Root Cause Analysis Blog

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

Have you ever wondered exactly what the differences in licensing the TapRooT System software are? Well, we’ve compiled a word document which lays out an easy to use matrix of how the licensing system works.

Click Here To Download The Version 4 Database and Licensing Differences Word Document.

Over the past few weeks, we’ve seen many customers who have Enterprise licenses merely using Single User installations for their users. And that’s perfectly fine, but at the same time, some of these users were using Export/Import files to keep themselves on track and that’s not an efficient way to use the TapRooT System Software.

Also note that this is excellent material for IT Departments as well as system administrators in getting a grip on how upgrading their licensing can benefit their company as well as what it entails exactly.

I hope this helped. See you next week!

Euclid of Virginia, Inc. is $3.1 Million poorer after Judge Carl C. Charneski imposed a record penalty (the most ever imposed by an EPA Administrative Law Judge for violations of a federal environmental statute).

No doubt this record fine sends a messge. The question is, will this example of an uncertain, delayed, negative enforcement cause other companies to comply?

For more information see:

http://yosemite.epa.gov/opa/admpress.nsf/93216b1c8fd122ca85257018004cb2dc/53d97f4e1898caeb85257228004ee8d7

For the full text of Judge Charneski’s decision see:

http://www.epa.gov/oalj/orders/euclidof-va-id-110906.pdf

Root cause analysis of this fine should be fairly easy. Either the company didn’t have a SPAC (Standard., Policy, or Administrative Control) to meet the EPA regulations or the company didn’t enforce the SPAC that they had.

The company certainly found out that the EPA was serious about enforcement.

I received the e-mail, available by clicking on the continue link below, that allows you to vote on your opinion of a legal case.

Interesting concept. I didn’t give them my e-mail address but you might consider it.

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Click on the continue link below to read about job openings …

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2007 is closer than you think. Check out our schedule of courses around the world and register for January courses at http://www.taproot.com/courses.php.

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Tropical disease arrives on U.S. shores - Several states report mosquito-borne virus - Root Cause?

Press Release by Newhouse News Service

Sources: Newhouse News Service, U.S. Army Center for Health Promotion and Preventive Medicine

ATLANTA — Chikungunya, a severe and sometimes deadly infectious

disease that has devastated the islands of the Indian Ocean, has

arrived in the United States.

Colorado, Louisiana, Maryland, Minnesota and at least a half-dozen

other states have reported cases of travelers returning from Asia and

East Africa sick with the virus, according to the Centers for Disease

Control and Prevention.

Chikungunya is spread through an infected mosquito’s bite. It is not

spread directly by an infected person to someone else.

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I found a complete list of DOE Facility Best Practices that I thought might interest readers.

See:

http://www.efcog.org/bp/p/bpmasterlist.htm

If you are interested in best practices, you should see the Summit schedule at:

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

for even more. Just click on the buttons on the left side of the site to see all the breakout session in a particular Best Practice Track.

What are the Best Practice Tracks at the Summit?

• Human Error & Behavior Change
• Safety & Risk Management
• Corrective Action Program
• Lean, Process, & Quality Improvement
• Medical Error Reduction
• Equipment Reliability & Maintenance
• Investigation & Root Cause Analysis
• Proactive Improvement
• Certified TapRooT® Instructor
• TapRooT® Software Techniques & Administrator

Hope to see you there sharing and learning best practices.

How does blame impact an accident investigation?

Imagine that your were the two pilots that successfully landed a Embraer Legacy jet after a midair collision with a Boeing 737. That you were bring the plane back to the US. That you had done exactly what the air traffic controllers had told you to do - which matched your flight plan - and that this was verified by the cockpit tapes. Yet you had been held under house arrest in Brazil since September and the judge in the case said that you may have to cool your heals for another 10 months.

How would you feel about cooperating with what is current a criminal investigation?

