Root Cause Analysis Blog

CNN/AP report … Click on link below for more info…

HOT SPRINGS, Arkansas (AP) — An explosion at an aluminum recycling plant early Tuesday killed two people and injured a third, a company spokesman said.

Click on photo above for bigger view.

Click here for a pdf of the News Conference Statement.

Click here for CNN Story about criminal charges that resulted from the Ladbroke Grove train wreck.

The following press release is from the U.S. Chemical Safety Board,

Washington, D.C.

Houston, Texas, October 31, 2006 - On a unanimous vote of 5 to 0, the U.S. Chemical Safety Board (CSB) today issued new safety recommendations calling on the U.S. oil industry to improve safety practices for refinery pressure relief systems, eliminating the type of atmospheric vent that caused the hydrocarbon release and explosions that killed 15 workers and injured 180 at the BP Texas City refinery on March 23, 2005.

The accident occurred during the startup of the refinery’s octane-boosting isomerization (ISOM) unit, when a distillation tower and attached blowdown drum were overfilled with highly flammable liquid

hydrocarbons. Because the blowdown drum vented directly to the atmosphere, there was a geyser-like release of highly flammable liquid and vapor onto the grounds of the refinery, causing a series of

explosions and fires that killed workers in and around nearby trailers.

The announcement followed by one day the release of new preliminary findings in the CSB’s ongoing, independent federal investigation of the accident. The Board’s final report is expected in March 2007.

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Yesterday the CSB issued a press release with some new information about the BP Texas City Refinery Explosion. The more I read … the madder I got.

I thought about not writing this article. Writing it certainly won’t win me any friends at BP. But if I can get the attention of just a few people who are in a position to:

• Stand up when bad decisions are being made.

• Tell their boss that a decision is wrong

• Resist budget cuts that erode safety margins.

• Enforce procedure usage and safety rules.

Then I may have helped save a life - or save multiple lives. And the risk I take will be worth it.

Also, remember that I have sympathy for everyone - including management - that was involved in the tragic accident. But the CSB press release posted yesterday in this blog and quoted below has convinced me that the explosion at the BP Texas City Refinery was NOT an accident.

15 people died in a very preventable disaster.

A disaster that management could have and should have prevented. Not an accident … even though we call it one.

CSB press release statements below are in red. Bold typeface is my emphasis (not the CSB’s). My comments are in blue.

The CSB lead investigator said:



“…eight previous instances where flammable hydrocarbon vapors were discharged from the same blowdown drum between 1994 and 2004. In two of these incidents the blowdown system caught on fire. The eight incidents were not properly investigated, and appropriate corrective actions were not implemented. The investigation of a 1994 incident resulted in an action item to analyze the adequacy of the blowdown drum. The area superintendent was responsible for the completion of this item. However, the item was never finished, and management officials did not follow up to assure completion.”



MY COMMENT: This quote points to the following root causes:

1. Inadequate incident investigation and root cause analysis from 1994-2004.

2. Inadequate corrective actions from 1994-2004.

3. Inadequate tracking of corrective actions and implementation from 1994 on.

Note that this failure existed for over a DECADE before the explosion at Texas City.

Also, this new information casts doubt on the “independent” Post Accident Process and Operational Audit Report that was recently released by BP. One of that report’s findings was that BP investigation process as implemented at Texas City was a “good practice“. That’s hard to justify if the findings above are true. Or can BP show that there has been a radical change in the incident investigation, root cause analysis, and corrective action processes being used by BP since 2004? And if these “good practices” come from corporate, then what does that say about the rest of the BP refineries and the rest of BP worldwide?

More from the CSB press release (in red) about BP management before the “accident”:

“The history of major accidents and fatalities at the plant was summarized in a meeting held in November 2004 by the refinery manager for 100 supervisors. He gave a sobering presentation entitled “Safety Reality” on the 23 deaths at the plant in the previous 30 years; on average, one worker had died every 16 months.”

Mr. Holmstrom (the CSB lead investigator) said, “In 2004, BP Texas City had the lowest injury rate in its history, nearly one-third the oil refinery sector average. However, the injury rate does not take account of catastrophic hazards or distinguish between injuries and fatalities. That year, the refinery experienced three major accidents that resulted in a total of three fatalities. One of these accidents was a major process-related fire. In late 2004, following these major accidents and other near misses, the Texas City leadership was attempting to improve the refinery’s safety performance. Several years of audits and reports had identified serious safety system deficiencies. However, the safety initiatives that were undertaken focused largely on improving personnel safety – such as slips, trips and falls – rather than management systems, equipment design, and preventative maintenance programs to help prevent the growing risk of major process accidents.”

“When personnel safety statistics improved, the refinery leadership believed they had turned the corner,” Mr. Holmstrom said. However, existing process safety metrics and the results of a safety culture survey indicated continuing serious problems with safety systems and concerns about another major accident. A Health, Safety, and Environment Business Plan presented on March 15, 2005 – just eight days before the ISOM unit accident – identified as a key risk that the Texas City refinery “kills someone in the next 12-18 months.”



