Root Cause Analysis Blog

A magazine sponsored a Dilbert quotes contest. They were looking for people to submit quotes from their real life Dilbert-type managers. Here are a few of the entries:

“We know that communication is a problem, but the company is not going to discuss it with the employees.” (Switching Supervisor)

Quote from the Boss: “Teamwork is a lot of people doing what I say.” (Marketing Executive)

“E-mail is not to be used to pass on information or data. It should be used only for company business.” (Accounting Manager)

“Doing it right is no excuse for not meeting the schedule. No one will believe you solved this problem in one day! We’ve been working on it for months. Now, go act busy for a few weeks and I’ll let you know when it’s time to tell them.” (R&D Supervisor)

“What I need is a list of specific unknown problems we will encounter.” (Engineering Manager)

And the winner was:

“As of tomorrow, employees will only be able to access the building using individual security cards. Pictures will be taken next Wednesday and employees will receive their cards in two weeks.” (Security Manager)

It seems that every profession has to create its own language.

For example, if you want to be a nuclear industry root cause analyst, you have to know what a CAPER is.

If you are interested, click on the link below to find out!

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In a recent article in its Up To Date Newsletter, OSHA has committed to performing enforcement inspections at all 81 refineries under its jurisdiction.  This is all part of its National Emphasis Program, which will target process safety management and compliance.  This is in response to the Chemical Safety Board’s report of the Texas City refinery explosion in 2005.

A major emphasis will undoubtably be equipment maintenance, operability, and integrity.  The BP refinery disaster highlighted a list of failed equipment problems, including:

• Failed tower level transmitter
• Failed remotely operated vent valve
• Unreadable Tower level sight glass
• Failed tower high level alarm
• Failed blowdown drum high level alarm
• Failed automatic level control system

All of these were known, (poorly) documented problems that were allowed to exist even before the unit start-up.

How many problems are we living with in our day-to-day operations?  How many recurring problems do we continue to fix as they occur?  Often, a simple root cause analysis of a particular failure will quickly uncover the underlying problems that are allowing these failures to exist in the first place, and continue to exist on a long-term basis.

Equifactor is great supplement to a process hazard analysis.  By understanding how your critical equipment can fail, you can factor undiscovered failure modes into your analysis.  This additional layer of protection may allow you to pinpoint and correct these types of problems from within your already-established PSM program.

See:

http://www.bayt.com/job/job.adp?xid=551446

I presented my paper at the IEEE/HPRCT Human Factors and Power Plants Conference. The paper for today is titled:

Improving and Existing Root Cause Analysis and Corrective Action Program

I had two attendee participation sections of the talk. These mini-Kaizen events required small teams to develop ideas based on Lean thinking to improve root cause analysis.

The first session looked at problems that cause waste in root cause analysis. The teams identified a waste type and develop a possible solution.

Heres what the teams said:

1. Waste: In an investigation, do things (interviews, evidence collection, …) over and over and waste time and effort because we didn’t plan enough before starting the investigation.

Solution: Better training for people so that they will be more efficient in performing the investigation, especially the pre-investigation planning.

2. Waste: People (including the facilitator/team leader) change in the middle of an investigation or multi-tasking (trying to get their regular work done) plus doing investigations just for political reasons.

Solution: Management needs to value investigations so that they assign adequate resources. Also, management need to stop requiring political investigations. How to get this accomplished? ????

3. Waste: Can’t get buy-in to corrective actions and waste time responding to push-back to effective corrective actions.

Solution: Involve management in corrective action development.

4. Waste: Takes to long to assign an investigator (evidence disappears, people’s memory isn’t fresh).

Solution: Pre-select and designate investigators and assignment is automatic.

5. Waste: CARB (Corrective Action Review Board) review and approval of an investigation is a waste of time (doesn’t add value).

Solution: Get good scope and charter from senior manager up-front. Give charter to CARB before review. May avoid the “You brought me the wrong rock” syndrome. Also, have a standard design for reports. May also eliminate CARB review of report (it is the team’s report) and only allow CARB to select corrective actions to implement.

