I just finished teaching the third day of the Equifactor® course here in Galveston, and one of my students (thanks, Jason!) brought up a great use for the custom table function in the software.
Normally, the custom tables are used to add your own equipment troubleshooting experience to the software. This will allow you to use TapRooT® to conduct root cause analysis of specific gear that may not already be included in the supplied tables. But what about process troubleshooting? For example, maybe your facility produces pure water. There are many problems you could have with this production process:
Low yield
Out of spec contaminant levels
Low pH
High pH
Poor clarity
Odor
These sound like “Symptoms”, don’t they?
You could make a custom troubleshooting table called (Process) Pure Water Production. Under that, you would list the symptoms of unsatisfactory performance, such as (Symptom) Poor Clarity. Under each symptom, list all the possible causes of that symptom (clogged filter, exhausted resin, flow too high, etc).
There is no reason to limit your custom tables to only specific equipment problems. This is a unique method of using the custom table feature in Equifactor®. It is yet another method of using the TapRooT Root Cause Analysis system to troubleshoot process quality issues.
Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training will be held in Knoxville March 5 - 9, where our company, System Improvements, Inc., is based. I moved to Knoxville from Indianapolis three years ago, and it wasn’t long before it felt like home. The folks here in East Tennessee love UT football, so we quickly found something in common: Peyton Manning. (Did I hear someone say SUPERBOWL CHAMPIONS? Oh, sorry . . . I’m a few days ahead of myself.) But you’ll find more than football in Knoxville!
For a small city, Knoxville offers some big choices in restaurants. When we have out-of-town visitors, we usually take them to Calhoun’s on the River. It’s a local favorite for wood smoked barbeque. The river location, (as opposed to the other two Calhoun locations in Knoxville), gives you the best feel for this town. If you want to dress up and go out, there is a restaurant just down the street from our office called Baker Peters Jazz Club. I think their steak is the best in the area, and the atmosphere of the Bakers Peter Mansion is unique and classy — it’s not cheap, but it’s worth it. Parkside Grill located at 338 N. Peters Rd. (very close to the Hilton Garden Inn) offers a full menu of comfort food including tavern beer cheese soup, fried green tomatoes, parmesan crusted grouper and tender, juicy filet mignon. On the tavern side, the drink specials and appetizers are well priced for happy hour. If you’re into mechanical bulls, playing pool and darts, or the two-step, bring your cowboy boots because there’s always a party going on at Cotton Eyed Joes.
If kicking back and watching a movie is your thing, the Regal Pinnacle Theater offers 18 screens. Located in Knoxville’s Turkey Creek shopping district, you will also find many find shopping and dining opportunities. That’s where you’ll find me on the weekends!
You’ll also have a chance to visit the Tennessee Theatre! Located in the heart of Downtown and listed on the National Register of Historic Places, the Theatre offers stellar performances by today’s hottest musicians. In fact, from their website, I found out Moe is appearing on March 7:
“Moe is an American jam band, formed at the University at Buffalo in 1990. The band’s first record, Fatboy (1992), established the band as a favorite of the same 1990s scene that made popular such bands as the Dave Matthews Band, The Disco Biscuits, Phish, and Widespread Panic. And just as Grateful Dead followers were coined Dead Heads, avid moe. fans embrace the term ‘moe.rons.’ They appeared at Woodstock ‘99, played in Central Park, were the guest band on Carson Daly’s late show in February 2005, and were the opening band for The Allman Brothers in the Summer of 2005. During an interview, guitarist Al Schnier commented about to someone who has never heard their music: ‘It’s an amalgamation of a wide variety of the history of rock, all regurgitated and recycled through the eyes, ears, hands, whatever of the guys in our band and all of that with a sense of adventure, a sense of humor, also a constant desire to push the envelope. All in this arena of taking chances, improvising live, and making things up on the spot.”
You can order tickets by phone at 865-656-4444.
