A recent article published indicated that pilot error for U.S. air carriers is down 40%. Pilot error has been a “prominent contributor” to aircraft mishaps as stated by the author of the study published in the January 2008 edition of “Aviation, Space and Environmental Medicine”. The author attributes improvements in Cockpit Resource Management (CRM) techniques, pilot training, and flight deck technology for reduction in pilot error. With that said, I have one question:

1. The accident rate did not drop with a 40% reduction in pilot error. If pilot error was the primary root cause why not?

If you find yourself blaming the the pilot, operator, or doctor in your company repeatedly for failures, you may need to a reassess your investigation robustness. You can always find data to support your conclusion of blame, but this comes with a price. You ignore data that is in conflict with your initial cause assessment. Unfortunately feedback for this error comes too late. If you would like additional information for removing the blame factor in order to conduct a proper incident investigation, contact us at System Improvements, Inc to discuss TapRooT®.

I read the following in the trade publication Machinery Lubrication (November 2007):
A multi-industry study published by the National Research Council of Canada showed that particle contamination was the root cause of 82 percent of wear-related failures.

My first thought was … Where did they get these statistics? Very few companies do a formal root cause analysis of every equipment failure.

My second thought was … Particle contamination isn’t a root cause!

Particle contamination would be a Causal Factor - just the start of the root cause analysis process in the TapRooT® System. There could be many causes of the contamination.

Want to learn a systematic process for finding the root causes of equipment failures? Attend the 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course.

You can schedule a course at your site for 10 or more attendees or send folks to one of our public courses:

Galveston, TX  January 15-17
Lake Charles, LA    January 23-25
Aberdeen, Scotland    January 30-February 1
Edmonton, Canada    February 20-22
Perth, Australia    February 20-22
Melbourne, Australia    February 27-29
Bogota, Columbia    March 5-7
Calgary, Canada    March 10-12
Houston, TX    March 26-28
Christchurch, New Zealand    March 31-April 2

For a complete list of future courses, see:

http://www.taproot.com/courses.php?d=3

Houston Chronicle story available at:

http://www.chron.com/disp/story.mpl/business/5405484.html

If you’ve attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, you’ve used TapRooT® to find the root causes of the crash of Eastern Flight 401 that happened on December 29, 1972.

Would you like to learn more about the rescues after the crash? Then see this article:

http://www.cnn.com/2007/US/12/25/jet.crash.memorial.ap/index.html

An accident waiting to happen (but not waiting too long).

Wii Bat Accident

Posted Today

A Nintendo Wii bat slams straight through a home theater system (with slo-mo replay included!)

Don’t expect many posts!

Thanks

Mark

Peace on Earth. Good will toward men.

Track Santa on Google Earth.

Merry Christmas to all and to all a good night!

The Navy Times reported that that several submarines and nuclear powered aircraft carriers could have substandard welds.

The corrective action? According to the article, a change in a policy and more training.

Are these strong corrective actions or weak ones? How will shipyard management know if the policy change is being followed?

What can you learn from this quality incident?

may be delayed!

Equipment troubleshooting requires a very logical though-process.  You have to understand the operation of the equipment not only by itself, but also in the context of the rest of the system.  A thorough knowledge of the equipment design specifications and the operating environment is required.

Most companies, when faced with a particularly stubborn problem, get their experts together in one room, discuss the problem, and then start listing the possible causes of the issue.  Fault trees and troubleshooting tables are referenced, and component technical manuals are available.  Then the fun begins.  Possible causes are listed up on the board, and then a troubleshooting plan is put together.

But where do these possible causes come from?  How do your troubleshooting experts arrive at their possibilities?  Invariably, this list is a compilation of the experiences of the troubleshooting team.  Each individual thinks back to when he’s seen these symptoms before, remembers what caused it that time, and then lists that problem as a possible cause.  This is the natural method of finding problems, and it is fundamental to good troubleshooting.

