Root Cause Analysis Blog

Freeways are characterized by the highest safety level (lowest fatality rates) when compared with other types of highways in rural and urban areas (American Automobile Association Foundation for Traffic Safety, 1995). But, freeway interchanges have design features that have been shown to result in significant safety and operational problems. Click here to view pics of some traffic routing masterpieces!

I was recently sent an article that described how a company, using “root cause analysis”, was able to determine the cause of a recurring motor bearing failure. This particular failure was recurring about every 2 years. After hooking up vibration monitoring gear, they were able to determine that the bearing was nearing failure again. Investigation uncovered that the failure was due to an uninsulated bearing (wrong part) being installed in the motor, allowing circulating electric currents to damage the bearing. Therefore, the root cause was the wrong bearing was installed.

This type of problem would shown up as a Possible Cause using an Equifactor analysis. But TapRooT users know they can’t stop there. “Mechanics installed wrong bearing”, would then be put back into our SnapCharT, and a whole range of questions arise. What was the experience ad training level of the mechanics? Did the procedure specify the correct bearing? Was procedure use required? Why did this bearing fail numerous times before an analysis was performed? Did the manufacturer communicate this possible problem to their customers? Is the correct bearing easy to identify in the supply room? Were supervisors required to inspect thenew installation?

All these questions become obvious once you have a workable SnapCharT that shows the glaring holes in your investigation. With these holes filled, a meaningful TapRooT anlysis can now e conducted.

The 2-Day TapRooT® Incident Investigation and Root Cause Analysis Team Leader Course will be held April 23 - 24 in San Antonio, Texas. This coincides with San Antonio’s granddaddy of events: FIESTA WEEK!!!

Fiesta Week takes place April 21 - 30. This historical event was initiated to celebrate the victory of the battle of the Texas Revolution when Mexican forces were defeated and Texas was assured its independence. It has evolved into a ten day CELEBRATION with parades, parties, food, art exhibits and much more!

Register for our incident investigation course today!

Bring your family, stay the entire week and fully participate in the Fiesta Week festivities because it’s not too late to register for the TapRooT® Summit immediately following the 2-day root cause analysis course (April 25 - 28). Your Summit days will be icing on the cake (to your 2-day root cause analysis course). You will learn best practices, discover advanced improvement skills, hear cutting edge topics presented by leading industry experts, share solutions and recharge your energy and enthusiasm for preventing injuries and saving lives!

Visit our website for more information or give me, Barbara, a call at 865-539-2139! I hope to meet you in San Antonio!

The articles/speeches at the end of this article and a CSB press release posted at the “continue” link below seem to indicate that the path to improved worker safety is more aggressive regulation and increased criminalization of bad safety management.

As you all know, I’m in favor of improved safety. But I think we should carefully consider if the paths being suggested are the best way to get there.

For example, let’s just do a quick estimate of the $$$ cost of criminalization of bad safety management …. (Yes - I know there are costs besides dollars and I value human life more than dollars but … I think looking at the potential dollar cost is eye opening when evaluating the options.)

The CSB spent more than $2 million investigating the BP Texas City Explosion. Why did they spend so much? Because it takes an exhaustive investigation to prove that BP had bad safety management. (From what I’ve heard so far, the criminal part of the investigation by the DOJ is just starting to get into full swing.) So let’s just use $2 million as an average investigation cost for one of the exhaustive investigations with senior management implications.

There are about 5,000 fatalities at industrial sites per year in the US. That doesn’t count the 98,000 deaths due to medical errors - which also could be due to bad management … and may be subject to criminalization of bad safety management. So a conservative guess would be 2,000 investigations per year at a cost of $2 million each.

Thus the government cost will be $4 billion per year for investigations. This does not including the cost of criminal prosecutions that result.

Of course, no rational manager would allow a federal investigation without conducting an equally costly investigation to prove they are innocent. Therefore, industry will match governments costs and spend $4 billion investigating their management in defense of the government investigation.

So far … $8 billion per year without legal costs. (Investigators - Get ready - This looks like a growth industry!)

Now for legal costs …

Let’s guess that 10% of the investigations go to prosecution …

That’s 200 per year.

How much will the high priced attorneys, expert witnesses, government experts, court costs, depositions, management time, … cost?

Let’s guess twice the investigation cost. That’s $8 million for each side or $16 million total for one case. (Look at the cost of special prosecutors if you think these costs are way off.)

200 X $16 million (cost for both sides) = $3.2 billion more.

That’s over $10 Billion/year invested in criminalization of un-safe management practices.

Of course, this is only a guesstimate… Problems with the estimate could include -

Government could get more efficient …

Bad management could improve … reduce costs

Industry could just leave US … avoid potential for prosecution

Courts - already overloaded - may not be able to handle 200 high priced cases with contentious corporate lawyers …

We may include the medical examples and the number would go up by a factor of 100 or more.