6. Waste: Can’t get qualified people assigned OR not enough people assigned OR assign a single investigator when a team was needed. Insufficient or incorrect resources cause delays and waste.

Solution: Get adequate pool of people (cross functional) trained and assigned to investigations from a full-time investigator pool.

7. Waste: Interviewing does not get “fresh” information - all the stories are too much the same. Waste time collecting the decided upon story.

Solution: Develop a standardized list of questions focusing on the “What” on-line to be completed by the supervisor before the crew goes home.

8. Waste: Time wasted trying to gather information at the scene.

Solution: Provide supervisor with evidence collection form and training on evidence preservation/collection.

9. Waste: Waiting to decide to investigate an incident while management decides if the investigation is worth investigating.

Solution: Assign a single person to decide if an investigation is required.

The second attendee exercise was to look at there root cause analysis system and Corrective Action Program and make it more efficient by applying lean thinking. They could choose one of three topics to attack:

1. What does the customer want (Customer Focus)?
2. Process improvements (making your root cause process more efficient).
3. Apply 5S (Sort, Set Order, Standardize, Shine, & Sustain)) to improve your root cause analysis.

Here is what the teams reported were their ideas:

1. Customer Focus: Educate the customer. Head CAP guy ASKS senior management sponsor what they want and then discuss what root cause analysis can produce.

2. Apply 5-S:

Sort - Sort incidents into equipment or human performance

Set Order - Develop a checklist for the investigator.

Standardize - Adopt a standard report format.

Shine - Provide training to have proficient investigators/teams.

Sustain - Do evaluations of investigations an improve as required.

3. Process Improvement: Instead of department head assigning an investigator and the “letting go” of the investigation, the department manager should assign the investigator/team and then get daily/weekly feedback (updates) from the team.

4. 5-S:

Sort - Sort out tools required for investigation.

Set Order/Standardize - Organize tools into a standard toolbox and a standard list of questions to be asked. .

Shine/Sustain - Continue to use tools.

5. Customer Focus: Develop a written charter and scope and provide it to the CARB and (if applicable) get the DOE (Department of Energy) rep involved early. Provide training for managers and management sponsor so that they understand the process and the value added. Must determine what the customer wants.

6. Customer Focus: CARB  should want (and focus on) preventing incident recurrence. How do you sell root cause analysis is designed to prevent incident recurrence/prevention? Need to understand CARB’s mental model. Need high level by-in to CARB reviews to prevent CARB membership from becoming a revolving door.

7. 5-S of Prep for Investigation:

Sort - Sort out what is needed to perform investigation. Tools, projector/computer, interview sheets, measurement devices…

Set Order - Get a box or room and put all the “stuff” needed there. Pre-set-up..

Standardize - Checklist for replentishing supplies so that the room stays properly stocked. .

Shine/Sustain - Keep the room/box stocked so that it is always ready.

8. 5-S:

Sort - Develop a list of info requirements for an investigation including extent of condition and extent of cause. Also list should include who should be on a team for types of investigations.

Set Order - Develop a standard investigation order that includes checking operating experience.

Standardize - Develop a standard procedure for performing an investigation … a checklist!.

Shine - Continue to look at  priorty/order of steps in an investigation. .

Sustain - Conducting assessments of investigations to improve.

9. Process Improvement: Why do people not want to do investigations? Look at investigation requirements and plan/look at time required/what is required. Make investigation their primary duty. Give people the time needed to do a proper investigation. Have a senior level manager champion to make sure resources are available.

- - -

One more idea. After the presentation someone suggested:

Have “in-process peer reviews” rather than post-investigation peer reviews. Designate the reviewer when the team is assigned and have them perform continuous reviews as the investigation progresses. MUCH MORE effective than post investigation review. Also, people must perform investigations frequently enough so they don’t forget lessons learned about performing better investigations.

