Root Cause Analysis Blog

Maybe they should have labeled it the

“DO NOT PUSH”

button.

(Click on picture to run the video. WMV format.)

How close can a “close call” or a “near-miss” be? Watch the video and see…

The following is a press release from the U.S. Chemical Safety Board, Washington DC.

Changes Urged to National Fire Codes, State Licensing and Inspection Procedures to Improve Safety of Facilities Handling Hazardous Materials

Danvers, Massachusetts, May 13, 2008 - A massive explosion and fire at the CAI/Arnel ink and paint products manufacturing facility in November 2006 occurred because CAI lacked safeguards such as alarms and automatic shutoffs that would have prevented a 10,000-pound mixture of flammable solvents from overheating in the unattended building, investigators from the U.S. Chemical Safety Board (CSB) said in a final draft report made public today.

Steam heat to the mixing tank was most likely inadvertently left on by an operator before he left for the day. As the temperature increased, vapor escaped from the mixing tank, built up in the unventilated building, ignited, and exploded. 

The 105-page report is set to be considered by the four-member Board at a public meeting in Danvers this evening, beginning at 6:30 p.m. at the North Shore Ballroom of the Sheraton Ferncroft Hotel, 50 Ferncroft Road. The meeting is free and open to the public. Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration.  The meeting is expected to conclude at approximately 9:30 p.m.

Following a detailed presentation by the CSB investigators, including a new ten-minute video of the explosion and its impact on the community, local and state officials and a Danversport resident are scheduled to present testimony to the Board describing changes to oversight of manufacturing facilities following the accident.

CSB investigators said that ink manufacturer CAI did not follow regulations or appropriate good practices for the handling of flammable solvents, and the CSB report proposes changes to national fire codes and to state licensing and inspection procedures to improve the safety and oversight of facilities handling hazardous materials.

Investigators said that on the night of the accident, ink base materials - including a volatile mixture of heptane and propyl alcohol - continued to heat and then boil after all the employees left work late in the afternoon.  The heating was controlled by a single, manual valve that needed to be closed by an operator to prevent the 3,000-gallon tank from overheating.

The building ventilation system was turned off at the end of the workday - a routine procedure - and vapor coming out of the unsealed tank spread throughout the production area and then ignited from an undetermined source, possibly a spark from an electrical device.  The explosion occurred at approximately 2:46 a.m. on November 22, 2006.

The blast ripped through the adjacent Danversport neighborhood, waking sleeping residents as windows were blown into bedrooms and shattered, ceilings fell, and belongings and appliances flew about.  The blast wave damaged scores of homes.  At least 16 homes and three businesses were damaged beyond repair, and approximately ten residents required hospital treatment for cuts and bruises.  The fire department ordered the evacuation of more than 300 residents within a half-mile radius of the facility.

‘The community damage was the worst we have seen in the ten-year history of the Chemical Safety Board,’ said CSB Board Member William Wright, who accompanied the investigative team to the accident site. ‘As others have noted, this explosion had a serious potential for life-threatening injuries and fatalities.’

The facility, shared by ink manufacturer CAI and paint manufacturer Arnel, was completely destroyed by the explosion and ensuing fire and has not been rebuilt.  Arnel ceased operations, while CAI continues to produce water-based inks at a facility in Georgetown, Massachusetts.

Mr. Wright said, ‘The immediate cause of the accident was the overheating of a highly flammable mixture for many hours.  We found an underlying cause was CAI’s failure to conduct a hazard analysis or other systematic review to ensure flammable liquids were safely handled during the manufacturing process.’

‘The company did not have automated process controls, alarms, or other safeguards in place.  The standard practice at the company was to shut off ventilation at night - to retain heat in the building and to allay residential complaints about fan noise,’ Mr. Wright said.  ‘When the mixture continued to overheat - absent automatic shutoffs and proper ventilation - the vapor accumulated and filled much of the building over a period of hours.  Without safeguards, it is likely that a small but foreseeable human error led to disaster.’

