Archive for the ‘Accidents’ Category

Fatigue a Potential Issue in an Investigation? Try FACTS!

Thursday, July 29th, 2010

An announcement from
CIRCADIAN Technologies

EXPERT SYSTEM TO ASSESS FATIGUE IN ACCIDENT INVESTIGATIONS

WEDNESDAY 28 JULY 2010

TRY FACTS FOR FREE

Have an accident you want to investigate? Try FACTS

WHAT IS FACTS?

FACTS is an online diagnostic expert system to help investigators and companies readily determine if human fatigue may have been a causal factor in an accident/incident.

ABOUT CIRCADIAN®

CIRCADIAN® provides Fatigue Risk Management Systems, Shift Schedules, Software, and Training & Publications to solve the challenges of the 24/7 workforce.

Learn More about CIRCADIAN®

FACTS is a web-based investigatory tool that helps users determine if human fatigue may have been a causal factor in an accident/incident. Developed by the world’s leading experts in sleep, fatigue, and circadian rhythms, FACTS generates results that correlate well (r = .91) with conclusions reached by experts who investigated NTSB and other industrial accidents.

FACTS helps you do the following:

- Determine whether or not fatigue affected the individual involved in an accident/incident.

- Calculate what percentage of your operations incidents/accidents/deviations are due to fatigue.

- Estimate the cost of employee fatigue impairment at your operation.

Have an accident you want to investigate?

FATIGUE ACCIDENT/INCIDENT CAUSATION TESTING SYSTEM (FACTS)

Fatigue is one of the most pervasive yet under-reported causes of human error-related accidents, incidents, and injuries in both the industrial and transportation sectors.

Because fatigue is difficult to detect (i.e., no blood, urine or breathalyzer test exists to identify it) companies have a difficult time quantifying the true impact and cost of fatigue in their operations.

To bridge this gap, CIRCADIAN® created an online diagnostic expert system to help investigators and companies readily determine (by standardizing criteria and with high probability) if human fatigue may have been a causal factor in an accident/incident.

- – - END OF ANNOUNCEMENT

One additional note …

One of the developers of FACT will be at the TapRooT® Summit to share information about the technique and how to use it.

This presentation is in the Changing Behavior and Stopping Human Error track from 10:40-12 on Thursday, October 28.

For more information on the TapRooT® Summit, see:

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

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“Hands-only CPR, pushy dispatchers are lifesavers”

Wednesday, July 28th, 2010

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Read more here: http://news.yahoo.com/s/ap/20100728/ap_on_he_me/us_med_hands_only_cpr

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Can You Lose Your CEO Job After an Accident? Ask ex-CEO Tony Hayward

Tuesday, July 27th, 2010

Of course, major accidents have bad outcomes. Now, many CEO’s should feel less secure after the recent BP Deepwater Horizon accident outcomes.

What and I talking about? Tony Hayward is “Standing Down” and accepting retirement after his leadership was questioned (see the BBC report at http://www.bbc.co.uk/news/business-10434908).

Previous BP CEO, Lord Browne, also “stood down” after the BP Texas City accident and a lawsuit over court testimony (personal in nature and not related to his BP work).

There are heated debates in many quarters about the criminal and personal liability that CEO’s should have for accidents at their companies, these developments should make CEO’s think about the risks that their employees face and their efforts to improve safety and environmental performance.

We already know that the BP Deepwater Horizon and BP Texas City accidents were preventable. We already know how to set up a world class performance improvement program. We already know how to apply advanced root cause analysis to analyze small problems and prevent big ones.

A CEO should make sure that his/her company is applying these improvement techniques and stopping major accidents before they happen.

What if they don’t?

They risk following in the footsteps of Lord Browne and Tony Hayward.

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19 Dead in “Love Parade” Stampede In Duisburg, Germany

Tuesday, July 27th, 2010

German prosecutors are investigating the causes of a crowd control failure that lead to the deaths of 19 at the Love Parade techno music festival in Duisburg, Germany.

For more information, see a Reuters story at:

http://www.alertnet.org/thenews/newsdesk/LDE66P0W2.htm

Are Cataracts the Root Cause of Several Sentinel Events?

Tuesday, July 27th, 2010

A Canadian Health Unit report said that a doctor’s cataracts are partly to blame for incorrect pathology reports that led to an unnecessary colostomy, two mastectomies, and at least four other cases of “serious concern.”

The story was reported by healthzone.ca. See the whole story at:

http://www.healthzone.ca/health/newsfeatures/article/840505–doctor-s-cataracts-partly-blamed-for-medical-error

How would you detect the gradual decline of someone’s visual acuity/performance that what a key part of their job?

With corrective surgery for cataracts so common and available, why didn’t the doctor act before his performance declined noticeably?

Should hospitals have a requirement for periodic eye test for older physicians whose practice required visual acuity?

1 person likes this post.

Medical device problems hurt 70,000+ kids annually

Monday, July 26th, 2010

..”About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.”

..”Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.”

..”The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.”

…”Malfunction and misuse are among possible reasons”

I read the article and then asked “AND”? There is so much more information that needs to be collected and compared.

… “is there damage with this equipment for children and adults?”

… “is there a difference between different manufacturers for the same types of equipment?”

…”what allowed 70,000 incidents to occur without having the root causes listed already?” …. yes I know there are patient and company privacy issues but that is not a good excuse!

