Root Cause Analysis Blog

Perhaps the biggest nuclear accident occurred in Russia in 1957. The accident, virtually unknown because of secrecy at the time, wasn’t announced until 1989.

For an AP article about the accident memorial and Greenpeace protest, see:

http://www.iht.com/articles/ap/2007/09/29/europe/EU-GEN-Russia-Nuclear-Accident.php

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For a short article about computer security incidents, see:

http://www.first.org/newsroom/globalsecurity/155335.html

Yes - people have and do use TapRooT® to analyze the root causes of security incidents - even computer security incidents.

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Opportunity is in Al Madina Al Munawarah, Saudi Arabia.

(more…)

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Salary $65-72K

Must have BS

For more info see:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=120734

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What is the “Never Event” Pledge?

If a hospital agrees to the Never Event Pledge, the hospital pledges to:

• Apologize to the patient and/or family affected by the never event;
• Report the event to at least one of the following agencies: the Joint Commission, a state
reporting program for medical errors, a Patient Safety Organization;
• Perform a root cause analysis, consistent with instructions from the chosen reporting
agency; and,
• Waive all costs directly related to the serious reportable adverse event.

Since this seems very reasonable, it seems surprising that more hospitals have not agreed to the pledge.

For the complete press release from the Leapfrog Group about this survey, click on the link below.

(more…)

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For details see:

http://news.bbc.co.uk/2/hi/uk_news/england/humber/7014566.stm

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This is a different, but not recommended, way to wait at the railway crossing. I can’t imagine how this happened, but it was probably better than getting hit by the train . . .

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The UK Rail Accident Investigation Branch (RAIB) has released a investigation report into a collision between a train and a road vehicle on the M20 overline bridge at Aylesford on 5 February 2007. The report contains six recommendations. For details see:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report362007.cfm

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Marine Safety Alert 4-07
United States Coast Guard Headquarters
Washington, DC

Hammar Manual Remote Release System Pneumatic Pump Units

An investigation into the circumstances surrounding a recent passenger ship grounding revealed difficulties the crew had in manually deploying the vessel’s liferafts from their mounting cradles.  The liferafts were fitted with individual Hammar Manual Remote Release System (MRRS) pneumatic vacuum pump units.  When the pumps are manually operated a vacuum is quickly and easily created that actuates a corresponding Hammar H20 hydrostatic release unit. In this case a large number of those pumps failed to activate the hydrostatic release units and, ultimately, the crew had to manually cut the liferaft canister lashings.  The crew was able to launch all of the vessel’s liferafts successfully in this manner.

The casualty investigation is not complete and additional recommendations are likely to follow.  However, in the interim, the United States Coast Guard strongly recommends that Hammar MRRS pneumatic pump units, as well as all other survival equipment, be maintained in accordance with the manufacturer’s recommended maintenance schedules.

MRRS pump units are clearly marked in black letters on a yellow background on the cylinder housing, “Lubricate piston every second year.”  The pumps that failed had not been lubricated as required. The malfunctioning MRRS pumps were replaced in kind with new units; USCG inspection showed that the new units operated properly.  Owners, operators, port engineers, inspectors and others involved in vessel safety should ensure that all appropriate steps are taken to properly maintain survival equipment.

Questions or comments regarding this safety alert may be addressed to Mr. George Grills of the U.S. Coast Guard Headquarters Lifesaving and Fire Safety Standards Division at 202.372.1385 or george.g.grills@uscg.mil.

This safety alert is provided for informational purposes only and does not relieve any domestic or international safety, operational or material requirement.

Released by: Office of Investigations and Analysis http://marineinvestigations.us

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Last week Steve Swarthout, TapRooT® Instructor, taught a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course for miners in Lima, Peru. He sent the following picture of people hard at work learning ways to understand and solve problems and improve performance by using TapRooT® …

Are you interested in having on-site TapRooT® Training for your company? Contact us for a quote and to arrange dates. Dates for 2007 are filling up fast, so don’t wait!

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KUALA LUMPUR, Malaysia  Nov 2

EDMONTON, Canada Nov 21

NEW ORLEANS Nov 30

LAS VEGAS Dec 12

Save time & money when learning advanced equipment troubleshooting. Prior TapRooT® Course attendees can attend just the last day of a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course to learn Equifactor® for equipment troubleshooting. These skills help you find the root causes of equipment problems and improve equipment reliability. Even non-equipment experts can learn to investigate equipment problems. Plus, take these extras back to work:

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

The book and the software cost $1615 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.