MY COMMENT:

It is hard to read about three fatalities and bad audit findings and understand how management could fool themselves into believing that they have “turned the corner“. With those statistics how could they believe that they had greatly improved safety? Maybe they had been living with bad practices for so long that they had no idea what good practices looked like.

Many people mistake the efforts needed to prevent cut fingers with the efforts needed to prevent major disasters. Although there can be some crossover, the proactive efforts needed are not the same. Don’t fool yourself. If minor injuries are decreasing, this could be because reporting has been discouraged. Engineering, management knowledge and involvement, adequate budgets, procedure compliance, and continuous improvement are needed to make and keep a hazardous facility safe.

And where was CORPORATE senior management? Is it OK in the BP culture to have three fatalities at one refinery? How many dead bodies are required to get corporate management’s attention? At DuPont, one fatality got the PLANT MANAGER replaced.

After reading the CSB press release, I don’t think that senior management at BP can seriously claim that they didn’t know. If they didn’t, it was because they were sticking their head in the sand. Just read the following: (from the CSB press release)

Earlier, a 2003 external BP audit referred to the Texas City refinery’s infrastructure and assets as “poor” and found what it termed a “checkbook mentality.” Budgets were not large enough to manage all the risks, but rather than expanding the budget, expenditures were restricted to the money on hand, in the opinion of the BP auditors.

A 2004 BP Group internal audit of 35 business units including Texas City found significant common gaps, including a lack of leadership competence which pointed to “systematic underlying issues,” widespread tolerance of noncompliance with basic safety rules, and poor implementation and monitoring of safety management systems and processes.

Chairman Merritt (CSB Chairman) stated that stringent budget cuts throughout the BP system caused a progressive deterioration of safety at the Texas City refinery. “BP implemented a 25% cut on fixed costs from 1998 to 2000 that adversely impacted maintenance expenditures and infrastructure at the refinery,” she said. Maintenance spending fell throughout the 1990’s at the then-Amoco refinery, and following the merger with BP further cuts were imposed. “Every successful corporation must contain its costs. But at an aging facility like Texas City, it is not responsible to cut budgets related to safety and maintenance without thoroughly examining the impact on the risk of a catastrophic accident.”

By 2002, an internal BP report had identified the cost reductions as contributing to a decline of infrastructure in Texas City that would require significant investment to correct. These findings were corroborated in a survey of the refinery’s safety culture in 2005 just prior to the accident, known as the Telos study. The survey interview with the Texas City refinery manager identified a history of decapitalization and a culture of “things not getting fixed.”

“The refinery manager was not alone in this candid assessment,” Chairman Merritt said. “Large majorities of the survey respondents reported significant maintenance backlogs that were harming safety. Disturbingly, most employees agreed that ‘production and budget compliance gets recognized and rewarded before anything else at Texas City.’”

Economic pressures were evident in numerous decisions that were causally related to the March 23, 2005, accident.

MY COMMENT:

Management shouldn’t try to claim that they didn’t know that dramatic and prolonged budget cuts would have a negative impact on safety at a refinery. When they cliam such things, they are either:

a) Proving that they don’t know enough to be in their job.

OR

b) Lying.

I know senior managers and they are smart enough to know.

Many (but not all) big oil companies cut expenditures in the refining end of the business when the price of oil and the refining margins were low (the 1990’s). But from 1995-2005, the BP/Amoco refineries had more fatalities (22) than all the other US refiners combined (21).(reference) BP managers and others should have known they were taking risks. My belief is that they hoped that the safety margins were large enough that they could delay maintenance and capital projects without experiencing any significant accidents or process outages. But well before 2005 they should have seen that this was not true. The signs were there if they were willing to see.

Since the price of oil and refining margins are now very positive, the same maintenance that was delayed due to lack of funds is now being delayed (at some refineries - but not all) because the units are making so much money that the companies say that they can’t afford to shut them down.

ALL REFINERY MANAGERS SHOULD BE AWARE: Skimping on maintenance of hazardous processes will come back to haunt the process owners. Warning signs can only be ignored for so long before an explosion and fire points out the weakest link in the safety chain.

We know - by the results - that BP erred too far toward the side of cost cutting and profit maximazation. The question that others must answer is … WHAT IS YOUR SAFETY MARGIN? Have other refiners learned from the BP accident?

Are they taking a hard stand against deferring maintenance and engineering upgrades despite the money that the downtime costs?

Are they insisting on insightful root cause analysis and effective corrective actions?

Are they tracking corrective actions to see if they are implemented and validating that the corrective actions were effective?

Are they enforcing procedure usage and positively reinforcing management system standards?

Are they continuously improving performance with the use of best practices that they find inside and outside the refining industry?

