Root Cause Analysis Blog

How much can a service outage cost? It’s costing Rackspace between $2.5 to $3.5 million because they guarantee reliability and provide credits if their service is out for more than a specified period of time.

With millions on the line, let’s hope they perform an adequate root cause analysis. The information in their preliminary release points to a series of electrical equipment failures. (They should have an Equifactor® Troubleshooting Chart for these.)

Here’s an article about the costs:

http://www.datacenterknowledge.com/archives/2009/07/02/rackspace-expects-credits-of-25-million/

Here’s information about the failure:

http://www.rackspace.com/downloads/pdfs/DFWIncidentReport6-29-2009.pdf

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See:

http://www.raib.gov.uk/publications/investigation_reports/reports_2009/report182009.cfm

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Rackspace, a web hosting company, had a 45 minute outage on June 29th. An Article in Web Host Industry Reviews says that they are going to perform a root cause analysis of the event.

Analyzing the root causes of web outages can be very similar to other outage analyses that people do using TapRooT®.

For example, BellSouth used TapRooT® to review 911 outages, long distance network outages, and local service outages.

Another high reliability computer service provider, Tandem Computers who was later bought by HP, used tapRooT® to analyze network and computer reliability issues/outages.

It really is amazing how even with different technologies, the same proven techniques can be used to find the root causes of human error and equipment failure.

If you would like to learn advanced root cause analysis to analyze service problems, attend a TapRooT® Course. For more information, see:

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

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Here is the story:

http://news.yahoo.com/s/ap/20090701/ap_on_re_af/yemen_plane_crash_7

This will make the investigation much easier and more likely to reach good conclusions; hopefully they find the other one.

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See:

http://www.raib.gov.uk/publications/bulletins/bulletins_2009/bulletin_07_2009.cfm

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Here is the story:

http://news.yahoo.com/s/ap/ml_yemen_plane_crash

It is pretty amazing that they were able to rescue a small child from the ocean; I’d like to hear more about that.

After the Air France crash and this, I can hear the kneejerkers now; Airbus can’t fly in bad weather!  Hopefully they can find the black box on this one.

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Here is the story:

http://cityroom.blogs.nytimes.com/2009/06/29/3-workers-hurt-in-sewage-hole-collapse-in-queens/?hp

Sad story.  What is troubling is that they had a previous fatality at the plant and appear not to have learned much from that experience as evidenced by the recent violations:

“Records from the most recent OSHA inspection, conducted earlier this year, show that the federal agency identified several serious violations at the plant, including violations concerning floor and wall openings and holes, industrial stairs, respiratory protection, medical services, and oxygen-fuel gas welding and cutting.”

How many fatalities does it take before people get the message?

Don’t get caught in this trap - attend a TapRooT® course and learn how to find the root causes of problems after they occur and proactively identify and address issues BEFORE they occur.  See the course schedule HERE.

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Did a series of computer failures lead to the recent Air France Crash in the Atlantic? here’s an interesting article from the Wall Street Journal:

http://online.wsj.com/article/SB124605948270463623.html

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Here is the story:

http://www.latimes.com/news/nationworld/world/wire/sns-ap-as-china-building-collapse,1,2363085.story

I posted a blog a few weeks ago with a similar story; a construction accident in a developing country where someone is “being held.”  The common theme is that blame is the focus with no mention of actually fixing the problem.  In this story, officials are “embarrassed.”  Can you say SCAPEGOAT?

They should be embarrassed.  They should be embarrassed that they don’t have good systems to prevent such incidents.  Meanwhile people are being hurt and killed. 

I’m not sure I would want to be a construction supervisor or safety manager in this environment; you might end up in jail!

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Download the PDF at:

http://www.raib.gov.uk/cms_resources/090622_R162009_Deptford%20Bridge.pdf

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Here’s an article from Abu Dhabi about a second fatal accident involving a child and a school bus. It’s interesting because the writer discusses the hierarchy of Barriers (we call them Safeguards in the TapRooT® System) and how they can be used when developing corrective actions. You usually don’t see this level of understanding of root cause analysis in a newspaper article or letter to the editor.

To read the article, see:

http://www.khaleejtimes.com/DisplayArticleNew.asp?col=&section=opinion&xfile=data/opinion/2009/June/opinion_June135.xml

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The short article from WTEN in Albany should make you think once again about the hazards involved in using a crane near a power line. See:

http://www.wten.com/Global/story.asp?S=10602635

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Read the story:

http://news.yahoo.com/s/ap/20090626/ap_on_bi_ge/us_nestle_recall

In my previous life, I have a great deal of experience dealing with regulators.  While I have had limited dealings with the FDA, I think the kind of approach Nestle is taking (if the article is accurate) is not very smart.