If you want stay through the weekend, Knoxville is close to the Smoky Mountain National Park. It might be fun to rent a cabin or chalet and kick back for a couple nights! McGhee-Tyson Airport is approximately 45 miles west of the Gatlinburg entrance to the park.
Our last Knoxville course filled up fast, so sign up for root cause analysis training in East Tennessee! And no worries, Bears fans are more than welcome.
Kevin McManus, a TapRooT® Instructor, has written an article about improving food safety by using TapRooT® to investigate food safety incidents. With all the high profile incidents that have received so much bad press (and cost the industry hundreds of millions in lost sales), food processing facilities should be interested in new ways to improve performance. If you are interested, see:
At some companies, the operations and maintenance departments are only peripherally involved in root cause analysis. Examples include:
• The Operations Department at a chemical plant that leaves investigations to an independent group but reviews the report and approves the corrective actions.
• A hospital where the Quality & Risk Management Staff do the investigations and the medical and nursing staff are only involved in interviews.
• The Operations Department at a refinery that leaves investigations of safety incidents to the Safety Depart¬ment, doesn’t perform investigations of other types of problems (production/maintenance/quality).
• A manufacturing plant where all root cause analysis is done by the Lean/ Six Sigma Team.
• A nuclear plant Maintenance Shop that doesn’t perform root cause analysis of equipment failures because the system engineers do apparent cause analysis.
• A Production Team at a drug company that leaves safety investigations to the Safety Department and quality issue investigations to the Quality Department.
This arrangement is common. Most line folks “just don’t have time” for root cause analysis. And, after all, isn’t having someone independent looking at your problems a good idea?
Don’t get me wrong, having trained, independent facilitators (safety/quality/lean/ six sigma) can help a facility ask questions that may otherwise be overlooked. But leaving root cause analysis to only independent staff can cause problems.
What types of problems? How can you involve operations and maintenance in a root cause analysis without compromising the investigation? Read on to find out! (more…)
Hello everybody, welcome to another edition of Tech Support Thursday.
This week we’ll tackle a question that has plagued many a Database Administrator and one that we hear often: “Do we really need to install the TapRooT System Software on the server?”
How many times have you heard something similar to this? Maybe more like:
“I don’t have time for an audit this week (month/quarter).”
“I can’t pull a supervisor away from production for an audit.”
“We’re already in good shape. I’m sure we don’t have any big things to catch anymore.”
Take a look at this link. Most of these problems should have been easy to catch during a good audit program. The problems found weren’t high-tech, esoteric, hard-to-find problems. These were the basics, begging to be found during routine audits. And I’ll guarantee those audits would have been a lot cheaper than the OSHA fines. Not to mention a safer work environment.
The EHS Audits group develops implements and maintains programs and systems to assess compliance with government requirements and company policy, as well as supports the continuous improvement efforts of our manufacturing facilities and businesses.
A successful candidate will be capable of coordinating and leading on-site audits and other similar assessments with minimal managerial oversight. Demonstrated leadership in all EHS program areas is not expected; however, a strong environmental and technical background is required along with the ability to undertake new environmental, health and safety program areas. The job requires approximately 50% travel, including international travel. Most travel is scheduled weeks in advance but some may be on a same day/next day basis.
Responsibilities Include:
- Identify all cases of noncompliance with environmental regulations and corporate policies at manufacturing plants in the course of audits.
- Identify weaknesses in facility procedures, programs, and management systems which may lead to noncompliance if not corrected.
- Partner with business management and Regional EHS managers in identifying appropriate corrective action alternatives, as well as tracking the implementation of these corrective actions.
- Develop timely and accurate audit reports.
- Promote the understanding of environmental obligations and
compliance assurance methods to facility staff in a clear and meaningful way.
- Effectively communicate audit findings/information to facility staff and business management.
- Review and analyze audit findings to identify potential trends.
- Identify weaknesses and improvement opportunities in auditing methodologies and protocols to raise the certainty of identifying
existing compliance problems.
- Effectively participate/lead cross-functional teams in development and implementation of global programs in response to complex EHS issues and be willing and interested in pursuing other non-audit EHS assignments as the opportunity presents itself.