Here are some recent reports from the UK RAIB:

The Rail Accident Investigation Branch (RAIB) has released its report into signal T172 passed at danger at Purley station on 18 August 2006. The RAIB has made five recommendations as a result of the report. Full report at:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report272007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into the derailment of a tram on the Croydon Tramlink on 25 May 2006. The RAIB has made two recommendations as a result of the report. Full report at:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report282007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a collision at Pickering station on the North Yorkshire Moors Railway on 5 May 2007. The RAIB has made two recommendations as a result of the report. Full report at:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report292007.cfm

See:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=117853

I’m off to the IEEE/HPRCT Human Factors and Power Plants Conference in Monterey, CA. The conference starts on Monday so don’t look for my regular posting (I’ll try to post anything interesting that I observe).

What am I talking about at the conference? Two topics…

Improving and Existing Root Cause Analysis and Corrective Action Program - Tuesday, 10:30 - 12, in San Carlos 1 room

Positive vs. Negative Enforcement - Which Promotes High Reliability Human Performance - Wednesday, 8:30 - 10, in San Carlos 2 room

If you are attending, stop by one or both of my sessions and say Hi!

A safety officer, a safety manager and a safety director were walking through a park on their way to lunch when they find an antique oil lamp.

They rub it and a Genie comes out in a puff of smoke. The Genie says, “I usually only grant three wishes, so I’ll give each of you just one.”

“Me first! Me first!” says the safety officer. “I want to be in the Bahamas, driving a speedboat, without a care in the world.”

Poof!

He’s gone.

“Me next! Me next!” says the safety manager. “I want to be in Hawaii, relaxing on the beach with my personal masseuse, an endless supply of pina coladas and the love of my life.”

Poof!

He’s gone.

“You’re next,” the Genie says to the safety director. The director says, “I want those two back in the office after lunch.”

One Michigan woman claims she has trouble chewing, talking and sleeping since eating the fruit chew candy:

Sweet Tooth Story

See:

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

See:

http://www.redgoldfish.co.uk/jsviewjob.asp?jid=224893

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

This week we tackle the hottest topic in the tech support area here at TapRooT HQ: What to do about Vista? Some version of Vista will run the 4.0.x System Software just fine, while others give an error such as “Run Time Error 52″.

How do you fix this? There’s more inside!
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See the link below for an AP story on incidents at a nuclear fuel plant in Erwin, TN.

http://www.chron.com/disp/story.mpl/nation/5069951.html

I know that reporters have to make their stories readable, but does the author, Ducan Mansfield, have to be so sensational?

Words and phrases like:

“three-year veil of secrecy”

“could have caused a deadly, uncontrolled nuclear reaction”

“revealed”

“stinging letter”

seem to be used to sensationalize administrative action to keep national security issues secret while releasing information about incidents at the Nuclear Fuel Services plant.

If the author wanted to, he could have used this sensational headline:

“Environmental Activists Disregard National Security
in Hopes of Damaging the Nuclear Industry”

What can incident investigators learn from this? Don’t think that your incident investigations will receive fair and balanced coverage.

Environmental activists and reporters may have an agenda. Whether the agenda is to get a story published or to damage a company, regulatory agency, or industry, may not be clear - but it makes little difference if your company’s reputation is damaged in the process.

The recent Skype outage provided some interesting fodder for root cause analysis. See the incident description at this link:

http://heartbeat.skype.com/2007/08/the_microsoft_connection_explained.html

The best “network” root cause analyst I know is Gerald Starling. He is a TapRooT® User who learned to find real root causes (rather than symptoms) while working at BellSouth.

With network/IT reliability being such a big issue in the internet age, you would think that more IT folks would be applying advanced root cause analysis and get beyond troubleshooting symptoms. Unfortunately, most people think they have found a root cause when they find a piece of code that can be fixed that stops the problem. Thus they stop at the symptom (Causal Factor in TapRooT®ese) and never fix the true root causes.

See:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=107629

See:

http://www.northcountrygazette.org/news/2007/08/16/ayu_fine/

Tailchi Ohno, the creator of the 5-Why technique, is quoted using the following example to demonstrate using 5-Why’s for root cause analysis:

1. “Why did the robot stop?”

The circuit has overloaded, causing a fuse to blow.

2. “Why is the circuit overloaded?”

There was insufficient lubrication on the bearings, so they locked up.

3. “Why was there insufficient lubrication on the bearings?”

The oil pump on the robot is not circulating sufficient oil.

4. “Why is the pump not circulating sufficient oil?”

The pump intake is clogged with metal shavings.

5. “Why is the intake clogged with metal shavings?”

Because there is no filter on the pump.

What do you think? Is “NO FILTER ON THE PUMP” a root cause?

Let me know your comments.

And if the inventor of 5-Why’s uses this as an example, should people call 5-Whys a root cause analysis technique?

See:

http://news.gov.hk/en/category/healthandcommunity/070817/html/070817en05004.htm

For more information see:

http://www.chron.com/disp/story.mpl/nation/5066044.html

See:

http://www.chron.com/disp/story.mpl/world/5064742.html

See:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=116882

Safety Coordinator
Date Submitted: 2007-08-16
Hiring Organization: Mayo Clinic
Location: Rochester, MN
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See this link:

http://www.psqh.com/julaug07/tortreform.html

Linda Unger, Tom Brower, and I are teaching a very full 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Seattle. The pictures below prove that we (and the students) really are there and we aren’t just goofing off in the great weather.

Why are TapRooT® courses full of people intensely learning? because the training is interesting, interactive, and very applicable if you are involved in improving performance, investigating accidents/incidents, or performing audits to evaluate and improve performance.

If you haven’t attended a TapRooT® Course and you are interested in root cause analysis, you should get signed up and find out what everyone else is learning about and what you are missing (so far).

For more information about TapRooT® Training, see:

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

For more details see:

http://jobview.monster.com/getjob.asp?JobID=60413350&JobTitle=Technical+Safety+Manager&q=taproot&sort=dt&brd=1&cy=US&vw=b&AVSDM=2007-07-24+16%3a33%3a00&pg=1&seq=6

For more information see:

http://www.gadball.com/Jobs/Details.aspx?jID=8330913&AspxAutoDetectCookieSupport=1

For details see:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=116300

If you get stuck in “stop and go” commuter traffic tonight, look around. There’s always bumper sticker wisdom (like the tidbits below) to help you pass the time:

As long as there are tests, there will be prayer in public schools.

I want to die in my sleep like my grandfather… Not screaming and yelling like the passengers in his car…

We are Microsoft. Resistance Is Futile. You Will Be Assimilated.

Cover me. I’m changing lanes.

I brake for no apparent reason.

Change is inevitable, except from a vending machine.

Time is what keeps everything from happening at once.

Born free…Taxed to death.

I get enough exercise just pushing my luck.

I didn’t fight my way to the top of the food chain to be a vegetarian.

OK, who stopped payment on my reality check?

It’s lonely at the top, but you eat better.

According to my calculations, the problem doesn’t exist.

Pride is what we have. Vanity is what others have.

How can I miss you if you won’t go away?

Make it idiot-proof and someone will make a better idiot.

Be nice to your kids. They’ll choose your nursing home.

Why is ‘abbreviation’ such a long word?

Always remember you’re unique, just like everyone else.

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

Washington, DC, August 9, 2007 - An investigative team from the U.S. Chemical Safety Board (CSB) has been deployed to the site of Tuesday’s acetylene fire at the Hughes Christensen Co. manufacturing facility in The Woodlands, Texas, a suburb of Houston.

The CSB deployed a team to the serious explosions and fire at Southwest Industrial Gases Inc. in Dallas on July 25 that caused three injuries, destroyed the facility, and forced the temporary closure of major highways.  Preliminary examination of news video suggests the involvement of a similar delivery trailer of Western International Gas and Cylinders Inc. in both incidents.  The trailers in the Dallas incident were destroyed by the fire.  This week’s incident reportedly resulted in the evacuation of 800 employees.