CSB Lead Investigator John Vorderbrueggen, P.E., said Massachusetts state fire regulations and local enforcement should be improved to better protect communities and employees.  He said, ‘The existing Massachusetts fire codes - as well as federal OSHA standards - have requirements for ventilation of flammable vapors to prevent dangerous accumulations inside structures.  But Massachusetts has not adopted the most current national fire codes for flammable liquids.  Our investigation also found that while the state requires local fire departments to periodically inspect facilities that handle flammable materials, the laws do not specify any inspection frequency or criteria for conducting those inspections.’

The CAI/Arnel facility was last inspected by the fire department in 2002, but the inspection focused on a newly installed fire suppression system and did not identify fire code or permitting violations.  In addition to the inadequate ventilation that contributed to the accident, non-causal fire code violations included improper venting of flammable storage containers, use of improper hoses for flammable service, and lack of fire walls.

Under the General Laws of Massachusetts, the CAI/Arnel property was required to have land-use licenses for flammable materials.  The only license, first issued to a predecessor company in 1944 and re-registered annually thereafter, initially authorized the presence of 250 gallons of ‘lacquer.’  In 1955, the property owners were granted an amended license by the Danvers Board of Selectmen to store and use 6,000 gallons of ‘miscellaneous’ flammable materials.

By the time of the accident in 2006, the registration record on file with the Town of Danvers referenced a ‘license’ to store and handle up to 11,500 gallons of ‘miscellaneous’ flammable materials.  However, the CSB found no record of such a license in the Danvers town files.  Therefore, the CSB concluded, the current licensed amount was 6,000 gallons, well below the more than 20,000 gallons of flammable liquid and more than 50,000 pounds of flammable solid, nitrocellulose, stored on site. 

The CSB found Massachusetts law to be unclear on the requirements and procedures for towns to approve requests for increasing the amounts of flammables to be stored at industrial sites, including whether or how adjacent property owners should be notified of intended increases.  The investigation also pointed out that the state’s licensing and registration forms do not require information on the specific types and quantities of materials stored.

A CSB survey of six Massachusetts municipalities - including Boston, Worcester, Springfield, Danvers, Leominster, and Georgetown - found significant variability in how state licensing and registration laws are applied.  Although the six municipalities issued a total of more than 400 flammable materials licenses, only two reported ever having denied a license application.

In addition to a license, Massachusetts regulations require companies to obtain separate permits from the local fire department for the storage of flammable liquids, gases, and solids.  However, at the time of the explosion in Danvers, no permits had been obtained by or issued to CAI or Arnel, except an expired permit for underground storage tanks.  The lack of permits had not been previously identified by the fire department.

Based on the quantities of flammable materials used, CAI but not Arnel was required to comply with OSHA’s Process Safety Management standard, which would have required the company to conduct a process hazard analysis.  Such a review could have identified the need for more sophisticated process control equipment, operator checklists, and continuous building ventilation.  The standard also requires the use of written operating procedures, which can reduce the occurrence of human errors.

However, CAI management stated the company was not aware of the Process Safety Management standard’s existence and had not implemented its requirements.  OSHA had not inspected the facility prior to the accident.

Finally, the report stated that national model fire codes developed by the National Fire Protection Association (NFPA) and the International Code Council (ICC) do not provide sufficient safeguards for flammable liquids heated inside buildings.  The standards - which are voluntary unless specifically adopted by states and localities - contain ambiguous language concerning process vessels and do not explicitly require automatic shutdown or cooling systems to prevent accidental overheating and the uncontrolled release of flammable vapor.

The CSB investigated a similar accident in 2006 at a Chicago-area concrete products company, where a vessel filled with heptane accidentally overheated inside an unventilated building, causing an explosion that killed a driver and caused property damage.

The investigation report makes numerous safety recommendations, which will be considered by the Board.  The report calls on the NFPA (based in Quincy, Massachusetts) and the ICC to revise the national fire codes to prohibit the heating of flammable liquids inside buildings in unsealed tanks that do not vent outside and to require automatic safeguards to prevent overheating.