My experience is that you must develop partnerships with your regulators so problems can be solved together.  Making life difficult for them will only come back to haunt you later.

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Here is the story:

http://www.cnn.com/2009/TRAVEL/06/26/airbus.problems/index.html

While we are far from reaching conclusions on what brought down Air France 447, there is at least some indication that air speed may have been a factor. 

Air France is replacing the air speed indicators (pitot tubes) on its fleet of A330  aircraft.  What we cannot tell from the article is whether the same exact type of pitot tubes are on the other aircraft mentioned, so let’s no jump to any conclusions.

One thing I would like to mention is that airlines do have processes for the crew to follow in the event of an airspeed discrepancy.  Why the Air France crew was not able to respond is a key question that is still unanswered, although we do know weather like they encountered requires a great deal of extra work on the part of the crew.

There are still more questions than answers.  Until we have those answers, I’ll be more than happy to step onto an Airbus.  I have confidence that the NTSB will do all possible to determine if this is a generic issue.

This situation brings up an interesting question - how do different companies in your industry share information about events?  In the case of the airline industry, the aircraft manufacturers share information with those that operate their aircraft, and entities like the NTSB do as well.  Not every industry has this type of feedback mechanism however.  Food for thought.
      

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Here is the story:

http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/062709dnmetdiver.bef91d9.html

OSHA is investigating.

It is hard to believe it is cost effective to hire someone to retrieve balls.  Then again, I guess you can’t leave them in there forever.  Sad story.

This just goes to show that no profession is immune to injury/death. 

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I’ll post the links here so that people can review the report.

The Executive Summary:

http://www.tva.gov/kingston/rca/Executive%20Summary-for%20VI-062409.pdf

The presentation slides:

http://www.tva.gov/kingston/rca/aecom.pdf

The independent review letter:

http://www.tva.gov/kingston/rca/letter.pdf

The complete report site:

http://www.tva.gov/kingston/rca/index.htm

I reviewed the slide show and the Executive Summary and I couldn’t find anything that I would call “root causes.”

I did see a good failure scenario that would make a good SnapCharT® and then could be used to identify Causal Factors (which are similar to the “Failure Conditions” in the presentation pdf). Their failure conditions were:

• Increased Loads Due to Higher Fill
• Hydraulically Placed Loose Wet Ash
• Fill Geometry & Setbacks
• Inusually Weak Slimes Foundation

But they didn’t analyze these factors to find the root causes behind them and they certainly didn’t look for Generic Causes.

They won’t be reopening this site so this accident won’t be repeated here. But I didn’t come away with lessons that TVA’s Management should be learning to improve their performance.

Am I missing something? Review the materials and see what you think.

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Nine are now confirmed dead after the Washington Metro train collision.

Two stories now speculate about the failure of circuits to detect the train that was approaching the other train stopped at the station. To read more, see:

http://abcnews.go.com/News/story?id=7927243&page=1

http://www.chron.com/disp/story.mpl/ap/top/all/6498184.html

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SAFETY ALERT NO. 212:

WORKERS INJURED USING DAMAGED LIFTING EQUIPMENT

Country: CANADA

Release Date: 22 June 2008

Type of Activity: Lifting, crane, rigging, deck operations

Type of Injury: Struck by

Two workers were injured when a lift sling dislodged from a winch hook that did not have a properly operating safety latch.

A service rig crew was in the process of laying down the working floor when they realized that the floor would not be able to come down all the way because a pressure switch was in the way. The operator began to raise the floor so the pressure switch could be turned. As the floor was raised to approximately 45 degrees, the winch hook came unlatched and the floor fell. To save time and speed up the operation, the floorhand and the derrick hand had stepped underneath the floor to pass a 36″ pipe wrench. This placed both individuals directly in the fall path of the floor. Both workers were contacted by the falling floor.

What Went Wrong?

The rig was equipped with two winch lines, the first of which had a damaged Kuplex hook. At the time of the incident the second winch line, which was not used, was fully operational.

The rig crew identified “overhead loads, swing paths, and pinch points” in a safety meeting.

The rig manager was aware that the safety latch on the winch hook was damaged and could not be properly secured. This was verbally communicated to all crew members and documented the hook in a hazard report.

