Here’s some pictures from the course that Mark Paradies and Chris Vallee are teaching…
Chris teaching…
Class listening intently…
Group exercise - spirited debate and learning!
If you haven’t attended a TapRooT® 5-Day Course, you are missing an opportunity to learn advanced root cause analysis that can help your company improve!
In 1988, Mark Paradies, with the help of David Busch and Kevin O’Connor, started System Improvements and developed the tools that started the development of TapRooT®. Linda Unger came aboard in 1989 to get things moving.
As you can tell from the old picture above, a lot has changed since 1988! TapRooT® has been developed, revised, and improved! And people have used TapRooT® to save lives, prevent injuries, improve the quality of products and services, improve equipment reliability and maintenance practices, improve productivity, and achieve operating excellence.
Because this a special year - the year that System Improvements turns 20 years old - we wanted to hold a special celebration. So at the TapRooT® Summit in Las Vegas on June 25th we will hold the System Improvements 20th Birthday Party!
Who will be there? All the Summit attendees. And we hope that includes you!
In addition, Mark Paradies, David Busch, Kevin O’Connor and Linda Unger - the people who got SI going - will be there.
Who else?
Elvis (Greg Miller) will provide entertainment. And Olympian Nikki Stone will sign autographs.
There will be food and drinks.
And there will be performance improvement exhibits.
We are planning more surprises for the party, but we won’t tell about them until the first day of the Summit.
The Judge deciding on the BP Texas City explosion criminal settlement could hear from survivors asking for a bigger penalty. For more in the Houston Chronicle, see:
The following press release is from the U.S. Chemical Safety Board.
Washington, DC, January 30, 2008 - On the first anniversary of a fatal propane explosion at a West Virginia convenience store, the U.S. Chemical Safety Board (CSB) today announced that testing has been completed on a key propane valve and outlined other issues that will be examined in the final investigation report.
The accident on January 30, 2007, at the Little General Store in Ghent killed four people and injured six others when propane gas was suddenly released through a liquid withdrawal valve during a changeover between two propane tanks. A volunteer firefighter and an EMT who responded to reports of the leak were among those killed when the propane cloud ignited, destroying the store.
The CSB has examined and tested the valve and found that on the day of the accident the valve was stuck in an open position.
Investigators are continuing their examination of regulatory and code compliance as well as West Virginia’s gas safety practices.
‘This investigation is about more than figuring out what went wrong with the valve, it is about getting to the root cause of this accident and preventing a similar incident from occurring,’ said CSB Lead Investigator Jeffrey Wanko, P.E., C.S.P.
On the day of the accident, a technician working for Appalachian Heating (a company that had a business arrangement with Thompson Gas) was preparing to switch propane service to Thompson Gas from a previous propane vendor, Ferrellgas. As part of the process, the technician was to transfer propane from the Ferrellgas tank to the newly installed one.
The Ferrellgas tank was located against the store’s outside rear wall. The Thompson Gas tank was located about ten feet away. While preparing for the transfer, propane began flowing out of the liquid withdrawal valve on the Ferrellgas tank located next to the store.
Lead Investigator Jeffrey Wanko said, ‘The placement of the tank facilitated gas entering the building and the ignition of the flammable gas and contributed to the high number of injuries and fatalities.’ The tank did not comply with National Fire Protection Association or Occupation Safety and Health Administration siting specifications which require that a propane tank be placed 10 feet from the building.
Investigators believe personnel involved in the installation of a new propane tank at the store removed a metal screw cap on the liquid withdrawal valve, in preparation for removing propane from the old tank. The malfunctioning withdrawal valve leaked, resulting in an uncontrollable release. The technician was unable to stop the flow and placed a 9-1-1 emergency call at 10:40 a.m.
CSB investigators found that in common with many states, West Virginia does not require technicians who install propane tanks to receive any formal training. The CSB is also examining the practices of 9-1-1 emergency call centers to provide basic emergency instructions for flammable gas incidents such as proper evacuation procedures. In this instance, Little General employees stayed in the building during the gas release.
The CSB’s final report and safety recommendations are expected to be complete in mid-2008.
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, contact Director of Public Affairs Dr. Daniel Horowitz, (202) 261-7613, or Public Affairs Specialists Hillary Cohen at (202) 261-3601, or Jennifer Jones at (202) 261-3603.
An 86-year-old woman (under anesthesia and not conscious) was dropped from a surgery table when a safety belt was released in preparation for transferring her to a mobile hospital bed. She died as a result of the head injury.