The report calls on the Massachusetts legislature to require companies to certify compliance with state fire codes and safety regulations, to require public input before allowing companies to increase the quantities of licensed flammable materials, and to require the Office of the State Fire Marshal to audit localities’ compliance with licensing and permitting requirements.

Other proposed recommendations call on the state’s Office of Public Safety to adopt current national fire codes for handling flammable liquids (NFPA 30) and manufacturing of coatings (NFPA 35), to develop standards and a mandatory frequency for fire department inspections of manufacturing facilities, and to require license and registration forms to specifically list the type and quantity of each hazardous material.

Pending completion of the recommended changes at the state level, the report calls for the Town of Danvers to undertake similar initiatives for certification, licensing, and inspection.  Additional, specific safety recommendations were directed to CAI, in the event the company resumes solvent-based processing at another location.  The draft report’s findings, statements of cause, and recommendations are all subject to approval by a vote of the Board and are subject to change.

For more information, contact Director of Public Affairs Dr. Daniel Horowitz at (202) 441-6074 (cell), Public Affairs Specialist Hillary Cohen at (202) 446-8094 (cell), or Sandy Gilmour at (202) 251-5496 (cell).

Why do I ask this you may wonder? In today’s world “keyword’s” help internet users find what they need…. sometimes. However, many times “keyword” searches limit your field of opportunities, regardless of what the meaning or purpose of the word may represent. So continuing down this train of thought, would you consider losing a customer an incident?

Oxford’s definition of Incident:

An event or occurrence : several amusing incidents.
• a violent event, such as a fracas or assault : one person was stabbed in the incident.
• a hostile clash between forces of rival countries.
• ( incident of) a case or instance of something happening : a single incident of rudeness does not support a finding of contemptuous conduct.
• the occurrence of dangerous or exciting things : the winter passed without incident.
• a distinct piece of action in a play or a poem.

The TapRooT® definition of Incident:
• The reason the investigation is being conducted and defines the investigation scope
• The incident usually the most serious event that took place

So would losing a customer be a “serious event”? What if you had a customer complaint and still have a chance to keep from losing the customer? I don’t know about you, but I want to keep my customers. By defining the possible loss of a customer as a significant incident what should your next step be? Think TapRooT®, a root cause analysis system and training that helps solve problems both reactively and proactively. The next step is to find out where to learn about TapRooT®:

1. TapRooT® Summit
If you want to learn how others in numerous industries have applied TapRooT® to resolve customer and product issues in oil refining, oil drilling, bio and medical manufacturing, medical care, aviation (service and manufacturing), nuclear regulatory agencies, engineering companies, chemical manufacturing, governmental agencies…. and numerous others, the TapRooT® Summit in June may be your answer. Click on Summit on www.taproot.com to select a topic track that fits your business needs.

2. TapRooT® Public Courses

Meet other industries in a our public courses as you learn the way to perform a solid TapRooT® investigation for any type of incident. Click on Courses on www.taproot.com for a location near you.

3. TapRooT® Onsite Courses

Let us come to your company and train your employees, supervisors, and managers in house. Call us at 865.539.2139 for quotes.

Watch as Safeguards prevent a fatality…

(Click on picture to play WMV format video.)

See:

http://www.taproot.com/wordpress/2008/04/08/taproot-system-software-dictionary-help-file-update-released/

How long does an investigation take? Depends on how many approvals are needed and how long the backlog is. See this note about a Coast Guard investigation of a barge incident:

http://www.natchezdemocrat.com/news/2008/may/10/report-barge-crash-not-done/

See:

http://jobs.nwsource.com/careers/jobsearch/detail/jobId/9166543/viewType/rss?rssref=stbiz

Ready to do a root cause analysis of this accident…

See this article:

http://www.thatsfit.com/2008/05/10/strange-but-true-accident-by-pelican/

Time for pelican root cause analysis?

The new TapRooT® Book is titled: TapRooT® - Changing the Way the World Solves Problems.

I’ve had several people ask me what’s new in the book and how can they find out more about the contents. Therefore, I’ve decided to post the Table of Contents as a pdf here so that readers can view it…

Just click on it to download the pdf.

