Root Cause Analysis Blog

For more info see:

http://maintenancetalk.com/blog.php/viblog/reliability_engineer_cedar_rapids_ia/

When a patient in injured or killed by a sentinel events, the doctor may also suffer. To download a copy of an interesting article, see:

http://www.bmj.com/cgi/reprint/320/7237/726

When I saw this article I thought it was new. Then I looked at the date at the bottom of the page. The article was from 2000! That made me think …

What has actually changed in the past 7 years in the efforts to achieve greater patient safety and quality of care? Have most of our solutions just been “band-aids”? Have we really made significant change in the reporting, root cause analysis, and correction of the causes of medical errors across the industry?

What do you think? Click on the title word “comment” below to leave your ideas…

If you ever start getting complacent as a pilot … You think it can’t happen to you … Just watch these videos … These pilots thought they were at the top of their game …

http://www.youtube.com/watch?v=pyiuI5NuktM&mode=related&search=

http://www.youtube.com/watch?v=L4W72s4qWcg&mode=related&search=

http://www.youtube.com/watch?v=zLDBgwrh6qs&mode=related&search=

http://www.youtube.com/watch?v=iza5uGIqccU&mode=related&search=

http://www.youtube.com/watch?v=QOnfGKCqDAg&mode=related&search=

http://www.youtube.com/watch?v=X4dy29MZUKc&mode=related&search=

http://www.youtube.com/watch?v=vRin-iBj_Vs&mode=related&search=

http://www.youtube.com/watch?v=TM0BXZD3Bu0&mode=related&search=

http://www.youtube.com/watch?v=Znx8CjueJqs&mode=related&search=

http://www.youtube.com/watch?v=wkGSTslqIzU&mode=related&search=

http://www.youtube.com/watch?v=s9RhyZeg7Y0&mode=related&search=

http://www.youtube.com/watch?v=zTZIyyOvpTI&mode=related&search=

http://www.youtube.com/watch?v=juC7FQUV6pY&mode=related&search=

http://www.youtube.com/watch?v=TRDJ9oyjcMc

http://www.youtube.com/watch?v=5m-SczxEscI&mode=related&search=

http://www.youtube.com/watch?v=57XRJKoq9Qg&mode=related&search=

http://www.youtube.com/watch?v=trmS4r6_yjQ&mode=related&search=

http://www.youtube.com/watch?v=mEWxoD6YLQM&mode=related&search=

http://www.youtube.com/watch?v=rcsZ7zHPlPM&mode=related&search=

Is it time for root cause analysis?

Tiger Woods slices a shot - Watch out Fans!

Or worse, a rally car leaves the road (see movie below).

Keeping spectators safe is an increasing concern. An AP story at the CNN web site explains some of the efforts the sports industry is taking.

My suggestion? Don’t forget to do a root cause analysis of these fan related sports injuries. Often you will find that the Safeguards are now inadequate for out current level of risk tolerance.

See this video and watch the wall just above their heads:

http://video.google.com/videoplay?docid=7912527611801359366&q=root+cause+analysis&total=34&start=10&num=10&so=0&type=search&plindex=8

An AP Story at the CNN web site said the following:

Comair pilots’ failure to notice clues that they were heading to the wrong runway was the primary cause of last summer’s deadly Kentucky plane crash that killed 49 people, safety investigators concluded Thursday.

“That’s the frustration of this accident — no single cause, no single solution and no ‘aha’ moment,” Hersman said. “Rather than pointing to a mechanical or design flaw in the aircraft that could be fixed or a maintenance problem that could be corrected, this accident has led us into the briar patch of human behavior.”

Is “pilot error” really a root cause? Should there be only one “root cause” for a major accident?

More from the article:

NTSB staff member Joe Sedor identified one possible overriding factor — unnecessary chatter between pilot Jeffrey Clay and first officer James Polehinke as they prepared to taxi and take off. Comair has acknowledged some culpability as a result of the talk, which violated FAA rules calling for a “sterile cockpit.”

Did the 40 seconds of conversation really cause the accident?

Ken Turnbull, a TapRooT® Instructor and experienced investigator of accidents (but not aviation accidents) will present his analysis of the crash at the 2008 Summit. If you would like to see how TapRooT® can be used to find the real root causes of a major accident, attend Ken’s talk.