The winch hook was taken out of service for repair after it had been identified as damaged.

A winch hook repair kit had been ordered and was on location at the time of the incident.

After the hook repair kit had been received, the rig manager had attempted to fix the winch hook but was unable to install the new latch locking mechanism.

Believing it would be “OK” for the task of positioning the work floor, the winch hook was returned to service.

When the rig operator began running the winch controls, the floor hand and derrick hand were standing out of the fall path of the rig floor.

At the time of the incident, both workers had moved below the fall zone of the rig floor before the rig floor was in position.

The winch hook was attached to the centre pad and an engineered sling was attached to the work floor. As the floor was raised, the weight of the floor transferred from the center pad sling to the work floor sling. Without the latch lock mechanism, the D-ring pushed out of the winch hook allowing the rig floor to fall.

Corrective actions and Recommendations:

Important hazard identification and control recommendations include:

Never use damaged equipment: Although all members of the rig crew were aware that the winch hook was damaged, the hook was returned to service and used to raise the rig floor.

Always give careful thought about your proper position for the task: In this case, both the derrick hand and the floor hand moved below the rig floor while it was being hoisted by the winch line and were standing directly below an overhead hazard.

Consider the need for design changes before an incident happens: In this case, the company initiated a review the work floor design after the incident and made changes to eliminate the necessity of having the winch hook on the work floor centre pad making lifting operations much safer.

A final thought: Efficiency is important and something we all take a lot of pride in. Always take an extra moment to consider your actions whenever attempting to save time or effort. Make sure your decision is a safe one.

DISCLAIMER:

This Safety Alert is designed to prevent similar incidents by communicating the information at the earliest possible opportunity. Accordingly, the information may change over time. It may be necessary to obtain updates from the source before relying upon the accuracy of the information contained herein. This material is presented for information purposes only. Managers and supervisors should evaluate this information to determine if it can be applied to their own situations and practices.

Source Contact:

This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).

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You’ll have to go to this link:

http://www.youtube.com/watch?v=N1U5I7W2TuM

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CNN reports that at least two people were killed and many were injured in a commuter train crash today.

For the CNN story see:

http://www.cnn.com/2009/US/06/22/washington.subway.crash/index.html#cnnSTCText

For a video report, see:

http://www.cnn.com/2009/US/06/22/washington.subway.crash/index.html#cnnSTCVideo

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Read this story about the finding of a recent audit report about the TVA ash spill in Tennessee:

http://www.chron.com/disp/story.mpl/nation/6483719.html

In this cases, there was a “Causal Factors” after the “Incident” (circle) on the SnapCharT®.

These type of Causal Factors don’t “cause” the incident, they do “cause” the accident to have worse consequences.

If you would like to learn more about advanced root cause analysis and incident investigation techniques, here are three ideas to consider:

1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Pick from course in:

• Niagara Falls, Canada (July 6-10)
• Melbourne, Australia (July 6-10)
• San Antonio, USA (July 13-17)
• Perth, Australia (July 20-24)
• Seattle, USA (July 27-31)
• Newcastle, Australia (Aug 3-7)
• Brisbane, Australia (Aug 3-7)
• Hong Kong, China (August 31 - September 4)
• Edmonton, Canada (September 7-11)

For complete course information, schedule of courses, and registration, see:

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

2. Already attended a TapRooT® Course but want to learn the latest improvements in the techniques? Attend the 2-Day TapRooT® Advanced Techniques Course that is being held on October 5-6 in Nashville, Tennessee. For more information and registration, see:

http://www.taproot.com/summit.php?t=pre-summit#taproot_advanced

3. If you want to learn best practices from around-the-world, attend the Investigation and Root Cause Analysis Track at the TapRooT® Summit on October 7-9 in Nashville, Tennessee. In addition to the great Keynote Speakers, you will also attend the following Best Practices sessions:

• Accident Analysis Presentations (Attack on the USS Stark, Crandall Canyon Mine, 230 Environmental Incidents)
• Success Stories from the Field (common cause analysis of multiple aviation accident investigations and proactive use of Safeguard Analysis for manufacturing quality improvement)
• DISCover How To Communicate After an Accident
• The Good, The Bad, and The Ugly: Which Describes Your Investigations and Reports and What Can You Do To Improve?
• TapRooT® User’s Best Practice Forum
• How To Prove That Fatigue Was the Cause of an Incident
• Advanced Ideas for Defining Causal Factors
• Lessons from Tennessee OSHA Fatality Investigations

For more Summit information or to register, see:

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

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Found this on U-Tube…

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For more info, see:

http://www.philly.com/philly/wires/ap/news/state/pennsylvania/20090619_ap_ohiomankilledinwesternpadrillingaccident.html

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Another sad crane accident kills a worker in Quebec. The regulatory authority fines two companies involved a total of $31,080 Canadian Dollars.