Is this really the best investment we can make in improving safety performance and saving lives?

I always think that instead of believing that the government (OSHA?) is the answer and is responsible for worker (or patient) safety, the managers and employees should be primarily responsible. Thus, System Improvements’ focus has always been on educating management and employees so that they can see the value of implementing best practices to improve performance and avoid disaster.

I know this may sound corny and optimistic … and it doesn’t always work … but I think it is the best way to change performance across industry in the US and around the world.

Don’t get me wrong. I understand the need for regulation. But I think that industry should be improving to the point that regulations look antiquated and unnecessary. Industry should “peer pressure” the bad performers (AND THERE ARE BAD PERFORMERS!) to improve (much as they have in the nuclear industry) to stay free of burdensome, inefficient regulations.

If we can’t make improvement happen without heavy handed regulation, I’m afraid that we will “regulate” ourselves out of jobs. Excessive new regulations and criminal cases will be just one more reason for companies move production to less regulatory intense parts of the world.

That’s why I need your help.

Let’s spread the word about proactive improvement, advanced root cause analysis, and stopping human errors. Let’s get management trained to understand the right way to improve performance. Let’s spread good practices around your company and industry.

If you think this sounds like a good idea, let me suggest that you start but attending one of the Best Practice tracks at the TapRooT® Summit. This is a great way to learn best practices and network with industry leaders. And if you can find several other people - including managers - who will attend with you, you can put together a high performance improvement team to change your site, your company, and perhaps start changing your industry.

That was MY GOAL when I started the Summit in 1994. And with your help, perhaps we can save jobs and lives by making improvement happen without excessive regulation. At least that is my hope.

I look forward to seeing you at the Summit in San Antonio on April 25-28, 2007.

- - -

Articles/speeches that got me thinking about this:

http://www.chron.com/disp/story.mpl/business/4654446.html

http://www.house.gov/apps/list/speech/edlabor_dem/RelMar20BPReport.html

http://www.house.gov/apps/list/speech/edlabor_dem/rel032207.html
(more…)

To see the report go to:

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

I’ll try to read and comment on it by the time I come home from England (next week).

The Chemical Safety Board has a web page that collates press reports about incidents from around the USA. See:

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

Keeping up with what is going wrong is a good way to learn lessons from other’s misfortune.

We finished up out course on a sunny mild Spring Friday. But earlier in the week it looked and felt like Winter.

Looking out the window from our classroom at the Ardoe House in Aberdeen.

Class working on first computerized exercise…

Class working on team exercise…

For more information about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training see:

http://www.taproot.com/courses.php?d=2

When an electrician investigated why an office water heater wasn’t working, he found a mouse had a “hand” in the problem:

For those who have been checking the CSB web site and are wondering …

“How come the BP report isn’t posted?”

The answer is that there were slight amendments made by the Board at the public meeting on Tuesday and those wording changes need to be made before the report is posted on the CSB web site.

When will the report be posted? Probably next week. So stay tuned.

The spreadsheet below can be used to rate your improvement program. Use it to decide what to improve.

Click on the icon below to download the Excel spreadsheet.

GoodBadUgly.xls
The Good, The Bad, and the Ugly Rating Spreadsheet

Difficult but interesting reading, this deposition provides insight into the management of the Texas City Refinery.

Deposition (1st half):

http://galvestondailynews.com/photos/2006.December/BP-Parus-1.pdf

Deposition (2nd half):

http://galvestondailynews.com/photos/2006.December/BP-Parus-1.pdf

The UK Health & Safety Executive has issued the following press release:

- - -

NII issued a Consent on 09 January 2007 to allow THORP to reopen because it is satisfied that the licensee, British Nuclear Group Sellafield (BNGSL) has done all the work necessary to ensure it can be restarted safely. The actual date on which reprocessing of fuel at THORP recommences is a matter for BNGSL. HSE/NII will continue to regulate BNGSL to ensure safety is maintained across the Sellafield site and elsewhere.

Background

In April 2005, a camera inspection of the THORP Feed Clarification Cell identified the failure of a nozzle on an accountancy tank. This inspection also identified a quantity of liquor had leaked on the cell floor. Production operations in the cell ceased on the discovery of the liquor and have since remained embargoed across the whole of THORP, with the exception of work carried out to return the liquor to primary containment and to understand the reasons for the failure.
(more…)

Since I’m over in the UK teaching I can’t get to the public meeting on the BP Texas City explosion being held by the CSB today. But I’m trying to keep up on the news. In the UK, the controversy seems to be over the findings of cost cutting that, according to the press reports about what the CSB has found, are root causes of the explosion at the refinery.