CSB Investigator Robert Hall, P.E., who will lead the three-member investigative team said, ‘We will be examining the Hughes Christensen incident to see if there are further similarities to the Dallas fire.’

Hughes Christensen Co. is an oil drilling bit manufacturer.  The company is a subsidiary of Baker Hughes Inc., a Houston-based oil field service company.  Western International Gas and Cylinders Inc. is a supplier of industrial welding gases based in Belleville, Texas.

For more information, please contact Public Affairs Specialists Jennifer Jones at (202) 261-3603 or Hillary Cohen at (202) 261-3601.

To download the articles (pdf’s) click on these links:

http://www.fra.dot.gov/downloads/safety/fatiguewhitepaper112706.pdf

http://www.fra.dot.gov/downloads/Research/ord0621.pdf

Safety, Health and Environmental Job Openings (July 27, 2007)

Paul Shrenker Associates, Inc., has a list of Safety, Health, and Environment job openings at http://www.psassociatesinc.com/jobopenings.htm.

The list changes weekly so check back from time to time if you are interested.

Below is a movie of a crane accident that was sent to me by John Grout (mistake proofing expert).

click on the box above to view movie - WMV format

John was waiting at the light when the accident occurred. The video came from a police car that just happened to be driving by.

What can you learn from this movie?

One thing you might not think about when performing an investigation is all the sources of evidence.

Did anyone capture the accident on video tape?

You may even consider installing security cameras for dual purposes - security and evidence for future investigations. And don’t forget to record audio (like the airplane black boxes do).

LOCATION: New Jersey, Ohio, California, North Carolina

Company Name: Search Enterprises, Inc

CHEMICAL, PETROCHEMICAL, REFINERY & PHARMACEUTICAL RECRUITERS

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click on pdf below.

This fellow tied some interesting helium balloons to his truck before jumping on the Interstate. Wonder what the other drivers thought?? Click below for picture.

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For details on the job opening see:

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

Here’s a link to a security video that caught the collapse on tape:

http://www.cnn.com/2007/US/08/02/bridge.safety.ap/index.html#cnnSTCVideo

Press release from the NTSB:

Washington, DC — The National Transportation Safety Board is sending a Go Team to Minneapolis, Minnesota to investigate the collapse of a highway bridge there this evening.

Gary Van Etten has been designated Investigator-in- Charge of the seven member team. NTSB Chairman Mark V. Rosenker will accompany the team and serve as principal spokesman for the on-scene investigation. Terry Williams is the press officer traveling with the team.

Once the team arrives in Minneapolis Thursday morning, Mr. Williams can be reached on his cell phone at (202) 557- 1350.

NTSB Public Affairs: (202) 314-6100

Of course I’m saddened by the loss of life that occurred when an interstate bridge spanning the Mississippi River collapsed. But I can’t help thinking of the broader implications of this failure.

Click for video of fallen bridge.

Fox News, CNN, MSNBC, and even the Weather Channel were talking about the tragic collapse. The TV talking heads we already starting to either guess, or ask their guests to guess, what the causes of the collapse were. In all the coverage I only saw one true bridge expert, who seemed credible, explain how metal fatigue (fatigue cracking) could lead to this type of failure. Most of the other anchors, on-scene reports, and experts babbled endlessly to fill the airtime.

These people obviously needed instant root cause analysis.

Our 24 hour news cycle can’t wait for real answers at to what happened and how a bridge could fail so dramatically and tragically. And our political system can’t wait until they start pointing fingers and placing blame.

A good example of this is the post Katrina coverage of the levee failures. Only recently has the information become available as to the long history of failures that caused that disaster. But the press coverage of that history - that includes legislative failures, compromises of public safety due to environmental lawsuits, and issues of project management by the Corps of Engineers - has been almost nonexistent. They couldn’t wait for a detailed analysis of the facts. Instead, they jumped on the blame train.