A story in The Montreal Gazette provides the following quote from a company President about the fine:

“It’s unjust,” Poirier said. “An accident is an accident.”

You don’t penalize something that could not have been prevented, she added.

Hmmm…

If they can’t figure out how to stop killing people when disassembling a crane, maybe they shouldn’t be allowed to operate cranes?

Maybe it’s time the company President attended a TapRooT® Course? I’d suggest the 5-Day!

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Watch this video (WMV format).

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People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator. But there can be times when an investigator needs to ask for help. This posting will provide some examples that could help you decide when to ask for help.

LEGAL

Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.

CUSTOMER DISPUTE

It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.

UNION ISSUE

Ever had an investigation that gets contentious with a union? This may be time to ask for help.

An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.

JUST LEARNING

TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.

INDEPENDENT INVESTIGATION/NEW SET OF EYES

Sometimes management may want fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and get beyond group think.

CONTROVERSIAL INVESTIGATION

I’ve seen investigations that might result in someone in upper management loosing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.

COACHING

Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.

OVERWHELMED

Too many accidents to investigate? Augment your staff with outside facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Want more info? Use the “Contact Us” button above or call 865-539-2139.

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Here’s an article that follows up on a previous post here at the Root Cause Analysis Blog.

The WSBTV story reports on the results of an OSHA investigation that does not include a root cause analysis.

Click here to see the OSHA report.

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An Article in the The Pratt Tribune says that cracks on wind farm turbine blades in Flat Ridge, Kansas, are due to a “manufacturing defect” and a “quality control defect in the manufacturing process.”

The problem was discovered during the root cause analysis of cracks at another wind farm. Since the same manufacturing process was used for the blades at the Flat Ridge site, the manufacturer has decided to replace the blades under warranty rather than waiting to see which ones start to crack.

First, if I am a manufacturer, a manufacturing defect is not a root cause. It is a causal factor that needs to be investigated. Since they have found out how the cracks occur (”During the manufacturing process numerous layers of laminate are used to make the fiberglass blades. During that process little folds develop that build up in a very defined location on the blades that will eventually lead to small cracks in the blades and cause pealing.”).

The “little folds developing” needs to be examined. It is probably the causal factor that needs to be examined to find it’s root causes.

Next, should these “little folds” have been caught in the design/manufacturing testing process?

Finally, how long have reports of these “little cracks” been coming in?

Because these cracks seem to occur across the manufacturing process (all the blades seem to have them), the root causes will be Generic Causes that apply to all blades manufactured. But are the problems with the design/manufacturing/testing process also present in other parts of the manufacturing process (not just the “little folds” on these blades)? That is a much bigger generic cause question.

What do you do to find the real fixable causes of manufacturing problems?

Do you look beyond the immediate causes to find root causes and then probe further to see if there are Generic Causes?

If you would like to learn a process that is used by industry leaders around the world, see:

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

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From Yahoo’s space news section, “a 14-year old German boy was hit in the hand by a pea-sized meteorite that scared the bejeezus out of him and left a scar.”

“When it hit me it knocked me flying and then was still going fast enough to bury itself into the road,” the boy said.

Now as a TapRooT® Root Cause Analysis Instructor and incident investigation facilitator, I do not want to ever hear our clients say this incident was just bad luck. It was a one of a kind occurrence that never happened before. In reality it would be pretty hard to substantiate those types of findings.

In this case however it appears to be pretty much bad luck but it has happened a few times before. Now I don’t plan on issuing a “Chicken Little” the sky is falling report but I will look up every now and then.
(more…)

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Washington, DC, June 9, 2009— The U.S. Chemical Safety Board (CSB) today sent an investigation team to the site of an explosion, fire and roof collapse at the ConAgra Foods plant in Garner, North Carolina.

According to media reports, at least 20 people have been transported to area hospitals and at least two were reported as unaccounted for following the explosion which occurred shortly before 11:30 a.m. today. The explosion caused the roof to collapse on one side of the building, knocked down walls, and blew debris about the area.

