MOVED FROM MANCHESTER TO WOODLAND GRANGE’SFACILITIES IN LEAMINGTON SPA
Woodland Grange (http://www.wgrange.com/), one of the UK’s most respected providers of management and safety training, is partnering with System Improvements to provide the 2-Day and 5-Day TapRooT® Courses in England.
The first course will be a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course that will be held on November 8-9 at their facilities in Leamington Spa, England.
I found an outstanding description of the difficulties encountered conducting a major investigation - the chemical release at Bhopal. The paper is entitled:
Investigation of Large-Magnitude Incidents: Bhopal as a Case Study
by Ashok S. Kalelkar and presented at the AICHE Conference on Preventing Major Accidents in May of 1988.
Hello everyone, welcome to another edition of Tech Support Thursday.
For those who aren’t aware, we’re currently actively developing a web-based version of the TapRooT System Software. This will allow large organizations to utilize browsers instead of individual client installations, something that’s been requested for quite awhile now.
But now that vision is a reality! We’ve sent out the notices and testing will begin soon. I’ll try my best to get you guys some screenshots and possible feedback quotes as this process continues.
It’s an exciting time for System Improvements, and we’ve only just begun!
If you are trying to reach Linda Unger or Mark Paradies this week, try waiting until next week.
They have “retreated” to a spot with no cell phone service and poor internet connections to start writing the 2007 TapRooT® Book.
Call 865-539-2139 and others at System Improvements will be glad to answer your questions until Mark and Linda return - hopefully with new and exciting material that will make using TapRooT® even more effective.
And if you are interested in more information about performance improvement, consider attending the 2007 TapRooT® Summit in San Antonio on April 25-28, 2007.
The web site (which should be up by mid-August) is:
ACTIONS WITHOUT THOUGHT …WHAT IS THE ROOT CAUSE???
Here is a question from a new TapRooT® user who attended a course and sent me this question…
From: Michael Baer
Just a quick follow up from the training class last week - I talked to Ken a little bit about this there & he suggested following up by email. We were discussing routine actions without thought; one of the things that comes through from the video ‘Remember Charlie’ that we use for our safety training. If I recall correctly, CCPS defines this as one of their possible immediate causes - I wasn’t clear about how (or if) this would fit in under the TapRooT® Root Cause Tree®.
After looking at the Root Cause Tree® & the dictionary again, I’m still not clear on the subject & would be grateful for your input. I would think that it would fall out under the 1st one of the 15 questions - but I’m not seeing something similar in the dictionary under Human Engineering or Work Direction. Did I miss something?
Despite expanding our staff of instructors, we’ve had a hard time accommodating all the root cause analysis course requests. The fall schedule is already starting to fill up. So if you are thinking about having on-site TapRooT® Courses at your facility during 2006,
PLAN AHEAD AND CALL NOW!
Linda Unger, Ken Reed, Ed Skompski, or I (Mark Paradies) will be glad to help you get a course set up. Just call 865-539-2139. Or e-mail us here.
Ken Reed - our Equifactor® expert - spent 21 years in the Nuclear Navy. He retired last year as a Master Chief on one of the newest submarines, the USS Seawolf. I suppose that is why he was so excited when he discovered this secret R&D photo for a new class of submarine/airplane.
Some initial reports indicate that a mechanical failure of the rudder may have been the cause of an accident aboard the Crowne Princess (operated by Princess Cruise Lines).
How do they troubleshoot equipment failures?
How do they analyze root causes?
I would bet there were previous near-misses that weren’t thoroughly investigated. I would also bet that if these near-misses’ root causes had been corrected, the cruise line could have prevented these injuries and this public relations fiasco.
The latest edition of the Equifactor Minute has been released. If you did not receive it, please email me here. You can download a copy of the newsletter here.
Topics in this edition include:
- TapRooT(R) Summit
- The Art of Maintaining Stand-by Pumps
- Equifactor(R) Software Improvements
- Up-coming Equifactor(R) Course Schedule
- Recent Blog Entries.
Let me know if you have anything you would like to see in up-coming editions of the newsletter.
The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.