Position Requirements:
Minimum of 8-10 years in manufacturing, technical fields with responsibilities for environmental compliance and management systems, preferably with some auditing experience in the pulp and paper industry.
If you are interested in this opportunity, please take a moment to review the position on our website ( http://www.internationalpaper.com ). From the International Paper homepage, click on the Careers link at the top of the page in the gray bar. Once on the careers page click on the link “Search for career opportunities”. This will bring you to a position search page were you can search for the specific opening by entering the keyword “40009377″.
In September of last year, a small business jet collided with a Boeing 737 over the Amazon rain forest, killing all those on-board the 737. Initial reports indicate that the pilots of the business jet, which landed safey, will share the blame for the collision with air traffic contollers. Questions still remain as to why the jet’s collision warning system was not working, and why the pilots were not following their flight plan. See the story here:
A recent report from a DOE site discussed an injury sustained by an electrician operating a hi-voltage switch on the front panel of a 480V switchboard. A ground fault in the down-stream circuit cause a fire-ball to exit the vents on the switchboard when the switch was shut, causing serious burns and eye injury. The report stressed that, if the electrician had been wearing proper PPE (flame-retardant shirt, safety glasses), his injuries would have been much less severe.
First, I’d like to stress that I don’t disagree with that particular finding. Wearing proper PPE is an important safeguard in any potentially–hazardous process. However, buried near the end of the report, other findings were mentioned:
– By the way, the ground detector that was installed didn’t work.
– By the way, preventive maintenance was not scheduled for the ground detector.
– By the way, the ground detector was the wrong type.
– By the way, PPE requirements were not posted on the panel as required.
– By the way, work control procedures already in place were not followed.
These are the kinds of things that you can easily find with a frequent, comprehensive proactive audit plan. It is good to see that these problems were found by the investigating team. It would have been even better if they had been found by an audit team. Compare your work practices with industry standards, such as NFPA 70E: Electrical Safety in the Workplace. Take a look at your high-voltage, hazardous operations, and see if you have the right controls in place. Everything may seem to be operating just fine, until an unknown failure pushes the deficiencies in work control to your attention. Don’t wait for the fire-ball to find you.
2. You replace the hard disk and try to load your “daily” automatic backup and it’s blank.
3. You load your last “complete” automatic backup (about three weeks old) and it is blank too.
4. You finally find a backup that’s not blank and it is 4 months old.
5. You send the broken hard disk off to the people who are the experts in disk recovery and they say - “Sorry - it’s unrecoverable.”
That’s what happened to me last week.
Luckily, I have a wonderful staff and they are helping me recover.
But for now, I won’t be posting on the blog or responding to routine e-mails.
Ken and Barbara will be keeping you up-to-date on the blog.
Barbara will be answering my e-mails.
And I will be on a one month sabbatical to get the new version of the TapRooT® Book completed.
By the way, the book writing process is going well and I will post some samples on this blog as we progress.
As for our “investigation” of the failure, it is complete and the corrective actions have been implemented. Next time, there will be a backup and an additional backup. And they will be checked as working appropriately on a weekly basis.
The BP Refineries Independent Safety Review Panel, headed by former Secratary of State James Baker, has released its final report concerning the circumstances around the 2005 explosion. The 374 page report is located here.
The Review board was convened at the request of the Chemical Safety Board, and included many distinguished members, including the former head of the U.S. Navy’s Nuclear Propulsion Program, Admiral Skip Bowman, and former Washington State Senator Slade Gorton.
Remember my post last summer about why you should take TapRoot® training inSan Antonio, Texas? Well, I’ve got more great news about why you should register for the TapRooT® Summitin San Antonio, April 25 – 28:
Fiesta Week!!!
We’ve combined the TapRooT® Summit with the biggest party in the State of Texas!
Fiesta San Antonio began in 1891 as a flower parade to honor the heroes of the battles of the Alamo and San Jacinto. By 1895, it became a weeklong celebration surrounding the Flowers Parade. Today, it’s a family-oriented, ten-day celebration with over 100 different events. Just look at this schedule!
