Root Cause Analysis Blog

Click on the video below … Should you laugh or should you cry?

If you owned the helicopter, you would cry!

So you’re working on a huge SnapCharT and something terrible happens—the power goes out in the building. Unfortunately your battery was dead on your laptop, you weren’t aware, and in an instant you lost days worth of work.

You didn’t have any backups of the file. You call TapRooT tech support, desperate, worried and wanting to know if there’s anything that can be done (there is). But you are also told you need to implement backup procedures on your charts.

“How do I do that?”

That’s what we learn today. Click on to see how!

(more…)

Ken Reed - our Equifactor® Guru - is on vacation.

Sorry - no maintenance/equipment reliability root cause news today.

But if you are headed for the 5-Day Course in Groton next week, you’ll see Ken there (he’s teaching it).

But please stay tuned for more maintenance and equipment reliability improvement ideas next Wednesday.

And for your enjoyment, here’s a picture of an equipment failure…

(click on picture to enlarge)

Did you see the one step away from death video and picture that I posted last Tuesday?

I saw an incident (near-miss) and recorded it.

Now others can learn from it and use it in their safety meetings to raise awareness about fall protection and proper work practices.

If you see something that just isn’t right … for example, a:

- quality problem

- safety problem

- near-miss

- production upset

- maintenance issue

- equipment failure

- environmental release

- or any other “event”

Take a picture or a video and send it to me at “info@taproot.com” and I’ll post it here to share it with others.

If you want to remain anonymous, just let me know and I won’t use your name or your company’s name with the posting.

By passing along pictures of problems you can help others save lives, save jobs (by improving quality and preventing operating and maintenance problems), and save the environment (by preventing accidental releases).

And please feel free to use the pictures, videos, and other information from this blog to make performance better at your site.

And if you want to improve your systematic performance improvement attend a TapRooT® Course and the TapRooT® Summit.

Thanks for your help.

Mark

What can you learn from 24 tragic accidents? Alberta Workplace Health & Safety has posted reports with lessons learned from 24 accidents. See their conclusions at:

http://www.hre.gov.ab.ca/cps/rde/xchg/hre/hs.xsl/123.html

Safety Position Available at Rockwell Collins in Cedar Rapids Iowa

Salary Range is 80K-100K

(more…)

Hello everybody, and welcome a special Friday edition of Tech Support Thursday. Yes, I know that’s confusing. But what we’re learning today is not confusing in the slightest. However, not knowing how incident import and export works can be confusing.

Ready to learn?

Click on to see the intricacies of importing and exporting TapRooT System Software incidents!

(more…)

How do you find root causes?

Try this!

It is National Clean Hands Week September 17-23 and Back to School time. This is to try to raise awareness about the role clean hands play in preventing the spread of infectious disease. Clean Hands Prevent Disease Save Lives is the mission for the Clean Hands Coalition, for which Dr.Will and Henry the Hand Foundation are founding members. For activities during National Clean Hands Week visit www.cleanhandscoalition.org.

Exciting news is that Henry the Hand’s School Kit is available to start the School year off on the right foot to reducing absenteeism and try to prevent the September “spike” in illness that occurs each year. Visit www.henrythehand.com to order your School Kit and download free posters and Coloring Book to post or give away, in order to teach the children the true primary prevention for infectious disease. More than 22 million school days are missed each year due to the common cold (CDC). Some viruses and bacteria can live between 20 minutes and 2 hours on a desk top, cafeteria table or door knob.(CDC)

Thank you for helping to “spread the word not the germs”.

Just for the health of it!

Dr Will

Henry The Hand Foundation

11714 US 42

Cincinnati, Oh 45241

Henry the Hand’s 4 Principles of Hand Awareness:

1. WASH your hands when they are dirty and BEFORE eating.

2. DO NOT cough into your hands.

3. DO NOT sneeze into your hands.

4. Above all, DO NOT put your fingers into your eyes, nose or mouth.

The 4 Principles of Hand Awareness have been endorsed by the AMA and AAFP.

Click on movie above to play (Quicktime .mov format)

Click on picture to view larger version

I’m in Chicago teaching a 5-Day TapRooT® Course.

Across from our hotel is a construction site (I haven’t been able to identify the construction company but the high-rise is called the Cityfront Plaza).

I took the video above and some still photos of some block layers workin about 10 stories up with no fall protection and no railings between them and a 10 story fall.

They lean over the edge.

They work with their backs to the edge.

SO FAR no one has been killed.

But they are only one step away - just one moment of not thinking - from death.

I’m going to try to identify the general contractor and find their safey person because they obviously need to intervene before something bad happens.

PS: This isn’t the only safety problem that we’ve observed - just the one with the highest likelihood of a fatality.

