Root Cause Analysis Blog

In a recent press release, the CSB announced that they are requesting $10,600,000 for FY 2009. That’s a $1,637,000 increase (17.7%).

The press release says that the increase is to be used to sponsor more investigations (done by more people) and more safety videos.

This request comes as the CSB this year completed it’s most expensive investigation - the BP Texas City Refinery Explosion. That investigation took almost 3 years and cost over $2.6 million dollars to complete.

Seeing such big numbers may make you think …

How much have we budgeted for personnel, consulting help,
training, and software for investigations?

You might not work with government budgets, but you may want to think about budgeting for investigation needs.

For TapRooT® Users, here are some items to remember to budget for:

1. Training (see 2-Day, 3-Day, and 5-Day Public Course or call 865-539-2139 for an on-site TapRooT® Root Cause Analysis Course quote)

2. Summit attendance (and don’t forget the pre-Summit courses) and travel

3. Investigation assistance (help with difficult investigations)

4. Software (license, maintenance fee, individual user license)

5. People (don’t plan to perform investigations in your spare time)

If you aren’t doing 2009 budgets yet, put these ideas away until later in the year. Then be prepared to ask for what you need to make your reactive improvement program (incident and accident investigations based on root cause analysis) work.

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Six months of NTSB investigation and the politics of failure are starting to heat up.

A recent article claimed that a “design flaw” was the root cause of the I-35W Bridge collapse. But a more recent article suggests that “premature jumping to conclusions” may be politically motivated and that the root causes are still under investigation.

For more info see:

http://minnesota.publicradio.org/display/web/2008/01/31/ntsbsixmo_stachura/

Politics, politics, politics …. certainly politicians have nothing to do with the failure of public roads.

Investigations - either at companies or involving the government - can get tricky when the focus is on who to blame.

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India, Pakistan, Egypt, Qatar, Saudi Arabia, the United Arab Emirates, Kuwait and Bahrain suffered internet problems when a cable was cut by a ships anchor. The ship was anchored off the coast of Egypt.

Instead of discussing the root cause of the ship cutting the anchor, lets think about the Safeguards that were in place to protect the cable.

So what keeps a ship from dropping an anchor and cutting a cable? Luck?

Any better ideas?

Use the comments field to provide your ideas.

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The accident occurred at Humax Peat Works near Nutberry in England. The UK HSE is investigating the cause.

For more information, see bthe BBC story:

http://news.bbc.co.uk/2/hi/uk_news/scotland/south_of_scotland/7219501.stm

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A steelwork was killed in an accident at the Severstal’s plant in Cherepovets, Russia.

For the complete story, see:

http://www.reuters.com/article/rbssIndustryMaterialsUtilitiesNews/idUSL3170342620080131

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Interesting “incident” that probably needs some root cause analysis.

It seems an Air Canada flight was diverted to Shannon when one of the pilots “went nuts” and had to be restrained. The pilot was taken to a hospital in Ireland for treatment.

An Air Canada spokeswoman said:

“At no time was safety compromised.”

Neat. I guess pilots aren’t really that important to modern day air transportation!

For more info see:

http://www.nydailynews.com/news/us_world/2008/01/30/2008-01-30_copilot_dragged_screaming_off_flight-1.html

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The judge didn’t immediately accept the BP guilty plea. However, she said that she can only consider a plea agreement presented to her:

“I must not evaluate a hypothetical plea that has not been presented.”

Rosenthal delayed a ruling to allow plaintiffs’ attorneys and prosecutors to submit filings on complicated legal issues that dominated several hours of arguments after the victims had their say. The judge didn’t set a date for another hearing.

She said the company can withdraw its guilty plea if she rejects the agreement

For more, see:

http://www.chron.com/disp/story.mpl/business/5513462.html

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If you are considering attending the TapRooT® Summit in Las Vegas on June 25-27, you might want to take a “virtual tour” to see where the Summit will be held and what’s right around the corner.

Our friends at Google have made this very easy to do.

Click on this link:

http://maps.google.com/

Then paste in this address in the “Search the map” field:

160 Flamingo Road, Las Vegas, NV

There will be a box that says “Address;” on it over the map. Below a picture on the box is the words “Street view”. Just click on the words “Street view” and you will see a street view picture of the Summit hotel (just like the one below).

You can then click on the picture and drag to change the direction you are looking. You can click on the little man symbol on the map and drag him to different locations to see different parts of town.

Try going down the street to the left, making a right on South Las Vegas Blvd (the strip) and standing in the street in front of Caesar’s Palace. You can’t do that in real life!

This is a pretty neat Google feature that’s only available in selected cities. Use it to help you plan your Summit trip to Vegas.

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Assist in the development and implementation of the internal H&S compliance and management system.

Implement and lead self-assessments and audit programs and prepare briefings for management

Requirements

A Bachelor’s Degree in Science (or equivalent)

Additionally, a strong background in operations and knowledge of Health and Safety regulations are essential.

You must be willing to travel up to 50% of the time.

Enterprise Products offers a competitive wage and benefits package.

Pre-employment screens required.

For consideration, please e-mail your resume and salary history to:

rrleclair@teppco.com

(Richard LeClair) with the job title (Safety/PSM Assessment Specialist) in the subject heading.. No phone calls. EOE.

Company Description

Established in 1968, privately held EPCO, Inc. and its affiliates own significant equity interests in five publicly traded partnerships with a combined enterprise value of approximately $48 billion. The EPCO family of partnerships comprises one of North America’s largest midstream energy networks, providing a variety of services, including transportation, gathering, storage, processing, fractionation, and terminaling, to producers and consumers of natural gas, natural gas liquids, crude oil, refined products, liquefied petroleum gases, and petrochemicals.

Recipient: Mark Paradies mark@taproot.com

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