Root Cause Analysis Blog

Recognized among Fortune Magazine’s 100 Best Companies to Work For in 2005 and 2006, The Sherwin-Williams Company is one of the world’s leaders in the manufacture and sale of coatings and related products.   Founded in 1866, we are ranked among the U.S. Fortune 400 Companies with annual revenues exceeding $7 billion.

Position Responsibilities:

This position is responsible for developing, implementing and sustaining an environmental management system ( EMS ) that conforms to the international standard ISO 14001.   The EMS will be administered at a corporate level and will incorporate all manufacturing and major distribution centers for the company.    Obtain and maintain ISO 14001 certification at the corporate level, including maintaining procedures, manuals and associated documents. Provide assistance, training, and leadership necessary to implement ISO 14001 at the manufacturing and distribution centers company wide.   Manage / track corrective and preventive actions related to ISO 14001.   Track company progress at meeting targets and objectives and prepare progress reports for management review.   Manage the EMS audit program including audit schedules, conduct internal audits, prepare audit reports, and track corrective preventive actions for the EMS program at S-W Manufacturing plants and major distribution facilities. Assist in developing and conducting various training programs as they relate to ISO 14001.

Experience Required:

Minimum 5-8 years experience implementing and sustaining management systems in accordance with ISO standards.   Minimum of 3 years experience with ISO 14001.   Experience with implementing and sustaining Corporate ISO programs at multiple sites.   Experience and knowledge of environmental reporting and regulations, project management, and training is preferred.

Education Required:

Bachelor’s degree (BA or BS) Environmental Science, Engineering or QA discipline or equivalent from an accredited four year college or university.   Certified ISO 14001 lead auditor preferred.

How to apply:

Apply_now@sherwin.com

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.

Have you noticed the empty shelves where Peter Pan and Great Value peanut butter used to be?

It has been recalled.

Another expensive food quality problem.

Kevin McManus, a TapRooT® Instructor and food safety expert, wrote an article titled:

Are You Hungry for TapRooT®

That is available at his web site: http://www.greatsystems.com

It seems that many food processors could used advanced root cause analysis to investigate recall problems. It would be even better if they were applying TapRooT® PROACTIVELY to find and fix the causes of the food safety/quality issues before they become recalls.

Note that one of the Saturday session at the TapRooT® Summit is a session for Pharmaceuticals Manufacturers and Food Processors to discuss quality improvement and improving manufacturing performance. If a Food Processor wanted to jump ahead in the performance improvement race, they could go to San Antonio and:

1. Attend the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course on April 23-24.

2. Attend the TapRooT® Summit on April 25-28. I think that one of these tracks would probably be the most applicable:

- Corrective Action Program Best Practices
- Lean, Process, & Quality Improvement Best Practices
- Proactive Improvement Best Practices

and then on Saturday attend the Pharmaceuticals Manufacturers and Food Processors Benchmarking session.

I don’t think you could find a better six days to get new ideas and best practices that one could use to prevent food safety issues. Why? Because these won’t be the same old industry sessions. They will be cross-industry best practices from around the world.

I hope to see quite a few food processing companies take advantage of this timely opportunity.

For more on the peanut butter recall see a Business Week/AP article at:

http://www.businessweek.com/ap/financialnews/D8NDRL380.htm

Have you seen the 10 Reasons to attend the TapRooT® Summit?

They are:

1. Sharpen your skills and receive updates on critical issues;
2. Learn best practices;
3. Discover advanced improvement skills;
4. Network with industry peers and leaders;
5. Further career development;
6. Receive practical tools and techniques to use at your facility;
7. Feedback from our past attendees encourage attendance;
8. Hear cutting edge topics presented by leading industry experts;
9. Enjoy Fiesta Week in beautiful San Antonio; and
10. Share solutions and recharge your energy and enthusiasm for preventing injuries and saving lives!

Do you need just one more reason to attend the TapRooT® Summit?

OK, how would you like to win an iPod?

System Improvements will be giving away 10 iPods over the course of the Summit.

On Wednesday, one will be raffled off as a prize for on-time attendance at the sessions.

On Wednesday night, two will be presented for the best male and female costumes for the Wednesday Night party. If your duds are picked as the best “Old West Outfit” … you win!

On Thursday, one will be raffled off as a prize for on-time attendance at the sessions.