I know the BEST are. But here is a message to the REST:

YOU DON”T HAVE TO WAIT FOR A DISASTER TO LEARN TO IMPROVE!

BP had adequate warning prior to the 2005 explosion. The deaths could and should have been prevented.

The whole management chain will have to live with their consciences. They should thank their lucky stars that this refinery wasn’t in the UK, or senior management might be facing jail time (which is rare in the US).

Hindsight is too late to prevent the 15 deaths at the BP Texas City Refinery. So the question that YOU need to ask is:

IS YOUR FACILITY LEARNING FROM BP’s MISTAKES?

If you are at a refinery or some other hazardous facility … Are you waiting for your own disaster to provide an opportunity to improve?

Don’t be penny wise and pound foolish.

Don’t cut corners for short-term profit gains.

Don’t put people’s lives at risk to look good on the quarterly report.

If you are in senior management, your job is NOT to kill people to maximize shareholder return.

INSTEAD:

You must know what is going on.

You must know enough about the operations of your company to be able to judge the impact of budget cuts.

You must have proactive indicators that tell you if efforts to economize have gone too far. They must be proactive so that you prevent fatalities.

You must insist on tough standards.

You must understand and insist that your facilities use advanced root cause analysis and you must have measures of the effectiveness of the corrective actions they implement.

You must hold yourself accountable for the performance of those who report to you. If they let safety slide, it is YOUR FAULT. You can’t make excuses that you didn’t know.

The well being of every employee is your responsibility.

If a preventable fatality happens, you have failed.

Many may think these words are harsh. Some may say that I’m being too hard on BP. There were many managers at BP that should have acted from 1994 to 2005 so you can’t hold any one manager responsible. Some may say that the managers who just happened to be there when the explosion occurred are nothing more than scapegoats. They may be partially right.

But anyone who takes the big bucks to manage a high hazard facility needs to make sure that under their watch, they run a tight ship. They should be able to stand up and proudly say that they did everything they possibly could to keep people safe and prevent fatalities.

And I’m not speaking from ignorance.

I’m not bragging, but I put my career at risk by standing up to senior management on more than one occasion. So I know what it feels like to be pressured to not speak out. And I know the risk to your career when you do. But I stood in the breach and gambled my future when I saw decisions that could have cost lives. And I sleep well knowing that no one was killed on my watch.

After the damning information provided in the CSB press release quotes above, the senior managers who didn’t quit and leave in disgust from the Texas City Refinery from 1994 to 2005 - and by default, their senior corporate management - can’t say they did everything they could to safeguard the lives of those who worked for them. They let their workers down.

Why?

They should have known and they should have acted.

The 15 deaths are a result of their inaction (or their ineffective action). That’s why I get so mad when I read the CSB information. The billions of dollars of BP profits in 2005 are NOT worth those 15 lives.

Make no mistake. I believe what I wrote in the 2003 article “Stop the Sacrifices“. I wrote it for senior managers in the construction industry. But senior managers at BP should have read it. Perhaps the 21st century will be the new age where we stop sacrificing employees to maximize profits. It certainly is time for senior management to stop claiming that they just couldn’t see accidents coming. In BP’s case, the evidence was there for anyone who cared to look.

If you disagree or if you have an opposing view, please feel free to comment by clicking on the “Comments” link below.

And if you agree, please feel free to let me know by clicking on the “Comments” link below.

But no matter what your opinion of this article, TAKE ACTION to make your improvement program WORLD CLASS. Do everything you can to prevent accidents and save lives at your company. You won’t be sorry that you did.

For more information, go to: BP Investigation Information Page

Washington, DC, October 30, 2006 – In preliminary findings released today, the U.S. Chemical Safety Board (CSB) stated that internal BP documents prepared between 2002 and 2005 revealed knowledge of significant safety problems at the Texas City refinery and at 34 other BP business units around the world – months or years prior to the March 2005 explosion that killed 15 workers, injured 180 others, and was the worst U.S. industrial accident in more than a decade.

CSB Chairman Carolyn W. Merritt said, “The CSB’s investigation shows that BP’s global management was aware of problems with maintenance, spending, and infrastructure well before March 2005. BP did respond with a variety of measures aimed at improving safety. However, the focus of many of these initiatives was on improving procedural compliance and reducing occupational injury rates, while catastrophic safety risks remained. Unsafe and antiquated equipment designs were left in place, and unacceptable deficiencies in preventative maintenance were tolerated.”

Ms. Merritt pointed to earlier CSB findings that the equipment directly involved in the flammable release on March 23 was of an obsolete design already phased out in most refineries and chemical plants, and that key pieces of instrumentation were either known to be not working or known to be unreliable by unit supervisors.

The CSB has scheduled a news conference for Tuesday, October 31, in Houston, Texas, where additional new findings and safety recommendations will be presented.