What can you learn from the summary of the fatalities of a province? The first thing I saw was that NONE of these deaths had to happen. They all could have been prevented. And some by fairly simple actions. This list would make great topics on hazard awareness for safety meetings.

Click on the yearly links to read more at:

http://www.hre.gov.ab.ca/cps/rde/xchg/hre/hs.xsl/2572.html

Here’s some bad instructions and comments …

On Sears hairdryer:

Do not use while sleeping.

(Gee, that’s the only time I have to work on my hair!)

On a bag of Fritos:

You could be a winner! No purchase necessary. Details inside.

(The shoplifter special!)

On a bar of Dial soap:

Directions: Use like regular soap.

(and that would be how?)

On some Swann frozen dinners:

Serving suggestion: Defrost.

(But it’s ‘just’ a suggestion!)

On Tesco’s Tiramisu dessert: (printed on bottom of the box)

Do not turn upside down.

(Too late! you lose!)

On Marks & Spencer Bread Pudding:

Product will be hot after heating.

(Are you sure? Let’s experiment.)

On packaging for a Rowenta iron:

Do not iron clothes on body.

(But wouldn’t that save more time?)

(Whose body?)

On Boot’s Children’s cough medicine:

Do not drive car or operate machinery.

(We could do a lot to reduce the construction accidents if we just kept those 5 year olds off those fork lifts.)

On Nytol sleep aid:

Warning: may cause drowsiness.

(One would hope!)

On a Korean kitchen knife:

Warning: keep out of children.

(hmm…something must have gotten lost in the translation…)

On a string of Christmas lights:

For indoor or outdoor use only.

(As opposed to use in outer space.)

On a food processor:

Not to be used for the other use.

(Now I’m curious.)

On Sainsbury’s peanuts:

Warning: contains nuts.

(but no peas?)

On an American Airlines packet of nuts:

Instructions: open packet, eat nuts.

(somebody got paid big bucks to write this one…)

On a Swedish chainsaw:

Do not attempt to stop chain with your hands.

(Raise your hand if you’ve tried this…)

On a child’s Superman costume:

Wearing of this garment does not enable you to fly.

(Oh go ahead! That’s right, destroy a universal childhood belief.)

I’ve seen these long ago (early 90’s) but found them at:

http://www.lotsofjokes.com/cat_122.htm

See job posting notice below (Word document).

safety coordinator JD 1.doc

If interested, apply on line at http://www.utmedicalcenter.org.

Safety Coordinator

M-F, 8a - 5p

UHS - Environment, Health & Safety - Full - Reg Full-Time

Job Description: Conducts facility inspections and drills; serves as “expert” in NFPA and JCAHO fire/safety issues; consults on technical environmental, industrial hygiene, and safety issues/concerns; identifies and evaluates hazards; manages hazardous waste; responds to administrative and technical questions demonstrating a level of expertise; develops and delivers training programs; represents the department on local committees and UHS in area/regional activities.

Job Qualifications: BS/BA , Safety,Fire Safety, Industrial Hygiene, Public Health, Ind/Env Engineering Required. MS preferred. Relevant certifications beneficial. 5 years relevant experience in Environmental Health Safety activities desired. Hospital experience with Life Safety and JCAHO strongly preferred. Strong computer(MS Office) and presenter skills. Team player.

Janet Rowe-Eikenberry, MPH, MS, CSP

Director EHS/Disaster Coordinator

UT Medical Center

1924 Alcoa Highway

Knoxville, TN 37920

865-544-9537 ph/865-544-6102 fax

How does TapRooT® Work?

Here’s a paper that outlines an environmental incident and how TapRooT® helped the investigator dig into the problem.

Just click on the paper below to download the pdf…

To Download the August e-Newsletter go to:

http://www.rootcause.net/

The topics covered include:



- Editor’s Letter

- The Wikipedia On-line Encyclopedia Needs Your Help with Root Cause Information!



- Another Great Reason to Attend our ‘07 Summit in San Antonio, Texas!

- Nap, Caffeine or Provigil? by Bill Sirois



- Time is Running Out: Schedule Your 2006 On-Site TapRooT® Root Cause Analysis Courses NOW!!!



- Will Your Emergency Response Team Recognize a Hazardous Situation?



- Woodland Grange Sponsors 2-Day Public TapRooT® Course in November In UK



- July/August Root Cause Analysis Blog Topics



- SKF Sponsors 2-Day Public Equifactor® Course in Europe in September and 3-Day Public Equifactor® Course in Dubai in November



- Version 5 Beta Testing Has Begun!



- TapRooT® Summit 2007 Track: Human Error Reduction & Changing Behavior Best Practices



- Where is the Best 2006 TapRooT® Root Cause Analysis Training?



- Q&A Column



- Feedback from our Course Participants



- Business Improvement/Structured Problem Solving Methodology Survey



- J.O.K.E. of the Month

First Person Account on 9/11/01.