And on Friday, at the end of the Planning & Mentoring Session, one will be raffled off for at each of the breakout rooms (six total).

There will be a mixture of standard iPods, Nanos, and Shuffles in the prize mix.

So if you needed just one more reason (or 10 more reasons … 10 iPod prizes) to attend, sign up NOW!

And make sure you get your hotel reservation as space in the reserved block of rooms goes away as of March 22 and other hotel space in San Antonio will be tight because of the Fiesta Week celebrations.

Agrium has extended their search deadline.  This position will be posted for the next 30 days.
Position is in Denver, CO.
______________________________________
Agrium is one of the world’s largest nutrient and fertilizer producers with annual sales over $4 billion. Agrium continues to grow its markets and operations throughout the world.  Headquartered in Calgary and in business for almost 70 years, Agrium produces and markets three major nutrients required for healthy crop production: nitrogen, phosphate and potassium, as well as controlled release fertilizers.

Agrium is a great place to work, proud to be chosen as one of the top 100 employers in Canada .  Make the move to join our more than 7,000 employees across North and South America and begin growing your career now. We are currently recruiting for the following position in our Denver Office:

EH&S Systems Manager

Provides governance for Agrium on EH&S matters, including policy development, visionary goals and Key Performance Indicators, maintenance of Agrium’s EH&S Management System (EMS), Agrium’s EH&S Compliance Assurance Program.

Specific responsibilities will include:

• Annual review and maintenance of Agrium’s EH&S Policy.
• The development of visionary EH&S goals and key performance indicators for all Agrium; their annual allocation to the Business units and stewardship of the results quarterly. 
• Ownership of, and continuous improvement in, Agrium’s Environmental, Health and Safety Management System (EMS).    This includes the training of business unit personnel to keep them current on the requirements of Agrium’s EMS and consultation with the business units as they develop their own systems.
• Ownership of, and continuous improvement in, Agrium’s EH&S Compliance Assurance (audit) Program (CAP).   This includes training of business unit personnel to keep them current on the requirements of Agrium’s Compliance Assurance Program and consultation with the business units as they develop their own audit programs.
• Annual, high-level systems assessments of business unit compliance with Agrium’s EMS .
• Makes regular topical presentations to the Corporate and Board EH&S Committees and periodically to the CEO.

·          Contributes to the writing and review of monthly, quarterly, annual and sustainability reports.

Qualifications of the position include:

·          The successful candidate will have at least a bachelor’s (four year) degree in the sciences, engineering, management or other area of study relevant to this position. 

·          Strong preference will be given to candidates with professional designations/certifications from BEAC (Board of Environmental, Health and Safety Auditor Certification) and CEAA (Canadian Environmental Auditing Association).

·          Ten to fifteen years of related experience in roles of increasing complexity, working knowledge of environment, health and safety legislation in Canada and/or the United States and recent experience in the development, writing and application of management systems and audit programs. 

• Good communication skills (verbal, written, report writing and presentation)
• Strong computer skills (word, excel, SAP, internet research and power point).   

Agrium offers a competitive compensation package commensurate with experience including salary and incentives along with pension and benefit coverage.  If this opportunity fits your qualifications, please send your resume by February 19, 2007 to:

Agrium Inc.
Human Resources
13131 Lake Fraser Driver SE
Calgary , AB T2J 7E8
Fax: (403) 225-7603

www.agrium.com

AP/CNN reported that six people were killed and fifty people were injured in a bus crash near Uppsala in Sweden.

The story had an interesting quote:

“The cause of the crash was not immediately clear …”

Those who analyze root causes know that this is ALWAYS true immediately after an accident. Even if you think the cause is obvious … you are probably wrong! Finding root causes requires careful, systematic analysis of the facts.

