Root Cause Analysis Blog

Santa Claus: Risk Assessment

Name: Santa Claus, aka Criscringle, Father Christmas, Father Frost, Joulupukki, Kris Kringle, Père Noël, Sabdiklos, Saint Nicolas, Sancte Claus, Sinter Klaas, Weinachtsmann

General job description:

Santa Claus is employed for only two nights a year. His duties are as follows:

* Delivering presents from the Elves’ factory in the North Pole to all the good children world-wide

* Carrying out work whilst the children are asleep to avoid detection

* Delivering presents in a eight-reindeer flying sleigh

* Gaining access to premises from the roof via chimney

* Payment in the form of tips (generally mince pies and sherry)

* Enhanced CRB Documentation must be provided

Logistics of job:

Previous research has shown that:

* Santa visits over 1500 homes per second

* The average speed of his sleigh is of the order of 3.6 million miles an hour.

* The sleigh carries about 156,000 tonnes of cargo.

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See this site:

http://www.shponline.co.uk/jobs.asp

Click on the CONTINUE link below to review several postings…

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Friday joke time. And since Christmas is right around the corner…

Do you remember the Christmas Hunting Incident that I posted last year?

Click on this link to see the Christmas Incident. (You’ll need Flash to be able to view.)

For another politically incorrect Christmas joke, see:

http://www.mistletoeandmeat.com/

Merry Christmas!

Remember: Don’t Drink and Drive (or hunt) during the holiday season.

Also … I will be on vacation next week so don’t expect many (or perhaps any) postings!

And have a Happy New Year!

Hello everybody and welcome to another action-packed edition of Tech Support Thursday.

Today we’re going by the old addage of letting the pictures speak their thousand words.

Ready to see 3,000 words worth of beautiful screens and reports that are coming your way in TapRooT System Software Version 5? Look inside…

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Are you looking to improve the performance of your equipment? Are you tired of seeing the same equipment failures happening over and over again? Would you like to get out of the “break and fix” cycle at your facility? Try applying the easy to use Equifactor® Equipment Troubleshooting module of the TapRooT® Root Cause Analysis System to your machinery problems. Equifactor®, in concert with the rest of the TapRooT® System, will help you find and fix the real root causes of those failures, instead of just fixing the same symptoms time and time again.

We will be holding Equifactor® courses throughout the world in 2007:

Jan 29-31 - Galveston, TX
Feb 26-28 - Halifax, Nova Scotia, Canada
Apr 11-13 - Gothenburg, Sweden
April 23-24 - San Antonio, TX (Pre-Summit course)
May 9-11 - Calgary, Alberta, Canada
June 13-15 - Aberdeen, Scotland
Jul 25-27 - Dallas, TX
Aug 8-10 - Lake Tahoe, NV
Nov 19-21 - Edmonton, Alberta, Canada
Nov 28-30 - New Orleans, Louisiana

Get those travel budgets in place now! And don’t forget about the Summit in San Antonio, TX April 25-28 (during the Fiesta!!).

To see safety related job opening in New York and Tennessee, click on the continue link below.

The Tennessee job is in the mining industry.

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Should you attend the Summit?

Ask yourself these questions:

1. Does your facility/company need to improve in any of these areas:

• incident investigation and root cause analysis
• safety and risk management
• human performance and behavior
• lean, quality, process improvement
• healthcare quality
• equipment reliability and maintenance
• proactive improvement

2. Are you a Certified TapRooT® Instructor that needs to maintain their certification?

3. Do you want to be more motivated to improve performance?

4. Would you like to get a team of people from your facility excited about performance improvement?

5. Do you need knew ideas to take your improvement program to the next level?

6. Do you need to refresh your TapRooT® knowledge?

7. Would you like to go to San Antonio during Fiesta Week?

8. Would you like to meet a bunch of new valuable contacts that can help you improve performance at your facility and advance your career?

9. Are you interested in benchmarking your improvement efforts against other industry leaders?

10. Are you interested in best practices from other industries that can be applied to improve performance in your industry?

If you said yes to any of these questions, you should sign up for the 2007 TapRooT® Summit.