So what would your next steps be? (more…)

Monday Accident & Lessons Learned: UK Rail Accident Investigation Branch Publishes Bulletin About a Train Collision with a Level Crossing Gate

Monday, July 26th, 2010

The UK RAIB’s report had three “Learning Points”:

1. Repeated occurrences of the same or closely related faults are likely to be a symptom of an underlying problem. Systems should be in place to identify repeated faults and to implement effective remedial action.

2. Maintenance requirements, particularly those applying to equipment connected with safety (such as the maintenance of gate stops (paragraph 13)), should not be left to local interpretation but should be determined by a competent person and recorded in a maintenance document.

3. It is important that signallers and crossing keepers at crossings of this type are given an unobstructed view of the gates, where it is practicable to do so.

To read the whole article, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/Bulletin%20(Stow%20Park)%2010-2010.pdf

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BBC Reports Tony Hayward Prepares to Leave BP

Sunday, July 25th, 2010

The report says:

Hayward’s departure could be formally announced within 24 hours, the BBC reports today, adding that his U.S. colleague Bob Dudley — now in charge of the spill’s cleanup — will likely be his successor.”

To read the whole story, see:

http://content.usatoday.com/communities/greenhouse/post/2010/07/bps-tony-hayward-quitting/1

Major accidents ruin careers. Now is the time to apply advanced root cause analysis to stop major accidents by learning all that you can from incidents and near-misses. Send your investigators to TapRooT® Training.

One more idea … Make sure you have folks at the TapRooT® Summit. Share best practices to improve performance and prevent accidents. See:

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

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BBC Reports 1 Dead, 41 Injured in Swiss Train Accident

Saturday, July 24th, 2010

See:

http://www.bbc.co.uk/news/world-asia-pacific-10744282

Zinc Plant Accident Kills Two

Saturday, July 24th, 2010

See the KDKA Channel 2, Pittsburgh, story at:

http://kdka.com/beaver/zinc.plant.explosion.2.1821201.html

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NYT Article Questions Transocean’s Maintenance Practices

Friday, July 23rd, 2010

The New York Times wrote an article titled “Workers on Doomed Rig Voiced Concern About Safety” that questioned the maintenance practices of Transocean aboard the Deepwater Horizon. Quotes from the article include:

Some workers also voiced concerns about poor equipment reliability, ‘which they believed was as a result of drilling priorities taking precedence over planned maintenance,’ according to the survey.

“’I’m petrified of dropping anything from heights not because I’m afraid of hurting anyone (the area is barriered off), but because I’m afraid of getting fired,’ one worker wrote.

““The company is always using fear tactics,” another worker said. ‘All these games and your mind gets tired.‘”

The two Transocean-commissioned reports obtained by The Times echo the findings of a maintenance audit conducted by BP in September 2009. But the Transocean-commissioned reports indicate that maintenance concerns existed just days before the explosion and the rig owner was aware of them. The 2009 BP audit found that Transocean had left 390 maintenance jobs undone, requiring more than 3,500 hours of work. The BP audit also referred to the amount of deferred work as ‘excessive.‘”

To read the whole story, see:

http://www.nytimes.com/2010/07/22/us/22transocean.html?_r=2&scp=1&sq=Transocean%20safety%20report&st=cse

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PRESS RELEASE from the Chemical Safety Board: CSB Issues Report on 2009 Explosion at Veolia ES Technical Solutions, L.L.C. Hazardous Waste Facility; Waste Industry Urged to Improve Safety Standards; Recommendations Issued to Ensure Safer Siting of Buildings

Friday, July 23rd, 2010

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Washington DC, July 21, 2010 – A U.S. Chemical Safety Board (CSB) case study released today on the 2009 explosion and fire at the Veolia ES Technical Solutions L.L.C. facility in West Carrollton, Ohio, calls on the industry to improve safety standards covering hazardous waste processing, handling, and storage facilities. The Board also recommended that fire protection codes be revised to require companies to determine safe distances between occupied buildings and potentially hazardous operating areas.

The accident occurred on May 4, 2009, when flammable vapor was released from a waste recycling process, ignited, and violently exploded. The blast seriously injured two workers and damaged 20 nearby residences and five businesses. CSB investigators found that the north wall of the lab and operations building – where the victims were injured – was less than 30 feet from the waste recycling processing area where the flammable vapor was released. 

CSB Chairman Rafael Moure-Eraso said, “This accident should not have happened. Our report notes that OSHA cited the company for inadequate attention to process safety management practices in the handling of flammable liquids. But in case of an accident, I believe it is absolutely critical that buildings at chemical facilities be sited safe distances from process equipment to maximize the safety of workers. We are making recommendations that would help ensure that operating areas with occupied buildings such as control rooms be sufficiently separated from process areas containing flammable liquids and gases that have the potential to explode.”

The Board issued a recommendation to the National Fire Protection Association (NFPA), which develops codes and standards for industry, urging NFPA to require companies to perform engineering analyses to determine safe separation distances between buildings occupied by administrative and other personnel not essential to process operations, and buildings housing the potentially hazardous process equipment.

The Board also revised a previous recommendation to the Environmental Technology Council, a hazardous waste industry trade group, to petition the NFPA to develop a standard specific to hazardous waste treatment, storage and disposal facilities. This would include guidance on reducing the likelihood of fires, explosions, and releases of hazardous waste.