I always joke that you should start your root cause analysis interviews with:

“You have the right to remain silent … Anything you say can and will be used against you in a court of law.”

That’s a great way to put people at ease!

For an AP story about the investigation and see CNN’s web site:

http://www.cnn.com/2006/WORLD/americas/11/23/union.brazil.ap/index.html

Ken sent me this e-mail about a recent on-site TapRooT® Root Cause Analysis Course in Northern Canada…

From: Ken Turnbull

To: Mark Paradies

Subject: Snow Bird Instructors

Date: Sun, 26 Nov 2006

While the home office is in a nice warm locations (Knoxville, Tennessee), a couple of your instructors practiced survival techniques at -28 degrees C (-18 degrees F) in beautiful downtown Hay River and walked to class through 10 inches of snow.

P.S. The one without the hat is the Canadian if it isn’t obvious!

Richard Gerow, a TapRooT® User in Canada, sent me this joke e-mail and what appears to be a real accident photo.

- - -

E-mail:

To my dear husband,

Before you return from your business trip, I just wanted to let you know about the small accident I had with your pickup when I turned into our driveway today.

Fortunately, it wasn’t too bad and I’m not hurt, so please don’t worry about me. I was coming home from the store and when I turned into the driveway I accidentally hit the gas instead of the brake. The garage door was down so it got bent a little but fortunately the pickup stopped when it bumped into your car.

Isn’t it great that your motorcycle wasn’t damaged?

I am really sorry but I know you have a kind heart and will not hold this against me. I love you and can’t wait to hold you in my arms again. I’ll see you tomorrow.

Your loving wife,

xxxx

Click on the link below for the picture…

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To all those who are thankful for their blessings …

HAPPY THANKSGIVING!

See:

http://www.cnn.com/2006/US/11/22/explosion.fire.ap/index.html

The CSB will be investigating the explosion at a Danvers, MA facility that exploded early this morning. 90 homes were damaged, but thankfully, only 10 minor injuries were reported.

Click here for details.

The construction injury is one of the most hazardous in the US. Deaths at construction sites top the list of work related fatalities. And the root causes of these deaths often point to management failures.

If you frequently visit this blog you’ve read the “One Step Away from Death” article and the “Stop the Sacrifices” article. Once you read these, you know what my thoughts are.

After a fatal scaffolding accident, the Massachusetts legislature may take action to pass a law that would put executives behind bars. For more information see:

http://cbs4boston.com/topstories/local_story_285092929.html

http://www.insurancejournal.com/news/east/2006/10/13/73262.htm

Good management prevents fatalities - thus there is no one to blame.

Bad management blames the worker - or anyone else besides themselves.

Healthcare Providers

Want more information on preventing nosocomial infections?

Then try these web sites:

http://www.mansfield.ohio-state.edu/~sabedon/biol2053.htm#vocabulary

http://www.cdc.gov/ncidod/dhqp/nnis_pubs.html

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

Or maybe you would rather learn the latest best practices in one of the Stopping Medical Error Track breakout sessions at the TapRooT® Summit?

William P Sawyer, MD, will lead a discussion of infection control and the prevention of nosocomial infections.

For more information about the Summit see:

http://www.taproot.com/summit

We have many training and light rail TapRooT® Users so I thought I would pass along news of a wreck in Germany. See the CNN web site for an AP story.

Sounds like they need root cause analysis to find the root causes of the collision.

Sometimes accident strike closer to home. In this case one of our frequent Summit speakers, Beverly Inman-Ebel, was hurt last month when she bit into a screw in a sandwich.

What is the lesson learned? Read Beverly’s e-mail below (reprinted by permission) and my reply and Beverly’s reply and then think what kind of response your company would give if someone was hurt by one of your products.

Seems like the accident, and the response, are good candidates for root cause analysis.

