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Archive for October 11th, 2007

Press Wants “Public” Access To MSHA Root Cause Analysis While it is in Progress - Federal Judge Says “NO”

Thursday, October 11th, 2007

You know I’m for good investigations and through root cause analysis of accidents with complete analysis of the Management System and any regulatory failures. And I think we all should have access to the results of government investigations. But the press is asking for access to a current - ongoing - MSHA investigation. I believe that kind of access is unprecedented and harmful. See if you agree…

MSHA is performing a root cause analysis of the Crandall Canyon Mine disaster. CNN, the Associated Press, the Salt Lake Tribune, the Denver Morning News and others filed a joint suit to STOP the investigation until a judge could decide whether the proceedings (the investigation) should be open to the public (see CNN story).

First, stopping a safety investigation by MSHA so that the press can see if they can be included seems totally outlandish to me. The CNN story makes it sound as if MSHA is covering up its mistakes and only the spotlight that the press can shine on an investigation will save the day and make MSHA come clean. And if the judge doesn’t see it like CNN sees it … the Congress should intervene! After all, it is CNN’s First Amendment (freedom of speech? - that’s their claim) right to have open access to the investigation.

Imagine being an investigator doing an investigation and having to bring the press along. If you think people (company owners, miners, and even MSHA employees) are reluctant to talk openly about their mistakes now, imagine if what they said was going to be the headlines in the morning paper (or on CNN) the next day.

Fortunately, the judge - U.S. District Judge Dee Benson - had better sense and looked at the Constitution. He wrote:

“Plaintiffs argue that the First Amendment mandates public access to the type of MSHA [Mine Safety and Health Administration] proceeding at issue in this case … They point, however, to nothing specific in the Constitution to support their claim.”

Good call Judge Benson!

How does CNN play this decision? They said:

“The press does not have the right to get access to the government’s investigation into the deadly August accident at the Crandall Canyon mine, a federal judge in Utah ruled Tuesday.

U.S. District Judge Dee Benson said there is no constitutional basis for him to make the investigation public.”

By the way, the press - just like everyone else - will have access to the COMPLETED investigation. MSHA posts fatality investigation reports on their web site and has a PRESS conference about major investigations when they are complete. The difference in this case is that the press has decided that they should be allowed to see the internal workings and raw data of the investigation.

Too me … that seems nuts!

Don’t get me wrong. I’m not naive. I know that government regulatory agencies - just like anyone else - doesn’t like to put their mistakes on public display. And there may be regulatory shortcoming in the mining permits that were approved for this mine. But the investigation and MSHA should be judged on their openness and honesty after the investigation is complete.

DISCLOSURE:

In the fairness of disclosure … MSHA is a TapRooT® User. We also have a former MSHA employee as one of our instructors.

That has nothing to do with my  belief that this request is nuts. But if I don’t disclose it … someone could say I was just trying to protect a client.

However, rather than protecting a client, I think I’m protecting self-critical analysis, investigations, and root cause analysis.

I firmly believe that the press does little to shine light on the root causes of disasters. (For example - Katrina.)

The press isn’t “bad” … it’s just that their timeline of interest is way too short to allow anything like root cause analysis. (See this article I wrote BEFORE any of this came out.)

The press should wait - like everyone else - for the investigation to be finished. Then they can criticize MSHA for not being self-critical enough IF that turns out to be the case.

Otherwise, I believe that total press access to an ongoing, detailed investigation would turn the investigation into a Hollywood press circus. The MSHA investigation of the Crandall Canyon Mine disaster would look more like the OJ Simpson trial.

I’m convinced, a politicized, instant answer press investigation won’t help improve mine safety - or safety anywhere. Their methods and time line just won’t allow it.

Do you agree or disagree? Let me know…

WEAPON FACTORY ACCIDENT IN BULGARIA KILLS ONE

Thursday, October 11th, 2007

The Sofia Echo reports an explosion and collapse of a warehouse roof killed one work at the Arsenal weapons plant in Kazanluk, Bulgaria.

For more see:

http://www.sofiaecho.com/article/worker-dies-in-a-weapon-factory-accident-in-bulgaria/id_25357/catid_66

Job Opening - GE Looking for a Lead Engineer - Fleet Support with TapRooT® Root Cause Analysis Skills

Thursday, October 11th, 2007

For details see:

http://www.bayt.com/job/job.adp?xid=616352

BBC Report - Second Accident Near (LNG) Jetty at Milford Haven in Pembrokeshire Causes Port Authority to Stop Activity Until Investigation is Complete

Thursday, October 11th, 2007

For more info see:

http://news.bbc.co.uk/2/hi/uk_news/wales/south_west/7035559.stm

Equifactor® and FMEA

Thursday, October 11th, 2007

 

Space-shuttleA Failure Mode Effect Analysis (FMEA) is used to determine the relative risks of a failure causing a specific effect, and then determining the priority of mitigating that particular failure mode.  It is used as a risk management tool to help determine where resources should most efficiently be spent.  Although usually used as a proactive tool, it can be applied after an accident during a root cause analysis to help determine what failure modes could have caused the effect seen.

One of the very first steps in conducting an FMEA is to know what failure modes are available.  You must know how the piece of equipment or the process can fail.  Where do you get this information?  There are several sources that are available:

  • System Experts at your facility
  • Equipment technical manuals
  • ISO standards (ISO-9000, QS-9000, ISO-16949, Mil-Std-1629A, etc)
  • Equipment troubleshooting tables

Another great source of information is the Equifactor® troubleshooting section of the TapRooT® Software.  For example, take a look through the Conveyor Belt tables, and start with the Possible Causes of failures.  This can lead you to failure modes that you may not have initially considered, including the causes of those modes.  By combining Equifactor® with other sources of information, you can ensure you have a complete list of possible problems to use during the FMEA process.

Job Opening - Hitachi Global Storage Technologies - HR Professional - Needs Root Cause Analysis Skills

Thursday, October 11th, 2007

See:

http://jobscentral.com.sg/profile/hitachi/retjobs.php?jid=76332