Here is the link to the NTSB’s press release:

http://www.ntsb.gov/Pressrel/2007/072607.htm

Physical exercise is good for you. We know that we should do it daily, but our bodies don’t want us to do too much, so we have worked out this program that does not require strenuous physical exercise. You are invited to use our program without charge! Like me, you may find you are already expert in many areas before you even begin! Here are the exercises in the program.

* Beating around the bush

* Jumping to conclusions

* Climbing the walls

* Swallowing your pride

* Passing the buck

* Throwing your weight around

* Dragging your heels

* Pushing your luck

* Making Mountains out of Molehills

* Hitting the nail on the head

* Wading through paperwork

* Bending over backwards

* Jumping on the bandwagon

* Balancing the books

* Running around in circles

* Eating crow

* Tooting your own horn

* Climbing the ladder of success

* Pulling out the stops

* Adding fuel to the fire

* Opening a can of worms

* Putting your foot in your mouth (advanced level)

* Starting the ball rolling

* Going over the edge

Here’s some pictures and video of the Explosion at the Southwest Industrial Gases plant near downtown Dallas…

Video:
http://www.wfaa.com/video/index.html?nvid=161536
http://us.cnn.com/2007/US/07/25/ireport.dallas.explosion/index.html#cnnSTCVideo

Pictures:

http://us.cnn.com/2007/US/07/25/ireport.dallas.explosion/index.html#cnnSTCPhoto

Timeline:

http://www.wfaa.com/sharedcontent/dws/wfaa/latestnews/stories/wfaa070725_lj_blastblog.acfe7846.html

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

Washington, DC, July 25, 2007 - An investigative team from the U.S. Chemical Safety Board is deploying to the site of this morning’s serious explosions and fire at the Southwest Industrial Gases gas cylinder distribution facility in Dallas.

The team of five investigators, including Supervisory Investigator Robert Hall, P.E., and Investigations Manager Stephen Selk, P.E., is expected to arrive in Dallas later today.  A CSB board member will be joining the team.

The explosions and fire were reported to cause serious injuries and to propel debris off site, forcing an evacuation and the closure of major interstate highways.

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Of course, on a personal level, every fatality is a tragedy. That’s why I wrote the article titled Stop the Sacrifices back in 2004. It caused a lot of controversy then but I still stand by the points I made.

However, today I’d like to look not at the personal tragedy side of the fatalities but rather at the statistical analysis of the fatalities.

A recent article in the Safety & Health Practitioner (a publication of IOSH in the UK) said:

“Fatalities in the construction industry last year leaped by 25 per cent, prompting calls for the HSE to abandon its influencing and informing approach and instead beef up enforcement in the industry.”

Later in the article it said:

“… deaths in construction this year significantly exceeded the record low of 59 in 2005/06.”

The question is, what is a “SIGNIFICANT INCREASE” in these statistics?

Since 2005/2006 was a record low, was the 25% increase just returning to historical levels? Was the 2005/2006 statistics a fluke - just blind luck? Another part of the article stated that the construction industry was booming. That presents a new questions:

“What were the deaths per 200,000 hours worked?”

People who have taken our Advanced Trending Techniques Course know that these type of statistics are often misused. They also know how to correctly analyze them. If you would like to be able to detect real signals from your safety data and avoid reacting to the noise (random variation) that exists in any statistics, plan to attend the 2008 advanced trending course that will be held in Las Vegas on June 23-24, 2008. You will learn to make sense out of the numerical chaos.

For more information see:

http://www.bayt.com/job/job.adp?xid=502195

For more information see:

http://www.eluta.ca/search?ptitle=Project+Engineer&position=ae4f2a5eed5d4fb7d3184569838dc944&imo=1

We recently received a great question from one of our clients:

“We have found a few cases where lack of an appropriate equipment strategy is the ‘root cause’ for a failure. For example, the machine has not been given the correct criticality rating so that it receives the right level of preventive maintenance, servicing etc. Or the preventive maintenance regime is not sufficient to keep it running well. It was not given the right level of PM at the start.

Where do you think this fits in the TapRooT® root cause tree structure? I have a particular interest in this as:

a) It is regularly surfacing as a finding in investigations and

b) It is an area we can influence in our reliability programs for plant equipment.”

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ONLY Prior TapRooT® Course Attendees
Can Attend the 1-Day Equifactor®

LAKE TAHOE, NV  August 10
KUALA LUMPUR, Malaysia  November 2
EDMONTON, Canada  November 21
NEW ORLEANS, LA  November 30
LAS VEGAS, NV  December 7

Save time & money when learning advanced equipment troubleshooting and failure analysis. Prior attendees of the 2-Day and 5-Day TapRooT® Course can attend just the last day of a public 3-Day TapRooT®/Equifactor® Course and learn how to use Equifactor® for equipment troubleshooting. These skills help you find the root causes of equipment problems and improve equipment reliability.