“The investigative report said the hospital did its own root cause analysis and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the ‘removal of the . . . safety belt from the patient was not verbally communicated.’”
“The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.”
I know this isn’t a complete Sentinel Event Report, but what do you think of “communication” and a policy of “putting their hands on the patient and having people on both sides of the bed before removing the safety belt” as the Safeguards to prevent future accidents? Are these Safeguards strong enough? Will they be effective?
Samsung, an industrial giant, was responsible for a crane on a barge that was being towed by two tug boats.
The weather was bad.
The seas were rough.
The barge broke loose from the tugs.
Now for the bad news … there was an oil supertanker anchored nearby.
With the whole ocean available for the barge to float in, what happens? It hits the supertanker that is at anchor, makes three holes, and spills 10,900 tons of oil.
But what can we all learn from this accident? Read about the protests and even suicides in the wake of the oil spill:
What reaction does the Environmental Health & Safety Engineer (EH&S) get from your employees? If it’s “oh no”, we better put on our safety glasses when we see her/him enter the work area, you have a “Hidden Factory”. Do you include EH&S in new facility or site designs? If not, you have a “Hidden Factory”. What is a “Hidden Factory” and what does it have to do with safety?
Six Sigma Black Belts and Quality Performance Experts have known about the “Hidden Factory” for years. Basically, you have company standards, policies, and procedures that are required to be used and then you have the cost of poor quality caused by short-cuts and business as usual non-standard practices. The pursuit of performance quality is to identify company requirements, identify how work is “really” being performed, and close the gap between the two to improve customer needs. The goal of any EH&S Engineer should be to recognize this “Hidden Factory”, the why’s behind the short-cuts, and their impact on SAFETY AND WORK COMPLETION. This also starts to close the gap between company risk and hazard assessments.
The EH&S will not be invited to see this internal company view if not she/he is not considered part of the work force. Prior to shutting down a site or work area for a non-risk of life-limb-enviroment violation, the EH&S Engineer should see how to help develop a safer process. Don’t be the outside enforcer, be the listener and helper. From past experience in the military and civilian life, this easy first step has been rare. It is easier to say people should be safe because it is the right thing to do. Recently however, I am seeing a positive change in closing this gap. Just this week while teaching a 5-day TapRooT® root cause analysis course in Edmonton, I had an operations lead in class with two of his EH&S engineers. Planting this first TapRooT® seed will encourage further discussions in the “Hidden Factory” for this company.
Farmer hides castle from building inspectors behind a wall of hay bales. Now I have heard of searching for a needle in a haystack but wow, a castle? But think about it , can you find the “castle” in your root cause analysis when it is right in front of your eyes? Unfortunately, this is the problem we have when using cause and effect diagrams and 5 why’s where you fill in the questions needed to be asked. If you are not familiar with human factors engineering and human behavior in systems, you might as well be looking for a “needle”.
Why are these other root cause tools ineffective you ask? WITHOUT getting technical, our own “rules-of-thumb” prevent us from seeing or recognizing anything that does not match our current understanding of the world we live in. Look at the picture above, do you see a young woman or an elderly woman? The mind prevents us from seeing one image over the other at the same time. A good root cause analysis prevents us from investigating an incident or reoccurring problem using our past understanding of limited subject matter expert experience. When I say limited, the implication is that the operator, safety officer, manager, and quality inspector only understand their part of the company processes; while good at what they do, total system influences on human performance is usually limited. A good root cause analysis should ask questions at the system level creating a new way of looking at the “castle”. This is why TapRooT® is a root cause analysis system and training that helps solve problems both reactively and proactively. Call us at 865.539.2139 if you are tired of looking for the “needle”.
Just finishing up another successful 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Edmonton, I saw this headline, “Fire Eases at Vegas’ Monte Carlo”. First question, does the hotel on fire perform proactive Safeguards Analyses? Second question, does the hotel scheduled for the TapRooT® Summit in June perform proactive Safeguards Analyses? Watching news before I fly to San Diego for another 5-day TapRooT® course, the news reported recent remodeling may be a clue for the fire. Will the Monte Carlo perform a Change Analysis I wonder? If this was your hotel, do the analyses listed above sound familiar? If not, contact us at System Improvements, Inc. at 865.539.2139.
An interesting story from American Samoa points out that hospitals can’t release information on a healthcare root cause analysis unless the patient consents.