To register, click here.

For more information, click here.

To download the complete Summit video, click here.

For the Summit Schedule, click here.

For video comments from Summit Attendees, click on their name below:

Debbie Baird, Ameren

Gerald Starling, StarMor

Daniel Gaffney, Qantas Airways

Phillip Curtis, Halliburton Scandinavia

Joey Willis, TODCO

Mark Devall, PCS Nitrogen

For Comments About the Summit and the Pre-Summit Training, click on the persons name below (and click on the course name for more course info):

Mike Rodriguez, ConocoPhillips Alaska - Getting the Most from your TapRooT® Software

Mark Cade, Consultant - Advanced Trending Techniques Course

Shannon Burns, Irving Oil Canada - Innovation and Creative Solutions

Bethany Butler, Irving Oil - Advanced Trending Course

Click here for Pre-Summit Course pictures.

Click here for some Summit Pictures…

Click here for some Summit Golf Tournament pictures.

Below is a Safety Flash that was released after a minor incident. Let me know what you think.

What was the root cause of this minor incident?

Was the corrective action adequate?

What else might you have done to improve on this safety flash?

Thanks for your comments and for the person who sent the safety flash to me for this blog.

ENVIRONMENT, HEALTH SAFETY & SECURITY - SAFETY FLASH

October 2006

Subject : Burst Vehicle Tyre (Manufacturer FALKEN )

What Happened:

A tractor and trailer arrived onsite to off load materials. The vehicle and trailer was parked for approx. 3 hrs prior to unloading .

During unloading of shell plate three (3) employees were standing alongside the trailer near the underbed carrying frame of the spare wheel. Without warning the spare wheel burst causing minor scratches to the thighs of the 3 employees.

Description of Product: Vehicle tyre manufactured by FALKEN 12.00R 24- 18PR.156/153 k Radial

Safety Warning : Always check spare wheel and tyre for damage or overinflation.

A check of the tractor and trailer operational tyres revealed all MICHELIN radials were in good condition. Lessons to be Learned: The seperation and release of wire strands and / or parts of the main tyre component at high pressure has the potential to cause damage, puncture of the skin, damage to property.

Recommendations:

1. Daily inspection of vehicle tyres including the spare may seem onerous or over the top to some drivers. The stringent requirements have been developed to safeguard personnel from faulty equipment if they are followed .
2. Ensure equipment is fit for use and conforms to approved standards
3. Vulnerable components guarded to protect others against impact damage, puncture of the skin damage to property.

Here is a Picture from the Knoxville News Sentinel:

See anything wrong?

Of course, standing on the top rung of a ladder is a common unsafe act (or at-risk behavior if you prefer that terminology).

But the other amazing fact was that they printed it with a story on the front page of the paper.

See: http://www.knoxnews.com/kns/local_news/article/0,1406,KNS_347_5217727,00.html for the story.

Many people don’t see unsafe acts even when they are taking pictures of them.

The Wall Street Journal says:

“Indiana workplace-safety regulators have proposed fining BP PLC about $384,000 for a series of violations at the company’s Whiting, Ind., refinery, the latest safety setback for the British oil giant at its facilities in the U.S.”

For more information see the article at:

http://online.wsj.com/article/SB116464904897133602.html?mod=home_whats_news_us

From Reuters:

“Two U.S. pilots said Friday they were not at fault for a collision between their small plane and a Brazilian airliner, which subsequently crashed over the Amazon and killed all 154 people aboard.”

For the complete article see the CNN web site:

http://www.cnn.com/2006/WORLD/americas/12/15/brazil.crash.reut/index.html

NUCLEAR WINTER WONDERLAND

I can’t help but post this song every December.

If you are in the nuclear industry (or just have a good sense of humor), hear the song (mp3 format) by clicking on this link:

http://www.taproot.com/blog/WorkinginNPP.mp3

I don’t know where it originally came from but a nuke industry guy sent it to me by e-mail 3 or 4 years ago.

It brings a whole new meaning to Nuclear Winter!