When you attend the 1-Day Equifactor® Course, you take home:

o Machinery Failure Analysis and Troubleshooting by Heinz Bloch.
o The TapRooT® Software that includes computerized troubleshooting tables.

The book and the software cost $1610 without the course. If you attend this course, you get the book, the software, and the training for only $995. If your company has a TapRooT® Software network license, you save $400 more (attend for only $595). Sign up 3 or more people at once and save $100 more. For course details see:

http://www.taproot.com/courses.php?d=17

For more details see:

http://www.thecareerengineer.com/cand-viewjob.php?jid=230099

Another state is considering their own law to improve patient safety and reduce preventable sentinel events. The Missouri Senate is considering a bill that requires incident reporting within 24 hours of the incident and root cause analysis within 20 days.

The bill defines root cause analysis as:

(6) “Root cause analysis”, a structured process for identifying
79 basic or causal factors that underlie variation in performance,
80 including but not limited to the occurrence or possible occurrence of
81 a reportable incident. A root cause analysis focuses primarily on
82 systems and process rather than individual performance and
83 progresses from special causes in clinical processes to common causes
84 in organizational processes and identifies potential improvements in
SB 578 7
85 processes or systems that would tend to decrease the likelihood of such
86 events in the future, or determines after analysis that no such
87 improvement opportunities exist.

To read the bill, see:

http://www.senate.mo.gov/07info/pdf-bill/intro/SB578.pdf

For the legislative status of the bill, see:

http://www.senate.mo.gov/07info/BTS_Web/Bill.aspx?SessionType=R&BillID=45607

What can inadequate root cause analysis get you? A warning letter from the US FDA and a big headache.

Recent press reports detail the headaches of Srtyker Ireland, LTD and their troubles with the FDA. For more information see these links:

http://www.reuters.com/article/health-SP/idUSN1926664420070619

http://www.fdanews.com/newsletter/article?issueId=10468&articleId=96073

http://www.fda.gov/foi/warning_letters/s6387c.htm

http://www.ryortho.com/NEWSSHORTS/volume3/issue20/06-22-07-NS-FDA.htm

How big a problem is failure to perform adequate root cause analysis in industries regulated by the FDA? A quick search of the FDA’s reading room warning letter database yielded 26 letters in the past 12 months. That’s not an exhaustive study, but it is an indicator. Many medical device manufacturers and drug companies need to do a better job finding and fixing root causes.

Lesson Learned? Think ahead! Get an advanced root cause analysis program in place before the regulator arrives with a letter. Then make advanced root cause analysis a key part of your performance improvement and operational excellence program.

For more information about advanced root causes analysis courses around the world, see:

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

Maintenance Managers should be interested in trained in ways to rapidly and accurately troubleshoot equipment problems and find their root causes. That’s why the TapRooT® System includes the Equifactor® Troubleshooting Tools that were developed from Heinz Bloch’s troubleshooting knowledge.

For more information about Equifactor®, see:

http://www.equifactor.com

For more information about the job posting, see:

http://www.nukeworker.com/job/view.php?job_id=4491

Video footage of the Brazilian airliner crash is available at this link:

http://news.bbc.co.uk/2/hi/americas/6907704.stm

Also note that the video shows a thrust reverser has been deactivated.

However, Tam airlines insists that this was an approved configuration by Airbus and Brazil’s Civil Aviation Agency.

Many people were already concluding the the runway length and weather was the cause of the crash.

This shows that perhaps people shouldn’t jump to conclusions when investigating the root causes of an accident.

I’m not sure exactly how this stress test works, but it is amazingly accurate. Read the full description before looking at the picture. Read carefully:

The attached photo has 2 identical dolphins in it, and was used in a closely monitored, scientific case study on stress levels. The study was performed at St. Mary’s Hospital in Oshkosh, Wisconsin. It showed that despite the fact that the dolphins are identical, a person under stress would find differences between them. If a person finds many differences, it means they are experiencing a great amount of stress.

Look at both dolphins jumping out of the water. If you find more than one or two differences, you may want to take a vacation!