Dr. Moure noted, “The Environmental Technology Council did not respond adequately to our 2007 recommendation, which we issued following an explosion and massive fire at the Environmental Quality hazardous waste facility in Apex, North Carolina, to work for more stringent standards in the hazardous waste industry. I strongly urge the industry to act now. These facilities, by their nature, contain wide varieties of flammable and toxic materials that can cause significant injury to workers and threaten the well being of nearby communities. Facility owners and operators need stricter technical requirements to improve the safety of life and property.”

The report notes that after a normal run of the tetrahydrafuran (THF) solvent recovery process at the Veolia facility, the unit operator began a routine shutdown. Completing the process required blowing nitrogen back through the circulation piping to clean it, prior to closing valves.

CSB lead investigator Johnnie Banks said, “At the time of the shutdown, witnesses reported hearing the sound of a sudden, loud vapor release and smelling a very strong odor of THF solvent which knocked several employees to their knees. It was a matter of just a couple of minutes until the highly flammable vapor ignited.”

The vapor drifted to the laboratory and operations building and found an ignition source inside the building. A worker in the control room reported being enveloped in a fireball that went through the building. The first explosion knocked over a bank of lockers, severely injuring an employee and pinning him underneath.

Because of the extensive fire damage, the CSB was unable to conclusively determine the exact initiating event for the vapor release, concluding one of two possible scenarios likely occurred. In the first scenario, air may have been drawn into a tank containing THF residue and peroxides, causing increased pressure in the tank and forcing flammable vapor from the tank to escape through a manway cover or a vacuum breaker.

In the second possible scenario, CSB investigators believe a line hose, intended to send pressurized nitrogen into a different tank, may have instead been connected to a tank containing unprocessed, flammable liquid. When the nitrogen was applied, it forced flammable vapor out through the tank vent. In either scenario, the vapor drifted to the operations building and ignited, causing the injuries.

In addition to issuing recommendations to NFPA and the hazardous waste industry, the Board also issued recommendations to Veolia, which is rebuilding the plant. The CSB called on the company to restrict occupancy in buildings in close proximity to the operating plant to personnel trained in the safe operation and orderly shutdown of the plant. The Board also called on the Center for Chemical Process Safety, a division of the American Institute of Chemical Engineers, to revise control room siting guidelines to address the characteristics of all Class 1B flammable liquids.

For more information, contact Public Affairs Specialist Hillary Cohen, 202-261-3601, or Sandy Gilmour, 202-261-7614, cell 202-251-5496

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Do you have $200K for Safety Violations?

Thursday, July 22nd, 2010

South Carolina manufacturing plant fined by OSHA for fall and electrical hazards…. I believe the term of the day was “willful” violations.

Read more here:

http://heraldbanner.com/local/x315773731/Local-plant-fined-197k-for-safety-violations

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Unexpected Events: Investigators Discover that WV Mine Filled Suddenly with Methane

Thursday, July 22nd, 2010

Every once in a while, investigators discover something unexpected. This seems to be the case in the Massy Energy Company mine explosion in West Virginia.

See:

http://www.cnn.com/2010/US/07/22/west.virginia.mine.explosion/index.html

Early investigation guesses focussed on Massey’s history of safety violations. This new information may show that past safety violations had nothing to do with this accident.

2 people like this post.

Wire Update Reports: Accident at North South Africa Mine Kills Two Workers

Wednesday, July 21st, 2010

See:

http://wireupdate.com/wires/7847/accident-at-north-south-africa-mine-kills-two-workers/

Justice News Flash Reports: Miami Train Accident: Downtown Metromover Collision Sends 16 to Hospitals

Wednesday, July 21st, 2010

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See:

http://www.justicenewsflash.com/2010/07/21/miami-fl-train-accident-sends-16-to-hospitals_201007215056.html

Reuters Reports BP CEO Tony Hayward is Scheduled to Resign

Wednesday, July 21st, 2010

See the MSNBC report of the Reuters story about a Times of London report at:

http://www.msnbc.msn.com/id/38335887

I would give you a direct link but the Times of London is by subscription only.

Quotes from the Times of London story include:

“‘You would be hard-pushed to find anyone within the company who does not think he is irreparably damaged – both by his own performance and by the event itself,’ a company insider was quoted as telling the paper.

The story says that this is part of a strategy called “Future BP” and his resignation should come within 10 weeks.

BP has denied that Mr. Hayward is resigning ever since the rumors started back in June and a BP spokesperson said today that  Mr. Hayward has the “… full support from the board and will remain in place.

Interesting internal politics after a major accident.

UK Rail Accident Investigation Branch Releases Two Reports Detailing the Root Causes of Recent Rail Accidents

Wednesday, July 21st, 2010

Here are the links to the reports:

Collision between a freight wagon door and signal in Kilsby Tunnel, 15 March 2010

Serious injury to a loader at Hoo Junction, Kent 14 April 2010

Root Cause Analysis Tip: The Myth of the Cost of Poor Quality

Wednesday, July 21st, 2010

One of the biggest trends in quality improvement was the term “The Cost of Poor Quality” tied with “Zero Defects”, with many COPQ financial models popping up in many Fortune 500 companies. In the safety world there was a similar drive with the term Cost of Compensation tied with “Zero Injuries” and OSHA driven recordables to be tracked.