Learn more about this course at: www.taproot.com/courses

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Even those intimately familiar with the terrain can make mistakes.

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CNN and the Associated Press report that a special effects technician died when a camera truck, performing a test run, struck a tree. The accident occurred at a racetrack south of London. The UK Health & Safety Executive will be investigation the accident.

For more information see:

http://www.cnn.com/2007/SHOWBIZ/Movies/09/25/film.setdeath.ap/index.html

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Associated Press and the BBC report that three crew members employed by Vroon Offshore Services Ltd in Aberdeen, Scotland, were found unconscious in a storage area aboard the rescue vessel Viking Islay. The three men had been working to secure an anchor chain. The vessel had been supporting the Ensco 92 drilling rig on BP’s Amethyst Field in the North Sea.

The ship returned to port in Immingham, Scotland, on Monday and the UK Marine Accident Investigation Branch has started an investigation and root cause analysis.

For more information see:

http://news.bbc.co.uk/1/hi/england/humber/7011856.stm

http://www.maib.gov.uk/latest_news/index.cfm

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TapRooT® Summit
Las Vegas
June 25-27, 2008

Plan to attend the 2008 TapRooT® Summit. This once a year summit of performance improvement experts is your chance to:

• Learn best practices;

• Network with people from a variety of industries … people who are facing the same issues that you face;

• Learn the latest advanced improvement technology;

• Be inspired by outstanding keynote speakers; and have FUN!

What do we have planned for 2008? Four of the 5 keynote speakers have been set …

The Doctor of Dreams, Marcia Wieder, will inspire you to achieve your dreams for improved performance at your facility.

Olympic champion, Nikki Stone, will share the lessons of overcoming an injured back to win the gold in aerial skiing.

Ed Frederick, Board Operator during the accident at Three Mile Island and now a performance improvement professional, will provide an inside view of the TMI accident and explain how it impacted those caught in the turmoil.

Lt. Col. Ralph Hayles, who will share his story of blame after a friendly fire incident during the first Gulf War.

That’s just the start.

Here’s just a sample of the breakout sessions:

• How to Identify Culture Issues When Performing a Root Cause Analysis

• Exelon’s Error Free Performance Tool

• Dr. Chiodo - Changing Behavior by Praising 49 Character Traits

• How to Get and Keep Management Support

• Latest Human Performance Improvement Ideas from the Institute of Nuclear Power Operations

• Dealing with Obstacles that Make Change Difficult

• Advanced Behavioral Management: Developing a Modern Safety Culture

• Is There a Tradeoff Between Process Safety and Industrial Safety?

• Managing the Risks of Change

• Advanced Behavioral Management: Developing a Modern Safety Culture

• Root Cause Analysis of Major Accidents

• The Good, The Bad, and The Ugly: Rating Improvement Programs & Incident Investigations

• What Do Managers Need to Know About Performance Improvement & Root Cause Analysis

• Bringing Safety to the Corporate Board

• What the Corporate Board Needs to Know About Safety

• How to Get & Keep Management Support

• The Human Design Spec - Minimizing Errors While Working in a 24/7 World

• Better Corrective Actions By Using Corrective Action Tools

• Culture Shift Secrets - Changing Systems to Shift Cultures Towards High Performance

• How to Identify Culture Issues When Performing a Root Cause Analysis

• Measuring Performance

• Pursuing Process Excellence - What it Takes to be One of the Best

• Morbidity & Mortality Reviews (Hot Case Rounds)

• Improving Patient Safety & Reducing Risk Go Hand in Hand

• MEDCAS

• Process for Running a Healthcare Root Cause Analysis

• Engineering Methods for Improving Equipment Reliability

• Hienz Bloch Day (a day of knowledge from Heinz and Ken Bloch)

• Maintenance Best Parctices

•  What’s New in TapRooT® Version 5 Software: A User’s Forum

• TapRooT® Software Techniques & Administrator Best Practices

• TapRooT® Version 5 Software Implementation (From Installation to Configuration)

• Trend Analysis Tools in TapRooT® Version 5 Software

ALSO, there will be 7 Networking/best Practices Sessions:

1. Transportation (airlines, air transport, shipping, rail, rapid transit, trucking) (Wednesday morning)
2. TapRooT® Advisory Board (Wednesday afternoon)
3. Manufacturing, Pharmaceuticals, & Food (Thursday Afternoon)

4. Oil E&P (Thursday Afternoon)
5. Refining, Petrochemicals, Chemicals, Plastics, Pipelines,& Terminals (Thursday Afternoon)
6. Mining (Thursday Afternoon)
7. Nuclear/Utility/DOE (Thursday Afternoon)

Another note…

We are planning on having a day (Friday) of special Spanish sessions for our Spanish speaking TapRooT® Users. These will be on Friday from 9:15 - 2:20.