Diana was in the Work Trade Center.



Sent: Tuesday, September 25, 2001 4:59 PM

Subject: 9/11/01 First Person Account

Teresa Bailey-Weirich gave us permission to send this to all BOMA members. Please note possible lessons you could learn for your emergency evacuation plans.

***********************

My friend, Diana Armstrong, forwarded this description of the September 11th disaster and the evacuation of the World Trade Center.

***********************

Dear All,

Now that I can begin to think clearly again, I would like to take the time to thank each and every one of you for your concern of my well-being. It was a very close call, and I am grateful to be alive.

As you probably all know by now, I narrowly escaped from the World Trade Center attack this past Tuesday, unlike the thousands who are still trapped beneath the rubble.

At 8:48am on Tuesday morning, I was reading my email like I do every morning. I had just gotten off the phone with a traffic engineer at the Port Authority regarding a file that I had transmitted to him on the previous day. As I was finishing off my usual peanut butter and jelly sandwich, I heard a loud explosion, which was immediately followed by tremendous building sways and vibrations. As I was thrown out of my chair, I immediately thought that this was an earthquake, but still thinking rationally, I thought that it was abnormal since there are no earthquakes in NYC, especially of this magnitude. I remember thinking that the building felt like it was going to collapse from this initial explosion.

As I picked myself up and ran to the emergency staircase located in the core of the huge building, I saw through the east facing windows debris and fireballs falling from the top of the building. The building had stabilized by the time I reached the stairwell, and evacuation had commenced quickly but calmly. Not knowing the gravity of what was happening above us, people had started pouring into the stairwell from the hallways of the different floors. I saw a coworker from my floor (72nd), and we held and consoled each other.

There were no public announcements in the stairwell, but the evacuation seemed to be going smoothly, there were no more explosions as far as we could tell, no smoke coming up the stairwell, and the building had stopped swaying. We all felt like we were out of imminent danger. As we started to make it down the stairwell, people started chatting and gathering their composures. I heard some people who had been there in ‘93 telling others that this was a piece of cake since the stairwell was dark and full of smoke in ‘93. Others were joking about how Mr. Silverstein, who had just recently taken control of the complex, must be fuming at what was happening.

A few moments passed and people began to receive messages over their pagers that a 767 had accidentally hit our building. There was no mention of a terrorist attack, and at no time was there any panic. Mobile phones were completely out in the core of the building due to its immenseness and the large distance from the core of the building to the exterior where signals were

usually stronger. There was no smoke at all in the stairwell, but there was a strange peculiar smell, which I later remembered it smelling like how it does when one boards an aircraft. I later found out that this was jet fuel.

Soon we heard shouts from the people above us to keep to the right. I started seeing blind people, those with difficulty moving, asthmatics and injured people filing down to our left. People were burned so badly that I won’t go into describing it. People kept filing down orderly and calmly, but stunned.

Sometime around the 30th or 40th floor, we passed the first firefighters coming up the stairs. They reassured people that we were safe and that we would all get out fine. By this point, they were already absolutely breathless, but still pushing upward, slowly and unyieldingly, one step at a time. I could only imagine how tired they were, carrying their axes, hoses and heavy outfits and climbing up all those stairs. Young men started offering the firemen to carry up their gear for a few flights, but they all refused. EACH and EVERY ONE of them. As I relive this moment over and over in my mind, I can’t help but think that these courageous firemen already knew in their minds that they would not make it out of the building alive and that they didn’t not want to endanger any more civilians and prevent one less person from making it to safety on the ground.

We continued down the stairwell, slowly and at times completely stalled. The smell of jet fuel had gotten so unbearable that people began covering their mouths and noses with anything that they could find - ties, shirts, and handkerchiefs. Every few floors, emergency crew were passing out water and sodas from the vending machines that they had split open from the hallways.

I had no idea how much time had passed by as I didn’t have my mobile phone with me.

Around the 20th or 15th floor, the emergency crew began diverting the people on our stairwell to a different stairwell. They led us out of our stairwell, across the hallway where I saw exhausted firemen and emergency crew sitting on the floor trying to catch their breaths. I began to think why? What’s going on? This whole operation looked very confusing. Nobody was giving us any indication as to what was going on. The wait in the hallway to get to the other staircase was excruciatingly long as we had to wait and merge with the people who were coming down the staircase into which we were filing. Why had they diverted us?

As we started to get down to the lower floors, water started to pour down from behind us. I figured that a water pipe had burst

or that it was water coming down from the rescue on the higher floors.