The Quality Iceberg

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The Safety Iceberg

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Yet the focus for both safety and quality were lead by lagging visible indicators. In other words good or bad, the findings are just too late. You march your troops with the “Zero Defects” and “Zero Injuries” flags raised and once you reach your destination you turn around and see who and what equipment you have left.

Now don’t get me wrong, identifying and being able to comprehend the end damage is a vital part of the process and unfortunately not realized by some. It is just NOT where you should focus your drive and effort.

So what now you may ask? “Build quality in… do not inspect quality in!”

The phrase above often goes to deaf ears because it is misunderstand. “If you do not assess the quality of your work, then how do you know if it is to standards,” people would ask. “I have to trust everybody’s work?” In the safety world the phrase “Safety must be part of every action we do,” is often trumpeted. But how?!

Start with these 3 steps first:

1. First things first, Quality and Safety are NOT silo’s and they should work together. Setting up a task that can be worked efficiently, correctly and safely by employees is a combined goal and SHOULD NOT be competing goals.

To save money, many companies do not cross-train employee’s from different departments. Why not if it makes sense? For example, while many of our clients started using TapRooT® Root Cause Analysis in their safety departments first, the more people saw the process used, the more operations and facilities come onboard for the same training.

Now this cross-training concept also works in the opposite direction. As the quality department leaders started working with the safety, quality tools from Stakeholder Analysis to Force Field Analysis were also shared with the safety department. After all, inside all world class companies are different departments that are all part of the same company with one goal.

2. Building Quality and Safety into a process starts in the beginning stages of planning but can be recovered after the employees try to use an existing process (it just costs more time and money!).

When our clients use our Root Cause Analysis process to investigate defects and incidents it soon becomes apparent that the opposite of each one of our root causes are best practices that can be implemented proactively.

While most Quality Experts are excellent at mapping out front end value streams, process maps and spaghetti maps, there is often a gap in knowledge of research and industry best practices in human engineering, communication, procedures, training and work direction. So if you were a Quality Professional and had access to multiple experts in front of you everyday, would you utilize them? Here is small list of courses that can give you best practice access: Best Practice Courses

3. No process, no matter how well designed is perpetually stable and it must be audited/assessed periodically based on risk for unknown and known changes…. note: this is not the same thing as “inspecting in quality”!

This is one of the most misunderstood ingredients relating to Inspections.

If you have a hold point inspection that must be completed by an Independent Inspector BEFORE a task can be completed or a part received or shipped, you are admitting that you have a high risk potential that is not capable of being completely mistake proofed.

– OR-

You have a process or task where you have not truly identified the human and equipment behaviors with their associated Root Causes, and have decided that it is worth spending the extra money and time to inspect instead of fixing the problem. You refuse to build in quality.

Now this is not saying that you should not target high risk tasks proactively and continually audit or assess these areas to ensure nothing has changed or is different. This type of inspection must still occur.

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Oil Spill in China

Tuesday, July 20th, 2010

“China rushed to keep an oil spill from reaching international waters Tuesday, while an environmental group tried to assess if the country’s largest reported spill was worse than has been disclosed.

Crude oil started pouring into the Yellow Sea off a busy northeastern port after a pipeline exploded late last week, sparking a massive 15-hour fire. The government says the slick has spread across a 70-square-mile (180-square-kilometer) stretch of ocean.”

Read more here:http://news.yahoo.com/s/ap/20100720/ap_on_bi_ge/as_china_pipeline_explosion

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White House Announces Bad News: Capped Well Leaking

Monday, July 19th, 2010

See:

http://www.chron.com/disp/story.mpl/ap/top/all/7114847.html

Wall Street Journal Reports on Mistake Made in Final Hours before the BP/Transocean Deepwater Horizon Blowout

Monday, July 19th, 2010

The Wall Street Journal article discusses twenty “anomalies” signaled that a blowout could be coming and unexpected pressure increase triggered disagreements between BP and Transocean employees. See:

http://online.wsj.com/article/SB10001424052748704196404575375460908534140.html?mod=WSJ_hpp_LEFTTopStories

Third Round of Hearings by the Joint Panel of Coast Guard & Bureau of Ocean Management, Regulation and Enforcement into the Causes of the BP/Transocean Deepwater Horizon Blowout, Explosion, & Spill Start Today

Monday, July 19th, 2010

Hearing
(hearing photo)

Today was the day that BP Well-Site Manager Don Vidrine was suppose to testify. However, he was removed from the list of witnesses. Later this week the other Well-Site Manager, Robert Kaluza, is scheduled to testify. Previously, he “took the fifth” (self incrimination) and declined to testify.

These hearings, although probably the worst way to interview witnesses, are still extremely interesting.

For an article about today’s hearings, see:

http://blogs.chron.com/newswatchenergy/archives/2010/07/update_coast_gu.html

Here’s the investigations web site where you can see live and recorded testimony:

http://www.deepwaterinvestigation.com/go/site/3043/

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Monday Accident and Lessons Learned: OGP SAFETY ALERT NO. 225: PIPE HANDLING OPERATIONS RESULT IN FATALITY

Monday, July 19th, 2010

SAFETY ALERT NO. 225: PIPE HANDLING OPERATIONS RESULT IN FATALITY

Country: USA

Location: OFFSHORE : Other offshore

Type of Activity: Lifting, Crane, Rigging, Deck operations

Type of Injury: Caught In, Under or Between

Function: Drilling

Applicabale Filter Categories: Caught between

Recently a fatality occurred during pipe handling operations on a deepwater drilling unit. A rig employee’s head was caught between the pipe handler’s lower travel assembly and a vertical support stanchion (pinch/crush point of 4 inches) as the pipe handler was being traversed across the pipe bay to the catwalk to retrieve a joint of pipe. The deceased was acting as a spotter for the pipe handler operator at the time of the incident and the pipe handler operator did not observe the incident due to his obstructed view of the spotter.

