What’s wrong with this picture?
Tuesday, September 30th, 2008
Received this today…. good thing the lightning lit up the way for the funnel cloud!
Archive for September, 2008
Job Opening: Noord, Holland - Project Management Officer - Needs Root Cause Analysis Skills
Tuesday, September 30th, 2008Captains Having a Bad Day at Sea - Various Ship Accidents
Tuesday, September 30th, 2008See:
TapRooT® in Aberdeen
Monday, September 29th, 2008System Improvements VP, Ed Skompski recently returned from teaching a course in Aberdeen. The following picture was sent in by an attendee of the course from Russia, Gazizov. Ed may be the only TapRooT® instructor with a bear named after him. Following is a pic of Gazizov’s children with “Eddy Bear.”
Rig Managers for RDC in Bahrain Attend 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
Monday, September 29th, 2008Sanjay Gandhi sent these photos from a root cause analysis course in Bahrain …
Do you want your folks to find and fix the real root causes of problems? Then have them attend a TapRooT® Course. Contact us to schedule one at your facilities. We teach them all over the world!
And if you are in the Middle East, there is a public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course being held in Bahrain on October 25-29, 2009. Don’t miss this chance to learn all about TapRooT® and how it can help you solve problems.
Monday Accident and Lessons Learned: Ranger Bearly Escapes
Monday, September 29th, 2008Start with the thought that this bear was probably trapped because it was not afraid of humans.
Next, put it in a steel trap and shake it down a dirt road until it is really mad.
Now, release it from the cage.
See what happens and then do a root cause analysis.
Is this the process your employees use to mitigate risk and improve performance? What could they learn from this…
Rick Brower, a TapRooT® User, sent me the pictures.
L
Everett, WA, Man Killed in Accident
Monday, September 29th, 2008A crate with 1,000 pounds of glass topped onto a worker and killed him at a manufacturing plant in Everett, WA. For more info, see:
Public TapRooT® 2-Day / 3-Day TapRooT® / Equifactor® Root Cause Analysis Course in Venezuela
Sunday, September 28th, 2008Marco Flores, one of our Spanish speaking instructors, sent these pictures from a recent course in Venezuela…
Pictures from the 2-Day Incident Investigation and Root Cause Analysis Course for ConocoPhillips Arroyo Grande
Friday, September 26th, 2008Heidi Reed, one of our TapRooT® Instructors, sent these photos from a recent 2-Day Course.
Playing the “marble game” and learning why we need root cause analysis…
Working on a root cause analysis exercise and reinforcing the lessons of the course…
If you need some help finding and fixing the root causes of problems at your facility, give us a call at 865-539-2139 to get your people trained to use advanced root cause analysis to solve problems. Or you can contact us here.
Job Opening: Detroit, MI - Refining/Chemicals Company - Project/Mechanical Reliability Engineer - Needs Equipment Root Cause Failure Analysis Skills
Friday, September 26th, 2008Friday Joke: Useful Work Phrases
Friday, September 26th, 20081. Thank you. We’re all refreshed and challenged by your unique point of view.