- - -

Beverly’s original e-mail:

From: Beverly J. Inman-Ebel

Subject: Beverly Inman-Ebel finds screw in Arby’s sandwich

Date: Thu, 16 Nov 2006 10:14:03 -0500

Dear Clients and Friends,

I am concerned about customer service, quality control and the lack of communication between Corporate America and its ultimate consumer. Here is my story.

On October 30, 2006 I purchased an Arby’s sandwich and it contained a screw that I bit down upon. (Pictures are at http://www.imagestation.com/album/pictures.html?id=2099380055&code=25248625&mode=invite&DCMP=isc-email-AlbumInvite.) I immediately called the store reporting the incident, leaving my name and cell number, and informing them I would come by the store with the evidence between 4:00-4:30 p.m. The store manager was not present when I arrived and the 2 people in charge refused to give me the franchise owner’s contact information. They informed me the owner had been called and the manager had my name and number. I told them I had hurt my mouth and had a dental appointment the next day.

No one called Monday, Tuesday, or Wednesday. On Wednesday, a local reporter told me his station would want to run the story. I refused and used Hoover’s database to locate and call a Senior Vice President of Franchises at Arby’s Restaurant Group in Atlanta. She promised that someone would call me by noon the next day or that she would call me. No one called.

The reporter called me again on Thursday, November 2nd and asked to run the story. I agreed. Reportedly, the TV crew went to the restaurant first and interviewed the manager and owner, then came and interviewed me. I was told the story would run 4 times that day. The owner called me placing blame on his managers for not calling me and on Arby‚s for the screw stating that he purchases the chicken salad mix and only cuts the apples and grapes at the restaurant. He said he would report this incident to his insurance company and they would pay for my teeth damage. The TV reporter called me minutes later to tell me the station was not going to run the story.

On Friday, November 3rd, I called again to Arby’s Restaurant Group and spoke to a representative in Customer Relations. She promised to call me back in an hour. No one called.

The insurance company has contacted me. Other than the one call from the franchise owner after a television crew appeared at his restaurant, no one from Arby’s has called me.

As a consumer, I expected to be important enough to receive immediate communication from Arby’s. I expected this to matter. Originally, all I wanted was to know how the screw really got in my sandwich, what Arby’s was going to do to prevent it from happening again, and to get my teeth fixed. Now I want to be heard and I feel I have a very small voice. If you are also concerned about customer service and/or quality control, please share this with others. They can Google my name and realize I am a real and reputable person. If you do, you make my voice a little louder.

Sincerely,

Beverly Inman-Ebel

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Here was my reply:

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AP story on CNN web site, see:

http://www.cnn.com/2006/US/11/17/crane.collapse.ap/index.html

Sometimes the difference between a creative innovation and a disaster in the making is a slim margin - luck.

Click on the PowerPoint below and try to decide if the ideas will be praised for their innovation (preventing global warming by reducing hydrocarbon emissions) or investigated to find root causes of a fatality.

reyesdelalogistica.ppt

HSE Professional for this Opportunity in Refining?



Seeking a Refinery Health & Safety Engineer.

If you know of someone that may be a good match for this opportunity, please let us know.

All referrals are kept in the strictest of confidence.

For a complete listing of our exceptional opportunities, please visit our website: www.er-inc.com



Position: Refinery Health & Safety Engineer

Compensation: Commensurate Upon Experience

Location: Midwest

Benefits: Full Benefits

Email Contact: Leif Hauser at LeifH@er-inc.com or (239) 949-3307

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See this link for an example of 5-Why’s applied to a problem:

http://www.reproline.jhu.edu/English/6read/6pi/ppt/maqpi/gifs/slide17.gif

I’m not posting this as a particularly bad example of 5-Whys. Rather it is a rather typical example of 5-Whys.

If that isn’t bad enough, look at this Fishbone Diagram:

http://www.reproline.jhu.edu/English/6read/6pi/ppt/maqpi/gifs/slide16.gif

Any TapRooT® User who views this example will know how much is missing from either root cause analysis.