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A Press Release from the Chemical Safety Board:

Washington, DC, October 30, 2006 – The U.S. Chemical Safety Board (CSB) today announced it is pursuing an investigation of the fire that burned from October 5 to 7 at the EQ North Carolina hazardous waste transfer and processing facility and forced the evacuation of thousands of residents from the Raleigh suburb of Apex.

No serious acute injuries occurred, but a number of responders and others were examined for chemical exposure and released.

The CSB investigation, which is expected to take six to 12 months to complete, will lead to a written case study, bulletin, or report that will be released to the public and likely contain new safety recommendations.

CSB Supervising Investigator Robert Hall, PE, said that his team had completed detailed first-round interviews of company employees, community members, and first responders and has begun reviewing documents obtained from EQ. “Credible evidence indicates that the incident likely began in the oxidizer section of the facility, where chemicals such as pool chlorination tablets were stored.”

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Continued from previous blog note…

Baby’s die and people ask: “How different do two bottles need to be to prevent a mix-up?”

Should the nurses have noticed the difference above when they took bottles out of a cabinet that was supposed to have the right bottles in it (but the pharmacy had accidentally stocked the wrong ones)?

In one article by AP, there was following quote from one of the one of the mothers:

Thursday Dawn’s mother, Heather Jeffers, said she blamed the nurses at the Indianapolis hospital for the overdose that led to her daughter’s death five days after she was born.

I can see how someone who just lost their newborn would blame those who injected the wrong drug.



But blame won’t prevent medical errors.

Blame never stops mistakes that are embedded in the system.



Blame is not a root cause.

I know what my friend John Grout would see - an opportunity for mistake proofing to help nurses avoid this problem.

Others say that “The 5 Rights” is the answer. (I’ve heard “If only they would have used the 5-Rights!”)



Still others claim that bar-coding would prevent these issues.

Why can’t we find the right answer and stop these tragic deaths?



If you work in the healthcare industry and would like to learn more ways to stop medical errors, there is a conference that I think you should attend:

The TapRooT® Summit

Dr. John Lighter has helped organize a special track for those interested in improving healthcare quality and stopping medical errors. For a complete schedule, click on the Medical Error Reduction button at this link:

http://www.taproot.com/summit.php?sched=1

In addition to the targeted breakout sessions focussed on improving healthcare and stopping mistakes, you will also be able to hear and meet several outstanding keynote speakers:

John Nance - Pilot, Author, ABC News Aviation Safety Consultant, and Healthcare Safety Speaker

Performance Lessons from the Cockpit to the Surgery Suite

Josh Davis - 5 Times Olympic Medalist

Olympic Success Lessons Learned

Judge Andrew Napolitano - NJ Supreme Court Justice and Fox News Consultant

Accident Lessons from the Courtroom

Beverly Chiodo - Award Winning College Professor

Character First!



Richard Hawk - Safety Speaker and Consultant

Creating a Vibrant Safety Culture

The Summit will be held in San Antonio, Texas, on April 25-28, 2007.

For more Summit information see:

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

To see a movie of what previous Summit attendees have to say about their experience see:

http://www.taproot.com/download/07SummitMovie.mov

To download a Summit Brochure, click here.

TapRooT® has a root cause called Labeling Needs Improvement. I think I should use this picture to define the root cause:

(Click on the picture to enlarge it and read the sign)

(Picture courtesy of Catherine French)

Do you have deadbolts on your workgroup and enterprise incidents? Well, in a way you do—whenever a user edits an incident, the door is ‘closed’ behind them and the incident is then ‘locked’ from other users until the active user finishes his or her work.

But what if that user’s software crashes? What if their network connection dies? The server still believes this incident is in use. Therefore we’ll need to ‘unlock’ it for other users.

Find out how inside.

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The NRC has some great reading on their website. In the library section they have 4 statistical studies on the failure results of various pieces of equipment over the past 20 years. They have looked at Pumps, Diesel Generators, Circuit Breakers, and Motor Operated Valves. For example, they have looked at pump failures from 1980-2000, listing the “proximate causes” and the “coupling factors” associated with these pump failures. You can see these reports for yourself here.

There is a lot of good data there (over 200 pages worth for the pumps), giving a statistical analysis of the contributing factors to these failures. Some statistics on the pump failures:

39% were due to Internal Component failures (includes dirt, lubrication, wear and tear), which they attribute to inadequate maintenance.
24% were Design problems (error in specs, incorrect calculations, mounting design).
20% were categorized as Human Error (incorrectly following procedures, poor procedures, inadequate training, accidental action).

These categories add up to 83%. And, after reading these, it is obvious that these are all human performance problems. The other 17% were attributed to Other (setpoint drift), External Environment, and Unknown. A high percentage of these are most likely also due to human error.

This drives home the point that very few equipment failures are due to the equipment just wearing out. Few pieces of gear make it to the end of life region on the Weibull curves, and even the random failures are not due to statistically calculated material failures, but due to the incorrect performance of people. The maintenance tech, operator, inspector, or designer almost always contributes to or intiates the failure.