Happy Holidays to All (especially those that keep the lights and heat on when it’s cold outside)!

Mark

working in a nuclear power plant song

Fatigue can be one of the causes of human error.

Any student that pulled an “all-nighter” before a test can testify to the fact that fatigue can lead to mistakes.

Also, it seems that residents - who are “in training” -need to have some sleep or, according to human factors research, their learning won’t be transferred to long-term memory.

So it seemed that medical societies were on the right track when they decided to set limits on resident’s hours of work that were judged to be excessive.

So here are the main previsions of the standard:

• An 80-hour weekly limit, averaged over four weeks. Review committees for various specialties may set more restrictive standards. Moonlighting done in the sponsoring institution counts toward the weekly limit. In addition, program directors must ensure that external and internal moonlighting does not interfere with the resident’s achievement of the program’s educational goals and objectives.

• Adequate rest between duty periods.

• A 24-hour limit on continuous duty time, with an additional period up to six hours permitted for continuity of care and educational activities.

• One day in seven free from all patient care and educational obligations, averaged over four weeks.

• In-house call no more than once every three nights, averaged over four weeks.

For more on the standard see:

http://www.acgme.org/acWebsite/newsRoom/newsRm_dutyHours.asp

What do you think? Will the standard prevent fatigue? Does any other industry regularly work people these long hours to provide “training.”

Please comment by clicking on the comments link below.

If you are at a medical facility and you need a tool to help judge the likelihood that fatigue caused an error, attend the TapRooT® Summit and go to the presentation by Bill Sirios titled: “Analyzing Fatigue Using FACT.”

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

This week we’re going to investigate the autosave feature of SnapCharT. How does it work? Where does it save the files?

The answers are inside

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CSB Press Release about Daytona Beach Wastewater Plant Explosion Investigation available by clicking on “continue” link below.

The investigation web page is at:

http://www.csb.gov/index.cfm?folder=current_investigations&page=info&INV_ID=57

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The following link is to an audio of an NPR report about tired doctors, fatigue, and error rates at hospitals:

http://www.npr.org/templates/story/story.php?storyId=6612904

Is the hospital industry the only industry that has normal shifts that last 24 hours or more?

What would you think if you were a patient and you knew your surgeon had been working for 24 hours straight?

Imagine yourself trying to diagnose a complex disease after working for 20 hours. Do you think you would be able to perform the difficult thought processes required?

Could these long hours explain some of the 98,000 deaths per year due to medical errors (the 98,000 is an IOM estimate)?

The impact of fatigue and investigating that impact is just one of the breakout sessions at the TapRooT® Summit.

This session is included in the following Summit tracks:

- Medical Error Reduction Best Practices

- Corrective Action Best Practices

- Human Error Reduction and Behavior Change Best Practices

- Investigation and Root Cause Analysis Best Practices

For a complete Summit schedule by track, click on this link:

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

Use the Display buttons on the lower left part of the page to see the various track schedules.

What do you do when you receive a customer complaint?

They are obviously (or are they?) a quality problem.

And they can get you bad press. (See the example at this link: http://hosted.ap.org/dynamic/stories/C/CT_SIKORSKY_COMPLAINTS_CTOL-?SITE=CTDAN&SECTION=NORTHEAST&TEMPLATE=)

Major customer complaints deserve a complete root cause analysis.

For advanced root cause analysis training that can help you dig into and solve quality problems that may cause customer complaints, see:

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

Click on the continue link below for more information.

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The Chemical Safety Board performs root cause analysis of chemical accidents and posts the results of thier investigations and news about other chemical accidents at:

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

First one tire blows …

Then another …

Hang on for a wild ride!

Any landing you can walk away from is a good landing…

Having a tire blow isn’t lucky … But walking away without a scratch from this near-miss (near-miss to a more serious accident) is lucky. The question in my mind is … Did they do a thorough root cause analysis and learn all they could have learned?

This sequence was recorded by a photographer for AirshowTraveler.com - a great place to visit for military and civilian air show photographs. The pictures were originally published at ARC Air Discussion Forums.

