corrective Action Helper(R) Module as part of the patented TapRooT(R) Software.

So if you would like to avoid quality issues, perform effective investigations, and get smiles from your third party auditors, take some TapRooT(R) Training and then implement TapRooT(R) at your facility as your problems solving / root cause analysis tool of choice.

For more course info see:

http://www.taproot.com/courses.php

One more note…

TapRooT(R) makes an excellent addition to any Lean or Six Sigma implementation as the root cause analysis tool of choice in those processes. It can also be used as the root cause analysis tool to supplement your thinking for Failure Mode and Effect Analysis to help you go beyond what you currently know. And the Equifactor(R) Analysis tool can help you improve the equipment reliability in your manufacturing processes.

So if you are addressing quality, productivity, safety, equipment reliability, or even environmental issues, TapRooT(R) should be a tool — an important and frequently used tool — in both your reactive and proactive investigation/improvement toolbox.

“I believe the up-armoring has caused more deaths than it has saved,” said Scott Badenoch, a former Delphi Corp. vehicle dynamics expert told the Dayton Daily News for Sunday editions.

That’s the quote from a CNN story on troop deaths in Humvees in Iraq.

Sometimes corrective actions can cause more problems than they cure. The story doesn’t say for sure that adding armor was a mistake - but it suggests that it might be.

The last R on SMARTER (a technique that we teach in our courses that helps people develop better corrective actions) stands for REVIEWED.

Part of reviewing a corrective actions is to have someone independent of the corrective action development team review the corrective action for unintended consequences.

Perhaps an independent review of the added rollover risk posed by armoring Humvees might have caught this problem before personnel were killed in increasing numbers of roll-over accidents and tens of millions of dollars were spent on armor that might actually increase the numbers of fatalities.

This is also an example of how reacting to a safety problem can cause unintended problems that might make safety worse.

It certainly makes one think that developing corrective actions to address problems is harder that one might think!

One more interesting point in the story…

Army spokesman John Boyce Jr. told The Associated Press on Sunday that the military takes the issue seriously and continues to provide soldiers with added training on the armored Humvee.

The Army also made safety upgrades to the vehicle, including improved seat restraint belts and a fire suppression system for the crew, he said.



Notice that the Army’s first response to a problem is …

TRAINING!

The corrective actions may or may not address the root causes of the roll-over problem. They certainly don’t address the potential problem that the Army may have made matters worse by adding armor in the first place. (How should the Army do better root cause analysis and corrective action development?)

If you would like to learn more about advanced root cause analysis and developing SMARTER corrective actions, I would suggest a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course. For more information see:

http://www.taproot.com/courses.php?d=2

CITY OF TEXAS CITY, TEXAS,

IMPLEMENTS INNOVATIVE POLICY

TO PROMOTE INDUSTRIAL SAFETY

A notice from the Voluntary Protection Program …

FALLS CHURCH, VA, June 16, 2006 - The city of Texas City, Texas, located approximately 40 miles southeast of Houston, last week enacted an innovative provision within its tax code that offers tax incentives for industrial facilities that demonstrate a commitment to safe operations by becoming certified in the Occupational Safety & Health Administration’s (OSHA) Voluntary Protection Program (VPP). VPP certification is OSHA’s highest honor to recognize the nation’s most effective industrial safety and health programs.

“We applaud Texas City’s leaders for this proactive and unprecedented effort that promotes not only a safer industrial district, but a safer community,” said R. Davis Lane, Executive Director of the VPP Participants Association. “VPP can significantly improve a facility’s safety performance. And now, Texas City companies will have added financial incentives to participate in the program and earn VPP certification. This is an outstanding precedent that we hope local governments throughout the country will follow.”

(more…)

(click on picture to enlarge)

Hello everybody, this week I’m going to talk about comments on SnapCharT files. How they work, what they do, and so on. 

Read on for more information!

(more…)

The following message is from the U.S. Chemical Safety Board, Washington

D.C.

Washington, DC, June 15, 2006 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today issued a safety bulletin following the agency’s investigation into the June 24, 2005, fire and explosions that swept through the Praxair Distribution, Inc., gas cylinder filling and distribution center in St. Louis, Missouri. The accident occurred when gas released by a pressure relief valve on a propylene cylinder ignited.

The Safety Bulletin, entitled “Dangers of Propylene Cylinders in High Temperatures: Fire at Praxair St. Louis,” includes key findings, best practices for cylinder storage, and safety recommendations.

(more…)

The following message is from the U.S. Chemical Safety Board, Washington, D.C.