What can you learn from this disaster at this early stage? First, if you are responsible for investigations of major accidents at your company, you had better be ready to deal with the press. They won’t be willing to wait for a detailed root cause analysis and they will get “experts” on the air to explain what “might have gone wrong.” You need to express concern and genuine sadness (which should be easy because you will be concerned and genuinely saddened) and then explain what you will be doing to find the real root causes of the accident without jumping to premature conclusions.

Another lesson learned from this accident could be that incident investigators need to be prepared to start an investigation and find out what happened and how it happened as quickly as possible to provide real information to the press rather than pure speculation. However, you should always caution those who will listen that WHAT HAPPENED and HOW IT HAPPENED still is not the ROOT CAUSES of WHY IT HAPPENED! What and how are just the information you need to draw your SnapCharT®. Further detailed, systematic analysis is required to find root causes.

What if you are senior management? You need to restrain your initial urge to jump to conclusions and start placing blame. This will be difficult because if you don’t find someone else to blame, you may become the target for blame. The example of how wrong this initial urge to place blame can go was demonstrated by the BP Texas City Refinery explosion aftermath. The entire senior management chain - from the Plant Manager to the CEO of a major corporation left the company under a cloud - either voluntarily or by being fired - after they tried to place the blame for the accident on the operator and the supervisor involved in the incident.

Perhaps the most important lesson learned at this point is that the best way to avoid the whole post-accident blame cycle is to avoid the accident entirely.

After the accident, the need for previous fixes is always apparent. However, to have truly excellent, zero accident performance requires management that carefully listens to the voice of the facility expressed by the root cause analyses of incidents, near-misses, audits, and proactive improvement initiatives. That’s why senior management needs a through understanding of advanced root cause analysis and performance improvement - something that is almost completely missing from the senior ranks of government as well as the senior ranks of many companies. Perhaps this is why disasters - natural or man-made - continue to create a constant supply of tragic headlines.

Some readers may be thinking - “HOLD ON, OUR MANAGEMENT UNDERSTANDS ROOT CAUSE ANALYSIS!” I’m sorry … 5-Whys, fishbone diagram, and brainstorming won’t do the trick. They aren’t advanced root cause analysis. They won’t produce the results needed to accurately and consistently find the read root causes of problems.

Government decision making and major corporate failures are notoriously hard to analyze. Government decision makers who started the chain of events or kept it progressing may be long gone. And the way major disasters are analyzed - with “blue ribbon commissions” - seldom produce the permanent change needed to change dysfunctional organizations.  The commissions are appointed by the powers-that-be and are often full of people either interested in ensuring that their political party or organization isn’t blamed (or the other party or organization is blamed) or have an agenda that skews their analysis.

This leaves us with the sad reality that disasters will probably continue to produce headlines because the knowledge and systematic processes needed to stop accidents probably won’t be learned by a large enough fraction of the population to demand change from our elected officials and corporate leaders.

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

Washington, DC, July 31, 2007 -The U.S. Chemical Safety Board (CSB) today released a new Safety Video concerning the dangers of uncontrolled chemical reactions. The video features computerized simulations and descriptions of four major reactive chemistry accidents investigated by the CSB, as well as commentary by two prominent chemical process safety experts.

Entitled ‘Reactive Hazards: Dangers of Uncontrolled Chemical Reactions,’ the video is being released simultaneously with the CSB’s final report on the Synthron accident which killed one worker and injured 14 others in Morganton, North Carolina, on January 31, 2007. The video features a computer animation of that tragedy narrated by lead investigator Jim Lay. The CSB Synthron report is being released at a news conference this morning at 11:30 a.m. in Charlotte, NC.

Other accidents discussed in the video are MFG (Dalton, Georgia); BP Amoco (Augusta, Georgia); and First Chemical Company (Pascagoula, Mississippi). 