Washington, DC, January 25, 2008 - Investigators from the U.S. Chemical Safety Board (CSB) today concluded the initial field investigation of the fatal accident at T2 Laboratories Inc. Among investigators’ findings thus far is that that the number of people injured was more than double what was known immediately after the accident.
Investigators say that 33 people were injured in the massive explosion and fire at the Jacksonville, Florida, chemical plant on December 19. Many of these injuries resulted from flying and falling debris due to structural damage to offsite buildings. The team plans to return to Washington, DC, later today to continue the investigation of the causes of the accident.
The explosion resulted in the death of four workers; preliminary findings indicate that the accident occurred as a result of a runaway chemical reaction during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl (MCMT or Ecotane®). The loss of control of the reaction probably occurred during the first step of the process where more than half a ton of metallic sodium was reacted in a steel vessel with other raw materials, producing hydrogen gas as a byproduct. T2 is a small company with about a dozen employees and the single production site in Jacksonville.
The reactor eventually overpressured and ruptured at a pressure of several thousand pounds per square inch. The contents of the reactor immediately ignited creating a fireball and mushroom cloud rising approximately 2000 feet high.
CSB Supervisory Investigator Robert Hall, P.E., said, ‘As a result of our interviews, the CSB has discovered that over 30 people were injured, versus the 14 reported the first few days following the accident.’ After conducting over 50 interviews CSB investigators determined the significantly higher number of injuries. Initial media reports of 14 injuries did not count individuals who sought medical attention on their own. Most of the injuries occurred off-site when a powerful blast wave swept through surrounding businesses; only 9 people were at the T2 site when the accident occurred.
Mr. Hall said, ‘We will conduct laboratory testing to quantify the amount of heat and pressure released by the reaction. Our goal is to discover what went wrong on December 19 and to prevent a similar accident from happening again.’
For more information, please contact Public Affairs Specialists Hillary Cohen at (202) 261-3601 or Jennifer Jones at (202) 261-3603.
Elizabeth Ward, of the British Kidney Patients Association, said: “I’m quite sure it’s the first time this has happened in this country. It’s hard to understand how this could have happened.”
What was she talking about? A kidney transplant patient was forced to have the new organ removed after just a few hours – when it was discovered that the patient’s blood type had been incorrectly recorded on a computer database.
The incident, which was only revealed in response to a Freedom of Information request, comes just days after Gordon Brown called for a system in which individuals are presumed to consent to the use of their organs for transplant unless they specifically stipulate otherwise.
The error took place three years ago and would have remained secret had The Mail on Sunday not seen a confidential report into the “profound error”.
The internal investigation did not name the hospital involved. The report concluded that the initial data entry mistake was “human error” but said “there was no means of identifying” who did it, or where the incorrect information had been entered.
Although the mistake was made by Hospital Trust staff, the report blamed UK Transplant for failing to set up a standard nationwide system for entering patient details. It said: “During this investigation it became apparent that any number of professionals could have entered the blood results on to the computer.
“UK Transplant do not have a uniform system in place. [They] have not been prescriptive in dictating practice, and have allowed local Trusts the freedom to adopt whatever systems they deem fit.”
But a spokeswoman for UK Transplant said the report was “misleading” as the organization had no responsibility for the way Trusts entered information. “We need to be clear that the mistake here was not with UK Transplant,” she said.
“Information that Trusts provide is what goes into the national database. In this case, we have correctly recorded incorrect data. Our system has been in place for several years and can be viewed by Trusts at any time to check the data we’re holding.”
Once again, BLAME (rather than a fix for the problem) seems to be a major issue.
A source at UK Transplant said the mistake was “extremely rare” as fewer than five of the 20,000 organ transplants in the past seven years were made in error.
Hmmm … 5 in the past seven years? That sounds like more than “This has never happened before.” And if the reports aren’t made public, how can this error rate be verified?
Exelon, a long-time Licensed TapRooT® User, was honored when their CEO, John Rowe, was named Best Electric Utility CEO by Institutional Investor.
John said: “Exelon has been one of the most consistently profitable companies in the electricity industry, having grown our operating earnings an average of about 12 percent per year over the past seven years. I’m honored to be recognized by the financial community and Institutional Investor for our success. It’s my job and the job of Exelon’s management team to deliver sustainable value to our shareholders, and I believe Exelon is uniquely positioned to continue on a successful path in the years ahead.”