German Translation of CSB Animation of the Explosion at BP Refinery, Texas City, Texas, Now Available
Washington, DC, July 17, 2006 - The U.S. Chemical Safety and Hazard Investigation Board (CSB) today posted on the agency’s website a German translation of the narrated video of the accident at BP’s Texas City refinery which occurred March 2005. This video, as well as the eight English language CSB Safety Videos, may be viewed online at the Video Room on http://www.csb.gov/index.cfm?folder=video_archive&page=index.
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:
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.
I write the daily Root Cause Analysis blog, the monthly TapRooT® Friends/Experts e-Newsletter and a semi-monthly Root Cause Network(TM) Newsletter. I think they are worthwhile and I do get comments and e-mails about them. But last month the blog got the following comment:
“In one month you’ve had 2 comments. Does anyone read much less care about this blog?”
That got me thinking … Does anyone care if I write the blog and the newsletters?
So I thought I’d let readers comment on the blog site by leaving a comment by clicking on the comment link below.
Please let me know:
- Do you want me to keep writing?
- Of the topics I write about, what is most helpful to you?
- What improvements have you made because of what you have read?
- What other topics would you like to hear about?
So click on the comment link below and give me your reply.
Mark and I just got back from the 12th Annual Human Performance, Root Cause, Corrective Action and Trending Conference held in Charleston, SC this week. If you are not familiar with this conference, it is set up for mainly those in the nuclear industry, discussing recent trends in those areas. It was a very well-organized conference, with a lot of great ideas and opportunities for networking with anyone interested in advanced programs covering these topics. I gave 2 talks:
Why Don’t People Follow The Rules
Evidence Preservation for Equipment Failure Troubleshooting
One common issue that I find is being seen throughout industry (including the nuclear industry) is the tendency to dive into equipment troubleshooting before a solid, usable troubleshooting plan is in place. I have discussed this topic in other venues, and I have found that it common in most industries, including mining, paper production, petrochemical, and power generation. I have attached a copy of my talk here. Please take a look at it, and decide how you are combatting this problem.
The US Department of Energy has made available several software programs to help facilities decide on the most energy-efficient equipment for their specific applications. For example, the MotorMaster+ software contains a database of over 32,000 motors (both domestic and international), describing the “best fit” motor for your application and showing potential energy savings. Other software available includes:
AIRMaster+
Chilled Water System Analysis Tool (CWSAT)
Combined Heat and Power Application Tool (CHP)
Fan System Assessment Tool (FSAT)
MotorMaster+ 4.0
MotorMaster+ International
NOx and Energy Assessment Tool (NxEAT)
Plant Energy Profiler for the Chemical Industry (ChemPEP Tool)
Process Heating Assessment and Survey Tool (PHAST)
Pumping System Assessment Tool 2004 (PSAT)
Steam System Tool Suite
These tools can be downloaded from their website or you can order a CD from the same site.
With the volume of recent literature discussing the advantages of energy efficiency in your facilities, these tools may help in your decision-making processes.
Often, with limited resources, we are trying to find ways to convince management that a particular system will make a measurable gain in productivity. For example, implementing an equipment vibration monitoring system can save the company money in various ways:
Planning repairs around scheduled maintenance.
Limiting overtime for emergency repair
Limiting emergency shipment of replacement parts
Eliminating waste on restarts
Eliminating waste due to the original equipment failure
These gains, of course, must be balanced against the cost of inplementing the changes. For example, the cost of implementing the PdM stratedy above will include:
Buying vibration monitoring sensors
Installing cabling for the sensors
Training personnel to use the system
Analyzing the results
So why do nearly 80% of PdM implementations either fail outright or show very little savings? The Answer…A PdM strategy that does not include a proven root cause analysis technique will continue to have the same problems show up over and over again. Wouldn’t it be nice if we could:
Detect impending equipment failure
Determine why the failure is occuring
Schedule corrective maintenance on both the equipment and the root cause of the failure for completion during a scheduled maintenance period
Never see this same failure again
Using a PdM system to detect and correct failures is only half the answer. The final strategy MUST include correction of the underlying reason of the failures. This is where the TapRooT(R) Root Cause Analysis system and the Equifactor(R) Equipment Troubleshooting module, melded with an effective PdM technique, will quickly recover the unrealized savings.