The CSB team will be headed by Investigations Supervisor Don Holmstrom. Board Member William Wark will accompany the team.

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 Public Affairs Specialist Hillary Cohen (on location) cell 202.446.8094; or Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074.

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The Associated Press came out with an article today about beefed up Inspections of Regional Airline Pilot Training. This increased activity is in REACTION to pilot errors listed following the New York Regional Jet Crash earlier this year. The good PROACTIVE note in this article was this comment, “Federal Aviation Administrator Randy Babbitt said in a statement they will also hold a meeting with the airline industry — both regional and major carriers — next week to seek better pilot training, cockpit discipline and other safety improvements.”

So what would you look at to determine the Training concerns:

1. “a series of critical errors by the captain and co-pilot preceded the crash of Continental Express Flight 3407 as it neared Buffalo Niagara International Airport on Feb. 12.”

2. “cockpit voice recorder showed the co-pilot describing her lack of experience flying in icy weather not long before the crash.” Did she miss training? Did the company decide not to train? Was she trained and testing needs improvement? Should there be continued training? Did practice and repetition need to be increased?

3. “captain may not have had hands-on training on a critical cockpit safety system. “Did he miss training? Did the company decide not to train? Was he trained and testing needs improvement? Should there be continued training? Was the task analyzed for this aircraft?

Then there was the Fatigue issue:

1. “co-pilot, Rebecca Shaw, lived near Seattle on the West coast with her parents and had commuted all-night to get to Newark Liberty International Airport in New Jersey on the East coast , where Flight 3407 originated”

2. “captain, Marvin Renslow, commuted to work from his home in Florida. It is not clear where either of them slept the night before the crash or how much sleep they received.”

3. “current rest rules “are less restrictive than truck drivers work under. Once you’ve been on duty for 13 hours, you are about 500 percent more likely to make an error, and once you’ve been on duty for 16 hours, you have the response rate of somebody who is legally drunk.”

Is the policy confusion or incomplete? Is the policy not strict enough? Does the communication of the Policy need improved? Is this a crew selection issue? A scheduling issue?

Now if you read the rest of the article linked below, you then have to ask about Oversight and Corrective Actions. There were “cracks” in the system? Don’t get me wrong, there are a lot of good aviation programs with good training….. maybe too many for the ratio of inspectors? What is the expectation of the controlling authority? How much is the push back from the private commercial sector when push comes to shove. After all, look at the discussion over the recent airbus accident and whether the pitot sensors needed to be replaced. According to reports, Air Bus highly “suggested” that they be replaced… and the air lines knowing that pitot sensor errors are only minor, instructed pilots to make sure they beefed their work around response for eradicate readings.

This is more than just a training issue. What questions do you have? Wonder where my questions come from? Come to one of our 5-day incident courses and walk through the early 1970 Florida aircraft crash.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training: http://www.taproot.com/courses.php#c1

Or even better, come to our Summit and Pre-Summit and talk with aviation industry experts trained in our process from Rotorcraft to Alaska Airlines. http://www.taproot.com/summit.php
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Update: Missile was NOT LIVE….. does this now condone the actions taken? No, all weapons are considered live until proven otherwise. The questions below still stand.

Here are some questions following a live catch of a missile while fishing.

1. What kind of bait do you use for missiles … little fishing boats?

2. What do you do if you catch a LIVE MISSILE that is corroded and unstable?…. I know, keep it on your boat for ten days and then turn it in to the authorities.

3. What do you do if a live missile gets loose and runs away? …. I might need a little help on this one.

Wow, I don’t know the charge in the missile, but this could have turned out really bad. The question is what type of investigation would this need to keep it from happening again. After all, no property damage or injury… it might just get an “Apparent Cause” analysis. That works, right?
(more…)

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Here’s a link to the US National Transportation Safety Board’s web page for aviation accident/safety statistics:

http://www.ntsb.gov/AVIATION/Stats.htm

After reviewing their data, ask this question:

“What can I learn from my accident/incident/near-miss statistics?”

Next ask:

“How am I analyzing my statistics?”

Then ask:

“Why are all these statistics reactive (backward looking)?”

Then ask:

“What could a trend that is proactive (forward looking)?”

If these questions make you think (you don’t already have answers translated into well functioning programs), you should consider attending the pre-Summit course titled:

“Advanced Trending Techniques“

Don’t be caught by surprise, Your statistics will provide a warning IF you are listening.

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Click here for the story.

$6 Million in damages - ouch!  And there may be an “inquiry!”