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A press release from the Chemical Safety Board:

Washington, DC, July 19, 2007 - An investigative team from the U.S. Chemical Safety Board (CSB) has been deployed to the site of Tuesday’s explosions and fire at the Barton Solvents facility in Valley Center, Kansas, north of Wichita.

The three-member team, led by CSB Investigator Randy McClure, will conduct an assessment to determine if a further investigation of the root causes of the accident is warranted.  The explosions and fire Tuesday led to the evacuation of thousands of residents and resulted in projectile damage offsite, as well as the destruction of the facility, reports indicate.  Investigators will be at the site today to begin the assessment.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

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 their website: http://www.csb.gov.

For more information, please contact Daniel Horowitz at (202) 261-7613 / (202) 441-6074 cell.

As of July 1, 2007, California law SB 1301 requires hospitals to report adverse events within five days to the California Department of Health Services (DHS). The law categorizes 27 types of adverse events that require reporting. What if the event is an ongoing, urgent or emergency threat to the welfare, health or safety of patients, personnel or visitors? Then the hospital must report the event within 24 hours.

For more information, see:

http://pub.ucsf.edu/today/cache/news/200707172.html

For details see:

http://www.londoncareers.net/jobs/job-80083.htm

The following is a press release from the White House:

The President intends to nominate John S. Bresland, of New Jersey, to be a Member and Chairperson of the Chemical Safety and Hazard Investigation Board for five year terms. Mr. Bresland currently serves as a Member of the Chemical Safety and Hazard Investigation Board. Prior to this, he served as President of Environment and Safety Risk Assessment, LLC. Earlier in his career, he served as Director of Environmental Risk Management at Honeywell International, Inc. Mr. Bresland earned an undergraduate degree from Londonderry Technical College in Northern Ireland and a graduate degree from Salford University in England.

The President intends to nominate Charles Russell Horner Shearer, of Delaware, to be a Member of the Chemical Safety and Hazard Investigation Board for a five year term. Mr. Shearer currently serves as Deputy Chief for Enforcement and Technical Matters in the Office of Health, Safety and Security at the Department of Energy. Prior to this, he served as Principal Deputy Assistant Secretary of Energy (Environment, Safety and Health). Earlier in his career, he served as Special Assistant to the Assistant Secretary of the Army (Installations and Environment). Mr. Shearer received his bachelor’s degree from Washington and Lee University, his JD from Widener University, and his LLM from Tulane University.

For details see:

http://jobview.monster.com/getjob.asp?JobID=58530489&JobTitle=Safety+Manager&sort=rv.dt&brd=1&cy=US&vw=d&AVSDM=2007-06-06+17%3a11%3a00&pg=1&seq=39

Chevron is looking for experienced Reliability Engineers with TapRooT® Root Cause Analysis Training. For details see the following links:

Pascagola

Houston

Richmond

San Ramon

El Segundo

Salt Lake City

ES&H Job Opening in Knoxville, Tennessee, that requires investigation of incidents and accidents:

Job Title: Environmental Health and Safety Coordinator - Knoxville
Company: Sea Ray Boats - Brunswick Corporation Req Number: brun-00005937

Location(s): Knoxville TN US

Company Profile:
Founded in 1959, Sea Ray is the world’s largest manufacturer of superior
quality pleasure boats. For more information, go to http://www.searay.com/.

General Responsibilities:

BASIC ACCOUNTABILITY STATEMENT

This position would work closely with other management personnel to further develop the Plant Safety & Environmental System. This position would be responsible for administering the Environmental Health & Safety (EH&S) System for the Sea Ray Knoxville Facility in the Forks of the River Industrial Park.

DUTIES AND RESPONSIBILITIES

Ensures plant safety by providing a safe environment for employees and actively supports the STOP program and Brunswick SMS procedures.

Develop and implement a proactive EH&S System, including company driven Safety Management Systems

Ensure compliance

Conduct inspections

Investigate incidents/injuries

High involvement with all Worker’s Compensation activities in direct coordination with Human Resources

Develop & ensure implementation of corrective actions, EH&S policies, and best management practices

Conduct all EH&S training for facility personnel, oversee monitoring activities, facilitate the Safety Committee

Prepare and maintain all EH&S documentation and reporting to deadlines, communicate with governmental agencies Oversee the EH&S reviewing of new/modified processes/equipment/chemicals.