Thanks to Gary Snyder (retired from the Navy and now working at Fluor - and a TapRooT® User) for pointing these great accident/near-miss photos out.

One more question …

Would YOU say this was an accident of a near-miss?

Click on the comment link below to leave your opinion.

Thanks

Mark

Three previous posting on this accident are:

Blame in Brazil

Bad Day for Brazilian Traffic Controllers

Series of Errors

Criminal charges have been filed against two pilots that, by the evidence, were flying at the altitude prescribed by controllers when they collided with a 737 over the Amazon.

For the most recent story see:

http://www.cnn.com/2006/WORLD/americas/12/08/brazil.pilots.ap/index.html

The Auditing Roundtable is seeking to fill the position of Manager of Education and Training

They are very excited about this newly created position .   

They asked that we share this information with other colleagues who may have an interest.

The contact is:

Kathy Rieth

Managing Director

Auditing Roundtable

FOR DETAILS, CLICK ON “Continue” BELOW.

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Wet concrete collapses and traps construction workers.

For information see:

http://www.cnn.com/2006/US/12/08/construction.accident.ap/index.html

This Friday’s incident isn’t the standard Friday Joke, but this PowerPoint has some really cool picture and explanations of where the pictures came from - SPACE!

Just click on this link:

SatPhoto01.ppt

to download the PowerPoint.

Thanks to Rhett Sinclair, insurance agent who helps support System Improvement with life insurance coverage, for passing along this PowerPoint.

Yes - I’m on the road teaching with Ken Reed and Tommy Garnett.

We deserve hardship pay. It was partly cloudy and in the low 60’s today. Too cool to swim in the pool today… Eat your heart out Canadian TapRooT® Users!

The course is going great!

Here’s a picture of Ken explaining a point to attendees.

Ken and Tommy deciding who teaches next…

Here I am teaching…

Here are pictures of students working on examples and discussing concepts in groups…

The day-1 course critiques say that the students are learning what they need to find the real root causes of accident, incidents, quality issues, equipment problems, environmental incidents, …

If you are interested in attending TapRooT® Training and learning the latest in root cause analysis, see:

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

Interested in nuclear industry best practices for managing people and getting good human performance? The IAEA has published a list. See this pdf:

http://www-pub.iaea.org/MTCD/publications/PDF/te_1364_web.pdf

For a story about the most recent problems in Brazil see:

http://www.cnn.com/2006/WORLD/americas/12/06/brazil.flights.ap/index.html

What is in the November Root Cause Network™ Newsletter:

INPO 8 vs. TapRooT® 10 (Page 1)

Last Chance for TapRooT® in ‘06 (Page 2)

2007 TapRooT® Courses (Page 2)

Attorney vs. Process Improver (Page 2)

Corrective Action: Firestone Tires (Page 2)

Mistakes Trending Mistakes (Page 3)



Courage at Work (Page 3)

Click here to download the pdf.

And what’s in the November TapRooT® Friends/Experts e-Newsletter?

Editor’s Letter: EXPLOSION ROOT CAUSE ANALYSIS: Comments on the CSB Press Release about the BP Texas City Refinery Explosion and Fire.

HURRY! It’s Your LAST CHANCE to Register for 2006 TapRooT® Courses!

You May Still Have a Chance to Register for Courses in the US, Canada, UAE, Kenya and Australia!



Medical Error Reduction Best Practices Track at the 2007 Summit, San Antonio, Texas

Learn How to Stop Human Errors at your Healthcare Facility.

Start Planning Your TapRooT® Courses for the New Year!

2007 is Closer than You Think! Register for January Courses Today!



“Quality Problems Need Root Cause Analysis” by Mark Paradies … Product Recall is a Quality Issue . . . and Quality Issues Need Root Cause Analysis

How to Navigate the Summit Website

The 2007 TapRooT® Summit Website is Up and Running, and We’ve Made it Easier than Ever for You to Customize your Schedule.



Root Cause Analysis Blog

Monday Accident & Lessons Learned / Summit Testimonials / Tech Support Thursday / 10 Most Popular OSHA Violations / Legal Woes and Root Cause Analysis: BP Texas City Explosion . . . and much more!