For the complete story see:

http://www.cnn.com/2007/WORLD/europe/02/27/sweden.bus.crash.ap/index.html

“Figures often beguile me,
particularly when I have the arranging of them myself;
in which case the remark attributed to Disraeli
would often apply with justice and force:
‘There are three kinds of lies:  lies, damned lies, and statistics.’”
Mark Twain autobiography, 1904

While the individual man is an insoluble puzzle,
in the aggregate he becomes a mathematical certainty.
You can, for example, never foretell what any one man will be up to,
but you can say with precision what an average number will be up to.
Individuals vary, but percentages remain constant. So says the statistician.
Arthur Conan Doyle

An except for the upcoming revision of the TapRooT® Book…
(Copyright © 2007)

Trending

Many people think they can spot a trend by looking at a bar or line graph. They can’t. Dr. Walter Shewhart’s work at Bell Labs proved that people can’t “eyeball” trends (Economic Control of Quality of Manufactured Product, D. Van Nostrand Company, 1931). If you try to manage by eyeballing trends, you actually make the process worse. This is the first way that trending gets a bad name.

How should trending be used? You should use statistics properly to measure performance, select targets for improvement, and detect significant trends.

How should you target areas for improvement? By using numerical measures of performance based on statistical analysis of either reactive or proactive data based on the measures previously described in this chapter.

How should you measure performance changes and detect significant trends before major accidents, quality problems, or plant upsets occur? By using methods developed for statistical process control to determine which trends are part of normal process variation and which trends are the result of actual significant changes in the system.

Thus, trending goes far beyond common practice of looking at a bar graph and saying, “up is good and down is bad.” This new way to trend can help you prove that performance has significantly improved or taken a turn for the worse. These graphs aren’t just someone’s opinion. This “new” way to trend is based on rules for optimizing performance that have been proven by Shewhart since the 1920’s.

Trending can:

•Use reactive measures to show the actual impact and payback of your improvement programs.
•Use proactive measures of key performance elements to predict where problems might occur so that you can take action before the problems cause major production outages, quality issues, or accidents.
•Use reactive data and show the areas where you will get the most “bang for your buck” when you spend time, money, and effort to improve performance.
•Show you that there aren’t any areas that will provide amazing returns for the effort invested.

You may ask, “If these statistical rules are so good, why haven’t I heard of them and why isn’t my company using them?” The answer is twofold:

1. Most mathematicians don’t understand the simplicity of this trending. They make things much too complex. Too hard. They get lost in p-charts, t-tests, and normal distributions. And they adopt formulas that just don’t work in the real world to predict performance.
2. You may have heard of the techniques but, once again, they seemed too hard. The techniques shared in this chapter are the basis for Statistical Process Control and Six Sigma.

There is one more way that trending gets a bad name. Managers, without statistical training, get frustrated with the unintelligible voodoo analysis of mathematicians. They can’t understand the basis for the trends and they just don’t want to waste their time. So what do they do? They “simplify.” How simple? How about up is good and down is bad. Then every reporting period people scurry around trying to find reasons to justify the normal variation that every process experiences. And we are right back to the bad practices that are proven NOT to work that we started this section discussing.

What if you don’t believe me? Let’s look at an “example” trend…

(To see the graphs - you’ll have to buy the book - they wouldn’t post here)

The figure above shows a graph of safety related incidents per month. Since safety related incidents are bad, up is bad on this graph. And if we used the normal straight-line approximation to “trend” and predict performance, we are at a crisis stage.

What should we do? Hire consultants. Fire the Safety Manager. Conduct a one-day safety stand down. Have the CEO make a video where he emphasizes that safety is a top priority. But wait … what was last month’s top priority? Oh, don’t bother me with details! This is a crisis! We need improvement and we need it fast before something really bad happens. Why? Because safety is out of control! Anybody can see from this graph that bad things are going up at an alarming rate. We must act now and act decisively!

And that’s the way trends are interpreted at thousands of companies and facilities around the world. Unfortunately, the answers we just interpreted from the graph by using a straight-line approximation are wrong. Wrong? How can they be wrong? Look at the figure below. The four points from the figure above are the same as the first four points in the figure below. No real action was being targeted to change safety performance. So the variation we are observing is just part of the random variation that happens all the time. There really was NOT a crisis.

(To see the graphs - you’ll have to buy the book - they wouldn’t post here)

What is wrong with reacting as if there was a crisis when there isn’t one? The attention to safety doesn’t hurt does it? Yes it does! Every child knows the story of the boy who cried: “Wolf!” and the story of Chicken Little crying: “The sky is falling! The sky is falling!”

Look at the results in the false trend example.