At this moment for the first time since the initial explosion, a sense of panic began to grip me. Only floor 7, then 6. A few more to go, and I would be free. I couldn’t wait. It didn’t matter that the water was ankle deep. I was a few floors from the ground. Floor 5,,,,4,,,,then all of a sudden, a loud boom, and the building began to shake unbearably again. People started falling down the stairwell as smoke started to rise from the bottom. The emergency lights flickered and then went out. The building was still shaking, and I could hear the steel buckling.

Rescuers below us shouted for us to go back up the stairs. At this moment, I was choking and shaking tremendously. I managed to climb back up to the 6th or 7th floor and opened the door to that floor.

The water had already risen to my ankles, and the floor was completely dark. A fireman led us with his flashlights to another

staircase by the voices of another fireman who was guiding him through the darkness. We finally made it across that floor to the other stairwell where we were greeted by the other fireman and told to hold. The look on that fireman’s face said it all. He said something under his lips to our fireman indicating the severity of the situation.

With the image of the firemen communicating to each other and hindsight, I believe that the fireman had whispered to the other one that Building Two had collapsed.

After a few minutes of huddling by the stairwell on the 6th floor, we were given the green light to run for our lives. I made it down six flights with a few other people and came out onto the mezzanine level of our building.

I don’t know what I was expecting to see when I got out of the stairwell, but I was not ready for this apocalyptic scene. It was completely covered in white dust and smoke. My initial reaction was that I couldn’t believe that one plane, albeit a 767, 80 floors above our head caused all this damage on the ground floor - inside.

I covered my head and ran towards the huge opening in the north side of the building through which we were being

evacuated. As I approached this threshold, the firemen yelled to us to get over to the wall of the building quickly. Debris was still raining from all sides of the building. We could see the other firefighters who were outside standing underneath the cantilevered parts of the black immigration building (4 and/or 5 WTC).

At their cue, we ran from our building to the outside world and back underneath the immigration building. I was completely disoriented, coughing, and looking at the strange new landscape at the WTC plaza - burning trees, wreckage, fireballs and dust, nothing short of a nuclear winter.

I climbed over huge pieces of steel wreckage and made my way through to the sky bridge leading to 7 WTC (which would be the third building to collapse). From there, I descended the escalators down to the street level onto Vesey Street and trotted to safety onto Church Street.

I immediately looked back and saw the charred remains of the upper floors of my building. Smoke filled the sky, and I began to have this eerie feeling that WTC 2 was not there. I couldn’t be sure because of all the smoke that was billowing from my building blowing eastward. As I was trying to find WTC 2, I saw the unthinkable happen in front of my eyes. WTC 1 began to

disintegrate from where it was burning. I turned around and ran.

I later learned that another 767 had hit WTC 2 around the floors where I sit in my building. I later learned that WTC 2 had collapsed when we were still inside my building on the fourth floor when it began to shake for a second time. I later learned that I had been spared from the sight of people falling from the higher floors. I am grateful to be alive and uninjured and to be able to share this life-changing experience with you.

And, I am so grateful for the courage of the firemen and policemen who gave up their lives to help us down the burning tower.

Sincerely

Diana

–

To: TapRooT® Friends/Experts

From: Mark Paradies

Subject: Follow up on SPECIAL EDITION: Terrorist Response

Cc:

Bcc:

The response to my e-mail has helped me see how many good, kind, wonderful people there are that really care about their fellow man.

I won’t reprint all the responses here because I don’t want to overwhelm people with things to read.

I will pass along information about people who are missing and in need of prayer for their rescue and for their loved ones.

I will also pass along a first hand report from my brother (who was 4 blocks away and lives in Greenwich Villiage - a part of what I think of as the dust zone) of his experience.

WHAT PEOPLE CAN DO AND HAVE DONE

I have received some wonderful prayers and expressions of sympathy from people from around the world. I think that for most of us, this is all we can do to help.

I want everyone to know that these include places and cultures FAR from the US including people from Canada, Mexico, Australia, Europe, Asia, South America, Africa, and the Middle East.

These thoughts and prayers come from people with many different faiths, including Muslims, who are shocked by the tremendous loss and have trouble understanding how someone could commit such an act.

I want to keep this hope and spirit alive so in this section I will pass along the names of people who need prayers or know of people who need prayers.

PRAYERS NEEDED

These three e-mails are passed along to add to your prayer list:

- - -

From Mary Lundgren:

Mary Lundgren

Manger-Performance Improvement



- - -

From James Johnston:

James C. Johnston, PE , CSP

AHPC Director- Safety,Occupational Health & Loss Prevention

- - -

From Bruce Brown:

Bruce

- - -

MY BROTHER’S STORY

Chris is five years younger than I am.

He lives in Greenwich Village.

He has a PhD in metallurgy and is an intellectual property attorney.

He works just 4 blocks from one of the World Trade Center Towers.