2. The fact that no one understands you doesn’t mean you’re an artist.
3. I don’t know what your problem is, but I’ll bet it’s hard to pronounce.
4. Any connection between your reality and mine is purely coincidental.
5. I have plenty of talent and vision. I just don’t care.
6. I like you. You remind me of when I was young and stupid.
7. What am I? Flypaper for freaks!?
8. I’m not being rude. You’re just insignificant.
9. I’m already visualizing the duct tape over your mouth.
10. I will always cherish the initial misconceptions I had about you.
11. It’s a thankless job, but I’ve got a lot of Karma to burn off.
12. Yes, I am an agent of Satan, but my duties are largely ceremonial.
13. No, my powers can only be used for good.
14. How about never? Is never good for you?
15. I’m really easy to get along with once you people learn to worship me.
16. You sound reasonable. Time to up my medication.
17. I’ll try being nicer if you’ll try being smarter.
18. I’m out of my mind, but feel free to leave a message.
19. I don’t work here. I’m a consultant.
20. Who me? I just wander from room to room.
21. My toys! My toys! I can’t do this job without my toys!
22. It might look like I’m doing nothing, but at the cellular level I’m really quite busy.
23. At least I have a positive attitude about my destructive habits.
24. You are validating my inherent mistrust of strangers.
25. I see you’ve set aside this special time to humiliate yourself in public.
26. Someday, we’ll look back on this, laugh nervously, and change the subject.
CSB Release Accident Investigation Report on Propane Explosion at Convenience Store
Friday, September 26th, 2008The following press release is from the U.S. Chemical Safety Board, Washington, DC.
CSB Investigation of the 2007 Little General Store Propane Explosion Emphasizes Need for Immediate Evacuation, Recommends Enhanced Training of Emergency Responders and Propane Technicians, Guidance for 911 Operators
Beckley, West Virginia, September 25, 2008 - In a draft final report released today, investigators from the U.S. Chemical Safety Board (CSB) conclude that inadequate propane technician and emergency responder training and unsafe propane tank placement were the primary causes of a fatal accident in January 2007 at the Little General convenience store in Ghent, West Virginia.
The propane explosion on January 30, 2007, killed two emergency responders and two propane technicians. Six others were injured. All of the victims had remained in the immediate vicinity of a propane release from a storage tank behind the store and did not evacuate the area. The store, which was leveled in the explosion, was located in rural West Virginia about 70 miles south of Charleston.
The draft report calls on West Virginia to provide annual hazardous materials training and drills for all firefighters and recommends improved training for propane service technicians throughout the country. The draft report and safety recommendations will be considered for approval by the CSB Board at a public meeting tonight in Beckley. The meeting will begin at 6:30 p.m. at the Tamarack Conference Center Ballroom located at One Tamarack Park (exit 45 off I-77).
All findings, causes, and recommendations remain preliminary pending approval by the Board. The Board will ask for public comments on the investigation at the meeting tonight.
The CSB also released today a seven-minute computer animation reenacting events during the nearly half-hour leading to the tragedy, from the beginning of the propane release to the eventual explosion.
The accident occurred as a junior propane technician, who had not been formally trained and had been on the job only one-and-a-half months, prepared to transfer about 350 gallons of propane from an old 500-gallon tank to a new tank.
Propane was released from the old tank’s liquid withdrawal valve after the technician removed a safety plug from the valve. The CSB later determined the valve had a manufacturing defect that caused it to be stuck in an open position. The CSB also determined that, probably because of a lack of training, the technician likely did not observe a telltale sign that the valve was defective: the safety plug has a small hole through which propane may be seen leaking if the valve is stuck open, before the plug is fully removed.
The CSB estimated the leak began at about 10:25 a.m. and that the building exploded just after 10:53 a.m.
‘We investigated this accident because of the tragic, unnecessary loss of life,’ said John Bresland, CSB chairman and CEO. ‘Nearly 30 minutes elapsed between the release and the explosion. If there’d been an evacuation during those 30 minutes, all of the lives would have been saved.’
The CSB investigation found that a propane tank had been installed against the back wall of the store in 1994 by propane supplier Southern Sun, in violation of OSHA regulations and the West Virginia state fire code, which require 500-gallon tanks to be placed at least ten feet away from buildings. Southern Sun was later acquired by Ferrellgas in 1996, but the tank remained where it was against the back wall.
On the day of the explosion, the tank location enabled the liquid and vapor shooting up from the valve to enter directly into the building through overhanging attic vents located above the tank. Propane then diffused down through the ceiling, and bathroom ventilation ducts also likely carried propane into the store.
CSB Lead Investigator Jeffrey Wanko said, ‘Our investigation team interviewed many delivery and service personnel who worked on this tank over the years. All of them were aware of the ten-foot separation requirement but none had reported the unsafe placement of this tank to their managers.’ Personnel mistakenly believed the unsafe tank placement had been approved, possibly under a variance. Ferrellgas inspections and audits did not uncover the unsafe tank placement over many years.