By the way, the authors (Mark Paradies & Linda Unger) will be doing a book signing at the TapRooT® Summit Reception in Las Vegas on June 25.

Accident

The Press-Register reported that teams of investigators from OSHA, the state fire marshall, and Louisiana-Pacific were investigating an explosion that injured six workers. Louisiana-Pacific spokeswoman Mary Cohn said:

“They have begun the process of conducting the root cause analysis, but it’s too early to say.”

Cohn said it wasn’t the first such accident at one of the company’s oriented strand board plants.

“We have had some smaller fires in the thermal oil areas, but none of this magnitude,” she said.

My Comment…

Sounds like its time to be more proactive and use advanced root cause analysis to investigate smaller fires and perhaps do proactive audits before there are ANY more fires.

Whenever you have had previous smaller incidents and you then have a major accident, there is something wrong with the response to your previous incidents. The 15 Questions on the front side of the Root Cause Tree® point the investigator toward the MANAGEMENT SYSTEM - Corrective Action Near-Root-Cause Category.

Lesson That You Can Learn

This accident should make you think …

Am I doing all that I can to learn from smaller problems?

Will my responses effectively solve the root causes of problems so that big problems will be prevented?

Are my corrective actions fixing symptoms or the real root causes of the problems?

If you don’t have good answers to the questions above, perhaps now is the time to attend a TapRooT® Root Cause Analysis Course BEFORE you have a major accident at your facility.

Industry leaders from around the world send people to the TapRooT® Summit to learn performance improvement best practices.

Even though there is still a month and a half until the Summit in Las Vegas, registration is well underway. Therefore, we can share a sample (not a complete list) of the companies that are sending people to the Summit (random order):

ExxonMobil
Genentech
Exelon
Alcoa
GE Hitachi

Marathon
First Energy
Chevron
US Military Healthcare Command
Arkema

Duke Energy
Ameren
Occidental
Barrick Gold
ConocoPhillips

Allegra Printing
Rio Tinto
AERA Energy
Integris Health
CGG Veritas

Ashland
PCS Nitrogen
Terasen Gas
Navistar
Braunschweigishe Kohle Bergwerke

Floriday Power & Light
Flint Hills Refining
Oceaneering
AAR Corp
Plains Exploration & Production

Cameco
Quebec Iron & Titanium
GE
RasGas
Canadian Nuclear Safety Commission

Hess
South Texas Project
MYR Group
Constellation Energy
Flint Energy Services

National Defence Canada
Arab Potash
Woodland Grange
Lawrence Berkeley Lab
The REACH Group

Mirant
Chevron Phillips Chemicals
Southern Company
MI-SWACO
Pratt & Whitney

Gulbrandsen Technologies
Petro-Canada
EnCana Oil & Gas
Absolute Radiography
National Security Technologies

DSTL
YANPET
Total
Monsanto
Southern California Edison

Dayton Power & Light
Southcoast Hospitals Group
BUMED
Freeport-McMoran Copper & Gold
SKF

That’s quite a list and it’s only about 1/3 of what we expect by June 25th.

To find out more about why these industry leaders send people to the Summit, watch the videos at the bottom of the page at:

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

To register for the Summit, see:

http://taproot.com/summit-single.php

Sanjay Gandhi taught a  5-Day to one of our mining clients in Zimbabwe. Here’s the class photo…

Sanjay is third from the right in the front row.

See:

http://www.poetenergy.com/careers/showPosition.asp?id=334

See:

http://bauschandlomb.jobs2web.com/job/Principal-Mechanical,-Design-Job/244374/

I’ve heard of cutting off the branch you are sitting on, but this is a little bit different.

(.wmv format)

(link to pictures with major findings highlighted)

If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.

It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?

A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.

My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.

Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.

For details, see:

http://www.nukeworker.com/job/view.php?job_id=6700

Why do articles about medical errors have an erie similarity?