He was walking to work in the morning and he saw people pointing, looking into the air. When he looked up he saw a giant hole in one of the WTC Towers with fire coming out. He said he really could NOT believe what he was seeing. So he went to his office.

Shortly thereafter he heard that a second plane had just hit the other tower. He went to his boss and they decided that people should go home. They started telling people who were all standing around in disbelief.

Everyone went down to the lobby of the building. He says that he was in the lobby of his building when the first WTC Tower collapsed. The dust and papers blotted out the sky. They waited until the dust cloud passed and started to subside and they decided that this was the time to leave.

He had made it a couple of blocks when the second tower collapsed. He could see the second dust cloud coming so he ducked into the lobby of another building and waited for the second cloud to pass and clear somewhat.

He then continued north with the crowd and eventually made his way to his apartment.

The firm he works for is still closed for business. Their building is too close to “ground zero.” They are working out of their homes until the recovery and clean up efforts are complete enough to make their building accessible.

Chris’s apartment is South of 14th street - inside the “dust zone.” He has to go through checkpoints to go home if he travels outside Lower Manhattan.

Of course, Chris gave me a detailed an account of the metallurgy of steel and how the extreme heat from an aviation fuel fire would cause a phase transformation in high strength steel and cause it to loose it’s strength (as opposed to the “melting” described on TV). This was the cause of the collapse of the top of the towers. The momentum of the debris from the top of the tower was then enough to cause the collapse to continue down the building.

I just wish all the other stories could turn out as well as Chris’s story. Unfortunately, it looks as if there will be thousands of casualties.

SOME FINAL THOUGHTS

Let our prayers be with those who are still wondering about their loved ones and acquaintances who are still missing and those searching for them. Perhaps more miracles are possible. They just found some firemen alive a few minutes ago.

Once the final toll is known, let our prayers go out for those suffering from loss and those who will be permanently changed by the horror that they have witnessed.

Let us also remember the hero’s - some that we know about and some that we will never hear about - that helped, or were trying to help, those at the scene in New York and Washington.

Also let us remember the heroics of the crew and passengers of the high-jacked jets.

Evil will always exist in the world. We must remember that there is also tremendous good and that most people are kind and loving. I think that is what makes evil so hard to understand.

ONE LAST IDEA

Several people have suggested that we (System Improvements and all the e-newsletter readers) somehow volunteer our efforts to help with the investigation.

I’m not sure what I think about this.

First, I think that there is a potential for us to contribute to the effort.

I saw the “increased security measures” that were proposed yesterday (no visitors in the secure area of the terminal, no pocket knives allowed on board, and no curbside check in) and I thought that these measures would not do anything to prevent what happened or to prevent future incidents.

So I think that someone obviously needs help.

But with the biggest investigation in the history of the US already started, it is almost impossible to find the right person to volunteer to. AND that person is already, no doubt, overwhelmed with all the “help” they can stand.

This reminds me of what I advise people in the 5-Day TapRooT® Course. You have to prepare for the investigation BEFORE the accident happens.

Perhaps we have already helped by training some of the investigators in the TapRooT® System? This is probably the only contribution that we can (and probably have) made to the investigation.

But if anyone has any ideas of ways to help, I am ready to listen.

THANKS AGAIN, to all for the wonderful e-mails that I have been receiving. Continue to pray and keep your hopes up.

Mark Paradies

Partner & President

System Improvements, Inc.

238 S. Peters Road, Suite 301

Knoxville, TN 37923

865-539-2139

From: Mark Paradies

To: TapRooT® Freinds/Experts

Subject: SPECIAL EDITION: Terrorist Response

Date: Wed, 12 Sep 2001 10:55:34 -0400

OUR HEARTS AND PRAYERS GO OUT TO THE VICTIMS

First and foremost, our hearts and our prayers go out to the victims of this shocking and terrible act and to anyone who knows anyone who is dead or missing.

My brother, who lives in Greenwich Village and was several blocks away from the World Trade Center when the first plane hit has been evacuated and is OK.

OUR INSTUCTORS AND STUDENTS ARE OK

As for our instructors, none were traveling that particular morning. Several are temporarily stranded at courses across the US but we expect this will be resolved soon.

As for our students traveling to courses, because of our course schedules, none were traveling that morning.

We don’t have any information about other TapRooT(R) Friends and Experts. There are about 50 people who have had TapRooT(R) Training or receive our newsletter or e-newsletter that either work in the World Trade Center or in nearby buildings. They of course are in our prayers.

If you know someone that is dead or missing and you would like us to pray for them or their family, please let me know.

TERRORIST RESPONSE POLICY

(TapRooT(R) COURSE ATTENDEES PLEASE READ)

As for upcoming courses and travel, we have adopted the following policy:

We, along with President Bush and the rest of the American Government, will not be intimidated by terrorist acts. Therefore, we will continue with business as usual.