And BEFORE the Summit we will be offering an extensive list of advanced courses, including:

2-Day TapRooT® Incident Investigation
& Root Cause Analysis Course

2-Day Equifactor® Equipment Troubleshooting
& Root Cause Analysis Course

2-Day Advanced Trending Techniques Training

Advanced Equipment Reliability Techniques Training

Advanced Interviewing & Evidence Collection Training

Stopping Human Error Course

Innovation & Creative Solutions

Risk Management Best Practices

Hazard Recognition Best Practices

Getting the Most from Your TapRooT® Software

TapRooT® and FMEA for
Healthcare Root Cause Analysis

So start planning to attend.

The Summit Fee is $995.

A Course and the Summit is $1890. (Save $200)

If you sign up 3 or more for the Course and the Summit the fee is $1690 each. (Save $400 each).

If you want to sign up 10 or more and hold a special company meeting at the Summit, call Mark Paradies or Linda Unger at 865-539-2139 to arrange your meeting and get additional discounts!

That’s all for now but be watching for the Summit web site when it’s ready:

www.taproot.com/summit

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OSHA came under considerable scrutiny after the BP Texas City explosion. The question most commonly asked was:

“Why didn’t OSHA spot the problems that led to the explosion and
stop it before the explosion and the loss of 15 people?”

Also asked was:

“Why didn’t the PSM rule keep this accident from happening?”

That focus on OSHA and the PSM Rule has led OSHA to focus more on refinery safety. Richard Fairfax, Director of OSHA’s Directorate of Enforcement Programs, told a US House of Representatives committee that, before the end of 2008, OSHA would conduct enforcement inspections at all 81 refineries under federal jurisdiction.

Thus refineries should be preparing for these inspections and improving their PSM implementation.

Areas where BP Texas City proved woefully inadequate were incident investigation and corrective action implementation. The accident at the Texas City Refinery was foretold by prior incidents. If these incidents had been addressed by implementing effective corrective actions to fix the incident’s root causes, there would have been no accident. Fifteen lives would have been saved!

If you are at a refinery, how are your programs in this area? Do you need to improve your incident investigation, root cause analysis, and corrective action implementation programs?

The TapRooT® System is used by many US and international refineries to enhance their investigation programs, improve safety, and improve process/ equipment reliability. If you are at a refinery that isn’t using TapRooT®, I’d recommend attending one of our courses to see what you have been missing.

What if you are at a refinery that is already using TapRooT®? You can still improve! One of the reasons that we sponsor the annual TapRooT® Summit is to give TapRooT® Users the chance to learn from the best practices of others and get the most from their use of TapRooT®.

But you can’t learn from the Summit if you don’t attend. What sessions should you attend? (There are so many good ones.) A single refinery probably needs several attendees … at least one for each of the following tracks:

1.  INVESTIGATION & ROOT CAUSE ANALYSIS BEST PRACTICES TRACK
• What’s New in Investigations and Corrective Action
• Investigation Lessons Learned from the Field
• Root Cause Analysis of the Accident at Three Mile Island (exercise)
• FACTS - Computerized Analysis of Fatigue as a Cause of an Incident
• TapRooT® User Best Practices
• Management and Performance Improvement
• TapRooT® User Success Stories from Healthcare & Industry
• Root Cause Analysis of Major Accidents (3 Investigation Presentations)
• Planning Your Improvements

2. CORRECTIVE ACTION PROGRAM BEST PRACTICES TRACK
• Innovative & Creative Solutions
• Evaluating the Effectiveness of Corrective Actions
• Using TapRooT® to Evaluate Common Causes & Extent of Condition
• Better Corrective Actions by Using Corrective Action Tools
• What Do Managers Need to Know About Performance Improvement & Root Cause Analysis
• How to Identify Culture Issues When Performing a Root Cause Analysis
• How to Get & Keep Management Support
• The Good, The Bad, & The Ugly: Rating Improvement Programs & Incident Investigations
• Root Cause Analysis of the Accident at Three Mile Island
• Planning Your Improvements