To arrive at its list of Best U.S. CEOs, Institutional Investor surveyed portfolio managers, analysts and other investment professionals. It asked these individuals to name the best U.S. CEOs in the sectors in which they invest. Some 900 people at 425 institutions responded, offering first, second and third place votes in each of the sectors with which they were familiar. These votes were weighted to produce a score for each executive that Institutional Investor used to compile the rankings.
Additional information can be found at www.iimagazine.com and in the January issue of the magazine.
Exelon Corporation is one of the nation’s largest electric utilities with more than $15 billion in annual revenues. The company has one of the industry’s largest portfolios of electricity generation capacity, with a nationwide reach and strong positions in the Midwest and Mid-Atlantic. Exelon distributes electricity to approximately 5.4 million customers in northern Illinois and Pennsylvania and natural gas to approximately 480,000 customers in the Philadelphia area. Exelon is headquartered in Chicago.
Part of Exelon’s success is due to their efforts to improve performance both reactively and proactively by finding the root causes of human performance and equipment problems. As part of the TapRooT® Summit, Exelon will be sharing one of their performance improvement programs - Exelon’s Error Free Performance Tool.
For more information about the TapRooT® Summit, see:
Marine Information Notice (MIN) 315 published December 2007describes MCA research project 555 which is a study into the safety of davit-mounted, side launched ships’ lifeboats and their launching systems. The primary objective of the study was to make proposals for measures to improve the hardware performance of lifeboats and contribute to the prevention of accidents.
ISO certified small manufacturing company is looking for a Director of Quality that has Six Sigma and Root Cause Analysis skills. For more information, see:
Are you interested in improving safety and risk management at your facility?
Would you like to learn safety and risk management best practices from industry leaders from around the world?
Would you like to network with people from a wide variety of industries who face similar challenges to the ones that you face and who may be able to share unique insights and new solutions to help your company improve?
Then you should be planning to attend the Safety & Risk Management Best Practices Track at the TapRooT® Summit.
The Summit has 9 Best Practice Track sessions and 5 Keynote Speakers. The Safety & Risk Management Best Practice Track sessions include:
Wednesday 10:30-12: Hazard Recognition: The First Step in Safety & Risk Management - Peter Berkholz, Engineering Manager, Capability Resources Australia
Wednesday 1-2:20: CHANGE
1) Change Dealing with Obstacles that Make Change Difficult - Hal Curry, Consultant, Hal Curry & Associates
2) Managing the Risks Associated with Change - Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia; & Jim Whiting, Managing Director, Risk @ Workplaces Pty., Ltd. Australia
Wednesday 2:40-3:55: Accident Investigation Examples
Root Cause Analysis of Major Accidents:
1) Lexington Airport Runway Mixup - Ken Turnbull, Consultant
2) Cameco Cigar Lake Mine Flood - Mark Wittrup, Cameco
3) Texas City Refinery Explosion - CSB Speaker (invited)
Thursday 9:15-10:25: Advanced Behavioral Management: Developing a Modern Safety Culture - Bob King, Director HSE Training/Consulting, Woodland Grange, UK, & Neil Roberts, Consultant, Woodland Grange, UK
Thursday 10:25-10:40: Panel Discussion - Is There a Tradeoff Between Process Safety & Industrial Safety? Panelists
Brian Hennesey, ConocoPhillips
Valerie Barnes (US NRC)
Bob King (Woodland Grange, UK)
Ken Turnbull (Consultant)
Thursday 1-2:20: TapRooT® User Success Stories from Healthcare & Industry - Linda Unger & Barbara Phillips (Facilitators)
(Three Success Stories to be presented by industry and healthcare users of TapRooT®)
Thursday 2:40-3:55: The Good, The Bad, & The Ugly: Rating Improvement Programs & Incident Investigations - Michele Lindsay, Principal Consultant, P2, Canada; & Mark Paradies, President, System Improvements
Friday 9:15-10:25: Senior Executive Involvement in Safety
1) Bringing Safety to the Corporate Board - Dave Prewitt, VP, FedEx
2) What the Corporate Board Needs to Know About Safety - Bob King & Darby Alan - Woodland Grange, UK
Friday 10:35-11:55: Planning Your Improvements
(Improvement planning session with help from experienced TapRooT® Consultants)
In addition to these smaller group discussion sessions, you will also attend 5 Keynote Speaker sessions:
Wednesday Lt. Col. Ralph Hayles (retired), Gulf War Veteran, Lessons Learned from Friendly Fire Nikki Stone, Olympic Aerial Skiing Gold Medal Winner, Overcoming Setbacks to Achieve Olympic Success
Thursday Carolyn Griffiths, UK Rail Accident Investigation Branch Chief Inspector, Lessons from Setting Up an Independent Accident Investigation Organization Ed Frederick, Exelon Nuclear (Board Operator at TMI during the accident), The Accident at Three Mile Island - An Insider’s Perspective
Friday Marcia Wieder, Doctor of Dreams, You Can Make Improvement Happen
Where will this exciting and useful Summit be held? Las Vegas on June 25-27, 2008.