What Went Wrong?:

The BOEM (formerly MMS) investigation revealed that unidentified crush points existed between the lower travel assembly and the vertical support stanchions of the trolley system. It was concluded in part, from the investigation that the pipe handler operator failed to confirm an “all clear” with the spotter and failed to exercise his Stop Work authority when he lost site of the spotter. The Lessee/Operator failed to provide the necessary additional oversight to ensure that the pipe handler operation was conducted in accordance with their lifting policy. The drilling company’s line management also failed to:

Provide a more formalized training program to include the hazards associated with the operation of the pipe handler.

Identify the specific pipe handler operational tasks, hazards and respective mitigations in order to develop and implement guidelines for personnel working around the strong-back area.
Provide additional onsite supervision to both the Operator and Spotter during the pipe handler operation.

Properly implement their Management of Change policy with respect to new personnel in new positions. The company’s Management of Change policy was also identified as being too complex to implement.

Corrective actions and Recommendations:

Therefore, BOEM recommends the following to Lessees/Operators and their Drilling Contractors for any type of overhead trolley beam mounted crane (trolley crane) operation, including but not limited to a pipe handler:

Inspect trolley crane operations with the intent to identify all potential hazards and mitigations (including pinch/crush points), and communicate these findings with all necessary personnel.
Review Stop Work authority programs with their personnel, while stressing the importance of the individual’s responsibilities and authority to exercise Stop Work as necessary.

Review trolley crane training programs to ensure that the program covers not only the proper operation of the equipment, but also includes the limitations, capabilities and potential hazards. If the training includes onsite hands-on training, the verification/certification should be done by senior facility management.

Review the Management of Change policy for clarity and to ensure the program recognizes and manages changes, conditions and inactions in a given situation or unexpected events.
Install and maintain safety barriers (signage, red zones, tiger striping, temporary barrier tape, handrails, etc.) to prevent access to the trolley crane’s traversing path.

Clear the trolley crane’s path of general storage. Telephone, intercoms or stored items located under the trolley crane should be removed and relocated to a safer area.

Consider the feasibility of installing cameras or mirrors in areas where the trolley crane operator’s view is obstructed.

Consider the feasibility of re-engineering the trolley crane to possibly eliminate any additional Spotter involvement.

Conduct pre-tour meetings for all tours, including short change crews. The short change crew involves multiple employees filling new roles and/or not working on their normal crew shift.

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A Press Release from the Deepwater Horizon Joint Investigation

Saturday, July 17th, 2010

Witness lists of fact-finding joint investigation available for July 19-23, 2010

 Clients 3043 319603        Clients 3043 319515

NEW ORLEANS – The following are links to witness lists for July 19-23, 2010 for the third round of public hearings in this fact-finding joint investigation.  The purpose of this joint investigation is to develop conclusions and recommendations as they relate to the Deepwater Horizon MODU explosion and loss of life on April 20, 2010. The facts collected at this hearing, along with the lead investigators’ conclusions and recommendations will be forwarded to Coast Guard Headquarters and BMOE for approval. Once approved, the final investigative report will be made available to the public and the media. No analysis or conclusions will be presented during the hearing.

Click on the dates to link to individual witness lists:

July 19, 2010

July 20, 2010

July 21, 2010

July 22, 2010

July 23, 2010

For Deepwater Horizon joint investigation information: www.deepwaterinvestigation.com

For Deepwater Horizon oil spill response information: www.deepwaterhorizonresponse.com

More About the Well Integrity Test

Friday, July 16th, 2010

See:

http://www.chron.com/disp/story.mpl/business/7110760.html

United States Steel Coke Oven Explosion Injures 20 Workers

Friday, July 16th, 2010

The Associated Press reported that an explosion of a coke oven at a plant in Pittsburg injured 20 people, at least six critically. The explosion happened during maintenance on the B “battery” (bank) of the ovens.

For more info, see:

http://www.chron.com/disp/story.mpl/nation/7109029.html

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Finally Success: Oil Flow Stopped!

Friday, July 16th, 2010

I heard it yesterday afternoon but I waited until this morning just to be sure…

Looks like the well in the Gulf is finally capped.

Here’s the picture from the site:

http://www.bp.com/liveassets/bp_internet/globalbp/globalbp_uk_english/incident_response/STAGING/local_assets/html/Skandi_ROV2.html

Here’s a picture from that site:

Wellnotleaking

The worry now is that pressure will build and rupture the well casing. This could make future efforts to use relief wells to finally permanently stop the flow more difficult or impossible. But government scientist approved this latest effort.

Let’s cross our fingers and pray this goes well!