But others may think that the answers presented are OK - maybe even way better than their current analysis.

That’s why I shake my head when someone mentions 5-Whys or Fishbone Diagrams as a root cause analysis tools. It appears to be better but it just leads people down the road to the same old ineffectice answers that they always seem to get. It doesn’t get people beyond their current thinking.

I decided to drive from 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Leamington Spa, England, up through the mountains in Scotland and over to the 5-Day TapRooT® Course in Aberdeen, Scotland. I left on Friday to visit Hadrian’s Wall. On Saturday, I drove up into the Scottish Mountains. Sure enough, in the mountains I saw my first snowflake of the year. (Pictorial proof below.)

Are you ready for WINTER DRIVING?

Is your fleet of vehicles prepared?

Do you have your windshield scraper (my rental didn’t).

Have you scheduled a safety briefing about winter driving.

If you need to develop a winter driving presentation, here are some links that will help:

Advice from the Weather Channel:

http://www.weather.com/activities/driving/drivingsafety/drivingsafetytips/snow.html?from=iForecast

Advice from the AAA in Chicago:

http://www.theautochannel.com/news/2005/01/05/315414.html

Advice from the National Safety Council:

http://www.syracuse.com/weather/snow/stories/driving.html

Advice from the American Chemical Society:

http://www.chemistry.org/portal/a/c/s/1/feature_ent.html?id=c373e9080ab0eede8f6a17245d830100

Advice from the UK:

http://www.2pass.co.uk/snow.htm

Advice from Australia:

http://www.cccsc.asn.au/Text/driving.html

5 Tips for not getting stuck:

http://www.crackedwindshield.com/snow-tips.html

4WD driving on snow:

http://4wheeldrive.about.com/od/winterdrivingtip/

A word document with more advice:

Winter Driving.doc

(Click on object above to open)

Ah, a nice warm place with a fire to stay!

And the next day - most of the clouds and snow were gone!

What’s it like to be in a TapRooT® Course?

The critiques tell us that it is a very positive experience.

Most people find it hard to believe how much they have learned in 5 days of a 5-Day TapRooT® Course..

Many come to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training wondering how we will keep them busy for 5 days. Will they be bored to tears? Will the instructors know what they are talking about?

The answers are:

- You won’t be bored at all. The course is described by attendees as being action packed - very busy! Time seems to fly by. Many tell us that they wished they had more time to absorb all that we teach even though every major learning objective is reinforced with a hands-on exercise.

- The instructors are very knowledgeable. They have extensive experience doing investigations. Attendees report they are pleasantly surprised by the extensive knowledge of the instructors and the attitude and enthusiasm they bring to the course.

I’ve had investigators with 20 years of experience come to the course who were surprised by how much they learned from the course. Their only comment - THEY WISHED THEY HAD CONE SOONER.

Here are some class photos from the first day of the course in Aberdeen:

Team discussed incident.

Team builds their SnapCharT®

More discussion around a SnapCharT®.

Another team discussing an incident.

Barry explaining a point to team members.

And don’t forget - many courses are held in resort locations. (Unfortunately - Aberdeen in November really doesn’t qualify as a peak season for a resort). So plan to come early and stay a few days after the course is over.

To see the locations for upcoming courses, go to:

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

Since I’m in the UK teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Aberdeen, I thought this topic was definitely appropriate for the Monday Accident.

What can you learn from UK Marine Accidents from 1990 to 2006?

Go to the UK Marine Accident Investigation Branch (MAIB) web site, read the reports, and find out!

See:

http://www.maib.gov.uk/publications/investigation_reports/2006.cfm

If you would like to look at just the 10 most recent reports, see:

http://www.maib.gov.uk/publications/index.cfm

For details see:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=324

How would you feel if you were the lineman for OG&E who popped the cover off this electrical panel?