The NRC does not list the root causes that they determined for these failures. However, a telling example of their conclusions can be seen on page 33 of the pump report, which blames one particular pump failure as being due to “operator inattention to detail.” I can almost read the corrective action for this: “Conduct training with all operators, emphasizing the importance of reading and following all written procedures.” In more common words, “Tell the operators to be more careful.”

The 10 most frequently sited OSHA Violations from October 2005 - September 2006 are:

1. Scaffolding–General Requirements (1926.451) with 7,895 violations

2. Duty to Have Fall Protection (1926.501) with 5,746 violations

3. Hazard Communication (1910.1200) with 5,586 violations

4. Respiratory Protection (1910.134) with 3,410 violations

5. Lockout/Tagout (1910.147) with 3,068 violations

6. Powered Industrial Trucks (1910.178) with 2,582 violations

7. Electrical–Wiring Methods, Components, and Equipment for General Use (1910.305) with 2,396 violations

8. Machine Guarding–General Requirements (1910.212) with 2,296 violations

9. Ladders (1926.1053) with 2,115 violations

10. Electrical–General Requirements (1910.303) with 1,791 violations

Once you review this list you need to step back and try to assess ….

What Does It Mean?

Are these the biggest safety hazards in industry?

Or are these just the safety hazards that OSHA inspectors like to look for?

My belief is that Management and Supervision failing to enforce work standards, policies, and administrative controls is the BIGGEST workplace safety hazard. But I could be wrong. I don’t have a statistic for this.

What do I know? I know that all the violations listed on OSHA’s top 10 list are violations of standards, policies, and administrative control;s. It is doubtful that all these violations would be occurring if management was enforcing the rules.

What rules need better enforcement at your facility?

Scaffolding?

Fall Protection?

Lock-out/Tag-out?

Machine Guarding?

What can you do to improve enforcement and save lives?

Perhaps you should consider attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?

What does root cause analysis training have to do with enforcement of the rules?

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training teaches innovative guidance for positively enforcing the rules (rather than infrequently disciplining people for breaking the rules). A concept that many would benefit from trying.

Just one more reason to attend this excellent, guaranteed, root cause analysis training.

If you thought the pictures were interesting (and you could use them to teach a lesson), wait until you read the additional information about the accidents and the lessons learned for each of the accidents below.

And if reading about accidents makes you think about preventing them, consider attending a TapRooT® Root Cause Analysis Course and learn to use advanced root cause analysis to reactively investigate problems or to proactively head them off.

Now for the answers to last weeks pictures…

1.

EQ Resource Recovery Fire

near Detroit, MI

Aug. 9, 2005

Investigation: Inconclusive.

David Allison, Fire Chief in Romulus, Michigan, said. “Unfortunately, a lot of the evidence was burned up.”

EPA Comments:

http://yosemite.epa.gov/opa/admpress.nsf/7c02ca8c86062a0f85257018004118a6/db0bdabd26e88a38852570bc0073e6b6!OpenDocument

2.

Same fire as picture 1 - different view. (Ha! That’s a trick question!)

3.

Valley Solvents & Chemicals

Fort Worth, TX

July 28, 2005

Info:

http://www.infowars.com/articles/us/texas_chem_plant_explosion_injures_4.htm

No final investigation found.

4.

Buncefield Terminal Fire.

Hemel Hempstead, UK

December 11, 2005

For more Information:

http://www.taproot.com/blog/2006/08/monday_accident_lessons_leardn.html

http://www.taproot.com/blog/2006/08/here_are_some_more_pictures_of.html

5.

Great Chicago Fire

October 7, 1871

Info:

http://www.chicagohs.org/fire/intro/gcf-index.html

http://www.prairieghosts.com/great_fire.html

6.

AZF

Toulouse, France

September 21, 2002

Info:

http://www.uneptie.org/pc/apell/disasters/toulouse/home.html

http://pedagogie.ac-toulouse.fr/histgeo/monog/azf/azf.htm

7.

Giant Refinery

Gallup, NM

April 8, 2004

Info:

http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=47

8.

Bombay High Platform

ONGC

India

July 28, 2005

Info:

http://www.mace.manchester.ac.uk/project/research/structures/strucfire/CaseStudy/HistoricFires/Other/default.htm

http://www.hinduonnet.com/fline/fl2217/stories/20050826003602500.htm

http://www.hindu.com/2005/07/28/stories/2005072818230100.htm

9.

West Pharmaceuticals

Kingston, NC

January 29, 2003

Info:

http://www.csb.gov/index.cfm?folder=completed_investigations&page=info&INV_ID=34

10.