The BP Texas City Refinery explosion case drags on (since 2005). An AP story about the BP plea agreement with Federal Prosecutors says:
“Federal prosecutors took the harshest option available in brokering a $50 million fine proposed as criminal punishment for BP PLC’s deadly 2005 Texas City refinery explosion, the company and the government said in court filings Tuesday.”
Sometimes you read stories and you just can’t believe what you are reading.
For example, a New York Times story explained that a government office - the Office for Human Research Protection - shut down a John Hopkins University research project.
The project was using checklist to reduce post-operative infections. Using 5-step checklist had cut the rate of bloodstream infections acquired in the I.C.U by two-thirds. Over 18 months, the program saved 1,500 lives and $200 million dollars.
So why did the government shut it down? The study was breaking the rules. What rules?The NY Times article said that:
“…by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations.”
Here is the logic for the finding reported by the NY Times:
“A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore, it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.”
By this tortured logic, I’m surprised that any study or improvement efforts are allowed in the medical field. No wonder improvement in the medical industry progresses so slowly.
“Canada ranks 23rd out of 30 countries surveyed in “consumer friendliness” of its health-care system” cites a report by European and Canadian researchers in the Canadian Press. Having more in common with publicly financed and governed European health-systems, the “think tank” researchers wanted to compare Canada with like populations in this first annual “consumer index”. Not including publicly-commercially financed countries such as the United States would provide a better base-line of performance for Canada.
What will the affect of this study be? Canada performed well in survival rates of heart attack, cancer, and other medical procedures, but failed in areas such as treatment waiting times, range of services available, and access to new diagnosis tools and new medicine. First question to ask is whether there were countries that performed well in the latter categories but failed in survival rates? As a medical consumer, what is more important to you, survival rate or “friendliness”? As a medical business, what is important, survival rates or “friendliness indexes” that would bring new customers to your business or longer term survival rates? If business operation policy is changed to perform well in this survey, this will also affect how you perform future sentinel investigations.
As a medical health-system provider, should you chance changing your policy and procedures based on this survey? When business risk assessments and hazard risk assessments diverge this is bad practice. This practice tends to split quality, safety, and operation personnel reducing a one-company mission. How can you prevent this company split? Ensure sentinel investigations and corrective actions are based on accurate human performance and equipment root cause analyses? If you see this bad practice occurring in your medical health service, you may find TapRooT® an effective solution. Contact us from this site to learn what medical health providers have taken on this challenge with TapRooT®.
Back in December, I wrote about an accident investigation that was never completed because the “facts” didn’t agree. I asked “How would readers complete the investigation” and asked for comments. The comments can be seen at:
Having conflicting information is a common problem when investigating an accident.
The best way to detect conflicting information (facts that don’t match) is to put the information collected on a SnapCharT®.
Using a SnapCharT® to display the information sometimes will make the non-factual information obvious (it doesn’t agree with the other stories or the physical evidence). Other times, either story is possible, and you can display how each set of facts is plausible.
What do you do when you have two sets of plausible stories? I try to analyze each possibility, develop causal factors for both stories, analyze each stories root causes, and then look at the potential corrective actions. If I can develop corrective actions that correct the root causes for BOTH stories, I don’t have to know which one is right. If I can’t develop effective corrective actions that will prevent the recurrence of both stories, then I need two sets of corrective actions, one for each story.
In my experience, the main reason (although not the only reason) for conflicting stories is that people are trying to avoid blame and are are either:
1. Telling the investigator a story that won’t get them in trouble.
OR
2. Telling the investigator what they think the investigator wants to hear (to keep the interviewee out of trouble).
The best way to avoid people “telling stories” is to develop a “just culture” or “no blame” environment where accident/incident investigations are seen as performance improvement opportunities rather than witch-hunts. Making this change requires senior management support.
WHAT DO YOU THINK?
Are my suggestions a practical way to deal with conflicting “facts.”