Fiesta San Antonio is only 94 days away!! Register for the Summit today . . . hotel space will be limited!
A safety panel headed by the former U.S. Secretary of State James Baker and commissioned by the U.S Chemical Safety Board is due to release its report on Tuesday. No other details are yet available.
Often we take for granted that sometimes, stuff just happens. The work environment is just dangerous, and we sometimes have no choice but to accept the risk. Steel workers building skyscrapers, miners, and carpenters work around dangerous equipment or in hazardous conditions that just don’t allow 100% safety. We can try to mitigate the conditions, but “we just have to accept some losses.”
…or do we? Take a table saw, for example. We can put guards on them, we can put child locks on the power switches, we can require the use of push blocks, etc, but when we operate the saw, we all know there is just no way to guarantee that we won’t get a finger cut off by the saw blade. Therefore, there is a decent chance that, if you operate a table saw for a living, you may lose one of those precious digits.
Take a look at these videos. Then, go back to your facility and take a look at those areas where we have decided that there is nothing we can do but accept an elevated level of risk. Remember, the best safeguard is to engineer the hazard out of the process.
If you took a nice, long holiday break, your jolly good spirits probably ended the moment you opened your e-mail inbox. A dozen e-mails from the same customer? Did they not read your “Out of Office” autoreply stating you were on vacation?
Well, here are some “Out of Office” autoreplies that are sure to get a second look the next time you’re out:
“I am currently out at a job interview and will reply to you if I fail to get the position. Be prepared for my mood.”
“You are receiving this automatic notification because I am out of the office. If I was in, chances are you wouldn’t have received anything at all.”
“I will be unable to delete all the unread emails you send me until I return from vacation. Please be patient and your mail will be deleted in the order it was received.”
“Thank you for your email. Your credit card has been charged $5.99 for the first ten words and $1.99 for each additional word in your message.”
“I am unable to respond to your e-mail because I’ve run away to join a different circus.”
“The e-mail server is unable to verify your server connection and is unable to deliver this message. Please restart your computer and try sending again.”
“Thank you for your important message, which has been added to a queuing system. You are currently in 352nd place, and can expect to receive a reply in approximately 19 weeks.”
And for those special people who expect an e-mail response within minutes of sending an e-mail:
“Hi. I’m thinking about what you’ve just sent me. Please wait by your PC for my response.”
Most TapRooT® equipment reliability professionals are using Equifactor® to help troubleshoot their equipment failures, but how can you use Equifactor® as a proactive tool? Here are some great ideas.
When a new piece of equipment arrives, how should it be installed? Use the Equifactor® troubleshooting tables to discover the common failure modes of your new gear. You may remember that baseplate design (materials, resonant frequency rejection, etc) should be considered when mounting that new pump.
The best time to decide on PdM requirements is prior to installation. Getting the vibration monitoring transducers and temperature detectors wired in is much more difficult once the machine is installed. Use Equifactor® to see what can fail, and then decide on how you will monitor for these types of failures. Get your PdM requirements figured out early.
Once it’s installed, it is important to operate it correctly. While the vendor manual may discuss start-up and shutdown procedures, it may not consider your unique operating environment or specific uses. Will your machine have a duty-cycle drastically different from the original design? Is the environment extremely dusty? Equifactor® will remind you to look at these factors.
What logs should you maintain? How often should you take these logs? Look at common failure modes to help verify you are monitoring the right parameters.
Vendor manuals give good guidelines concerning preventive maintenance periodicities, but you may also want to use RCM methods to streamline these requirements. Equifactor® can help here, too, making sure the maintenance requirements will cover all probable failure modes.
For already-installed equipment, use Equifactor® to conduct an audit of your gear (possibly in conjunction with an RCM determination or an FMEA). This may open up ideas you hadn’t previously thought about.
Be creative in your use of Equifactor®. It is an excellent tool when performing a root cause analysis of equipment failures, but you don’t have to wait until it breaks to fix it!