The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

See:

http://skorcareer.com.my/jobs/engineer-mmc-utilities/engineering/2008/05/

The Air Force Link reports that Col. Richard Haddan will chair an investigation board looking into a recent crash of a T-38 training jet. The crash killed Maj. Brad Funk and his student, 2nd Lt. Alec Littler.

No other information will be released prior to the completion of the board’s investigation.

(Investigators gone wild!)

SPARE TIME INVESTIGATIONS

I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!

(Spare time maintenance.)

SOMETHING FOR NOTHING

Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

- Poor investigations & corrective actions

- Repeat incidents

- Increased risk of big accidents

- Risk of regulatory action after a big accident or because of repeat incidents

- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

- Overworked, disheartened investigators

- Investigators trying to dodge investigation assignments

- Disenchanted employees who look at investigations as a waste of time

- Inaccurate investigation statistics

- Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.

(Climb the ladder to work on the roof. A reasonable assignment?)

REASONABLE ASSIGNMENTS

If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

HOW MUCH WORK?

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”

(Benchmarking at the Summit.)

BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES

Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!

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

Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.

Here’s a video of the crash that caused the investigation we previously reported on.

I’ve seen the pictures of landings over this beach, but this is the first video…

Once a year we offer a special class that teaches the TapRooT® Software called “Getting the Most from Your TapRooT® Software.”
This year the course is in Las Vegas on June 23-24.

This course is an intensive review of the TapRooT® Version 5 Enterprise (web) Software including:

- installation,

- configuration,

- data migration (from Version 4),

- administration,

- best practices,

- custom reports, and

- future release information.

Learn all the capabilities built into the amazing TapRooT® Software.

If you are a TapRooT® Power User or Software Administrator, don’t miss this course. Sign up at:

http://www.taproot.com/courses.php?d=15

A subway accident is scary. On Sunday, the derailment of one wheel on two cars of a subway train required 449 passengers to be evacuated on a “rescue train.”

The accident caused Monday commuter service to be disrupted.

For more info, see the AP article at:

http://www.nj.com/news/index.ssf/2008/05/nycs_r_and_n_subway_lines_are.html

72 people have died after an accident in east China. The corrective action that has made headlines is the firing of officials. So far, eight have been fired. For a story with more information, see:

http://afp.google.com/article/ALeqM5gVmWAIUCA2mL6PlOR8ySRM3eHJmw

Is this effective corrective action?

For details, see:

http://www.myedinburghjobs.co.uk/Jobsite/Jobs/783596/Health-Safety-Manager

For more details, see:

http://www.expatengineer.net/jobs.nsf/z/129516

For details, see:

http://www.eluta.ca/search?ptitle=Production+Supervisor&position=af1b3528232630ee26e5204c3e81a3b2&imo=1

http://www.hospitalcompare.hhs.gov

What hospital in your area has the best and worst record for a type of treatment that you need? See the link above, review the performance measures, and find out before you decide where to have treatment.

Fatalities at sporting events are difficult to imagine. It seems we are past the point of gladiatorial combat where the spectacle of death was part of the show. But not every sport has heard about safety. For some interesting reading, see the following articles about a fatality during a practice run for a street luge race and an actual accident at a Formula 1 race.

Street Luge Article:

http://www.kansascity.com/115/story/596177.html

Formula 1 Accident Article:

http://www.telegraph.co.uk/sport/main.jhtml?xml=/sport/2008/04/28/umkova228.xml

The difference? Engineered Safeguards!

Your body is no match for a tree at 60 miles per hour.

But your body can survive a 150 miles an hour crash into a wall if it is properly protected.

In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.

As a TapRooT® root cause analysis instructor and a Six Sigma Black Belt for System Improvements, Inc., I ask the question in this article’s title to numerous safety leaders from multiple industries. What do you think the typical responses are before they attend a TapRooT® course…..

1. No Lost Time Injuries
2. No Fatalities
3. No Near Misses

What’s wrong with these answers? After all, to be best in class for safety you must report these types of numbers. What if I asked your company’s safety leader the following question… “what did you do wrong today to cause this person to get hurt?” This is basically the same question as above except now the safety leader has to answer that the safety department was not successful at the end of the day.