For a sample of a press report in the UK, see:

http://observer.guardian.co.uk/business/story/0,,2031053,00.html
Here are a few of the key quotes from the story …

“The CSB says it has evidence in emails and other documents of budgetary considerations taking precedence over investment.”

“Merritt says that internal and external reports between 2002 and 2005 pointed to problems: ‘There was a complete failure to listen to the evidence that they were hearing: that this facility had been squeezed to the breaking point. That was received from their managers as well as from surveys by consultants.‘”

“CSB has emails indicating Texas City managers turned down requests for funding, claims Merritt. ‘We know that pleas from the plant managers were dealt with by instructions to continue cost cutting,’ she says. One such came from Walter Wundrow, a refinery investment manager, who refused an engineer’s request to install a flare, instructing him to ‘bank $150m savings’.”

“Merritt says there is an ‘iron-clad’ case of a causal link between cost savings and the accident. However, she emphasises that much had been done since the explosion. ‘There are huge changes going on in Texas City and a great deal of determination and effort to put things straight. But real culture change is very difficult.’”

I’m sure that by the time I wake up in the UK tomorrow, there will be a report posted on the CSB web site that I will need to read to see the totality of the evidence that the CSB has been collecting.

From the CSB Press Release about the root cause analysis of the BP Texas City Refinery explosion, I found the following comment:

By March 23, operators had been working 12-hour shifts for 29 or more consecutive days. “Fatigue causes cognitive fixation and impaired judgment and could lead operators to fixate on one operational parameter - such as the apparently declining liquid level - to the exclusion of other indicators,” Ms. MacKenzie said. Fatigue has been recognized as a cause of major accidents in the transportation sector. Fatigue prevention regulations have been developed for aviation and other transportation sectors, but there are no fatigue prevention guidelines that are widely used and accepted in the oil and chemical sector.

- - -

29 days on 12-hour shifts.

I remember the feeling. In my own experience at day 46 on 12-hour shifts we had an electrician almost get electrocuted (a near-miss). We didn’t conclude that fatigue was a factor (This incident occurred way before I invented TapRooT®). But now I know that it was related to fatigue.

When I hear that operators were on day 29 of 12-hour shifts … the “bad decisions” made based on faulty indicators just before the BP Texas City explosion start making much better sense. And firing the operators and supervisor after the accident make much less sense.

If you are interested in a way to judge if fatigue is a cause of an incident, you should attend the TapRooT® Summit to hear Bill Sirois talk about the FACT technique for assessing fatigue during an accident investigation. For a complete Summit schedule see:

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

BP has posted a press release on their web site in response to the yet to be released to the public CSB root cause analysis investigation report of the explosion at BP’s Texas City Refinery.

To me, the most interesting statement in the release was:

Notwithstanding the Company’s strong disagreement with some of the content of the CSB report, particularly many of the findings and conclusions, BP will give full and careful consideration to CSB’s recommendations, in conjunction with the many activities already underway to improve process safety management.

(italic emphasis above added by me)

To see the release go to:

http://www.bp.com/genericarticle.do?categoryId=2012968&contentId=7031189

The following message is from the U.S. Chemical Safety Board, Washington DC

U.S. Chemical Safety Board Investigators Conclude ‘Organizational and Safety Deficiencies at All Levels of the BP Corporation’ Caused March 2005 Texas City Disaster That Killed 15, Injured 180.

Full Board to Weigh Recommendations to OSHA, Oil Industry, BP, and Union to Improve U.S. Refinery Safety at Public Meeting Tonight

Houston, Texas, March 20, 2007 - In a 335-page final report released today, federal investigators from the U.S. Chemical Safety Board (CSB) conclude that ‘organizational and safety deficiencies at all levels of the BP Corporation’ caused the March 23, 2005, explosion at the BP Texas City refinery, the worst industrial accident in the United States since 1990.  The report calls on the U.S. Occupational Safety and Health Administration (OSHA) to increase inspection and enforcement at U.S. oil refineries and chemical plants, and to require these corporations to evaluate the safety impact of mergers, reorganizations, downsizing, and budget cuts.

CSB Chairman Carolyn W. Merritt said, ‘It is my sincere hope and belief that our report and the recent Baker report will establish a new standard of care for corporate boards of directors and CEO’s throughout the world.  Process safety programs to protect the lives of workers and the public deserve the same level of attention, investment, and scrutiny as companies now dedicate to maintaining their financial controls.  The boards of directors of oil and chemical companies should examine every detail of their process safety programs to ensure that no other terrible tragedy like the one at BP occurs.’

The CSB report calls on BP to appoint an additional member of the board of directors with expertise in process safety, and calls for BP senior executives to establish an improved incident reporting program and use new indicators to measure safety performance.