Mr. Wanko said, ‘Had the tank been ten feet away from the building - as required by OSHA standards and the state fire code - it is unlikely that an explosive concentration of propane would have built up inside the store.’
CSB investigators found that the junior technician, an employee of Appalachian Heating, had been working alone and unsupervised on the propane system at the Little General, despite having no formal training. As propane continued to escape and infiltrate the store, the technician called his supervisor, who had left for another jobsite, then called 911. Despite the severity of the release, the technicians did not recommend an evacuation of the store and the surrounding area.
The 911 operator dispatched the Ghent Volunteer Fire Department to the report of a propane leak at the Little General. Subsequently, a volunteer fire captain, firefighter, and two emergency medical technicians arrived at the store. Four employees remained inside the store, after posting a sign saying, ‘Store closed due to gas leak.’
At about 10:53 a.m., the captain told the firefighter to ‘Make sure everybody’s out, okay?’ But before the firefighter could act, the propane ignited from an undetermined source and the store exploded. Debris struck and fatally injured the two technicians, the fire captain, and an emergency medical technician. The workers inside the store survived with serious injuries.
CSB Investigations Supervisor Robert Hall said, ‘We found that emergency responders’ training was not sufficient to enable them to recognize the need for immediate evacuation.’ West Virginia only requires initial hazardous materials training for firefighters, generally a four-hour course when firefighters begin their careers, but refresher training is not required. The Ghent volunteer fire captain had received hazardous materials training only once, in 1998.
The CSB also found West Virginia and 35 other states have no requirements for training or qualification of propane technicians.
Chairman Bresland said, ‘Emergency responders often need to call on propane technicians for assistance during propane-related emergencies. There is a need for training of both firefighters and technicians so they may work together to safely deal with propane releases that threaten the lives of residents, workers, and responders.’
Training should include appropriate emergency measures including the need for immediate evacuation in the case of a significant propane release, the CSB said.
Mr. Wanko noted that propane emergencies occur frequently: ‘There are about 17 1⁄2 million propane installations in the United States. Firefighters respond to propane emergencies nearly every day. Propane technicians, firefighters, and 911 operators have to be prepared for these emergencies.’
Mr. Wanko said that 911 operators typically use a set of guide cards to acquire pertinent information from callers and give appropriate instructions while dispatching responders to calls for help. However, there is no card specific to propane emergencies.
‘Such a guide card would prompt operators to ask about the size and nature of propane leaks and potential dangers, and increase the likelihood of timely evacuations while firefighters determine the extent of the threat,’ Mr. Wanko said.
At the public meeting tonight in Beckley, the CSB Board is expected to vote on 12 safety recommendations aimed at preventing similar accidents in the future.
The draft report recommends that the governor and legislature of West Virginia require training and qualification for all propane technicians. To improve training across the United States, the report recommends the National Fire Protection Association amend the national fire codes to call for specific training and testing for all personnel who handle propane.
To assure propane technicians are knowledgeable in handling emergencies, the draft report recommends that the Propane Education and Research Council, established by Congress to promote the safe use of propane, revise its training program to include emergency response guidance. Investigators said this training should emphasize the need to evacuate the scene of a release until all the hazards are known.
The draft report also recommends that Ferrellgas establish an improved inspection program and auditing system for propane installations.
The draft report calls on West Virginia to require annual hazardous materials training for all firefighters and emergency medical technicians in the state. The report also recommends that the West Virginia State Fire Commission require all fire departments to perform at least one hazardous materials response drill each year.
Following approval of the draft report, the CSB plans to release a 23-minute video, ‘Half an Hour to Tragedy,’ containing the 3-D computer animation of the events in Ghent and a description of the causes, consequences, and lessons of the accident. Featured in this video will be West Virginia State Fire Marshal Sterling Lewis, Jr., CSB investigators, and CSB Chairman John Bresland.