With the full support of all those involved, all of our courses this week are being successfully completed. This includes our public course that ends today in Lansing, MI.

On-Site Courses:

For on-site courses next week, we fully plan to be there and hold the courses.

We believe the airlines will be back in operation and that we will be able to fully support these courses.

If your corporate security group believes that there is a current and credible threat of a terrorist attack, we will, of course, cancel the course and reschedule it to another date AT NO COST to the client.

Public Courses:

For our public courses, we believe that there is no clear current danger.

Our 5-Day course in Syracuse next week will be held (one of our instructors, Hank Hedges, is local so that course is not even dependant on resumption of airline service).

The same is true for our 2-Day course in State College, PA (Joel Haight lives there).

However:

- if a student in either of these classes is afraid to travel, OR

- if they believe that they are threatened by terrorist activity, OR

- if their corporate security prohibits travel, OR

- if they are too upset to participate in training, OR

- if they cannot schedule transportation to the course,

THEN they may transfer their registration to any future course of their choice at NO ADDITIONAL FEE BY SI. If they can’t find a course to transfer to, we will refund the entire course fee.

IF YOU ARE SCHEDULED FOR A COURSE IN THE NEXT TWO WEEKS, please e-mail us to let us know if you will be there or if you need to transfer to another course. Or you may call us at 865-539-2139.

INVESTIGATION

Of course the investigation into this terrible act is already starting.

We have not been asked to participate and have no knowledge beyond the speculation in the news reports.

We have trained many government employees who may be part of investigation teams (including employees at the NTSB, FAA, FBI, Secret Service, DOT, Treasury Department, Department of State, NSA,OSHA, EPA, and the DoD).

We hope and believe these investigations will focus on the facts and the actions that can be taken to prevent or reduce the likelihood of future acts of terror of this type.

We hope this does not become a hunt for people to blame (besides the terrorist and their organizations who obviously should be brought to justice for their illegal acts).

We know that people in Boston and New Jersey at the airports and families of the airline crews will wonder if they did everything they could have done to protect the passengers and stop this act.

Of course, the investigation will probably show that there is room for improvement. However, this should not be interpreted as a condemnation or blame for any employees who were trying to do their

job.

The full weight of our anger and response should be directed at those who purposefully and willfully chose to commit a horrendous criminal act and those that knowingly supported them.

When seemingly unfathomable acts are committed by those with criminal intent, there may be no way that we here on earth can ever adequately punish those involved. However, I believe that there is or will be an ultimate reckoning for evil deeds. The people involved in this act are surely reserved a special place on the list of those who will receive punishment that is far beyond our control.

Mark Paradies

Partner & President

System Improvements, Inc.

238 South Peters Road, Suite 301

Knoxville, Tennessee 37923 USA

865-539-2139

When I went back to read the e-mail communications that were sent in the aftermath of 9/11, I found the emotions I felt then flooding back.

I think that on this day - the fifth anniversary of that tragic day - it is right for us to reflect on the emotions we felt on 9/11. Reflect on the loss that occurred but also on the prayers that were shared and on the strange hope for the future that followed the attack.

So I thought I would re-publish three of those post-9/11 e-mails to let others share the feelings we all had in those hours and days that followed 9/11.

The first is our initial e-mail to our TapRooT® Friends and Experts e-Newsletter Subscribers.

The second e-mail has replies from our readers and my brothers story.

The third e-mail is a first hand account that was forwarded to me from a subscriber.

As for a follow-up about those that are mentioned in the above emails, I haven’t found out any more about those that were missing.

My brother has married and moved away from New York. He now lives in Tampa with his wife and 2 year old son.

AND THE WORLD SEEMS TO BE FOREVER CHANGED.

It seems that somehow those evil acts on 9/11 have somehow taken part of the goodness of mankind out of the world.

People are now more suspicious. You can’t even bring a bottle of water on a plane - it might be a part of a bomb.

And the political discourse in the US has descended to a new low. It’s sad how quickly we went from brotherhood and prayer to political squabbling.

But I guess what we need to remember is that as a country, we are strongest when ideas come from the caldron of contentious innovation. We are strong enough to allow decent and different ideas. That is freedom.

One last thought on this day is how much we owe the troops and others who continue the battle that allow us the freedom to descent. Don’t ever forget the personal sacrifices that those sailors, airmen, marines, and soldiers make. They especially deserve our thoughts and prayers as we remember those who were lost in 9/11.

I already know that allowing “power naps” during long or late night shifts INCREASES performance and reduces fatigue. So the FAA rule change below seems to “fly in the face” of actions needed to reduce controller fatigue.

Read the article at the following link and let me know what you think:

http://www.cnn.com/2006/TRAVEL/09/08/air.controller.naps.ap/index.html

Ladies and gentlemen, start your engines (and registrations)! The 2007 TapRooT Summit Website is here!