(Click on picture to enlarge - picture courtesy of Catherine French)

So the questions is … was it a root cause analysis of a:

1. Customer Service Interruption

2. Snake Bite

OR

3. Heart Attack

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

This week we’re mired in Version 5 development and so I’ll make this one short and to the point for all of those Database Administrators and Network Admins all over the world who use our software and plan to upgrade to the full-blown Enterprise Edition of the software:

The Enterprise Edition of TapRooT System Software must be fully installed on the SQL Server hosting it.

There is no way of installing it elsewhere, installing the database seperately, or any other tricks that are going to get the Version 4 TapRooT System Software on your SQL Server. There are certain procedures that are ran as the software installs, as well as serial number validation. Procedures which cannot be avoided.

So for all of you DBAs out there, I apologize as I know it’s uncomfortable to install ‘client’ software on a server. But it is a must. And the System Software client can be uninstalled via Add/Remove Programs in the Control Panel as soon as the software is fully installed and running.

NOTE: This is not an issue in the Version 5 software. But we’ll cover that when it’s time.

Thanks for reading! See you next week.

Are you interested in mining industry best practices?

See these at the MSHA web site:

Automated External Defibrillator (AED)

Adding Pipeline on a Dredge

Building A Safety Culture

Can You See What You’re Breathing?

Changing Screening

Cold Weather Hazards

Contractors are Miners, Too

Ensure A Healthy Workplace

Fatigue

Handling Caustic Soda

Haulage Road Housekeeping

Heat Stress - Summer Alert

Improving Your Pre-shift Inspection

Is that Cell Phone conversation worth the Price?

Keeping the Truck Driver in the Cab

Maintaining the Bank Edge

Mentoring

Mounting and Dismounting Equipment

Noise Reduction in the Cab

Open Pit Traffic Control

Oxygen-Acetylene Cutting Operations

Plan Your Work and Work Your Plan

Recognizing Work Zones

Red Flags of Substance Abuse

Reducing Silica Exposure

Signs, Signs, Everywhere There’s Signs

Substance Abuse

Support the IRS (Increased Roof Support)

Suspended Loads

Underground Air Quality

Wellness

Windshield Access

Workboat Safety

But where can you meet with industry leaders and learn their best practices? Simple … try the TapRooT® Summit.

There are 10 different best practice tracks at the Summit:

• Human Performance & Behavior Change Best Practices

• Safety & Risk Management Best Practices

• Corrective Action Program Best Practices

• Lean/Process/Quality Improvement Best Practices

• Medical Error Reduction Best Practices

• Equipment Reliability & Maintenance Best Practices

• Investigation and Root Cause Analysis Best Practices

• Proactive Improvement best Practices

• Certified TapRooT® Instructor Best Practices

• TapRooT® Software Administrator Best Practices

For a schedule for each of these tracks see:

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

ONE MORE NOTE: One of the speakers at the Summit (Safety & Risk Management Track) will explain MSHA’s efforts to improve mining safety.

Over the next two days (Wednesday/Thursday) I’ll be teaching a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Class at Woodland Grange’s Facilities in England.

This is the first time that System Improvements has teamed up with Woodland Grange to teach TapRooT® in the UK.

I am impressed with Woodland Grange’s facilities in Leamington Spa, England. They are about a 20 minute taxi ride south of the airport in Birmingham, England - so travel arrangements are fairly easy from anywhere in Europe.

The staff is friendly and very competent and the rooms are quite nice. And the room rate includes all meals (I just ate a wonderful supper from an excellent menu). And they have an on-site pub.

Nearby is Warwick Castle. If you have an extra day, it is well worth the visit.

Also nearby is Stratford-upon-Avon - The birthplace of William Shakespeare.

So if you are looking for a place to attend a course in Europe next year, I highly recommend this location.

The 2007 courses scheduled for Woodland Grange’s facilities in Leamington Spa include:

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course - January 29-30.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training - June 18-22 and November 19-23.

Hope you or someone from your staff can make a course.