Tugboats and Ike
Friday, September 26th, 2008See the story from the Houston Chronicle of how tugboats saved the day (working during hurricane Ike in the Houston Ship Channel):
Job Opening: Brussels, Belgium - IT Problem Manager - Need Incident Investigation, Root Cause Analysis, and Trending Skills
Friday, September 26th, 2008Train Accident Root Cause Analysis Released by UK RAIB
Thursday, September 25th, 2008
This accident report that details the collision of a train with a footbridge is at:
http://www.raib.gov.uk/cms_resources/20080925_R182008_BarrowuponSoar.pdf
Error-prone Investigation Team shut down…..
Thursday, September 25th, 2008
Actually the title of the AP news article is “Error-prone Detroit police crime lab shut down“.
“….found erroneous or false findings in 10 percent of 200 random cases audited. The crime lab operation will be turned over to the state police. Barren says the lab’s commander will be removed and its 33 officers reassigned.”
I don’t know what’s more disturbing, the errors made or the corrective action taken. If your investigative processes in safety, quality, or other business transactions were audited for accuracy like a CSI lab, what would they find?… what would the reaction be if errors were made? … what would the impact be from the results or actions taken from the investigation?… when did the errors occur (evidence gathering or analysis)?
Accident on Nuclear Submarine Kills One
Thursday, September 25th, 2008A Machinist Mate Third Class was killed while cleaning near the rudder of the USS Nebraska, a nuclear powered ballistic missile submarine.
When you put a face with a fatality, the accident becomes much more personal.
Let’s hope that a thorough root cause analysis is performed and real lessons learned are shared to stop “rudder accidents” from happening again. (This isn’t the first time someone has been crushed by a rudder.
How To Finance an Important Safety Improvement
Thursday, September 25th, 2008The federal government may be requiring “high-risk” railroad tracks to install a fairly expensive satelite navigation based positive control system.
The Press-Enterprise wrote:
“The cost of installing train controls along the 338 miles of Metrolink track in Riverside, San Bernardino, Los Angeles, Ventura and Orange counties would be between $23 million and $67 million, based on Metrolink estimates. That’s $70,000 to $200,000 per mile, officials estimated.”
With costs this high, how do you fund the safety improvement? That’s a question that every company must face when funding expensive improvements.
When it comes to a nationwide effort (all systems should work together so that a train crossing the country uses a single system), the temptation is to require federal funding.
What do you think? Should the whole country chip in? Or should the railroads involved fund the improvement?
Free Arc Flash Webinar
Wednesday, September 24th, 2008Escalator Accident - Still Another
Wednesday, September 24th, 2008Kansas judge overrules jury verdict, says BP Corp. liability case could be retried
Wednesday, September 24th, 2008“The city is seeking about $478 million for clean costs and damages as well as punitive damages.”
Read more at: http://www.kake.com/home/headlines/29638274.html
Pilots who fell asleep during landing procedures have completed their FAA mandated suspension
Wednesday, September 24th, 2008Fired by GO airlines, it is uncertain whether the pilots are now flying for another carrier. According to the article, no action was taken against GO because they had provided the pilots with a 15-hour break before their shift, nearly double what the FAA requires. Below are just a few facts collected from the article, can you see other opportunities that may have been missed during the investigation?
* Pilots fell asleep on the Feb. 13 flight from Honolulu to Hilo.
* One pilot was later diagnosed with a severe obstructive sleep apnea…. preventing a restful night of sleep.
* Unclear how both pilots fell asleep on the brief midmorning flight
* No problems were found in the aircraft’s pressurization system and carbon monoxide levels.
* The pilots failed to respond to nearly a dozen calls from air traffic controllers over a span of 17 minutes.
* About 44 minutes into what is usually a 45-minute flight, the controller was able to establish radio contact. By that time, the plane had passed the airport at Hilo by 15 miles, and the controller ordered the flight crew to return.
* The pilots were able to reverse course and landed safely at Hilo International Airport.