3. EQUIPMENT RELIABILITY & MAINTENANCE BEST PRACTICES TRACK
• How to Become Best of Class in Equipment Reliability by Maximizing Uptime - Heinz Bloch
• Best of Class in Equipment Reliability: Part II - Heinz Bloch
• Examples of Extreme Equipment Failure Investigations - Ken & Heinz Bloch
• Using TapRooT® to Solve Complex Equipment Problems - Ken Bloch
• Evaluating the Effectiveness of Corrective Actions - Brian Hennesey
• Engineering Methods to Improve Equipment Reliability
• Maintenance Best Practices
• Culture Shift Secrets – Changing Systems to Shift Cultures Towards High Performance
• Planning Your Improvements

4. SAFETY & RISK MANAGEMENT BEST PRACTICES TRACK
• Hazard Recognition: The First Step in Safety & Risk Management
• Dealing with Obstacles that Make Change Difficult
• Managing the Risks Associated with Change
• Root Cause Analysis of Major Accidents
• Advanced Behavioral Management: Developing a Modern Safety Culture
• Panel Discussion - Is There a Tradeoff Between Process Safety & Industrial Safety?
• TapRooT® User Success Stories from Healthcare & Industry
• The Good, The Bad, & The Ugly: Rating Improvement Programs & Incident Investigations
• Bringing Safety to the Corporate Board
• What the Corporate Board Needs to Know About Safety
• Planning Your Improvements

5. HUMAN ERROR REDUCTION & BEHAVIOR CHANGE BEST PRACTICES TRACK
• Exelon’s Error Free Performance Tool
• Human Performance Improvement Research
• Advanced Behavioral Management: Developing a Modern Safety Culture
• The Human Design Spec - Minimizing Human Error While Working in a 24/7 World
• Latest Human Performance Improvement Ideas from the Institute of Nuclear Power Operations
• Character Driven Success - Dr. Beverly Chiodo
• Changing Behavior by Praising the 49 Character Traits - Dr. Beverly Chiodo
• Innovative & Creative Solutions
• Planning Your Improvements

With all the knowledge you bring back to your refinery, you are sure to have one of the best incident investigation, root cause analysis, performance improvement, and corrective action programs in the industry.

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Engineer will work in final tractor assembly area to support manufacturing work teams in meeting their safety, quality, delivery and efficiency goals. Daily activities may include, but are not limited to: industrial engineering, ergonomic, quality, and efficiency improvements, and root cause analysis. For more info see:

http://www.hotgigs.com/logged_in/search/index.cfm?profileid=Ji5BPipZLkYiCg%3D%3D&userid=JS5BWixYXlwgCg%3D%3D&id=Ji5BPipZLkYiCg%3D%3D&page=viewsearchresults&Mode=G&override=true

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Do you need root cause analysis training?

Would you like to take a short holiday in early December?

Do you need to learn effective equipment troubleshooting techniques?

Do you like to gamble but you want a sure thing when you investigate incidents or solve equipment problems?

The the:

2-Day Incident Investigation and Root Cause Analysis Course on December 10-11

or the

3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course on December 10-12

both in Las Vegas, just might be the perfect combination!

For more course info click on the link above.

For course registration and hotel information see:

http://www.taproot.com/courses.php?d=284&l=1

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The Sydney Morning Herald reported that the head of surgery at Mount Druit Hospital complained about a recent root cause analysis and implied that staffing changes and shortages are a danger to emergency patients. For more information see:

http://www.smh.com.au/news/national/surgeons-fear-hospital-unsafe/2007/09/21/1189881777216.html

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For details see:

http://news.bbc.co.uk/2/hi/uk_news/england/shropshire/7006248.stm

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Brian Locker (the instructor in the back row - left - with the red shirt) sent this graduation photo from the 5-Day TapRooT® Advanced Root Cause Analysis / Equifactor® Equipment Troubleshooting Class he just completed for GE in Taiwan.

If you would like to schedule advanced training at your site, click here to contact us.

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If you are interested in attending a TapRooT® Root Cause Analysis Team Leader Course in Europe, the course on October 15-19 in Amsterdam is a great opportunity to learn and visit an amazing city.