Washington, DC, June 14, 2006 - The U.S. Chemical Safety Board (CSB) today announced it will pursue an investigation into the June 5, 2006, fatal oilfield incident at Partridge-Raleigh Oilfield in Raleigh, Mississippi, sixty miles southeast of Jackson.

Around 8:30 a.m. on Monday, June 5, 2006, three workers died and one worker suffered broken bones while attempting to install new piping to connect two 400-barrel capacity oil production tanks and one salt water tank to a 500-barrel capacity power oil tank. All four workers were employed by Stringer Oilfield Services.

CSB investigators arrived at the oilfield on Tuesday, June 6, 2006 to conduct an assessment of the incident site. They conducted interviews with eyewitnesses, who describe the four workers standing on top of the production tanks, preparing for the new piping installation just before the incident occurred. As one worker lit a welding tool, explosive vapors in two of the tanks likely ignited, causing two rapid explosions that threw one worker over twenty-five feet from the tank and scattered debris as far as 130 feet away. Emergency responders found the welder, the sole survivor of the blast, hanging from one of the oil tanks. He used fall protection equipment prior to starting his work.

(more…)

(click on picture to enlarge)

There are hazards in the workplace … but some are rather unexpected.

Should we implement a wildlife audit to find and remove all the unexpected hazards at this plant?

I still remember the raccoon that started a multi-million dollar plant upset, environmental release, and fire at a refinery. [The plant operators were feeding the raccoons because they thought they were cute and the raccoons (when supplied with an unlimited food supply) were breeding like crazy. It was just a matter of time until something bad happened.]

Do you have any good wildlife incident photos or stories to tell? Forward them to me at info@taproot.com.

For a complete set of slides from a talk given by NRC Commissioner Peter Lyons on May 29, 2006, about improvements to the US NRC’s operating experience program, see:

http://www.nrc.gov/reading-rm/doc-collections/commission/speeches/2006/s-06-13-slides.pdf

Thanks

Mark

Every day there are infections passed from one patient to another at hospitals. Each of these infections is a small incident. If the infection is difficult to control and the patient dies, it is a major accident.

The sad part of these infections is that they are almost 100% preventable by simple techniques. Most could be prevents by doctors and nurses properly washing their hands. For an example program see:

http://www.henrythehand.com/pages/content/infection_control.html

Will Sawyer, M.D, is the creator of this program and I’ve asked him to discuss it - and the issue of changing doctor behavior - more extensively at the Medical Error Reduction Best Practices Track at the TapRooT(R) Summit (April 25-28, 2007, in San Antonio).

Sometimes the lessons learned from a fatality can be a simple change for the better.

Want to see a web site with lots of pictures of crane accidents?

See: http://www.craneaccidents.com/

Plenty of lessons learned as well…

(click on picture to enlarge)

How do you investigate crane accidents to find their root causes?

If you haven’t had any root cause analysis training, you need to get some!

Attend a TapRooT(R) Course to learn advanced root cause analysis techniques.

I know that with root cause analysis training and investigations all over the world, I sometimes have a hard time figuring out if I can contact my instructors. This site really helps:

http://www.timeanddate.com/worldclock/

The Canadian Patient Safety Institute (CSPI) is looking for a Director of Patient Safety Research & Medical Quality.

For more information, click on the link below.

(more…)

(Click the picture to make it bigger so you will get the joke.)

Hello everyone, welcome to another Tech Support Thursday.

Note: This article is for advanced users and IT professionals only.

This week I’m going to diverge some great and—up until now—internal use only procedures on recovering corrupt SnapCharTs.

Why was this information internal-only until now and how do you do it? Read on!

(more…)

I want to maintain the highest possible reliability of 2 parallel centrifugal pumps. One is the operating pump, and the other is a stand-by pump, required only as a back-up in case the running pump fails. What is the best run-time strategy to maximize the reliability of the pumps?

My first thought was, “50:50, of course!” That way the wear and tear on the pumps is spread out over both pumps, doubling the effective lifetime of the equipment. Seems reasonable to me.

Unfortunately, if you are using this strategy, there is a good chance you are significantly accelerating the wear on the pumps, resulting in increased downtime!! Read all about it…
(more…)

I took this picture in Scotland while on vacation. I couldn’t believe the ladders that they were using for church spire work.

Are they legal or illegal?

http://www.thenewstribune.com/news/local/story/5774982p-5162905c.html

To start leearning about what happened, the first step is to draw a SnapCharT(R). So try it with the information in the article above and see what you learn.

Then post a comment with what you’ve learned.

Sent to me by Linda Unger, VP at System Improvements:

Was this a two for one sale or just common courtesy in New York (note that they both have New York plates)? I think the root cause was that they wanted to become the Friday Joke!