Zapped While Stealing Copper Wire
Wednesday, September 24th, 2008Here’s the start of an article from London Times:
“A man was killed trying to steal a copper cable which was carrying 11,000 volts, an inquest heard today.”
“Kirk John Thompson was electrocuted at the derelict Panteg steelworks, in Pontypool, South Wales, when his bolt croppers pierced the plastic coating of a cable still connected to the National Grid.”
Investigation into the Fire on an HGV Shuttle Train in the Chunnel
Tuesday, September 23rd, 2008
A press release from the UK Rail Accident Investigation Board:
The Bureau d’Enquêtes sur les Accidents de Transport Terrestre (BEA-TT) and the UK Rail Accident Investigation Branch (RAIB) are carrying out a joint investigation into a fire that occurred on a heavy goods vehicle (HGV) shuttle train in the French part of the Channel Tunnel.
On the afternoon of Thursday 11 September 2008, a fire broke out on a train carrying HGVs from the UK terminal at Folkestone to the French terminal at Coquelles, just outside Calais. The train was subsequently stopped 11.5 km kilometres from the French tunnel portal (39 km from the UK portal).
As soon as it was known that there was a fire on board the train, the train drew to a halt with its amenity coach (in which the HGV drivers travel during the transit) alongside a door giving access to the service tunnel, which provides a place of safety in case of emergencies. The service tunnel runs between the two rail running tunnels, with access doors at regular intervals.
All 29 passengers and 3 crew from the train left the train and walked to the service tunnel. They were later transported from there to the Coquelles terminal. Several were suffering from the effects of smoke inhalation; there are also reports that some had minor cuts and bruises.
The fire spread to involve other HGVs on the train.
Once all the personnel had been safely evacuated from the fire scene, the fire services of both the Pas-de-Calais and Kent tackled the fire itself. The fire was not finally extinguished until mid-morning on Friday 12 September.
A Binational Emergency (BINAT) was declared by the Prefet of the Pas-de-Calais, invoking the provisions of the Binational Emergency plan for co-operation between the emergency services of the two countries to tackle a major incident within the Channel Tunnel.
The joint investigation into the accident will be led by BEA-TT (in whose territory the train stopped) and will be independent of any investigation by the Intergovernmental Commission which is the safety authority for the Channel Tunnel.
The findings of the investigation will be published in a report, including any recommendations to improve safety. This report will be available on the BEA-TT and RAIB websites. See:
Industrial Pressure Washer Accident
Tuesday, September 23rd, 2008Attorney Trolls for Metrolink Accident Business with Blog Entry
Tuesday, September 23rd, 2008The Financial Crisis: The Folly of Action Without Root Cause Analysis
Monday, September 22nd, 2008How many people believe the current financial disaster has received a thorough root cause analysis? Do you? Yet we are in the process of spending trillions in an attempt to “fix” it.
Since politics and greed are near the heart of this failure, it is unlikely that the government will ask for real investigation into the causes of the decline of so many financial institutions. Performing a real root cause analysis would reveal too many errors, blunders, broken rules, and perhaps criminal activity. Instead, scape goats will be identified during political which hunts.
Was it the Fed? Political cronyism with appointments at Freddy and Fanny? Stupid accounting rules? Greed at investment banks and hedge funds? Inadequate regulatory oversight? The result of beltway lobbyists and their contributions on the political process?
A thorough root cause analysis could pinpoint the reasons why our systems are failing.
But instead of a thorough root cause analysis, you and I will be stuck with the bill for the failure of others without any guarantee that the real causes are being corrected.
Talk about waste, fraud, and abuse … I think we are witnessing it on a grand scale … and there is very little we can do about it.
Coal Mine Accident in China Kills 31
Monday, September 22nd, 2008Classic Accident: 1986 Challenger Accident Investigation
Monday, September 22nd, 2008Don’t Want this Guy to be My Pilot
Saturday, September 20th, 2008Risk taking must be in his blood…