BP Texas City Refinery

Texas City, TX

March 23, 2004

Info:

http://www.taproot.com/blog/2005/09/bp_texas_city_refinery_explosi.html

http://www.taproot.com/blog/2005/09/osha_fines_bp_texas_city_refin.html

http://www.taproot.com/blog/2005/11/more_bp_explosion_newsmore_bp.html

http://www.taproot.com/blog/2005/12/bp_issues_extensive_final_repo.html

http://www.taproot.com/blog/2006/04/bp_texas_city_explosion_follow.html

http://www.taproot.com/blog/2006/10/bp_texas_city_post_accident_pr.html

http://www.taproot.com/blog/2006/09/monday_accident_lessons_learne_12.html

http://www.csb.gov/index.cfm?folder=current_investigations&page=info&INV_ID=52

http://www.chron.com/content/chronicle/special/05/blast/index.html

http://www.taproot.com/blog/2006/09/monday_accident_lessons_learne_12.html

Click here for the story.

Click here for a video.

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

CSB to Hold November 9, 2006, Public Meeting on Combustible Dust Hazard Study Findings and Proposed Recommendations in Washington, DC

Washington, DC, October 20, 2006 - The CSB today announced it is convening a public meeting related to its investigation of combustible dust hazards at industrial facilities. The Board will be considering the findings and proposed recommendations of the draft report. The meeting will begin at 9:30 a.m. on November 9, 2006, in the Diplomat/Consulate room of the Embassy Suites Downtown Washington, 1250 22nd Street, NW, Washington, DC.

Pre-registration is not required, but to assure adequate seating attendees are encouraged to pre-register by emailing their names and affiliations to dust@csb.gov by November 2, 2006.

The investigation team will present its draft findings on the history of combustible dust fires and explosions in the United States. Proposed recommendations to prevent future dust explosions will also be described. The Board will discuss the findings and proposed recommendations of the draft report and hear public comments concerning the issue. The Board may also vote on approval of the report and recommendations.

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I know that accidents aren’t supposed to be funny. But sometimes you have to laugh when you see what people do.

Vote for the funniest car accident picture by using the comment link.

And don’t even try to think about the root causes of these accidents.

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Ok - place your vote by clicking on the comment link below and telling me which accident picture (by number) was the funniest.

The following is a press release from the Chemical Safety Board (CSB):

Houston, Texas, October 15, 2006

The U.S. Chemical Safety Board (CSB) issued a safety bulletin and new safety recommendations today based on the investigation of the July 28, 2005, hydrogen fire in the resid hydrotreater unit (RHU) at the BP refinery in Texas City, Texas.

The fire occurred four months after the explosion in the refinery’s isomerization (ISOM) unit that killed 15 workers and injured 180. The July 28 fire caused $30 million in property damage. Weeks later, this accident was also cited in the CSB’s urgent recommendation for BP to examine its safety culture at all its North American refineries.

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Wilkommen.  Terve.  Welkom.  Benvenuto.  Bienvenida.  Welcome!

Hello again everyone, nice to see you’re back for another edition of Tech Support Thursday.  This weeks edition is geared towards helping our users in foreign countries with installation of the TapRooT software.  So, if you are located outside of the United States, or know someone who is, read on.

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Here’s a note for people at Licensed TapRooT® Sites. Do you know:

• About the TapRooT® Licensed Client Discount for public 5-Day TapRooT® Courses?
• How to get an additional multi-attendee discount?
• The benefits of attending a 5-Day Course?

First, the licensed client discount. The regular tuition for a 5-Day TapRooT® Course is $2,295 US Dollars. But people from licensed sites can attend for just $1,795. That’s a $500 savings.

Second, if you sign up 3 or more people at one time, you can get an additional $100 off for each attendee. So their tuition would be only $1,695 each.

Third, here are the benefits of attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. People attending the 5-Day TapRooT® Course have these advantages over those who just attend just the 2-Day TapRooT® Course:

• They get much more practice with the software and come away with an excellent understanding of how to apply it when investigating an incident. This improves the efficiency and consistency of their investigations.
• They learn about the optional TapRooT® Techniques that aren’t taught in the 2-Day: Change Analysis, Equifactor®, and CHAP. This helps them solve especially difficult equipment and human performance problems more creatively.
• They get much more practice with the standard TapRooT® Techniques (SnapCharT® and the Root Cause Tree®) and with Safeguards Analysis. This helps make them be more efficient and effective when performing an investigation.
• They learn much more about improving human performance and changing behavior. This helps them tackle the most challenging investigations stemming from human errors. information and more accurate information when they perform interviews.
• They learn how all the TapRooT® Techniques work together in an investigation process which will help them feel confident that they can lead even difficult investigations.
• They learn more about using the TapRooT® System proactively to improve performance. They can help your company become more proactive in solving problems by seeing and fixing problems before they can become accidents and incidents.

So if you know people that frequently lead difficult investigations or people who need a refresher from their 2-Day TapRooT® Course, you should get them registered for the 5-Day TapRooT® Course. They will come away with the knowledge required to be a TapRooT® Champion at their site. I guarantee it will be money well spent.