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

CSB Investigator Deployed to Fatal Incident at South Carolina Chemical Manufacturer

Washington, DC, November 5, 2006 – An investigator from the U.S. Chemical Safety Board (CSB) has been deployed to the site of a fatal incident yesterday at 3V Inc., a chemical manufacturer in Georgetown, South Carolina, northeast of Charleston. Reports indicate that one worker died and another was injured inside a confined space, a dryer. The company has told CSB staff that the interior of the dryer had an oxygen-deficient atmosphere.

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A report at the CNN web site includes the following quote:

“The tower instructions reported by Folha may have been the first of a series of problems that led to the crash.”



The term “root cause analysis” can be confusing to some. Why? Because they may believe that it is possible to find a single “root cause” for a major accident or incident.

In TapRooT® Courses we train investigators that major accidents are caused by a series of events. These events have causes. Usually several of these causes could have been prevented, or significantly reduced the consequences of, the accident and thus are labled “causal factors”. We train investigators to analyze these causal factors using the Root Cause Tree® to find the fixable root causes that can be corrected to prevent future repeats of the causal factors and thus the accident.

Thus root cause analysis is actually a way to find many - not just one - ways to improve performance and prevent accidents.

I saw an AP story on the CNN web site about runway safety. The third line in the story was:

“Our runways are out of shape, and the Bush administration has failed to move to correct the problem,” Sen. Frank Lautenberg, a New Jersey Democrat, said Thursday. “If we don’t get serious about runway problems, the result could be disastrous.”

I thought … “Is the root cause of everything politics?”

I didn’t know that George Bush was supposed to be out building runways. I thought he was the President?

What do I know…

I understand that the FAA has a regulation that requires runway upgrades by 2015, but I thought there were local airport authorities that actually take care of each airport - either by local taxes or landing and gate fees collected from the airlines.

I also know that there is a federal tax on tickets - but I have no idea how that money is spent.

I know that for about the past 20 years the air traffic control system has really needed upgrades and that the federal government isn’t very efficient at making improvement happen. Wasn’t Al Gore working on improving government efficiency?

I also know that the federal budget is huge. Doesn’t congress vote on the budget? With all the pork that congress adds to the budget, I’m sure there is room for MORE SPENDING…

I know this is an election season and politicians think that everything bad is a result of their opponent, but shouldn’t the media - newspapers, TV, and radio - be smarter than to pass along political rhetoric as fact?

A small lesson that root cause analysts can learn from this story:

- Evaluate what people tell you.

- Obviously everything that people say isn’t facts.

- Make sure that statements match physical evidence.

- Ask yourself if the person telling you something has an agenda.

Then your root cause analysis can be more accurate & truthful -

more FACT-BASED and less AGENDA-BASED

than the stories that appear in the news.

Richard Gerow, a TapRooT® Users that works for Timberwest Forest Corporation in British Columbia, sent the picture above (click on it to enlarge).

He was up in northern BC doing an audit of a helicopter company and he says they “got a little bit of snow”.

The snow came down in just 37 hours.

The person you can see is STANDING UP.

And Richard says that the bad news was that the DROVE to the audit - which would normally take 6 hours. The drive home wouldn’t be fun.

Maybe it is time to start thinking about winter driving?

Here’s a video (click on object below) to watch.

Winter presents special challenges for driving, walking, … all sorts of outdoor activities.

Are your facilities ready?

Have people prepared their cars (and company cars) for winter driving?

• snow tires

• chains

• window washer full and appropriate anti-freeze

• blankets and supplies if stranded

• what else???

Have you had your winter preparation safety meeting?

The further NORTH your plant is, the more likely you are to prepare. But I’ve seen plants in the deep south damaged do to freezing of outdoor pipes. Why? People didn’t get ready for mother nature.

So don’t let a lack of preparation be the root cause of winter problems at your plant. If global warming takes this winter off, be prepared!