1. The Safety Manager lost his job unnecessarily. (Certainly not a positive outcome for the Safety Manager.) The new Safety Manager is more likely to overreact to future trends and cause even more unnecessary emergency changes.
2. Money was wasted hiring consultants and implementing fixes that probably were a waste of time. Since time, money, and effort are scarce resources, they had to be taken away from some other work. This other work (that may have been necessary) was not completed on time. Therefore, an opportunity was lost.
3. Employees become jaded. Why? Because every month (day or week) there’s a new crisis. A new set of priorities. A new video from the CEO. Sooner or later, people lose their sense of urgency. They lose faith in their management. They stop reacting to new initiatives because they know that these will blow over just like the last management fad. They become complacent.

You might think that this is bad. But we’ve seen worse. Much worse. We’ve seen millions of dollars wasted on improvement programs that were scrapped just months after they were completed with NO payback on the investment. We’ve seen hundreds of people transferred or “right-sized” during a crisis transformation program in reaction to imagined trends.

Finally, we’ve seen people stop reacting. Why? Too many crises. People who cried wolf too often. And there wasn’t a way to clearly communicate the lessons that could have been learned from the real trends. A real crisis was at hand but nobody reacted appropriately. They were simply overwhelmed by false crises and didn’t react to the real crisis.

We believe that this was one cause of the BP Texas City Explosion and Fire. There was a data warning management of a process safety problem, but it wasn’t analyzed and presented appropriately. The result? The loss of 15 lives. Turmoil in management. Increased gasoline prices due to even tighter refinery capacity. These fatalities and losses didn’t have to happen. It was a waste of human life. A disaster that could have been avoided. The result of poor measures, poor trending, and reacting to random variation. The result? A real failure that could have been avoided if proper measures and trending had been in place.

So we are convinced … reacting to random variation has a negative impact. But what if you aren’t convinced? Then you still don’t understand the impact of natural variation. And you need to play the marble dropping game developed by Dr. Lloyd S. Nelson and described in Dr. W. Edward Deming’s book, Out of Crisis (MIT, 1982).

Would you like to learn more about trending? Attend the Advanced Trending Techniques Course just prior to the Summit.

VW is recalling 790,000 vehicles that could have improperly installed break lights. Now that’s a quality incident.

If it costs just $30 per vehicle for the recall, the the cost will be about $24 million dollars.

How much proactive root cause analysis and corrective actions could you buy with $24 million?

Instead of waiting for problems to solve with reactive analysis, proactive analysis prevents problems.

For more on proactive root cause analysis, watch for the new TapRooT® Book to be released this Summer. Or attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.

For more about the recall, see:

http://www.cnn.com/2007/HEALTH/02/26/volkswagen.recall.ap/index.html

The Rail Accident Investigation Branch in the UK has completed an Interim Report of the train derailment at Grayrigg, Cumbria, UK. Pretty amazing amount of information for a report turned around so quickly (the accident was Friday).

Download report at:

http://www.raib.gov.uk/publications/interim_reports/070226_I012007_grayrigg.cfm

Safety Coordinator for Washington Hospital Services is a full time safety position. Washington Hospital Services, located in Seattle, has 39 rural Washington hospitals in its workers compensation program. The job would require assisting approximately 12 of these facilities in implementing compliance models for state, federal and Joint Commission standards, safety inspections, providing support and training on different standards and models and implementing programs that reduce frequency and severity rates in the facilities. It requires travel to rural areas of the state. The pay is approximately in the 50K range and there is a whole range of very good benefits attached.  It requires the knowledge of the paradigms of hospital safety, zero lift programming, ergonomics, chemical and waste management, radiation safety, working with safety committees, training on safety models. A CSP or equivalent is suggested. Contact Beverly Simmons @ Beverlys@wsha.org or telephone @ 206. 285.3955

Interested in databases of pipeline incidents? See the PHMSA web site:

http://ops.dot.gov/stats/IA98.htm

See what lessons you can learn from others mistakes.

I am looking for a healthcare safety consultant in the New Jersey area with some travel involved, but not heavy. Must understand the innerworkings of healthcare organizations, must be able to sell ideas and coach customers into industry best practices in employee health and safety as well as general liability. Excellent opportunity with an industry leader in safety services…Zurich Services Corporation. Insurance experience not necessary. Anyone interested should contact me directly.

I handpicked 8 special courses for people interested in improving performance (especially TapRooT® users) and scheduled them on Mon/Tues before the 2007 TapRooT® Summit.