To see the list of upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses, see:

http://www.taproot.com/courses.php#c1

Best Regards,

Mark

Hello everybody, today I have another video treat for you. This time we get a TapRooT Summit testimonial from Mark Devall, from PCS Nitrogen. Enjoy!

 Join me next week for another video!

Interested in a web site with maintenance best practices from DOE sites? See:

http://www.efcog.org/bp/maintenance.htm

Now that you’ve had a look at the DOE web best practice site, consider attending a conference with a whole track about maintenance improvement and best practices - the TapRooT® Summit.

Equipment Reliability & Maintenance Best Practices Track of the TapRooT® Summit

(Track Leader - Ken Reed)

1. How “Minor” Mechanical Failures Lead to Major Accidents (Wednesday, 10:30-12: Ken Reed)

2. 7 Step Method for Electronic Troubleshooting (Wednesday, 1-2:20: Ken Reed)

3. Equipment Failure Show & Tell (Wednesday, 2:40-3:55: Ken Turnbull & Steve Swarthout)

4. Rickover’s Legacy - Safety and Equipment Reliability - Secrets of the Nuclear Navy’s Success (Thursday, 9:10-10:20: Ken Reed)

5. Developing an Equipment Troubleshooting Strategy (Thursday, 10:40-12: Ken Reed)

6. Equipment Reliability Best Practices (Thursday, 1-2:20: Ken Reed, Facilitator)

Two Speakers:

SKF Speaker - To Be Determined

TapRooT(R) User - To Be Determined

7. Lessons from The Crime Scene - Evidence Preservation for Accident Investigation Thursday, 2:40-3:55: Ken Reed)

8. Proactive Use of Equifactor(R) to Improve Equipment Reliability (Friday, 9:15-10:25: Steve Swarthout)

Also, Summit attendees can attend a special pre-Summit 2-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course and save $200 off the course tuition when they also sign up for the Summit.

Health Physicist - Thousand Oaks , CA

(Job ID: amge-00022880)

Job Summary:

Purpose:

As a member of the Radiation Safety department within Environmental, Health & Safety (EH&S), the health physicist will be responsible for the development, management and implementation of a site radiation protection program that supports a R&D organization. This position will provide health physics support for a radiochemistry group.

(more…)

Interested in some Department of Energy Management Best Practices? They include:

Best Practice #1 - Roles, Responsibilities, Accountabilities, and Authorities (R2A2’s) (08/08/02)

Best Practice #4 - Application of a Senior Management Executive Steering Committee for ISM Leadership (08/08/02)

Best Practice #11 - Regulatory Agency Action and Inspection Tracking Systems (12/16/03)

Best Practice #19 - Problem Evaluation Request (PER) — A Comprehensive, Low Threshold, Electronic Work Initiation / Problem Identification System

Best Practice #20 - Joint Review Group (JRG) — A Senior Review Committee For Complex/High Risk Work Packages

Best Practice #30 - 360 Degree Photography Implements ALARA Principle (12/08/04)

For details see:

http://www.efcog.org/bp/management.htm

- - -

Now that you’ve had a look at some Department of Energy best practices, start thinking about attending a Summit with 10 tracks of best practices - the TapRooT® Summit. Pick from any of the following 10 tracks (or customize your experience by attending the sessions you choose from any track):

Proactive Improvement Best Practices

(Track Leader - Brian Locker)

Lean, Process, & Quality Improvement Best Practices

(Track Leader - Kevin McManus)



Investigation & Root Cause Analysis Best Practice

(Track Leader - Dana Barclay)

Safety & Risk Management Best Practices

(Track Leader - Ken Scott)

Human Error Reduction & Changing Behavior Best Practices

(Track Leader - Joel Haight)

Corrective Action Program Best Practices

(Track Leader - Michele Lindsay)

Medical Error Reduction Best Practices

(Track Leader - Don Lighter, M.D.)

Equipment Reliability & Maintenance Best Practices

(Track Leader - Ken Reed)

TapRooT(R) Certified Instructor Certification Maintenance

(Track Leader - Linda Unger)

TapRooT(R) Software Techniques & Administrator Best Practices

(Track Leader - Ed Skompski)

For a complete schedule of the sessions in each best practice track, see:

http://www.taproot.com/summit.php?sched=1

It is amazing how many explosions and/or fires happen each year. If you try to make a list of just the industrial fires and explosions, it is long and sad. But pictures of the fires, explosions, and the aftermath can help people understand why safety is important. Why safety rules, procedures, training, and management attention is so important.

Can you name the facilities where the accidents below happened?

Better yet, do you know the root causes of these fires and/or explosions and what you need to do to prevent them at your facility? The answers to these questions can keep your facility safe.

Performance improvement comes from hard work and dedicated people applying industry best practices and advanced root cause analysis. This lesson has been proven over and over again.

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For more information on a Summit to learn industry best practices see:

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

For more information about advanced root cause analysis training see:

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

The video below reminds me of investigators who quickly jump to conclusions when analyzing root causes.