It is NOT a JOKE when preventable winter weather related accidents happen.

Hello everybody! This week we’re tackling a simple compatibility problem: Which SQL Server should Enterprise Users use?

For our enterprise clients, they use Microsoft SQL Server to host their database (Workgroup and Single User installations utilize Microsoft Database Engine—MSDE), and up until last year the most recent version of Microsoft SQL Server was 2000. However, Microsoft has released 2005, which prompts this notice for all Enterprise Users:

TapRooT System Software is NOT compatible with Microsoft SQL Server 2005. Use Microsoft SQL Server 2000 instead.

Of course if you have any questions about this, feel free to contact us via the link in the top right of the menu, or at techsupport (at) taproot (dot) com! See you next week!

Press Release from the Chemical Safety Board:

Washington, DC, November 2, 2006 - The U. S. Chemical Safety Board (CSB) today issued a Safety Video on the November 5, 2005, nitrogen asphyxiation incident at the Valero Refinery in Delaware City, Delaware.

The video includes a computer animation depicting events leading to the accident, and features commentary by Lead Investigator John Vorderbrueggen, Board Member John Bresland, and a field expert.

The CSB video on the accident, entitled “Hazards of Nitrogen Asphyxiation: Fatal Accident at Valero Refinery,” is available for streaming or download on www.CSB.gov, and may be ordered on a DVD by filling out a request form on the video player.

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When a major accident happens, the lawsuits can get nasty.

I ran across a document posted on the web that looks to be part of a lawsuit related to Sarbanes-Oxley compliance or the Sherman Anti-Trust laws in the US. I don’t know why individuals would be filing this suit, but lawyers might be able to explain it. The web site where the document is posted certainly does seem to focus on any negative information that can be found about BP. The document is posted at:

http://www.bpconcerns.com/Documents/CharlesHamelLetter2/tabid/76/Default.aspx

Why is a document posted at an “anti-BP” (my interpretation of the site) web site interesting?



1. When you read Attachment C you start to see the types of problems and expenses that can be generated by evan a simple request for documents that might occur because of a lawsuit after an accident. Here is just one item from the 20 item list:

“13. From 1998 to present, provide all emails warning of

problems on the Isomerization Unit from Petrospect

Inspection and Jacobs Engineering.”

Imagine how hard it would be to make sure that you had collected all (every) e-mail that anyone had written that warned of “problems” from a “Petrospect Inspection” and from a contractor - Jacobs Engineering. And remember, that’s just one of 20 information requests.



2. The document claims that “benchmarking” - and more specifically the Solomon Refinery Benchmarking Studies - is the root cause of the explosion at the BP Texas City Refinery.



The document points to the studies and management’s actions and then blames the explosion on senior BP managers wanting to increase their pay by improving their results in the benchmarking studies. Thus “benchmarking” is the root cause of the explosion. That’s the claim the letter at the web site makes.

WOW! And I thought my interpretation of the information released from the CSB was critical.

There is much that can be learned from the document - but let’s just look at a few of the less obvious points:



1. You never know when someone will subpoena your e-mails!

2. One item that you should consider is that you are probably underestimating the costs of an accident. When you estimate the costs, don’t forget the legal woes that can result from an accident.

3. Another unanticipated “cost” is the people who can loose their jobs over the residual blame that will, no doubt, ruin the reputations and careers of many. This started with those who were directly involved at the unit that exploded. But senior BP management is also finding out how far the blame can spread.

4. The PR nightmare after an accident is not a minor issue.

These less obvious costs of an accident aren’t the primary reasons to prevent accidents, but they are issues that are real and often overlooked when considering the benefits of maintaining excellent performance.

A Note for TapRooT® Users:



As you know, the TapRooT® System isn’t designed to place blame. Instead, it is designed to discover ways to improve performance. Therefore, the “root causes” hinted at (benchmarking and greed) in the document cited above aren’t a part of the TapRooT® System.