PRE-SUMMIT COURSES - San Antonio, TX - April 23-24, 2007

Advanced Trending Techniques

Stopping Human Error

Risk Analysis & Risk Management Best Practices

How to Interview & Gather Evidence

Innovation & Creative Solutions

TapRooT® Incident Investigation & Root Cause Analysis

TapRooT®/Equifactor® Equipment Failure Root Cause Analysis

Getting the Most from Your TapRooT® Software

Pick one to attend.

The cost? Just $995.

Register 3 or more people to save $100 per person.

Save $200 off the course tuition by registering for the Pre-Summit Course & the Summit.

See http://www.taproot.com/courses for course info or click on the specific course links above.

For the latest on the investigation and root cause analysis, see the Rail Accident Investigation Branch Web Site:

http://www.raib.gov.uk/publications/current_investigations_register/070223_grayrigg.cfm

The RAIB will publish a report at the conclusion of its investigation.  The report will be available at the RAIB website. You can subscribe to automated emails notifying you when the RAIB publishes its reports. See:

http://www.raib.gov.uk/publications/newsletter_subscription.cfm

The investigations, root cause analysis, and lawsuits continue. On the lawsuit side of the accident, read about the latest legal maneuvering at:

http://www.chron.com/disp/story.mpl/business/4578434.html

Keynote Speakers
Experts Share Their Secrets of Success

Who will you hear from?

Performance Improvement Lessons from the Cockpit to the Surgery Suite, 
John Nance
Military & Commercial Pilot, Aviation & Medical Safety Expert, & ABC Aviation Safety Analyst


Olympic Success Lessons Learned 
Josh Davis
Olympic Gold Medal Winner


Character First! 
Beverly Chiodo
Award Winning Educator


Creating a Vibrant Safety Culture 
Richard Hawk
Safety Expert


Accident Investigation Lessons from the Courtroom Judge Andrew Napolitano
Judge Andrew Napolitano
New Jersey Supreme Court Justice and Fox News Legal Analyst

Need more info?

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

The Virgin Train from London to Glasgow derailed Friday night. For intial information see:

http://www.guardian.co.uk/transport/Story/0,,2020412,00.html

We’ll be waiting for reports on the root causes of the derailment.

Preventative measures can deter children from potentially hazardous bouts of make-believe. “Defuse the ticking time-bomb known as your child’s imagination before it explodes and destroys her completely,” said child-safety expert Kenneth McMillan. Wait, is this the Friday Joke? Well, for more guidelines on how to curtail your child’s boundless imagination, read this late breaking research on CNN:

Child-Safety Experts Call For Restrictions On Childhood Imagination

If you’ve ever wondered how we started holding the TapRooT® Summit, what the Summit is, or why you might want to attend, read this blog entry…

You might confuse the TapRooT® Summit with the many excellent courses we sponsor each year. After all, what is the difference between a Summit and a course?

Although the Summit shares the TapRooT® name with the courses, the focus of the Summit is quite different. So perhaps a quick Summit history lesson will show you the difference between the Summit and our great root cause analysis courses.

I organized the first Summit in 1993 (to be held in 1994) because, after attending, and even helping organize, many conferences over the years, I saw a need for a conference with a focus on performance improvement, human factors, incident investigation, and the latest improvement technology. A conference that was NOT oriented to research (although I appreciate good research). A meeting oriented toward practical applications that could be implemented at industrial facilities and in service organizations.

Wow! That’s a mouthful!

I also saw that there was MUCH to be gained by sharing information and ideas ACROSS INDUSTRY BOUNDARIES.

Thus this summit could not be held by one professional organization (with only a safety, quality, or equipment focus) or by a society oriented toward one industry (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …). And it had to be international — as most companies were expanding to worldwide operations.

This was a problem.

I had to start from scratch to organize, publicize, and pay for a meeting that needed to be held, but didn’t have an already established audience nor did I have a conference staff.

Some said I was nuts!

But I knew it needed to be done. And nobody else was going to do it. So I become a conference organizer.

So in 1994 we held our first Summit in Gatlinburg, TN (with just 30 attendees).

It was a start. We learned quite a lot.

Feedback was very favorable.

And we decided to do it again.
(more…)

Lee Dawson, TapRooT® Expert and HSE Manager at M&ISE in Milton, Australia offers an opportunity for our readers to help answer this question!