To view the video click on: DeadFly-2.wmv

How does your root cause analysis system help you avoid jumping to conclusions? TapRooT® Users have a systematic process that produces evidence driven investigations and fact based root cause analysis. Don’t assume you know the answer. Use TapRooT® to get:

• Repeatable

• Defendable

• Explainable

• Documented

• Evidence Driven

• Fact Based

Root Cause Analysis.

Click here to find out about our training and here to find out about our software.

Hello again, folks.  It looks like another week has passed, and we all know what that means. Tech Support Thursday has arrived, and only one more day until Friday.  Unfortunately, tomorrow is Friday the 13th, so if you have Paraskevidekatriaphobia (Fear of Friday the 13th), just take tomorrow off.

Inside I’ll go over some basics on the MSDE SQL engine that runs the single version of TapRooT System Software.

Today we are addressing an issue many people have, and we get quite a few calls for help on also.  Does the picture look familiar?

If so, read on and we’ll show you why this happens and how to fix it!

(more…)

A recent audit of NASA contractors found that the root causes of many failures were being coded improperly, causing many to be improperly tracked and corrected. For example, when a wire harness was taped instead of clamped, the code “Operational Degradation” was used instead of “Workmanship.” In another example, a finding of “Excessive Corrosion and Rework Damage” was coded as “Environmental Damage”, but no code was assigned that covered the “rework” problem.

Why would these codes be used inproperly? Several reasons may exist:
- There is unclear guidance as to how to apply the cause codes
- There codes are used for multiple puposes. For example, in the cases above, the cause codes are used to apply corrective actions and to assign monetary award levels based on the type of code. Seems pretty likely that someone (who is trying to obtain the award bonus) may “err” conservatively when assigning a cause code!

When your maintenance techs are performing mantenance, they are often required to assign a cause code of some type to identify why a repair was required. What motivations are in place to make your techs put in the right code? Is there a policy in place to determine the code?

Using Equifactor® in conjunction with TapRooT®, the ambiguity disappears. It is no longer up to the whim of an individual with unknown motivations to assign a root cause. TapRooT® assigns root causes based on the information from human performance experts, with little room for bias. By using Equifactor® with TapRooT®, you can obtain consistent root causes that make your results trendable, and therefore useful.

Openings in the Environmental, Health and Safety

Anyone interested in learning more about these positions please contact:

Paul Shrenker, phone 413-267-4271

New website with up-to-date job openings:

http://www.psassociatesinc.com/jobopenings.htm

EHS Lead for this oil and gas company located in Southwestern WY. The ideal candidate should have 10-15 years EHS experience to include environmental permitting and documented success in accident reduction. BS in Safety, Environmental or related and certification (CIH or CSP) desirable.

HSE Superintendent for a chemical manufacturer in the Baltimore, MD area. This person will have 4 direct reports and also be responsible for the contracted security staff. The ideal candidate should have 8+ years of safety experience in a manufacturing environment (preferably chemical), supervisory experience, VPP experience and a BS in Safety, Engineering or related.

EHS Manager (Business Unit) for this chemical manufacturer located in the Charlotte, NC area. This person should have EH&S experience in a chemical plant, have a BS in Chemical Engineering or Chemistry, PSM experience and preferably multi-plant experience. The position will handle 3 locations located in TX, NC and TN.

(more…)

Here is an initial CNN report:

http://www.cnn.com/video/us/2006/10/06/forte.nc.hazardous.fire.news14carolina/content.html

Local news coverage:

http://www.wral.com/news/10012555/detail.html

CNN’s report on the end of the evacuation from Associated Press at:

http://www.cnn.com/2006/US/10/07/plant.fire.ap/index.html

The Chemical Safety Board released the following press release:

CSB Deploys Investigators to Site of Chemical Fire and Public Evacuation from North Carolina Hazardous Waste Facility

(more…)

First Job Opportunity:

Human Factors / Operations Engineering Consultant – Aviation, Transportation and Defense

Second Job Opportunity:

Human Factors Internship or Post-Doc Opportunity

(more…)

I came upon these statistics at the Houston Chronicle web site in a section about deaths at refineries:

http://images.chron.com/content/news/photos/05/05/15/page.html

The stats show that from 1995 through 2005 there were 43 total fatalities with 22 of those (over 50%) at BP Refineries.

These somewhat gruesome statistics makes one stop and think.

But as I pondered these statistics I thought about the reports on medical errors and needless deaths at hospitals. By current estimates in a 10 year period there would be about 900,000 deaths due to errors at hospitals.

The risk at hospitals and refineries can be measured by results. What risk does your facility have?

For those looking to improve performance and stop fatalities, you need to have a comprehensive continuous improvement plan. Plus you need to learn advanced root cause analysis and best practices from your industry and from other industries to help you stop bad things from happening.

For advanced root cause analysis training, see this link:

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

For a place to learn best practices, see this link:

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

But don’t wait for a fatality to get started.