The independent Baker panel, formed and funded by BP in response to an urgent CSB safety recommendation, issued its final report in January 2007.  It found ‘material deficiencies’ in the safety of BP’s five U.S. refineries in Texas, California, Indiana, Ohio, and Washington.  The 11-member panel also issued ten safety recommendations, including calling on BP’s corporate board to closely monitor safety performance at its facilities.  The Baker panel was not charged with determining the root causes of the March 2005 explosion.

CSB Investigation Background

Chairman Merritt said, ‘Our investigation of BP was the largest and most complex undertaking in the agency’s nine-year history.  Under the leadership of Supervisory Investigator Don Holmstrom, the team interviewed 370 witnesses, reviewed more than 30,000 documents, and conducted a far-reaching program of equipment, instrumentation, and chemical testing.’  The final report is scheduled to be presented at a CSB public meeting beginning at 6 p.m. tonight at the Nessler Center, Wings of Heritage Room, located at 2010 5th Avenue North in Texas City.  The report and recommendations are subject to approval by the full Board at the public meeting.

BP cooperated with the investigation, furnished documents and interviews on a voluntary basis, and committed to widespread safety improvements and investments following the accident.  BP published its own report on the explosion in December 2005, pledged the total elimination of the kind of unsafe disposal equipment that led to the explosion, and developed a new siting policy to remove trailers from hazardous process areas.  All 15 fatalities occurred in or near trailers that were sited as close as 121 feet from a blowdown drum that vented flammable liquid and vapor directly to the atmosphere.

Safety Harmed by Cost-Cutting, Production Pressures, and Failure to Invest
(more…)

It’s time to register for the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in historic Charleston, S.C., a city rich in history and culture shaped by European, African and Caribbean influences. The TapRooT® root cause analysis course is scheduled for June 4 to June 8.

Charleston is a world-class city with a beautiful harbor and pristine beaches. Visitors will enjoy a wide range of activities including fine dining, golf, and shopping. The Old City Market shops (located between North and South Market Street in Historic Downtown Charleston) offer locally handcrafted products, or enjoy shopping at the upscale shops on King Street.

History buffs will love the historical buildings, museums and walking tours that focus on the Civil War (as well as ghost tours!). In fact, Fort Sumter, where the Civil War began, is accessible by boat. The Magnolia Plantation (accessible by car or boat ride from the city marina) features 50 acres of lawn and gardens as well as a portrayal of early American life. Charleston Carriage Tours are also a popular way to explore this city

For more information about Charleston, visit these sites:

Charleston Area Convention and Visitor Bureau

The Charleston Post & Courier

Charleston Metro Chamber of Commerce

Register for the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course today!

In an article from the Houston Chronicle, I found the following quotes from a speech at the National Petroleum Refiner’s Association made by Carolyn Merritt, Chairperson of the Chemical Safety Board:

The “ineffective or nonexistent” oversight of safety by the British oil company’s board of directors also played a direct role…

“Somebody has to be asking the question: ‘What is happening, and is this being done?’ “  … Yet those questions were rarely asked, she said.

With this information foreshadowing the report to be released today by CSB, BP’s management should be ready for a report that will be highly critical of their safety management efforts.

Malcomb Gresham - one of our TapRooT® Instructors from Risk@Workplces in Australia (see: http://www.workplaces.com.au/events/training_info.asp) sent me the following pictures from one of our clients. Taken during a recent Typhoon, I see a bad day at sea…

For more info see:

http://www.taproot.com/blog/2007/03/csb_to_release_root_cause_anal.html

Starting today, I’m teaching a 5-Day TapRooT® Advanced Root Cause Analysis Course in Aberdeen, Scotland with the other instructor, Kevin McManus.

Next, I head to Telford, England, for the IOSH Meeting. I’ll be presenting a talk on root cause analysis on Wednesday afternoon. Please stop by if you are attending the meeting.

On March 28-29 (Thursday/Friday), I’ll be teaching a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Manchester.

On Saturday, I fly back and start making final preparation for the TapRooT® Summit (coming up on April 25-28).

I’ll try to post when I can and send some pictures of the classes and the conference.

Ken and Barbara will be posting while I’m gone - taking up the slack so-to-speak while I’m teaching and presenting in Europe for 2 weeks.

Praxair is currently seeking Mechanical Reliability Engineers for their Baton Rouge, LA (Geismar Plant) and Texas City, TX Plants.

Engineers will be responsible for moderately complex engineering projects. Performs project engineering work from design to implementation in accordance with Praxair policies. Participates as a key contributor on project and technical teams and may provide technical guidance to others as assigned. Has fully mastered one technical skill and has general knowledge of other technical skills. Works independently and makes technical decisions based on full awareness of viability, cost and other benefits. Develops and implements innovative solutions.