From Lee:

About two years ago, a police sergeant friend of mine attended a BBQ at my place. Since I’m a safety guy, the discussion eventually led to the amount of youth carnage on our roads.

He asked if it would be possible to get a base understanding of why so many 17 to 25 year old kids were being killed on our roads, and why when all the efforts everyone was putting in, it always failed to reduce the toll? And could we as parents of a heavily effected community do something about it?

To cut a very long story short, we researched the trends and clearly identified some major contributing factors that everyone seemed to have overlooked in combination with each other, I guess it’s all the TapRooT® training kicking in.

During the very early stages of our research, it showed us that a section of the brain that is required to accept cause, effect and consequence will not physically develop until over the age of 25. It also showed us the hormone release in teenagers physically actually attacked this growth part of the brain until we came out of puberty.

It further proves that the youths brain can be dramatically effected by cognitive tunneling, and cognitive object focusing. This dramatically increases the risk when driving, interesting but basic stuff so far. Note: The armed forces are spending some time on these issues, in particular the effects on concentration levels with (HUD) heads up display in fighter jets. (This is well worth considering as a TapRooT® causal factor.)

Using a mobile phone is another example. The brain accepts about 1850 bits of information at any one time. It needs to break that information into four main categories, (DIPI) Dangerous, Important, Pleasurable, and Interesting, for us to respond to any given situation (more possible TapRooT® causal factors).

The average adult brain, over 25s, converts the 1850 bits into an average of seven main units of information, then uses this to scan the four DIPI categories. The average youth’s brain, (under age 25) with the same inputs, can only convert this into an average of four units of information.

These basic units of information are used to scan the subconscious for memory related responses to situations and act accordingly, generally based on experience or in other words cognitive memory. This process helps us to survive. When we fight or flight, or when we stay and play are very good examples of this.

Now remembering that the youth’s brain has not yet developed the capacity to understand the concept of risk related cause, effect and consequence, there can be no, or at the very best only a basic, cognitive memory of danger. Saying all this, the kid’s four units of information available to the brain does not consider danger as a part of the equation. Take the D out of DIPI, therefore , and it’s now down to three units of information available to the brain. They are in a lot of trouble when they get behind the wheel!

Throw in a distraction, which has been identified as the major contributing factor to accidents on our roads, and you have a potential disaster occurring every time they drive, hence the reason for our road toll.

We took this information, with a great deal of other research, and developed a youth driver training program for our local high school. It’s simply based on cognitive developments and mentoring with the focus on driving.

It does not teach a kid how to get a license and it does not teach defensive driving. It shys away from trauma related images, and deals specifically with placing risk awareness and cognitive learnings about cause and effect into their minds through simple mechanical compliance learnings.

Over the last year, the local community high school completed the first trials for us with outstanding success, to the point where we had kids saying comments like “you are teaching me how to die on the road, not how to drive” to their driver’s instructors.

We have now generated huge community interest, with a que of high schools asking for the program, and a major Australian University has come on board to assist in further research and development. The local government has put the process before parliament for Federal support, and some major Australian companies are showing an interest in sponsoring the program.

Further community interest in remote mining towns and various mining companies have asked if we could develop the same process for apprentices and general employees with a focus on adult learning due to the related mining industry road incidents etc.

We have already developed multimedia teaching modules and have the University working on developing the program to allow delivery through mobile devices, and we have had some initial inquiries from America. This is extremely exciting for us and we can’t wait to develop this avenue further.

To date we have been unable to identify any similar process world wide and are now calling for expressions of interest from any group that may be interested in supporting us. This is something that should be shared and I see the perfect platform to share via safety professionals around the world.

We have already started to save lives and reduce the road trauma. We call the program B.R.A.K.E, Behavior, Risk, Attitude, Knowledge, and Education, and have formed a charitable foundation under that name. We hope to eventually give this program free to all schools. Any one interested in coming on board should e-mail me and I will gladly send more info.

~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~~

Thanks for the great information, Lee!

These pictures are from Oswego County in Upstate New York.  I’m from Watertown, not too far away.  This is a 2–lane road in relatively open, flat rural country.  I guess this almost qualifies under the “Natural Disaster” selection on the Root Cause Tree®!