Remember, use the schedule to choose exactly what track is best for you, or click on the Breakout links and customize it as you see fit!

Next years’ Summit should be fantastic fun and will undoubtedly be one for the record books! So what are you waiting for? Sign Up Now!

To whet your appetite, here’s another testimonial video from a satisfied attendee:

From many sources on the internet…

This is a bricklayer’s accident report that was printed in the newsletter of the English equivalent of the Workers’ Compensation Board.

Dear Sir;

I am writing in response to your request for additional information in Block #3 of the accident reporting form. I put “Poor Planning” as the cause of my accident. You asked for a more complete explanation and I trust the following details will be sufficient.

I am a bricklayer by trade. On the day of the accident, I was working alone on the roof of a new six-story building. When I completed my work, I found I had some bricks left over which, when weighed later, were found to weigh 240 lbs. Rather than carry the bricks down by hand, I decided to lower them in a barrel by using a pulley which was attached to the side of the building at the sixth floor.

Securing the rope at ground level, I went up to the roof, swung the barrel out, and loaded the bricks into it. Then I went down and untied the rope, holding it tightly to insure a slow descent of the 240 lbs of bricks. You will note on the accident reporting form that my weight is 135 lbs.

Due to my surprise at being jerked off the ground so suddenly, I lost my presence of mind and forgot to let go of the rope. Needless to say, I proceeded at a rapid rate up the side of the building.

In the vicinity of the third floor, I met the barrel which was now proceeding downward at an equally impressive speed. This explains the fractured skull, minor abrasions, and the broken collarbone, as listed in Section 3, accident reporting form.

Slowed only slightly, I continued my rapid ascent, not stopping until the fingers of my right hand were two knuckles deep into the pulley which I mentioned in Paragraph 2 of this correspondence. Fortunately, by this time I had regained my presence of mind and was able to hold tightly to the rope, in spite of the excruciating pain I was now beginning to experience.

(more…)

Hello again everybody, how’s it going? Over here at Taproot HQ we’ve been getting a few calls on the ability to produce PDF reports.

Did you know there’s an Export function available on the reports generated by the TapRooT System Software?

But did you also know that some of those reports simply won’t export to PDF correctly? So what if you want to create a PDF of a Root Cause Tree but don’t have the full version of Adobe Acrobat?

Inside I show you how. And it’s 100% free!

(more…)

More data has been released concerning the Alaskan oil pipeline leak that shut down a major portion of the Prudhoe Bay oil field on the Alaskan North Slope. It appears that BP changed their pipeline PM requirements based on the history of failures, then did not check to see if this new schedule was working correctly. After years of running a pig through the pipeline at fairly close intervals to clean the pipes, they decided to stop the cleaning and only conduct spot ultrasonic testing of the piping instead. Another pig inspection and cleaning was slated for next year (9 year interval), but leaks were found last month that required the shutdown. The company now plans to replace 16 miles of deficient piping.

Anytime a major change is made to a PM schedule, many risks must be considered. In hindsight, it may be easy to say that BP poorly anticipated the consequences of their change in maintenance strategy, but how do you mitigate these possible consequences?

It would be nice to know what the possible modes of failure are when changing (or initially developing) a maintenance plan. Once these failure modes are known, you can tailor your preventive maintenance to target the most likely (or catestrophic) failures.

Equifactor® to the rescue! When you initially install a new piece of gear, why not take a look at Equifactor® to determine how your machine might fail? Set up your PM schedules to target these failure modes, and get rid of those PM’s that are not relevant to your piece of gear. This will allow you to funnel your maintenance dollars toward the areas actually needing the maintenance. Consider Equifactor® to be an important tool in your RCM toolbox.

Another consideration for developing (or changing) your maintenance strategy is the possible consequences of a failure. Drastic changes in a critical system may not be advisable. Smaller changes, or additional checks, might need to be instituted to catch costly failures resulting from changes to the maintenance plan.

While I’m on the topic of stopping medical errors, here’s an interesting article about fatigue from CNN:

http://www.cnn.com/2006/HEALTH/09/06/doctors.hours.cnn/index.html

I’ve mentioned needless deaths and injuries at healthcare facilities before in this blog, in our e-Newsletter, and in the Root Cause Network™ Newsletter.

A TapRooT® User forwarded me this link to a story in the London Daily Mail about mistakes and injuries at National Health Service hospitals in the UK:

http://www.dailymail.co.uk/pages/live/articles/news/news.html?in_article_id=402499&in_page_id=1770

It looks like their problems are similar to those experienced in the US.

Note that the TapRooT® Summit in San Antonio on April 25-28 has a whole track devoted to stopping medical errors. Perhaps the NHS should be sending an attendee … or maybe two or more!