The point is that that the above answers are what are called “lagging metrics”. It’s too late to know what was done wrong or even what was done right! Think about it… when a a fatality occurs the investigation team must exert a lot of effort and time to understand what happened, why it happened, and how to prevent it from happening again. Prevention….. if only the team had understood the everyday problems and root causes that were present before the incident occurred in this area of the business.

Did you know that it takes less time to perform a TapRooT® audit in predetermined areas of company and hazard risk than it does do perform a post incident investigation? So the question to ask again is “how do I know I was successful today in safety?” Your answer could be, “based on a predetermined risk assessment, we lowered the high risk areas in fall protection from 70% to 60%!”

For for ideas about proactive TapRooT® audits, call us at System Improvements, Inc. at 865.539.2139 or even better, attend the TapRooT® Summit in June and see how other top industries are using our proactive audits. Below is a list of proactive opportunities. See you in June.

* Safety & Risk Management
* Human Error Reduction & Behavior Change
* Corrective Action Programs
* Proactive Improvement, Operational Excellence, and Lean/Six Sigma
* Medical Error Reduction
* Equipment Reliability & Maintenance
* Investigation & Root Cause Analysis
* Management & Measuring Performance
* Certified TapRooT® Instructor
* TapRooT® Software Techniques & Administration

For details, see:

http://afp.google.com/article/ALeqM5hMTIeesS8CXfofZqKjKYIk9hOWHA

For more info see the AP story on the CNN web site.

Answer: It depends on how the child is sitting in the chair!

Portland, Oregon opened its doors to 30 employees from various industries attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis course. If you have never attended a TapRooT® public course and want to, who might you be be sitting next to? Here are the companies that attended our Portland course:

U.S. Mint
Intel Corporation
Alaska Airlines
Tidewater
Sause Bros.
Virgin America
Duke Energy Corporation
Southern California Edison
Lawrence Berkeley National Laboratory
Tyco Thermal Controls
Intrepid Potash

…. Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) teaches the difference between facts and events.

…. good investigation teams communicate and stay focused.

…. no blame… just the facts during the what phase of investigation.

…. facts…. facts… facts; you get it right here and your root causes and corrective actions stay connected to the true problems.

…. we teach…. you learn…. you practice …. we guide.

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is the world’s premier root cause analysis training. On top of that, it’s an amazing value. Why do I say that?

1. TapRooT® is the root cause system chosen by industry leaders worldwide. This course teaches all the TapRooT® root cause analysis tools. For a few success stories from users, see:

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

2. There’s more. Learn:

- advanced cognitive interviewing techniques,

- advanced human performance improvement methods,

- procedure improvement ideas,

- innovative, yet proven methods to change behavior,

- how to present investigation results to management,

- how to avoid common mistakes when trending addcident/incident data,

- advanced corrective action development techniques, and

- proactive performance improvement.

3. Attendees receive the patented TapRooT® Software. The course fee is only $2395. The software alone costs $1495. That makes the 5-Day TapRooT® Course an exceptional value.

Our special offers make the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training an even more outstanding value. The special offers include:

1. Prior Course Attendee Discount: Prior 2-Day TapRooT® or 3-Day Equifactor® Course attendees get a $500 discount off the course fee.

2. Licensed Site Discount: Attendees from a licensed TapRooT® Site/Com¬pany qualify for the $500 discount.

3. Multiple Course Attendee Discount: If you sign up 3 or more people at one time for a 5-Day Course, you get a $100 discount for each person.

The maximum discount is the $500 discount plus the $100 discount.

If your folks qualify, they could attend the 5-Day TapRooT® Course for just $1795 each. These special offers make the 5-Day Course an even greater value! For course info, locations, and dates, see:

http://www.taproot.com/courses.php?d=2

Use Safeguards Analysis to analyze this “event.”

(Click on the picture above to ply the .wmv format video)

If the truck tumbled down the hill, killing the driver and perhaps spectators, what would the Causal Factors and Root Causes be?