EDIT by Ken
I’ve received several emails informing me that these pictures are not, as a matter of fact, Oswego, NY. I apologize for the error. However, I also found it interesting that the 4 emails “insist” that the pictures are actually:

1. The Trans Canada Highway
2. Just outside of Denver, Colorado
3. Near Mt McKinley
4. In the mountains of Utah

Just goes to show how tough it can be to get “just the facts, ma’am!” Still, cool pictures, huh?

Statement of CSB Supervisory Investigator Don Holmstrom Updating the Public on the Investigation of the Valero McKee Refinery Fire

February 21, 2007 3:30 p.m. CST
Amarillo, Texas

Good afternoon and thank you for coming to this public briefing of the U.S. Chemical Safety Board. I have a prepared statement, and then I will take some questions.

We may have some reporters joining us by conference call; since there are some TV cameras here I’ll ask everyone to hold their questions until I reach the end of the statement, and I’ll ask those of you on the phone to mute your microphones if possible.

My name is Don Holmstrom, H-O-L-M-S-T-R-O-M. I am the supervisory investigator who has been here with our field team at the Valero McKee refinery near Dumas.

The Chemical Safety Board is an independent federal agency, established and funded by Congress in 1998. Our board members are appointed by the president and confirmed by the Senate, and we are structured similar to the National Transportation Safety Board.

The CSB conducts independent, scientific root-cause investigations of major chemical accidents. We do not issue fines, citations, or new rules but we do issue safety recommendations designed to prevent future chemical accidents across the country.

We issue lengthy, public reports on the root causes of accidents, and you can find examples of these report and much other information on our website, CSB.gov. You can also sign up there to get regular updates on our work, including this investigation, by email.

Many of you may know the CSB from our investigation of the major refinery explosion at BP Texas City back in 2005, which we plan to complete within the next month. In its history, the CSB has conducted more than 40 such investigations of major accidents at oil refineries, chemical plants, and other industrial facilities that handle or produce hazardous substances.

A five-member CSB team arrived in Texas late Saturday and began its work at the Valero McKee refinery early Sunday morning. We will be augmenting our team with several additional investigators this week; I will be returning to Washington this evening and briefing the agency on the investigation.

At the point, we proceeding with our accident investigation on multiple fronts, but no formal decision has been taken by the Board on the scope of the inquiry. If we do proceed to an investigation to determine the root causes of this accident, it may be a year-long process. However, we will continue to update the public on our progress as events warrant.

As all of you know, a major fire occurred at the Valero McKee refinery on Friday afternoon, causing more than a dozen injuries. One contract worker, who was critically injured, remains hospitalized. All of the CSB express our sincere hope for his recovery.

Yesterday, CSB investigators inspected the scene of the fire, approaching to within about 200 feet of the fire affected area. We plan to make closer approaches over the next several days as soon as we can assure the safety of our investigators.

The CSB team observed substantial heat damage to equipment and piping in a section of the Propane De-Asphalting or PDA unit.

The PDA unit uses propane to extract refinable materials from a heavy residue of the refinery’s crude oil unit. The PDA unit uses propane that is liquefied under high pressure of several hundred pounds per square inch.

No explosion damage was visible from our location. A pipe rack exposed to the fire was heavily damaged and deformed by the fire.

We do not have any estimate on how this damage might impact the restart of the refinery - which is outside the scope of our work — and we would refer all questions on that issue to Valero.

We have interviewed many eyewitnesses to the accident. The testimony suggests that there likely was a release of liquid propane. At atmospheric pressure, liquid propane rapidly vaporizes and expands to form a vapor cloud. This cloud ignited a short time later.

We are continuing to interview refinery employees and contractors. We are also examining documents provided by the company. Valero is cooperating with the CSB investigation.

Based on interviews, we are particularly interested in a specific area in the north section of the PDA unit, which was the likely location of the initial release. Confirming this as the location will require closer examination. This area was heavily damaged by the fire and has not yet been inspected by the CSB. We plan to enter this area in the very near future, and we plan to inspect specific valves, piping, and equipment in this area.

Near the PDA unit there were a series of large propane storage spheres. We did not observe any visible damage to these spheres from the fire.

However, there were three one-ton chlorine cylinders nearby that were exposed to the fire and some of the contents of the cylinders were likely released. Chlorine is a toxic gas. We understand that these cylinders have now been secured by Valero.