But what happens when a problem is outside the experience of the troubleshooters?  What if this particular fault is not caused by something familiar to the team?  How can they possibly find the cause?  If nobody has ever seen this problem before, it is very difficult to try to think of new possibilities.  Usually, this is discovered after many hours (days? weeks?) of troubleshooting, and all expected possibilities are proven wrong.  That can be a significant amount of wasted effort.

What we really need is a reference that will give you a list of possible causes for the symptom you are seeing.  Where would we get a magic reference like that?  Hey, that’s what Equifactor® does!  Instead of only looking for the “normal” reasons for a particular symptom, Equifactor® lists a whole range of “unusual” reasons for the failure.  At the end of a difficult troubleshooting effort, ever hear your team say, “That’s a new one on me!”  Using Equifactor®, you would no longer be surprised by these “unknown” failure modes.

Start out your troubleshooting sessions with a complete list of possible causes.  Use Equifactor right from the beginning, and reduce your downtime!

The TapRooT® Summit is one of the best places on the planet for cross-industry performance improvement networking.

Why is cross-industry networking and benchmarking important? Read this comment from a correspondent at a medical industry discussion forum and I think you will understand:

I too have worked in the nuclear power industry. Nuclear power conference organizers three years ago had me speak about hospital safety. I imagined myself as teaching these socially-challenged engineers a thing or two and prepared my best PowerPoint presentation, starting, of course, with a review of the Institute of Medicine study.  However, after hearing the speakers who went before me, I felt that I really had little new to offer.  Nuclear power facilities do have a measurable culture of safety, essentially mandated by the Nuclear Regulatory Commission.  The plants don’t have the option as we do in healthcare.  The slightest injury or a mechanical or operational mishap is known to everyone in the plant, in the media, and in the community (everything is transparent), not simply passed on to the safety director for follow-up, hoping that the media won’t find out.  It would help all of us to go to a nuclear power safety conference or simply arrange for a “safety” tour of the nearest nuclear plant.  We have more to fear working in a healthcare facility for a day than spending a day visiting a nuclear power plant.

Come to the best practice sessions at the Summit and find out what people are doing to improve performance in the:

medical,

nuclear,

aviation,

utility,

oil exploration and production,

refining,

chemical,

transit,

rail,

shipping,

pharmaceutical,

food,

DOE,

plastics,

pipelines,

terminals, and

manufacturing industries.

Learn best practices from leaders around the world.

See:  http://www.taproot.com/summit

Four accidents in a year? Two near death. Is this a lucky dog (as the vet seems to think) or an accident prone dog?

For more info, see:

http://www.thenorthernecho.co.uk/news/topstories/display.var.1907339.0.accidentprone_dog_whipped_by_cat_in_his_latest_mishap.php

If dogs can be accident prone, can people?

For complete info see:

http://www.bayt.com/job/job.adp?xid=715600

Last week one window washers was killed and one seriously injured in an accident in New York.

This week the union members of Local 32 BJ received more safety training.

For complete info see:

http://www.ny1.com/ny1/content/index.jsp?stid=8&aid=76589

Accident a school with tragic results. See:

Fatal Accident Causes Death – Company Fined

See:

http://www.crainsnewyork.com/apps/pbcs.dll/article?AID=/20071214/FREE/71214003/-1/rss01&rssfeed=rss01

Having a major accident is a good start for getting on this list:

1. Cintas Corp - OSHA Fine: $2,782,000

2. Thomas Industrial Coatings Inc. - OSHA Fine: $2,362,500

3. Southland Forming Inc. - OSHA Fine: $328,025

4. Davis Wire Pueblo LLC - OSHA Fine: $287,500

5. Crescent Manufacturing - OSHA Fine: $272,900

6. American Airlines - OSHA Fine: $262,500

7. Koch Foods - OSHA Fine: $253,500

8. St. Marys Foundary Inc. - OSHA Fine: $253,300

9. Provident Pharmaceuticals - OSHA Fine: $251,500

10. Abbyland Foods Inc. - OSHA Fine: $248,000

This is the list of the top ten OSHA Fines as of September 30, 2007 (the end of the government year).