Instead, TapRooT® would look at the company’s standards, policies, and administrative controls related to specific causal factors that caused the accident. These “SPAC” should have been stringent enough to prevent the accident that occurred. If they weren’t - that’s a problem … a near-root-cause in the TapRooT® System.

Or, if the SPAC were adequate, then they must not have been used (followed). That too is a problem … another potential near-root-cause.

A more detailed analysis of BP’s standards, policies, and administrative controls and the compliance with those SPAC is no doubt one of the things that the CSB has undertaken as part of their investigation and root cause analysis of the explosion at the refinery.

Everyone concerned about improving refinery safety - and process safety management - will be waiting for the final CSB investigation to get a more thorough understanding of the facts related to the failures that lead to this tragic explosion and fire and any failures in BP’s implementation of the Process Safety Management regulation (a SPAC) that lead to the explosion. Until the complete report is released, we will be left wondering about the causes - the complete root cause analysis - of the explosion, fire, and resulting 15 deaths.

A Note for TapRooT® Summit Attendees:



Judge Andrew Napolitano will be one of the Keynote Speakers at the TapRooT® Summit. His talk is titled:

Accident Investigation Lessons from the Courtroom

This talk will provide you with even more ideas about the legal complications and liabilities possible when performing an investigation. If you know others who are interested in this topic, tell them about the Summit.

I know Mark has already made his stance known on the BP refinery disaster (I refuse to call it an “accident”). As I read the report, one thing came through loud and clear:

Costs were cut in maintenance and infrastructure upgrades to save money at the expense of all else:
“BP implemented a 25% cut on fixed costs from 1998 to 2000 that adversely impacted maintenance expenditures and infrastructure at the refinery,” (the CSB Chairman) said. Maintenance spending fell throughout the 1990’s at the then-Amoco refinery, and following the merger with BP further cuts were imposed…“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.’”

These costs were cut by the original owners (they were getting ready to sell, why put money into maintenance and upgrades?), and then continued by the new management (even though they must have known what was going on). I don’t know their rationalization at this point, but you don’t need 20/20 hindsight or sophisticated root cause analysis to see what the results of this kind of budget control will do to an older facility.

Unfortunately, many of us face these same decisions every day. Many of us work at aging facilities, with older and outdated equipment. Do I let the old gear operate poorly, do I conduct extensive repairs to the equipment, or do I decide to invest in new, modern, up-to-date technology? This is not always an easy call. How do I make this decision?

First of all, you must be able to make a business case for whichever decision you make. You must compare the cost of maintaining the status quo to the costs and savings possible with the anticipated upgrade. The costs include unanticipated downtime, spare parts that may no longer be available, maintenance department salaries and overtime, excessive power usage, etc. The benefits can be ease of operation, safer equipment, less required preventive and corrective maintenance, energy efficiency, fewer environmental concerns, etc.

But this business case must include more than just dollars. Safety and risk mitigation must be included in the decision. No matter how much money you think you will save, if you are putting your workers at risk, that is the new bottom line.

And it is not just upper management who has the responsibility here. Although they may have the ultimate responsibility on paper, it is the front-line supervisors that can and must make the difference. Being told to just suck it up is NOT acceptable when equipment has deteriorated to the point that safe operation is a roll of the dice. You must stand up and be heard, more than once if that’s what it takes. You guys know the real conditions at your facilities, and you cannot accept dangerous conditions.

I am not so naive that I think this is easy. But I am enough of a realist to know that it CAN AND MUST BE DONE.

These kind of strikes always worry me ….



Widespread Brazilian flight delays could last to next week

11/01/06 12:19 PM, EST

Flights across Brazil were severely delayed Wednesday as air traffic controllers engaged in a so-called “work-to-rule” campaign, following regulations to the letter in a protest move that significantly slowed airline operations and could last until next week.

FULL STORY

Makes me think about the root cause:

“enforcement needs improvement”.