Our investigation continues. Team members continue to interview witnesses and to request additional documents from the Company. We will maintain a team at the site through this weekend and into next week.

That concludes my prepared statement. I’ll now be happy to take some questions from the media. Please state your name and affiliation. Reporters who are on the conference line are also welcome to ask questions; please just wait for a convenient pause and ask me to call on you.

[For more information, please contact Director of Public Affairs Daniel Horowitz in Washington, DC, (202) 261-7613 / (202) 441-6074 cell.]

Interested in databases of pipeline incidents? See the PHMSA web site:

http://ops.dot.gov/stats/IA98.htm

See what lessons you can learn from others mistakes.

Keynote Speakers
Experts Share Their Secrets of Success

Who will you hear from?

Performance Improvement Lessons from the Cockpit to the Surgery Suite, 
John Nance
Military & Commercial Pilot, Aviation & Medical Safety Expert, & ABC Aviation Safety Analyst


Olympic Success Lessons Learned 
Josh Davis
Olympic Gold Medal Winner


Character First! 
Beverly Chiodo
Award Winning Educator


Creating a Vibrant Safety Culture 
Richard Hawk
Safety Expert


Accident Investigation Lessons from the Courtroom Judge Andrew Napolitano
Judge Andrew Napolitano
New Jersey Supreme Court Justice and Fox News Legal Analyst

Need more info?

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

April 25, 2007 from 5pm- 8pm

Remember the Alamo!

There were more people from Tennessee than Texas defending the Alamo.  To celebrate the Alamo history during Fiesta Week, we are bringing a taste of Tennessee to the Summit.  How?  With Tennessee’s award winning bluegrass band: Pine Mountain Railroad to play at Wednesday’s reception.

And there’s more . . . a full dinner, refreshments, an exhibit by performance improvement experts, a chance to meet the day’s speakers, and a drawing to win an Apple iPod.

Wear your best “OLD WEST” outfit (or comfortable jeans) . . . there is a prize (iPod Shuffle) for best costume!

The event is FREE with your Summit attendance!  And bring your spouse (no charge).

Don’t miss the fun!

Get registered at www.taproot.com/summit

Why not take your 5-Day TapRooT® training in majestic Aberdeen? We have a course coming up March 19-23, 2007.

Aberdeen offers spectacular parks and gardens and is known as “Britain’s Flower Capital” because it has won the Beautiful Britain in Bloom award 10 times. Winter Gardens, (two acres of flowers under glass open year round); Cruickshank Botanic Garden in Old Aberdeen (run by the University); Seaton Park by the Don; and Hazelhead are just a few. You can find more by visiting this parks and gardens listing page.

The Balmore Castle is about 50 miles from Aberdeen on River Dee. It is used by the Royal Family as a summer residence, (usually occupied in August and September). Balmore Castle visitors will enjoy fishing, shooting, climbing and guided walks. And you will find 13 of “the world’s most unique castles” by taking the Castle Trail — an experience of a lifetime!



As Scotland’s third largest city, Aberdeen offers an interesting mix of opportunities in the evenings after your TapRooT® class. Visit these links for more information:

Restaurants in Aberdeen

Aberdeen and Grampian Highlands

City of Aberdeen Guide

Sign up for the Aberdeen 5-day course today!

Chevron Richmond crude unit fire picture from the story below…

For the news article see:

http://cbs5.com/local/local_story_050104400.html

Are you up to date with the new PPE requirements speciified in NFPA 70E? Come to a free seminar hosted by Aramak Uniform Services. It will be held Wednesday, March 7th in Goodlettsville, TN. See this file for details.

People of ask me, how long does it take and how many resources should we use investigating an accident and performing a root cause analysis?

Of course, the answer is: “It depends.”

What does it depend upon? Here are just some of many factors:

• The complexity of the accident.
• Your knowledge of the site.
• Your skill in performing investigations
• The amount of documentation and proof you must produce.

But the answer for the CSB’s investigation of the BP’s Texas City Refinery explosion is: “Over $2 million dollars.”

Where does the $2 million figure come from? From a comment by the CSB Chair & CEO, Carolyn Merritt.

Will the investment be worthwhile? We’ll have to wait for the report to come out to see.