Hello everybody, I tried to get this up yesterday but ran into technical problems. No matter, I’m here today with the first in a series of instructional and short videos to get you using the software. These videos are for novices or those who are about to embark on their first TapRooT course. They’ll get more complex as the series continues.
We’ve all made a typo before. But did it send you 13,000 km off course?
This “incident” is a great example of what a spelling error can do when using a computer.
Using the internet to book his ticket, the 21 year old German tourist wanted to go to Sydney, Australia. But he typed in Sidney.
The computer found a Sidney, Montana, USA, and found a routing to get him there. The tourist didn’t notice the route ENDED in the US - he thought he was flying THROUGH the US.
He punched the button and went to the airport in Germany thinking he would arrive in Sydney, Australia, where his girlfriend lived.
First stop Portland, Oregon.
OK - this may be an out of the way routing to go to Australia but who can tell what airlines will do.
Next stop Billings, Montana.
WHAT - Billings? This guy really needs a US geography lesson and a map.
But when he saw the commuter plan that was going to fly to Sidney (Montana), he knew it couldn’t cross the ocean and something was definitely wrong!
He spent three days in the chilly Billings, Montana, USA, airport before he got an additional $600 wired to him from his parents and friends so that he could buy a ticket from Sidney to Sydney.
Lesson Learned … Don’t trust the computer - it only does what you tell it to do!
I know I’m laughing at this mistake but I bet the guy from Germany wasn’t laughing …
… But before management can support an investigation, they need to support the establishment of the investigation program. Program documents need to be written, an organization needs to be established, training needs to be conducted for investigators and team members, software needs to be purchased and set up on a server, and all this requires a budget. Management will need to assign a program leader to do this. But the program leader cannot work alone. She or he will have to keep key executives involved and informed. The program plan needs to be management’s program plan. Thus management needs to involved in the develop an implementation plan and provide programmatic support.
But developing a plan is only the start. Management involvement will also be needed for implementing the plan and for continuous support of the program - including continuous improvement of the program. To be successful, this will have to be management’s improvement program.
As part of management’s continued involvement with the program, management will also need to learn to use the data the program produces to help them improve their management of the facility. This requires management to understand the basics of trending presented in Chapter 5.
How does one start to develop this level of management involvement? The only way it can be done is to get key managers at (or close to) the top of the organization to see the benefits of an improvement program using the power of advanced root cause analysis. Selling an improvement program to senior managers requires both winning their minds with hard numbers gained in a pilot program and winning their hearts by showing them how the tools will help them solve their most vexing problems. They must see how TapRooT® will make them look good.
Two key steps in this process of getting management involved are providing a motivating presentation that sells management on the concepts and getting the senior managers to participate in an investigation - either by presenting a detailed explanation of an investigation and the results or, even better, having them, or their key staff members, participate in an investigation and actually see the value that TapRooT® brings to an investigation.
There are eight great pre-Summit courses to pick from on April 23-24, 2007, in San Antonio, Texas. They are:
Getting the Most from Your TapRooT® Software
TapRooT®/Equifactor® Equipment Failure Root Cause Analysis
TapRooT® Incident Investigation & Root Cause Analysis
Advanced Trending Techniques
Stopping Human Error
Risk Analysis & Risk Management
How to Interview & Gather Evidence
Innovation & Creative Solutions
What one should you attend? That depends on which one will provide you and your company with the most value (ROI). To help you decide, I’ve provided a short course description for each course and some ideas how each course could help you improve performance at your site.
Just click on the “continue” link below to learn more…
A recent report from a DOE site discussed an injury sustained by an electrician operating a hi-voltage switch on the front panel of a 480V switchboard. A ground fault in the down-stream circuit cause a fire-ball to exit the vents on the switchboard when the switch was shut, causing serious burns and eye injury. The report stressed that, if the electrician had been wearing proper PPE (flame-retardant shirt, safety glasses), his injuries would have been much less severe.