Responsibilities also include providing focus on improving equipment reliability by making recommendations, refining and auditing the Preventive/Predictive Maintenance Program, completing reliability investigations, evaluating data, and monitoring craftsmen and contractor performance. Work in a team environment with operators, mechanics, and exempt professionals. Provide mechanical engineering support to operations and maintenance organizations. Define and implement enhancements to improve operations and reliability. Lead Root Cause Analysis Investigations of failures and develop corrective action to prevent reoccurrence. Assist in the implementation reliability programs. Track compliance with plants Mechanical Integrity Program. Work with teams in developing shutdown/turnaround work scopes. Review proposed changes to equipment as part of the Management of Change process, and provide mechanical engineering support for project work.
(more…)

Well . . . at least they obeyed the “do not remove this tag!” label . . . and the black cat is an appropriate, decorative touch . . .

(from www.thisoldhouse.com)

The following is quoted from a Toyota web site.

A Toyota Exec is talking about the Toyota Production System.

The article says:

- - - Start of quote - - -

When an error occurs, the first thing that needs to be done is fix the error. Minoura recalls that Ohno used to order them to ask the question “Why?” five times over because “that way you’ll find the root cause, and if you get rid of that it’ll never happen again.” However, Minoura emphasizes that on-the-spot observation rather than deduction is the only correct way to answer a “Why?” question. “I’m always struck that the five-why method doesn’t seem to be working as well as it should be because there’s been a lack of practical training. The reason is that they end up falling back on deduction. Yes, deduction. So when I ask them ‘Why?’ they reel off five causes as quick as a flash by deduction. Then I ask them five whys again for each of the causes they came up with. The result is that they start falling back on deduction again, and so many causes come back that you end up totally confused as to which of them is important.”

“Through real training,” Minoura says, “you’ll be able to discover dozens of problems and also get to their root causes. You’ll be able to make dozens of improvements. If you incorporate all the accumulated knowledge of root causes that you’ve got from always asking ‘Why? Why? Why? …’ into your equipment, you’re going to have something that no one else can come close to. I don’t think it’s got anything to do with nationality; it all has to do with whether or not you’ve received the proper training. I feel though that the tendency to give that kind of training and education forms the basis of Toyota’s approach to monozukuri.”

- - - End of quote from article - - -

Most people that talk to me about 5-Why’s, Cause-and-Effect, or Fault Trees stress the need for deductive reasoning to find root causes. Yet here is someone who worked under Ohno (the 5-Whys expert) who says that deduction is BAD - only direct observation is good.

I like the idea of direct observation. But I think people need more guidance than just asking “Why” 5 times to be able to solve difficult problems. Perhaps 5-Whys works for simple problem. But how do you know if a problem is simple before you solve it?

Maybe 5-Why’s would work for a dedicated master problem solver like Ohno. But it is difficult - or perhaps impossible - to train everyone needed to his level of skill.

That’s why in the TapRooT® System for Root Cause Analysis, we’ve built in an expert system to help people find the root causes of human performance and equipment problems. This helps everyone - from the novice problem solver to the expert - perform better root cause analysis.

And we teach people to use direct observation - the facts - to find root causes using a root cause analysis tool called the Root Cause Tree®.

And we’ve built this whole system into a patented Root Cause Analysis Software - the TapRooT® Software.

What is required to reap the benefits of the investment that we have made in developing TapRooT® into a world class problem solving system? Training for your people.

You will need to train your expert problem solvers in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.The software is included in the course fee for this course.

You will need to train your everyday problem solvers in our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

And your maintenance and equipment problem solvers need the 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course.

What kind of benefits can you achieve after this investment? See the Success Stories on the About TapRooT® page.

Would you like to learn about TapRooT® and hear first hand about what TapRooT® users are doing? Then plan to attend the 2-Day TapRooT® Course prior to the TapRooT® Summit and the TapRooT® Summit.

Your investment in improvement is safe because we guarantee all of these events!

Course Guarantee (last paragraph)

Summit Guarantee (bottom right of page)

Hotel space is filling up fast! There are still some rooms available at the Crowne Plaza Riverwalk at the special rate for the TapRooT® Summit.

Remember, it is Fiesta Week in San Antonio during the Summit. Therefore rates are higher and the good deal on the Summit rooms means rooms available are shrinking FAST!
Click here for lodging info…

Click here for Fiesta info…

What can you and your executive team learn from this press release from Lieff Cabraser Heimann & Bernstein, LLP? Read the release and see…

$55 Million Verdict Imposed Against DaimlerChrysler Corporation For Failing To Fix Known Transmission “Park-to-Reverse” Defect That Killed Young Father At San Pedro/Long Beach Maritime Terminal

– Millions Of DaimlerChrysler Vehicles In Use With Similar Park-to-Reverse Defect

Robert J. Nelson, Scott P. Nealey, and Chuck Naylor, counsel for Adriana Mraz and her three children in a wrongful death action against DaimlerChrysler Corporation, announced that a California-state jury today returned a $50 million punitive damages award against DaimlerChrysler for knowing and intentional failure to cure a defect in millions of its vehicles. On March 2, 2007, the same jury found DaimlerChrysler liable for the death of Richard Mraz and returned a verdict of $5.2 million in compensatory damages for Mrs. Mraz and her children.