You don’t have to have an accident to make this list … but it helps.

Perhaps your company want to learn from the accidents of others and avoid this list. How can you do it? One tool that can help is learning from near-misses and incidents by applying advanced root cause analysis - TapRooT®.

If you would rather read about Success Stories rather than failures?See what these TapRooT® Users say about success at:

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

The RAIB is carrying out an investigation into a collision between two road rail vehicles at Glen Garry, near Blair Atholl, on 5 December 2007. For more info see:

http://www.raib.gov.uk/publications/current_investigations_register/071205_glen_garry.cfm

Nuclear safety and politics just don’t mix well …

See this article for the strange nuclear safety issue that seems to be mixed with Canadian politics:

http://www.theglobeandmail.com/servlet/story/LAC.20071213.ISOTOPES13/TPStory/National

Blame - not safety (reactor safety or patient safety) - seems to be the main focus of the ongoing Canadian crisis.

This seems like a good example of how NOT to do root cause analysis and safety improvement.

See: http://www.taproot.com/wordpress/2006/12/15/friday-joke-nuclear-winter-wonderland/

Congratulations to Bapco (The Bahrain Petroleum Company) for winning the National Safety Council’s Robert W. Campbell Award. Bapco has been a TapRooT® User since 1996 and uses TapRooT® to improve safety and equipment reliability.

If you would like to be among the leaders in safety and equipment reliability using TapRooT® and network with these industry leaders, consider attending the TapRooT® Summit in Las Vegas on June 25-27. See:

http://www.taproot.com/summit

Linda, Chris, Ken and I are teaching two 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Las Vegas this week. Ken will also be teaching the Equifactor® Equipment Troubleshooting techniques.

Teaching great courses isn’t all that we are doing in Las Vegas. Katherine, our meeting planner, also is here and we are planning the details of the TapRooT® Summit (Las Vegas on June 25-27, 2008).

I thought that I should let readers know what we are doing so that you can start your planning for the Summit. This isn’t planning for the technical sessions (that’s done and I’ll share that next month). This is planning for the location and the fun we are going to have.

First, we are at the Westin Casuarina at 160 East Flamingo in Las Vegas. The hotel is just a block and a half off one of the busiest intersections on the strip. An easy walk and you are at Bally’s, the Bellagio (and their fountains), and Caesars Palace.

The hotel is nice - great soft beds, double-headed showers, and a friendly staff. And the TapRooT® Summit rate ($155/night) is a good value.

The hotel has a small casino (compared to some of the mega-casinos). It will be easy to network with others attending the Summit.

What is there to do in the area at night after the Summit concludes? Tons.

Every time I come to Las Vegas I marvel at how much there is to do. The shows are amazing. Of course, there are the standard Vegas shows. But there are also Broadway shows, famous entertainers, magic, and comedy, including:

Toni Braxton

Cirque de Soleil (”O”, Mystere, Zumanity, KA, The Beatles-LOVE)

Bette Midler

Momma Mia!

Lance Burton

Penn & Teller

The Producers

The Amazing Jonathan

Blue Man Group

Spamalot

Andrew Lloyd Webber’s Phantom

Barry Manilow

Rita Rudner

Carrot Top

And that’s just the start!

Next, there’s shopping. Within walking distance from the hotel are the Forum Shops (designer stuff at designer prices) and the Fashion Mall (everything).

Also, there’s a never ending list of casinos. Bally’s, the Bellagio, Caesars, Harrahs, Rio, MGM Grande, Bill’s, Las Vegas Hilton, The Orleans, Flamingo, Excalibur, Paris, Luxor, Mandalay Bay, Mirage, New York-New York, Planet Hollywood, Hooters, Venetian, Wynns, … it goes on and on. You could spend a week just visiting them all.