Wall Street Journal reports: “Oil Industry To Form Accident Group Following BP Spill”

Thursday, July 15th, 2010

For details, see:

http://online.wsj.com/article/BT-CO-20100714-708033.html

Wall Street Journal Takes Up Qualifications of the President’s Independent Commission to Investigate the BP Deepwater Horizon Accident

Thursday, July 15th, 2010

On June 16th, we published a blog article about the qualifications of the President’s Independent Commission to investigate the BP Deepwater Horizon accident. Many of the readers here commented on the qualifications and the overall response was that they didn’t seem particularly well qualified to find the root causes of the well blowout, explosion, and spill. See the comments here:

http://www.taproot.com/wordpress/2010/06/16/president-names-blue-ribbon-panel-to-investigate-gulf-oil-spill-are-they-qualified/

Last week, the Wall Street Journal published an article, “The White House Get’s Drilled,” that pointed out the bias of the Commission. It said:

By contrast, the President’s seven-member commission contains not a single expert on drilling or petroleum engineering and is instead loaded with such anti-oil and antidrilling activists as Natural Resources Defense Council President Frances Beinecke and former Florida Senator Bob Graham.

The also quoted Louisianna Democratic Senator Mary Landrieu, who said:

“I would suggest to my Democratic friends that if the shoe were on the other foot, and President Bush was the President and he had submitted a list of names like this to us and everyone was related to the defense of oil companies, we would say this is not fair.”

In reviewing the commissions qualifications, the Journal article points out the following:

About Commissioner Reilly: “Mr. Reilly is well known as a green activist who once ran the World Wildlife Fund, which is precisely what made him attractive as a GOP political appointee and for ConocoPhillips. Both were looking for environmental cover.

About Commissioner Beinecke: “‘Offshore drilling is a needless risk,’ said Ms. Beinecke in 2008, as part of her push for cap-and-trade legislation.

About Commissioner Boesch: “‘We should be redoubling our efforts to get off oil,’ said fellow commission member Donald Boesch in May. He wants ‘transportation not powered by liquid petroleum.’

About Commissioner Garcia: “Appointee Terry Garcia of the National Geographic Society rapped the Bush administration in 2008 for not doing more to ‘protect’ oceans from ‘commercial and recreational fishing, oil and gas exploration or deep-sea mining.’

About Commissioner Murray: “Harvard’s Cherry Murray is president of the American Physical Society that recently rejected calls from 160 physicists to alter its doomsday position on climate change, which demands immediate reductions in greenhouse-gas emissions to avoid ’significant disruptions in the Earth’s physical and ecological systems, social systems, security and human health.’

About Commissioner Ulmer: “The University of Alaska’s Fran Ulmer is on the board of the Union of Concerned Scientists, which wants the U.S. to curb its ‘oil addiction’ by requiring that cars get at least 42 miles to the gallon.

The article goes on to comment of the Commission’s new Executive Director, Richard Lazarus. The article says:

Underscoring its biases, the President’s commission has chosen prominent environmental litigator Richard J. Lazarus as its staff director. Mr. Lazarus has made a career out of suing private companies and governments to impose stricter environmental regulation.

This week, the Commission’s Executive Director wrote back to the Wall Street Journal. In an editorial, published today, he said:

The commission is co-chaired by two highly regarded public servants, former Sen. Bob Graham and former EPA Administrator Bill Reilly. They are individuals of enormous integrity and highly respected by industry, by members of Congress and by state officials, regardless of formal political affiliation.”

He also said:

You may also note that the commission recently named Richard Sears, a widely respected oil industry expert with 35 years experience, as its adviser on science and engineering, to augment the oil industry expertise of Mr. Reilly, who has served on the Conoco-Phillips board for over 15 years.

So, I thought I would look for Bio’s of Mr. Lazarus and Mr. Sears. Here’s what I found…

First, Mr. Lazarus. Here’s a link to his bio:

http://www.sandiego.edu/law/academics/faculty/bio.php?id=749

The bio seems to confirm the Wall Street Journal’s rhetoric.

Next, Mr. Sears. The first thing I found was this presentation he gave at TED:

The I found a bio attached to a Washington Post Viewpoint paid discussion. I quote it here:

Richard Sears is Vice President and Extra-mural Research Coordinator for Shell International Exploration and Production Inc. He is currently on loan to MIT for a period of three years, where he serves as Visiting Scientist in the Laboratory for Energy and the Environment. The intent is to create a research and technology relationship model for Shell with major US universities and manage Shell energy research activities at MIT as well as other research relationships in the Americas.”

In his more than 30 years with Shell, Richard has gained significant domestic and international experience, frequently representing Shell to partners, governments and national oil companies, including presentations to governmental authorities and ministers of eleven countries. He has been an invited and keynote speaker at industry conferences in the US, UK, Africa and Asia.
Prior to his current assignment, he shared responsibility for developing Shell strategy for deepwater exploration and development worldwide and was one of three vice presidents within Shell E&P responsible for the work of over 800 technical professionals across the globe from over 15 distinct geoscience, engineering and business disciplines.

Previous positions within Shell have included exploration geophysicist, technical instructor, economist, strategic planner, and general management.”

He is the author of numerous internal publications including field studies and case histories, geophysical research reports, and technical training manuals.

Richard has been a member of the Stanford University School of Earth Sciences Advisory Board since 2004. He is a Licensed Professional Geoscientist in the State of Texas, an active member of the Society of Exploration Geophysicists and a member of the American Association of Physics Teachers.

He earned his Master of Science degree in Geophysics and his Bachelor of Science degree in physics from Stanford University.