On April 13, 2004, Mr. Mraz suffered fatal head injuries when the 1992 Dodge Dakota pickup truck he had been driving at his work site, the San Pedro/Long Beach Maritime Terminal, ran him over after he exited the vehicle believing it was in park. The jury found that a defect in the Dodge Dakota’s automatic transmission, called a park-to-reverse defect, played a substantial factor in Mr. Mraz’s death, and that DaimlerChrysler was negligent in the design of the vehicle, for failing to warn of the defect, and then for failing to adequately recall or retrofit the vehicle.
(more…)

Press Release from the CSB

‘At a time when our gasoline refining capacity is stretched thin, the fire at the Valero McKee Refinery underscores how just a single supply disruption can impact what Americans pay at the pump,’ said CSB Chairman Carolyn W. Merritt, announcing the new investigation. ‘All of us have a strong stake in preventing such accidents that cause both human suffering and economic hardship.’
(more…)

If you are attending the 2007 IOSH Conference in Telford, UK, on March 27-28, stop by the System Improvements booth at the exhibit and I would be glad to discuss any of the many controversial subjects that we tackle here on this blog, including:

- Best root cause analysis techniques,
- Accidents and their causes,
- How to improve human performance,
- The new TapRooT® Book (coming out this summer),
- Equipment troubleshooting,
- The upcoming TapRooT® Summit,
- What’s wrong with 5-Whys, Cause-and-Effect, and Fault Trees when trying to find the root causes of an accident.

And while you are there, you can pick up your very own “Spin-a-Cause™” - the worlds fastest root cause analysis system!

Or drop in on my talk on Wednesday in Track E - Best Practices for Health & Safety, 14:45-15.15:

“Why the changing world of work needs advanced root cause analysis and a systematic safety improvement programme.”

So please stop by and say hello…

PS: While I’m over in the UK I’ll be teaching 2 root cause analysis courses:

2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in  Manchester, England, on March 29-30.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Aberdeen, Scotland, on March 19-23.

There’s still space available in both courses and time left to sign up. Hope to see your there!

It’s been almost two years since the March 23, 2005, explosion and fire at the BP Texas City Refinery, but the bad news hasn’t stopped. Continuing bad publicity is just one of the many ignored costs of a major accident.

The most recent bad publicity came from BP’s recently released 2006 Annual Report. BP had several references to the explosion, including: federal investigations (EPA, OSHA, and CSB), the Baker Commission Report, and an ongoing criminal investigation by the US Department of Justice. Newspapers picked up on a paragraph on Page 28 of the Annual Report that revealed that the Justice Department had issued subpoenas to BP for documents and testimony in a grand jury criminal investigation.

Also detailed in the report was pay for high level executives at BP. Again, reporters picked up on the fact that even though financial performance at BP was excellent for the year, outgoing CEO John Browne’s total compensation was cut by almost $2 million dollars (28% according to an AP story in the Houston Chronicle).

The Chemical Safety Board had announced that it will release it’s long awaited investigation root cause analysis report on March 20. This will no doubt mean another round of negative stories.

So what do you need to do to convince your management team to improve safety performance? Perhaps an example of potential criminal investigations and big pay cuts for executives will get their attention. Certainly these are more reasons among the many obvious reasons that companies should do everything in their power to prevent major accidents by using advanced root cause analysis proactively to improve performance before accidents occur.

For more on PROACTIVE use of root cause analysis to prevent accidents click on the button for the schedule of the Proactive Improvement Best Practices Track at the TapRooT® Summit.

Procrastination - the root cause of failure. That’s what you’ll say if you don’t book your hotel room ASAP!

The room block at the San Antonio Crowne Plaza Riverwalk will expire on March 22. After that, room will be difficult to obtain because it is Fiesta Week in San Antonio during the Summit.
So, BOOK YOUR ROOM NOW!!!!

Click here for lodging info…


(Sky Cam of San Antonio from web site)

Board to Convene March 20 Public Meeting in Texas City, Texas, to Release and Vote upon Final Report on BP Refinery Disaster

March 7, 2007 - The U.S. Chemical Safety Board (CSB) announced today that it will convene a public meeting on the evening of Tuesday, March 20, 2007, at the Nessler Center in Texas City, Texas, to release its final investigation report on the explosion at the nearby BP refinery that took 15 lives and injured 180 on March 23, 2005.