And the food is great. Every major casino has one, two, three, or four 4 start restaurants. The Forum Shops has several of my favorites including the Cheesecake Factory.

And we have our own entertainment at the Summit - the Wednesday night reception and exhibit.   

Elvis (Greg Miller) will sign us a couple of songs.

Olympic Gold Medal winner Nikki Stone

An iPod Shuffle prize for best costume (come in 50s/60’s attire to win).

An iPhone drawing for timely attendance (must get timely attendance tickets during the day plus must be at the drawing to win).

And there will be some surprises (I’ll announce these as the Summit gets closer).

One last note. I’m going out to The Revere Golf Club - the Concord course - later today. I’ve heard the course is great, but I wanted to see it for myself. On Friday of the Summit, we’ll have a scramble golf tournament that’s great fun and a great way to meet more people.

I’m looking forward to the Summit. I hope you are starting your planing and looking forward the the valuable information you will learn and the fun you will have.

Hope to see you there.

The Summit web site is:

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

I was reading a Houston Chronicle article about a BP civil trial. It said:

“BP has spent more than $1.6 billion settling 2,425 claims, including all involving deaths. The remaining claims involve injuries or property damage.”

Is that all the costs of that accident? No way.

Lost production …. Billions.

Bad PR … Billions.

Management turmoil … Billions.

Hit to the stock price … Billions.

Hit to employee morale … not billions but significant.

So if you are saving pennies and the results may be a major accident, you are making a fool’s bargain.

Penny wise, Pound foolish
Benjamin Franklin

Investing in advanced root cause analysis? A wise use of resources that produces returns for years.

What kind of returns do you get? See the Success Stories at:

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

Some posts don’t go out of style…

Here’s a link to an old blog post where you can download a PowerPoint with holiday safety tips:

http://www.taproot.com/wordpress/2005/11/22/powerpoint-holiday-safety-tips/

A South African web site reported on the trial after a refinery accident. The trial took place three years after the accident and the accident investigator admitted under oath that the accident investigation had never been completed.

The story said:

“Kgele Mathiba, the investigator, said the report was never completed because there were too many conflicting versions of events and opinions as to who was accountable.”

How would you complete an investigation with conflicting “facts”.

Read the story and give me your best ideas for how you would handle this type of difficult investigation. (Use the “Comments” link below.)

When your spokesperson says:

“We are doing our root-cause analysis of the situation and we will have the answers to the comments and concerns that were raised.”

You know that your company is in trouble.

For the complete article see:

“Safety agency demands answers over AECL violation that caused isotope drought.”
by Colin Perkins of the Canadian Press

It is interesting that major incidents in the nuclear industry usually don’t involve deaths or injuries. Instead, this incident is the result of misunderstanding a regulatory safety requirement. The continued reactor shutdown for regulatory concerns may cost lives because the medical isotopes that the reactor produces won’t be available to test for cancer and other diseases.

The Rail Accident Investigation Branch (RAIB) is advertising job vacancies for Rail Accident Inspectors. To view the details, please click here.

Click here to read the full article on the Rail Accident Investigation Branch Website.

The International Herald Tribune reports that 105 miners died in the second deadliest mining accident this year in China.

When the second deadliest accident kills 105, you know the Chinese mining industry needs major safety improvements including advanced root cause analysis.

TapRooT® is used to investigate mine accidents around the world. Some mining companies and regulatory agencies that use TapRooT® to investigate accidents, incidents, and near-misses and who use TapRooT® to proactively improve performance include (just to name a few):

- US Mine Safety & Health Administration
- Rio Tinto
- Barrick
- Mimosa Mining Company
- Syncrude
- Cameco
- Interwest Mining
- Alcoa
- PCS
- Arch Coal

To see a mining performance improvement success story, go to:

http://www.taproot.com/about.php?s=1

William Brand and Harry Harris of the Bay Area Newsgroup reported that an accident killed a man at the Port of Oakland this week.