Mark Paradies (President of System Improvements and one of the co-developers of the TapRooT® System) and Bryce Donaldson will be the instructors for the course.

The course will be held at the Marriott Hotel at Leidseplein Square.

Leidseplein is one of Amsterdam’s popular centers for nightlife, with theatres, cafes, restaurants, cinemas, the casino, the Lido theatre with live entertainment and music centres Paradiso and Melkweg. Street musicians, jugglers, fire-eaters and other performers make the square a lively place.

What else is there to do in Amsterdam. Here’s a link to World Travel’s guide page:

http://www.wordtravels.com/Cities/Netherlands/Amsterdam/Attractions

Hope to see you at the course!

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Have you signed up for the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in San Francisco? If so, your in for a treat. You course is being held at The Lodge at Tiburon - a small, freindly hotel in downtown Tiburon.

We’ve used the hotel for over a decade to hold TapRooT® classes and it’s one of my favorite places to teach.

Unfortunately, I’ll miss this class (I’ll be coming back from our Amsterdam course) but Ken Reed and Chris Vallee will be teaching - so your in for an excellent course.

The hotel has information about the area:

Area info

One of my favorite things to do is to take a 40 minute drive out to Muir Wood and visit the giant redwoods.

If you bring your significant other, think about getting a hot tub suite.

If they want something to do during the day, they can take the ferry over to Fisherman’s Wharf. From there you can get a tour of Alcatraz.

If they don’t want to go as far, they can just spend a day or two looking around the shops in downtown Tiburon and walk the San Francisco Bay Trail. Here’s a link to a recent review:

http://www.marinij.com/fastsearchresults/ci_4389996

There are lots of great restaurants within walking distance of the hotel.

Here’s a link to the Tiburon Wikipedia web site:

http://en.wikipedia.org/wiki/Tiburon,_California

If you haven’t signed up for this course yet, there are still a few seats and time to get your travel set. Here’s a link to the page to register for the course:

http://www.taproot.com/courses.php?d=241&l=1

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Oh, the difference a condiment can make:

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For more information, click here:

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Here’s the video:

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September 19, 2007
Marine Safety Alert 3-07 issued by the United States Coast Guard Headquarters, Washington, DC.

SECURING OF WATERTIGHT DOORS WHILE UNDERWAY

This safety alert reiterates the need for vessel operators to ensure that watertight doors are always closed while underway, except when being used for access.  This alert is the direct result of a collision between a 534′ cargo ship and a 166′ offshore supply vessel.  The incident occurred on the Mississippi River, in a restricted visibility situation.  As a result of the collision, the offshore supply vessel capsized and sank - the crew of five was lost.

During the ensuing investigation of this incident, evidence was uncovered that indicated the offshore supply vessel was operating with its watertight doors in the open position.  This is a violation of 46 CFR 174.210(e), which states that the master must ensure that a watertight door is always closed, except when being used for access. Watertight doors are a critical part of a vessel’s subdivision, and consequently a critical part of damage stability considerations, so the importance of keeping these closed is very obvious.  This becomes even more critical on smaller ships, which may only have one or two watertight doors to prevent flooding the entire length of the ship.

Please, keep these doors closed!

The Office of Design and Engineering Standards, Naval Architecture Division (CG-3PSE-2) developed this alert.  Questions pertaining to this safety alert may be addressed to LCDR Tracy Phillips at (202) 372-1373 or Tracy.Phillips@uscg.mil.

This material is provided for informational purposes only and does not relieve any existing domestic or international safety, operational or material requirement.

Released by: Office of Investigations and Analysis
http://marineinvestigations.us

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The Rail Accident Investigation Branch (RAIB) has released two reports on UK train accidents:

1. A collision at Swanage on 16 November 2006. The RAIB has made two recommendations as a result of their investigation, and three recommendations to address other matters observed during the investigation. See:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report352007.cfm

2. A derailment at Epsom on 12 September 2006. The RAIB has made three recommendations as a result of their investigation. See:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report342007.cfm

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See:

http://www.chron.com/disp/story.mpl/business/5146595.html

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The primary function of this position is to provide service and support in Asia pacific region on the failure analysis, risk assessment analysis and root cause analysis. The individual in this position is responsible for a wide variety of service related support functions including, but not limited to, the repair, maintenance on the DC/DC and power electronic products.

For more information see:

http://jobscentral.com.sg/viewSimpleProfile.php?eid=15034&jid=71903

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