Oversee proper handling and proper disposal of hazardous & solid waste. Stay abreast of changing regulations to ensure future compliance

Also responsible for communicating all relevant information to company & facility management, as well as all facility employees

Dotted line reporting to Director of Environmental Health & Safety, Sea Ray Group Education & Experience

EDUCATION

Bachelor degree in Occupational Safety & Health, Environmental Management or compatible degree is requested, along with a minimum of 5 years of EH&S experience in an industrial setting. Extensive experience of EH&S may replace degree requirement.

EXPERIENCE

Knowledge of OSHA, EPA, DOT, State and local regulations

Loss prevention, Risk Management and extensive Workers Compensation background

This individual must be familiar with Air Permit Compliance. Experience
with Title V air permits is a plus.

Extensive computer skills, organizational and communication skills

CONTACT INFORMATION

Contact immediately: Julie Glibbery, phone 865-525-9940 or cell 865-963-6824.
Email: julie.glibbery@searay.com

Company in Las Vegas looking for a Construction Safety Professionals:

A private construction company will be needing Construction Safety Professionals with various levels of experience in the near future for contracts that have been awarded, start dates are currently being scheduled. Note: This is not government work, but is fast-paced privately financed construction. Once the start date is announced, work will move rapidly. The construction company is not yet openly advertising for these positions and will remain confidential, at this time.

I have been asked to initiate a search for qualified safety professionals.

Location: Las Vegas, NV

Job description / duties / experience:
- High-rise building construction: hotels, casinos, condominiums, etc.
- Union worker force
- Preferred Experience: working with heavy construction equipment, fall protection, concrete placements, dealing with heat stress issues
- Long-term permanent positions with company benefits including relocation
- Salary: depending on experience

If interested, send resume to Dean LeBlanc at DWL74@comcast.net

No phone calls.

Dean LeBlanc
Safety Manager
Las Vegas, NV

The Cumberland Times-News reported on MSHA’s root cause analysis of a fatal highwall collapse at Tristar’s Caledonia Pit. For the story, click on this link:

http://www.times-news.com/local/local_story_191092144.html

For the complete MSHA investigation report, click on this link:

http://www.msha.gov/FATALS/2007/FTL07c0506.pdf

And once you’ve read the report, think of the management system violations (management shortcuts) that lead to this fatality.

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

Senate Committee Webcast about to Begin on CSB Lessons Learned

Washington, DC, July 10, 2007 - U.S. Chemical Safety Board Chairman Carolyn W. Merritt will testify today as the first witness in a Senate hearing entitled, ‘Lessons Learned from Chemical Safety Board (CSB) Investigations, Including Texas City, Texas.’ The hearing is scheduled to begin at 10:00 a.m. eastern time today, in the Dirksen Senate Building, Room 406. Please visit http://epw.senate.gov/ to view the hearing webcast. The webcast link will be posted on the committee website once the hearing begins.

The hearing has been convened by the U.S. Senate Committee on Environment and Public Works, Subcommittee on Transportation Safety, Infrastructure Security, and Water Quality, chaired by Senator Frank R. Lautenberg (D-NJ). Senator David Vitter (R-LA) is the ranking member.

The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

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.

For more information, please contact Jennifer Jones at (202) 261-3603 or Daniel Horowitz at (202) 261-7613.

The Associated Press published the following:

Zheng Xiaoyu’s execution was confirmed by state television and the official Xinhua News Agency.

“The few corrupt officials of the (State Food and Drug Administration) are the shame of the whole system and their scandals have revealed some very serious problems,” SFDA spokeswoman Yan Jiangying said at a news conference held to highlight efforts to improve China’s track record on food and drug safety.

“We should seriously reflect and learn lessons from these cases. We should step up our efforts to ensure food and drug safety, which is what we are doing now and what we will do in the future,” Yan said about Zheng and a separate case involving Cao Wenzhuang, the administration’s former pharmaceutical registration department director.

Is this an effective corrective action to the root causes of a problem?

To read the entire article, click here.

Barbara and I are both on vacation this week … so don’t look for many postings this week!

see this link

Root cause analysis skills needed.

see this link

Next time you need to shift the blame, make the guilty party obvious. Very handy during difficult accident investigations (only $4.95 to shift the blame for a lifetime — not bad!):

http://www.eastbankcom.net/shift/finger.html

Sometimes investigations of accidents border on the bizarre.
The attached PowerPoint has been around the internet several times but I still find it amazing.

Where is my Dozer.ppt
click above to open PowerPoint

Imagine performing the root cause analysis of this strange accident…