The meeting will begin at 6 p.m. central time at the Nessler Center’s Wings of Heritage Room, 2010 5th Avenue North, Texas City, TX 77590, (409) 643-5990.  The Nessler Center is adjacent to the Doyle Convention Center, near city hall.
(more…)

Change . . . why does change invoke such a negative response in some, yet others embrace it? Is it fear of doing something new and different or is it complacency? Things are good enough. We haven’t had a major failure yet, haven’t lost a big client, haven’t had significant quality problems . . . so it must be good enough. We have been doing it this way for years, besides, who has the time or energy to change things that are working just fine?

If you are not changing, the world around you is. We cannot prevent our environment from changing - our clients, competitors, regulations, technology or stakeholders. Maintaining the status quo will not allow us to meet the demands of this complex changing environment. Organizations that look at change as a means to create opportunities instead of simply as a threat, will find better ways to do things, new products or services to meet changing needs.

Steve Jobs at Apple is a great example of recognizing a changing environment (legal issues regarding downloading music), the changing customer wants and the improving technology and created the iPod and iTunes which has reshaped how people get and listen to music.

Albert Einstein stated, “We can’t solve problems with the same level of thinking that created it.” Change, by definition, requires different thinking than before; demanding solutions that are not part of your prior experiences. Who better than to do that than those who so clearly understand the problems or opportunities?

The challenge is humans are hardwired to set up mental patterns and to stick to them. We don’t naturally break these patterns. The mind is a self-organizing system. It allows us to be effective and efficient in carrying out tasks, especially repeated tasks. Trying to break these patterns goes against the way our brains work most efficiently. It can be very difficult to achieve the “out of the box” thinking that is required to change and innovate your processes, products or services by going about idea generation the same old way.

The good news is that innovation need not be left to those “gifted” with creativity. We can leverage the knowledge base and experience of those closest to the work. We can learn deliberate tools that can be applied to develop new ideas, processes, tools and systems to create the results you need to meet the complex demands of our changing world. It is possible to break old patterns and mental models that made you successful in the “old” environment and create a successful future. You can understand the innovative thinking process, learn the tools to shift paradigms, identify opportunities, reduce meeting time, improve decision making, and create truly new solutions so you can break those old mental models or patterns and change the way you do things. Can you risk doing the same things the same way?

Join Michele Lindsay, a certified Six Thinking Hats Instructor and a TapRooT® Instructor for the past nine years, for an interactive, practical course in breakthrough thinking. Create the outcomes to move you ahead of your competitors, address your client’s needs, fix problems and improve the way you conduct or provide business.

The objective of the Innovation and Creative Solutions course is to provide attendees with the opportunity to deliberately apply tools to reframe problems, identify opportunities, and develop and evaluate “outside of the box” thinking.

This 2 day Innovation and Creative Solutions Course is available at the TapRooT® Summit on April 23-24, 2007 in San Antonio, TX.

To see a course outline or download a brochure at: http://www.taproot.com/courses.php?d=9 or contact Michele Lindsay at (416) 452-1869, or at michelelindsay@sympatico.ca.

Are you interested in learning BEST PRACTICES in the areas of:

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

Don’t miss this Improvement Opportunity!

register at: http://www.taproot.com/store.php?e=summit

… or Defending Categorization
(an excerpt from a draft of the revised TapRooT® Book
available later in 2007, Copyright © 2007)

Some cause-and-effect gurus object to use of the TapRooT® System’s Root Cause Tree® because they feel that any categorization restricts the thinking of an incident investigator. They maintain that the only way to ensure a complete, unbiased, unbounded root cause analysis is to attack each problem from the viewpoint of basic engineering and human performance principles and let the evidence lead where it may by the use of cause-and-effect, deductive reasoning, and testing of hypotheses. Our extensive investigation research and development as well as basic psychological principles show that this thinking is wrong.

The deductive reasoning and “hypothesis proving” used in fault trees, 5-Whys, and cause-and-effect actually cause problems that we will explain in this article. We will explain how these problems are solved by the tools used in the TapRooT® System. For TapRooT® Users, this article supplies the evidence you need to defend the good practices that TapRooT® and the Root Cause Tree® are based on when you are faced with the argument that “categorization” is a problem.

TapRooT® and the Root Cause Tree® have extensive testing and field use that proves the Root Cause Tree® does not limit the thinking of investigators. Just the opposite is true. Once an investigator is trained in using TapRooT®, they find a broader range of causes – they are less restricted in their thinking – than before they were trained in the use of TapRooT®. This is true even if they were previously trained in using a cause-and-effect based root cause analysis system.

Why, when using TapRooT®, do analyst find causes that they would have previously overlooked? There are several reasons.