To me, he seems well qualified. But I wish I knew more about his oil drilling (not just oil exploration geophysical) experience and his experience leading accident investigations.

With that said, what influence does a consultant to the Commission have? He isn’t a commission member. I guess his influence is yet to be seen.

What do you think?

Does a well qualified consultant change your opinion on the qualifications of the President’s Independent Commission to investigate the BP Deepwater Horizon accident? Let me know by posting your comments here.

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Monday Accident & Lessons Learned – BP/Transocean Deepwater Horizon Explosion & Spill

Monday, July 12th, 2010

We’ve been posting lots of information about this accident since it happened. It’s now been over two months and the question I would like to ask is …

WHAT HAVE WE LEARNED?

Here’s a review of what’s been posted so far. Review it and then leave a comment with what you think we can learn so far.

APRIL

First Coverage on the TapRooT® Blog

Early Coast Guard Update

Rig Sinks

Amazing New Root Cause on Oil Rigs: “Human Error”

Video of Rig On-Fire

First Estimates of Cost – $1.6 Billion

Slow Motion Disaster in the Gulf

New Idea: Consider Oil Company’s Environment and Safety Record When Leasing Drilling Rights

Cost of an Accident: Legislative Costs

MAY

Bad Days Are Here for Everyone Who Touched the Macondo Prospect (Deapwater Horizon Rig) That Exploded Off Lousiana

TV News Coverage of the Oil Spill Off Louisiana

BP/Transocean Rig Explosion: Amazing Accident Pictures and Interview with Survivor

OGP SAFETY ALERT 220 – DEEPWATER HORIZON EXPLOSION AND FIRE RESULTING IN MULTIPLE FATALITIES AND RELEASE OF OIL

A Personal View of an Accident: Widow with Child on the Way Tells Her Side of BP/Transocean Rig Accident

Blame Before the Investigation: Looking for Villians Before the Oil Stops Flowing

More Blame and Reprecussions: BP/Transocean Rig Explosion and Oil Spill

BP/Tranocean Rig BOP Failure: The Smoking Gun Paper

BP/Transocean Rig Explosion: Interview with Survivors on ABC

New “Blame” Article in New York Times and a Article about Reduced Support for Offshore Drilling – Is There a Link?

Map of Gulf Oil Spill

Very Critical Article of Offshore Drilling

Interesting Blog Article about BP/Transocean Rig Accident

BP “Culture of Incompetence” says Congressman Bart Stupack

Is This an Investigation Technique or a Liability Reduction Technique

First Congressional Hearings – McKay

60 Minutes Report on the BP/Transocean Deepwater Horizon Explosion

Newspaper Calls for Investigation of “Safety Culture” at BP

Charles Perrow – Author of “Normal Accidents” – Talks About the BP/Transocean Deepwater Horizon Accident

The Cost of an Accident: More Lawsuits for BP

Monday Accident & Lesson Learned: Either You Are Leading the Solution or You Are Part of the Problem

MSNBC Investigates Scandal of BP Deepwater Horizon Incident – Corporate Homicide?

How Safe Is Safe Enough? – The Question Being Analyzed After The BP/Transocean Deepwater Horizon Accident

Top Kills Fails – BP to Try New Plan

Bad News After an Accident: BP Can’t Get Much Worse Press Than This…

For Those Who Want to Know More About Cementing

JUNE

More Bad News for BP – Already on Parole from the Texas City Explosion, Fed Now Opening a Criminal Probe of Deepwater Horizon Accident

Interesting Analysis of Regulatory Process in the Off-Shore Oil Industry … What Do You Think?

CNN Reports on “Criminal” Conduct by BP in Story Titled: “Rig survivors: BP ordered shortcut on day of blast”

Great Letter to the Editor in the Wall Street Journal Lays Out Causal Factors Immediately Before the Well Blowout

Houston Chronicle Story Says Criminal Charges Likely for BP the Corporation but NOT for BP Executives

How Long Must We Wait to Learn?

President Names “Independent” Blue Ribbon Commission to Investigate Gulf Oil Spill – Are They Qualified?

The Cost of an Accident – Your Reputation and $20 Billion Dollars

Well Design & Construction Causal Factors of the Deepwater Horizon Accident

More Bad PR for BP – CNN Story: “BP documents highlight PR strategy after deadly Texas blast”

Second Congressional hearings – Hayward

How Bad is the BP PR Impact? It Can’t Get Much Worse Than This…

Sky News Reports: BP Chairman Says “… embattled chief executive Tony Hayward is to have a changed role in dealing with the oil spill.”

Do Exxon and BP Take Different Approaches to Risk?

Cost of an Accident: Costs Sometimes Go Far Beyond the Company Involved

Are We Blaming BP Rather Than Learning From What Went Wrong?

CSB Press Release: CSB to Investigate Root Causes of BP Deepwater Horizon Blowout Accident

Joint Coast Guard & MMS Deepwater Horizon Joint Investigation Web Site

Lessons About Safety Culture from the BP Deepwater Horizon Accident that We Can Learn NOW

Link to the Executive Order that Establishes the National Commission on the BP Deepwater Horizon Oil Spill and Offshore Drilling

Columnist Laura Parker Comments on Multiple Deepwater Horizon Investigations

CBS News Reports: “BP’s Disaster: No Surprise to Folks in the Know”

The Wall Street Journal Reports: “Safety and Cost Drives Clashed As CEO Hayward Remade BP”

JULY

BP Investigation Presentation from the Deepwater Horizon Accident

BP Deepwater Horizon Fault Tree

Robert Bea’s Investigation

Here’s a PDF of Robert Bea’s Preliminary Findings About the BP/Transocean Deepwater Horizon Accident

Anadarko Withholds Payment of BP Spill Bill

That catches us up with what is known so far.