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The Spin-A-Cause™ looks different in Spanish but the need for advanced root cause analysis is just as great in Mexico as it is in the rest of the world. And that’s what these visitors to the booth are discussing…

If you have employees that would like to learn TapRooT® in Spanish, consider the upcoming 5-Day TapRooT® Advanced Root Cause Analysis Course being held in Monterrey, Mexico, on October 8-12.

RAIB Investigation Updates and New Reports

The RAIB is carrying out an investigation into an incident on Croydon Tram…

The RAIB is carrying out an investigation into a derailment at Mile End…

The Rail Accident Investigation Branch (RAIB) has released its report into a fatal accident involving a shunter at Dagenham Dock on 17 July 2006. The RAIB has made seven recommendations.

The Rail Accident Investigation Branch (RAIB) has released its report into the derailment of a freight train at Maltby North, on a freight only line between Doncaster and Worksop, on 28 June 2006. The RAIB has made four recommendations.

The Rail Accident Investigation Branch (RAIB) has released its report into a derailment at Trooperslane near Carrickfergus, Northern Ireland, on 23 April 2006. The RAIB has made eight recommendations.

The Rail Accident Investigation Branch (RAIB) has released its report into a possession irregularity near Manor Park on 19 March 2006. The RAIB has made three recommendations.

Above is a pdf of an independent report sponsored by the Army Corps of Engineers. Very interesting reading.

Digging in to it made me want to draw a SnapCharT®, define the Causal Factors, and start through the Root Cause Tree®. The problem is that the information is so extensive and the sequence of events is so long that it would takes weeks - or maybe months - to do a good, thorough root cause analysis. Then we would be ready to analyze Generic Causes and start developing corrective actions.

I already have so much to do that I just can’t find the time to dig in, find the root causes, and answers to fix the problems. To tell the truth, I barley had time to read the report (ah - great vacation reading).

Plus, my guess is that the Management System causes (of which there seem to be many) would require the government - local and national - and even Congress to change. Sometime you shouldn’t start a root cause analysis if you aren’t ready (or able) to fix the problems you find because root cause analysis without the ability to implement corrective actions is a waste of time.

Marco sent these pictures from a course recently completed in Mexico to Certify a Halliburton TapRooT®  instructor…

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

Charlotte, NC, July 31, 2007 - In a final report released today on last year’s fatal explosion at the Synthron chemical manufacturing facility in Morganton, North Carolina, the U.S. Chemical Safety Board (CSB) concluded that the company’s management of reactive chemical hazards was inadequate and that the facility was unprepared for a chemical process emergency.  The CSB also found that ineffective corporate oversight by French parent company Protex International contributed to the likelihood and severity of the accident.

The explosion occurred on January 31, 2006, as the result of a runaway chemical reaction in a 1500-gallon process vessel inside the Synthron production building.  One worker was fatally burned and fourteen others were injured, two seriously.  The blast destroyed the facility and broke windows up to one-third of a mile away.  Two churches and a home were damaged and were later condemned.  Synthron filed for bankruptcy following the accident, and the facility has not been rebuilt.

The CSB released a two-minute computer-animated video depicting the sequence of events that led to the Synthron explosion.  This computer animation is part of a new 20-minute CSB safety video on reactive chemical hazards, which was also released today.  The video will be distributed worldwide in an effort to draw increased attention to the dangers from uncontrolled chemical reactions.

‘The accident at Synthron emphasizes the need for effective corporate oversight, emergency planning, and reactive chemical process training and safeguards,’ said Board Member John S. Bresland.  ‘If these measures had been in place, this accident could have been prevented.’

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It’s been a long time coming but if you are in the UK you should start thinking about your corporate criminal liability if your company is found responsible for a fatality. The new law takes effect on April 6 of 2008. For more information see:

http://www.shponline.co.uk/article.asp?pagename=news&article_id=6363

http://cps.gov.uk/legal/section5/chapter_b.html