A previous fatality in September has longshoremen worried about port safety.

What caused these fatalities? The story implies that the push for production may be leading to unsafe work practices.

Seems like the Port should be considering advanced root cause analysis to find the real causes of these accidents and develop effective corrective actions.

You may, however, drink and create signs.

So who needs Equifactor®, anyway?  Discussions with reliability experts and maintenance technicians have made it clear to me that there are a whole range of people who can benefit from the TapRooT® Equipment Troubleshooting software module.

–        Troubleshooting teams who are stumped when it comes to the root cause of a particularly tough failure analysis

–        Reliability experts who need help instituting a preventive maintenance, operating, and PdM plan for new equipment installations

–        Maintenance managers wishing to capture equipment troubleshooting techniques from retiring experts

–        Facilities managers working to reduce costs due to unscheduled, frequent equipment downtime

Equifactor® should be used by experts who are tired of finding “root causes” that don’t seem to prevent repeat failures.  Don’t settle for “Improper Bearing Lubrication” as your root cause.  Once you have determined a symptom like this, feed it back into the rest of the TapRooT® Root Cause Analysis system to find and correct actual root causes of the equipment failures.

Upcoming 3-Day Equifactor® course locations:

December 10-12         Las Vegas, NV

January 15-17            Galveston, TX

January 23-25            Lake Charles, LA

Jan 30-Feb 1              Aberdeen, Scotland

February 20-22          Edmonton, AB, Canada

March 5-7                  Bogota, Columbia

It is good to note that the fire department responded quickly and there were no fatalities. The supervisor’s response after investigating the accident was to focus on why the waiter did not check before locking the door. If he had been more attentive this accident would have never happened…..I must confess though, while the damage and location are correct this fire actually occurred in someone’s house and a dog was to blame. Authorities say the woman was taking garbage outside Tuesday evening when the dog somehow shut the door behind her. Firefighters arrived to find heavy smoke with flames shooting from the roof of the home.

Had you known that this was a dog instead of a waiter would you have changed your focus to the cook instead during your root cause analysis? Why should this bias your investigation? Is this how your company leads investigations? We can help you avoid this bias with our TapRooT® root cause analysis process.

Medical device manufacturer seeks an engineer with quality and mechanical / manufacturing background. Candidates should have at least 2 years experience, knowledge of both FDA and international regulations related to medical devices or similar products, experience with Failure Mode Cause Analysis(FMEA), Root Cause Analysis, etc.

A recent article stated that the Canadian Transportation Safety Board was due to do release the crash report for an Airbus A340. The aircraft came in too high and too fast in bad weather and “simply” ran out of runway. Not seeing the full report yet, I have to ask what root cause analysis process was used in this accident investigation?

With the advanced instrumentation and glass cockpits of today, how and why did this accident occur? I can’t prevent bad weather so the corrective action based on the report must be don’t attempt to land in bad weather…If this seems wrong to you then I suggest that you try the TapRooTç root cause analysis process.

The following is an excerpt from Appendix B in the upcoming TapRooT® - Changing the Way the World Solves Problems - book. The material is copyrighted and is used here with permission of System Improvements.

Comparing TapRooT® to 


Other Root Cause Tools

Price is what you pay. Value is what you get.…

Risk comes from not knowing what you’re doing.

Warren Buffett 

Choosing the tools you will use to improve performance is one of the most important choices that a business can make. The tools you choose and the systems you set-up, along with the people who use them, will determine your company’s performance in the future. By Warren Buffett’s theory, you need to know what you are doing or you will be taking unnecessary risk.

(more…)

The RDC Process Improver is responsible for developing, improving, and directing the warehouse and shipping teams to achieve departmental and organizational goals, specifically the warehouse Key Performance Indicators (KPI’s).For more information, see:http://www.gadball.com/jobs/details.aspx?jid=10976377&AspxAutoDetectCookieSupport=1