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Here is the story:

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090604/NEWS/90604003/-1/NEWSMAP

We don’t know much, other than the fact that this did not have to happen.  The first of many questions I have is why is someone under a load from a forklift?  What policies and safeguards are in place?

Excerpt:

“The Occupational Safety and Health Administration was notified of the accident and opened an investigation to see if there were any violations.”

At the very least, it appears that the general duty clause could be cited.

Do you have the policies, safeguards, procedures, training, and management system best practices in place to avoid such incidents in your facility?  If you want to learn more, you should attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course.

We have courses in the near future in Gatlinburg, Jakarta, Niagara Falls, Melbourne, and San Antonio to name just a few.  To see the schedule and to register, click here.

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Here is the story:

http://www.dglobe.com/event/article/id/23380/

Interesting; the second major event and repeated attention by OSHA.  While the fines may not be much, shutting down the plant and paying all these medical bills must be quite costly at this point. 

Excerpt:

“The second violation pertained to the employer’s investigation report following the ammonia leak in January 2008. The report said JBS did not adequately address … several factors that may have contributed to the accident.”

So they’ve had all these problems, OSHA told them that their report last year did not dig deep enough, and now they have had another major incident.  Had they taken action the last time this event would not have happened.

I would love to know the final cost of these two major incidents and the fallout from all these inspections.  I would bet it is enormous.  And that does not consider public perception, which is hard to measure but very real and a bad public opinion about an organization can be very damaging to the business.  

Do not fall into this trap.  Send your investigators to advanced root cause analysis training so they can find ALL the REAL root causes and so they can correct them effectively, protect your employees, and save big $$$$$$.

Here is the schedule of TapRooT® courses.     

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This title got my attention, “Driver ‘dozes off’ on India train.” Problem is that I did not expect to read these next lines from the article:

When some of the passengers managed to reach the engine, they apparently found the driver snoring away.

Now I understand the role of damage control and the need to investigate this incident. What I don’t agree with is how the Authority handled the public and media response. Either there was a medical condition, he was asleep, or this was inattentiveness. Regardless of the final investigation report, this should be considered a Near Miss. (more…)

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To view the report, see:

http://www.raib.gov.uk/cms_resources/090603_R132009_UWCs.pdf

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Surely something a heavy as a rail cargo container can’t just blow off of a train…in 2 separate incidents.

Here’s the RAIB report:
http://www.raib.gov.uk/publications/investigation_reports/reports_2009/report122009.cfm

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Here is the story:

http://www.knoxnews.com/news/2009/jun/01/contractors-stand-down-safety/

While safety stand downs are safety 101 and usually mean “we don’t know what else to do,” I thought this was an interesting way to raise awareness on a statewide basis.  It also shows that TOSHA wants to partner with businesses rather than just focus on enforcement; I like it!  If you participated, GOOD FOR YOU!  Every life saved is a step in the right direction.

I live in a new subdivision here in Knoxville, TN, and have witnessed a total lack of fall protection, rickety scaffolding, and more.  One day I was out walking the dog and the scaffolding at one house was so scary I ran home to get my camera (always looking for good blog stuff), and by the time I got back the scaffold had been taken down (they saw me looking).  The moral of that story is that they knew what they were doing was wrong.  The last thing I want to see in my neighborhood is someone getting hurt.

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Here is the story:

http://news.yahoo.com/s/nm/20090601/ts_nm/us_france_plane

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Two Stories:

http://www.chinadaily.com.cn/china/2009-06/01/content_7957666.htm

http://www.shanghaidaily.com/sp/article/2009/200906/20090601/article_402703.htm

Excerpts:

“Zhao Tiechui, director of the State Administration of Coal Mine Safety, said yesterday that an excessive amount of explosives triggered the accident. Coal mine owners put the emphasis on accelerating construction instead of work safety, he told Xinhua News Agency.”

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This is an all too common story in the mines of developing countries.  They’ve already started telling people the cause of the accident and they have “detained” management, including the safety manager.  I don’t think they’ve had time to do a proper investigation!  I wonder if these detainees will cooperate or has their fate already been sealed?

I’m not sure I agree with the approach of this particular government agency, we still hear frequent reports of fatalities in China’s mines, so there is at least some evidence that their efforts are not working.  The MSHA here in the US has proven they can work with companies to solve problems and reduce accidents; hopefully China and the other developing countries will someday catch on and develop a process to improve safety.  Just locking people up after an incident is not good enough.

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