First, when using TapRooT®, investigators use tools in addition to Root Cause Tree®. These tools that are used before using the Root Cause Tree® encourage a better collection of information before the root cause analysis begins. SnapCharT® is especially helpful for organizing investigation information and spotting missing or conflicting information. Equifactor®, CHAP, Change Analysis, and Safeguards Analysis are excellent tools to help the investigator understand what happened before they start analyzing why it happened. Thus when using TapRooT®, investigators are often better prepared to find root causes and less likely to jump to conclusions than they are when they use systems based primarily on cause-and-effect (which doesn’t have these built in information collection tools).

Second, very few investigators have the broad knowledge, training, and experience in all of the fields needed to use cause-and-effect to analyze a complex accident. What kind of knowledge and experience would be needed? A short list includes: equipment engineering, maintenance, operations research, management theory, human factors, ergonomics, and training theory. Therefore, most people need guidance to direct them to the wide variety of Root Causes that should be considered when investigating a problem. They get this guidance when using TapRooT® and the Root Cause Tree®. We have not seen this level of high quality guidance in any other system.

Third, even experienced gurus fall into a common trap. They develop “favorite cause-itis”. The concept of “finding the answer you want” has been proven by independent research. Thus, experienced investigators have a tendency to ignore information that does not fit their hypothesis and look for information that confirms their hypothesis. This tendency is called a confirmation bias. A short list (of thousands) of research papers from the past 40 years that confirm the existence of a variety of types of confirmation bias, and the effects of confirmation bias to many fields, include:

Thus, experienced investigators trying to confirm a hypothesis (the method used when building a fault tree or implied in the deductive reasoning used in most applications of 5-Why’s and cause-and-effect), will not have an “unbiased analysis” that they hope to achieve by avoiding categorization. Instead, they need a system (like the Root Cause Tree®) that focuses on a broad spectrum of possibilities. They need to use facts to select or eliminate the conditions under which the problem occurs (and thus what best practices can be used to eliminate the condition – just like the Root Cause Tree® provides). They need the guidance of the 15 Questions and the Basic Cause Categories of the Root Cause Tree® to make sure they avoid the “favorite cause” confirmation bias trap.

Fourth, almost all thinking is categorical in nature. For example, language is a categorization of certain sounds into standard meanings. Thus, a dictionary of a language is a book of categorized meanings and pronunciations. Thus, someone who opposes the use of the Root Cause Tree® because it is categorical is just replacing one well-thought-out, well-defined set of categories with another set. The new set is the one that they don’t realize that they have in their mind. Often, we have observed that the set of categories in a guru problem solver’s mind is more restrictive (as measured by the variety of outcomes in their investigations) than the categorization presented by the Root Cause Tree®. You can, therefore, think of using the guru approach (with no well thought out categorization) as trying to communicate without a standard language, without a dictionary, and without even having a standard alphabet. Imagine how effective this unstructured communication would be…

Finally, the Root Cause Tree® is not just categorization. The Root Cause Tree® is not a simple checklist. It has an expert system (the 15 Questions, the Basic Cause Categories, and the Root Cause Tree® Dictionary questions) built into it. Thus the problems encountered when using a “pick-list” of root causes have been solved by the structure and expert systems built into the Root Cause Tree®. The comparison of the Root Cause Tree® to a pick-list of root causes is a false comparison. When you see this false comparison used by those who wish to justify the use of other, less well developed, root cause analysis techniques, you will then realize that their system can’t compare to the robust, proven tools used by TapRooT®, including the Root Cause Tree®. Therefore, they have developed a weak straw man to make their system look superior in comparison to a purposefully chosen weak system – a simple pick list.

Our research and experience, in addition to independent research on confirmation bias, shows that the structure and categorization used in the Root Cause Tree® doesn’t need to be apologized for. Rather, the structure and categorization of the Root Cause Tree® is a vast advantage over other non-structured, poorly categorized techniques that don’t have expert systems built into them, such as 5-Why’s, cause-and-effect, and fault trees.

The next time you are asked to defend the Root Cause Tree® versus root cause analysis based on cause-and-effect analysis, fault trees, or 5-Why’s, you will be armed with the facts that show the superior design of the TapRooT® System.
(more…)

Research published in the January Journal of Occupational and Environmental Medicine puts the cost of fatigue related lost productive time for US workers at over $100 billion dollars per year.

Note that this cost does NOT include the cost of fatigue related accidents and incident.

When you perform a root cause analysis, how do you determine if an error was related to fatigue?

If you don’t have a good answer to this question, you should sign up for the TapRooT® Summit and attend the session by Bill Sirois, Executive VP and COO of Circadian Technologies. Bill will be presenting a technique called FACT that is based in fatigue research and can help you decide if an accident is due to fatigue.

The TapRooT® Summit is scheduled from April 25-28, 2007, and will be held at the Crowne Plaza Riverwalk in San Antonio, Texas. For more information see:

http://www.taproot.com/summit