Whenever a company or government agency has problems that result in fatalities, action speaks louder than excuses and statistics. The families and loved ones of the 2,159 people that died last year in the UK due to medical errors probably are NOT comforted by the fact that those who died were, according to a UK NHS spokesperson, “… a tiny proportion of the millions of patients who use the NHS each year.”

From the spokesperson’s insensitive comment, I guess we should thank the NHS for not killing a large fraction of the patients.

Perhaps I am particularly sensitive to this issue because my mother was harmed by a medical error at a hospital in the US. At the time of the mistake, it could have been fatal. The mistake caused significant “loss of function.” It wasn’t detected until I arrived at the hospital 48 hours later (I was on the road teaching a 5-Day Course). The loss of function eventually contributed to her death a couple of years later.

We never sued anyone but the experience made stopping medical errors much more personal.

Now you may understand why I’m so passionate about improving the quality of care at hospitals. I understand the personal loss that these errors lead to. And I know that dramatic improvement is possible and is cost effective.

So if you are at a medical facility, please don’t be offended by my critical analysis of the state of care - and other’s articles that highlight errors. Rather, consider attending the Summit because you know it was organized by someone (me) with a personal interest in the success of improvement in the medical industry. Stopping medical errors is a high on my list of priorities as I hope it is for everyone who works in the medical industry around the world.

LINK TO SPANISH VERSION of BP REFINERY EXPLOSION VIDEO

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

CSB Posts Spanish-Language Version of Agency’s Animation of BP Texas City Explosion Events; May Be Downloaded for Training

Washington, DC, September 5, 2006 - The U.S. Chemical Safety Board (CSB) has posted on its website a Spanish translation of the narrated video of the accident at BP’s Texas City refinery which occurred March 23, 2005. This video, as well as eight English-language CSB safety videos, may be viewed online in the Video Room at CSB.gov.

(more…)

What’s in the latest Root Cause Network™ Newsletter?

Here’s a sample:

• TapRooT® + Six Sigma = Successful Improvement (Page 1)

• ‘07 TapRooT® Summit (Page 1)

• INPO’s Top 8 Error Prevention Tools (Page 2)

• 1.5 Million Serious Medication Errors (Page 2)

• SBAR (Page 3)

• Why is Manufacturing Leaving the USA? (Page 3)

• Comments from the ‘06 Summit (Page 3)

For more past issues see:

http://www.rootcause.net/

The Chemical Safety Board has released their plan for the future of the agency. They are requesting public comment by September 29, 2006. All comments should be sent to strategicplan@csb.gov.

Download the whole document here:

http://www.csb.gov/news_releases/docs/2007StrategicPlanDraft.pdf

An excerpt from the plan follows:

Over the next six years, the CSB will diligently implement this Strategic Plan and will continue its vigorous efforts to protect workers, the public, and the environment from chemical accidents. The agency will develop Annual Performance Plans that include yearly targets on the road to implementing the five strategic goals. Each annual plan will have specific personnel and groups assigned to complete each action item, and the Board and senior staff will monitor overall progress. The CSB reports regularly on its activities to Congressional committees, members, and staff; the Office of Management and Budget (OMB); and the public.

The CSB Strategic Plan contains the following sections:

• Legislative mandate

• Elements of plan

• Key factors affecting goal achievement

• Relationships with other bureaus and agencies

• Program evaluations

• Consultations used to develop the plan

The CSB uses the Strategic Plan as a guide in setting priorities, allocating resources, and making day- to-day decisions. The plan is regularly examined and is updated every three years.

The plan’s 5 strategic goals are:

1. Select and complete accident investigations that recommend actions with a high potential for protecting workers, the public and the environment.

2. Select and complete safety studies that recommend actions with a high potential for protecting workers, the public, and the environment.

3. Broadly disseminate the findings, lessons, and recommendations from CSB investigations and studies.

4. Achieve implementation of CSB safety recommendations.

5. Maximize CSB’s effectiveness by strengthening human capital and infrastructure.

For details from the plan, see the link above.

I’ve been waiting for the CSB report on the BP Texas City Refinery Explosion to write more about the explosion and investigation, but I thought that this talk given at the 2006 CCPS Process Safety Global Congress might interest readers while their waiting for the CSB to issue their report.

To read a transcript of the talk, click on the link below:

http://www.aiche.org/uploadedFiles/CCPS/John%20Mogford%20Center%20for%20Chemical%20Process%20Safety%20Speech.pdf

We’ve all had a bad corrective action program review meeting. Off the wall questions, last minute changes, unreasonable cost constraints, and more.

What did Dilbert face? See this link:

http://www.dilbert.com/comics/dilbert/archive/images/dilbert2916120060814.gif

Does this make you think of your last root cause analysis meeting when you arrived at the corrective actions approval?