“Lessons from the Crime Scene” by Ken Reed … What Can Be Learned about Equipment Malfunction from a Crime Scene Investigation?



Q&A Column

Which SQL Server should Enterprise Users use?



J.O.K.E. of the Month

Place Your Vote for the Funniest Photo!



Click here to download a pdf of the e-Newsletter.

To sign up to receive both of these newsletters by e-mail, click here.

For an interesting discussion of the difference in medical error reduction efforts in Japan and the US see:

Obstacles to Reducing Human Injury and Death Due to Medical Error

by Robert B Leflar, a law professor at the University of Arkansas.

Notice that the main difference is the type of blame oriented system that healthcare providers face in the two countries …. and NEITHER blame oriented system has eliminated errors.

When will they learn that lawyers don’t cause system improvements. They aren’t trained to and they don’t look for system causes. Instead they look for who is at fault.

For an article about the difference between the legal perspective and the process improver perspective see page 2 of this pdf:

http://rootcause.net.temp.omnis.com/articles/NL80Nov06.pdf

written by Mark Paradies.

At SI we often work with VPPPA sites and we are members of the VPPPA network. That’s why I was interested to see that VPPPA now has a job posting site. See:

http://www.vpppa.org/jobs/listing.cfm

I often have people question the need for root cause analysis of incidents and near-misses. But failing to perform good root cause analysis and fix the causes of incidents is almost always a precursor for a serious accident.

As the case against Network Rail slowly makes it’s way through the UK courts (it’s been 7 years since the accident at Ladbroke Grove that killed 31 and injured 400), The London Times reported that there had been six incidents when signals were passed when red between 1996 and 1998 at that same sight and either the incidents were not investigated or corrective action was not implemented prior to the accident.

Since that accident, Network Rail has implemented a “Train Protection Warning System” or “TPWS” that Network Rail says would greatly reduce the chance of this type of accident.

However, the London Times says that in 2006:

• The number of trains passing danger signals has risen sharply.
• Between July and September of 2006, there were 94 cases of signals being passed at danger (SPADS) and that four of them were “potentially severe” (that sounds really bad).

So … This leads UK train riders to wonder:

“Are current SPADS being investigated adequately with advanced root cause analysis

and are effective corrective actions being implemented in a timely fashion?”

When I see 94 SPADS in three months, I really have a hard time believing that they are doing effective root cause analysis.

So it doesn’t sound to me that they learned from the lessons of the Ladbroke Grove disaster.

Under the TapRooT® System this failure to learn would fall under the Management System - Corrective Action - Corrective Action Needs Improvement root cause.

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

December 1, 2006, 4:00 p.m.

CSB Investigator-in-Charge John Vorderbrueggen, PE, issued the following factual update to the investigation of the Danvers, Massachusetts, chemical plant explosion on November 22, 2006:

Today, 11 CSB investigators were in Danvers, including CSB Investigation Manager Stephen Selk, P.E., P.Eng., an expert in accident and blast reconstruction, who met with CSB blast modeling specialists and other team members.

Since gaining access to the site on November 28, 2006, CSB investigators have completed three entries into the explosion site for close observation and photography of the equipment, structure, and debris.

Two three-member teams of investigators have worked in the surrounding community interviewing residents and documenting structural damage. The data will be used in an effort to calculate the nature of the shockwave that caused damage to scores of homes and businesses. The work in the community is expected to be completed today.

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Imagine yourself doing a safety audit of this job. It would be hard not to laugh (or cry).

(Click on the pictures below to enlarge)

You approach from a distance …

What is going on???

Oh No! They are lifting him up!

That’s when you realize, they are doing this on purpose!

Don’t laugh … It’s just another day on the job for the tree trimmers.

Malcolm Gresham, one of our instructors in Australia, sent these photos from a job in Northern Western Australia (Port Hedland).

If you have photos that we could use on this blog site to highlight safety problems, accidents/incidents, root cause analysis issues, or acts of stupidity that you just couldn’t help but laugh at, please send them to me by e-mail at info@taproot.com.