Now tell me what we can learn by leaving your ideas as a comment here…

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Anadarko Withholds Payment of BP Spill Bill

Sunday, July 11th, 2010

The Houston Chronicle reports that Anadarko Petroleum is withholding payment on a bill sent by BP to help pay for the spill.

The article says:

“The company has argued that it’s not responsible for costs arising from an operating partner’s ‘negligence’ or ‘willfull misconduct’ — something it accuses BP of in relation to the spill.”

The article also said:

“Last month, Anadarko CEO James Hackett said BP should shoulder the costs of the spill. BP has said it strongly disagreed with Anadarko’s allegations.”

For more info, see:

http://www.chron.com/disp/story.mpl/business/7101935.html

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New BP Spill – This one in Michigan

Tuesday, July 6th, 2010

See:

http://www.fox28.com/Global/story.asp?S=12713354

Here’s a PDF of Robert Bea’s Preliminary Findings About the BP/Transocean Deepwater Horizon Accident

Tuesday, July 6th, 2010

Click the document below to open…

Bobbeapreliminaryanalyses

My evaluation of the preliminary findings is that they are at the level of the causal factors. Still more work to be done to get to root causes.

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Robert Bea’s Investigation

Tuesday, July 6th, 2010

Here’s a video about the preliminary findings of Robert Bea’s investigation of the BP/Transocean Deepwater Horizon accident.



Visit msnbc.com for
breaking news, world news, and news about the economy

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Monday Accident & Lessons Learned: Run Over by Equipment Video

Monday, July 5th, 2010


    

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Union Calls for Root Cause Analysis of Fatal Accident in Guyana

Saturday, July 3rd, 2010

Here’s a quote from the West Indian News:

As the worst accident in the Kwakwani area, resulting in deaths, critical injuries and traumatized workers, it cannot be swept under the carpet as a simple road accident. While the Union is encouraged at the efforts made to save lives, it will not be satisfied to be told that this is as far as it goes. We need a root cause analysis to determine all factors contributing to this very sad loss of lives and injury and immediate short and long term measures to be implemented so that such situations of hazards are removed or minimized in the daily lives of bauxite workers.

See the whole article at:

http://www.thewestindiannews.com/bauxite-union-reiterates-calls-for-ministry-of-labour-of-guyana-to-intervene-now-to-stop-injuries-loss-of-income-and-life-at-bauxite-company-of-guyana-inc/

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BP Deepwater Horizon Fault Tree

Thursday, July 1st, 2010

A TapRooT® Instructor forwarded this to me. What do you think? Does this add to your knowledge of the accident?

Bpfaulttree

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BP Investigation Presentation from the Deepwater Horizon Accident

Thursday, July 1st, 2010

Here’s a PDF of the preliminary BP Investigation downloaded from the House of Representatives Energy and Commerce web site:

Bpinvestigationpresentation2

Review the slides and see what you think.

Compare their four “critical factors” to the multiple Causal Factors at these two links:

http://www.taproot.com/wordpress/2010/06/11/great-letter-to-the-editor-in-the-wall-street-journal-lays-out-causal-factors-immediately-before-the-well-blowout/

http://www.taproot.com/wordpress/2010/06/17/well-design-construction-causal-factors-of-the-deepwater-horizon-accident/

What are they missing if they don’t look at additional Causal Factors?

Anything else that you see about this investigation presentation that makes it easy or hard to understand?

Please leave your comments.

The Wall Street Journal Reports: “Safety and Cost Drives Clashed As CEO Hayward Remade BP”

Wednesday, June 30th, 2010

A very interesting article in The Wall Street Journal. See:

http://online.wsj.com/article/SB10001424052748703964104575335154126721876.html

Some interesting quotes…

Meanwhile, company officials continued hammering home the message on costs. Mr. Shaw, the Gulf of Mexico head, made the point at a meeting for top managers in Phoenix in April 2008. His aim, according to an internal BP communication, was to instill a ‘much stronger performance culture’ in the organization, based on strictly managing costs and ‘this notion that every dollar does matter.’”

- – -

A former BP engineer who retired last year said the Gulf of Mexico operation under Mr. Shaw became focused on meeting performance targets, which determined bonuses for top managers and low-level workers alike. The engineer says even small costs got targeted: BP no longer provided food at lunch meetings, and eliminated the fruit bowls that were offered as part of a healthy-living drive a few years earlier.

- – -

Talking about pipeline leaks in Alaska … “The state [Alaska] also said it was ‘deeply concerned with the timeliness and depth of the incident investigation’ conducted by BP. It took four months to provide a report that other oil companies typically submit in two weeks.”

- – -

Some think the cost drive affected safety. Workers had ‘high incentive to find shortcuts and take risks,’ says Ross Macfarlane, a former BP health and safety manager on rigs in Australia who was laid off in 2008. ‘You only ever got questioned about why you couldn’t spend less—never more.’ BP vigorously denies putting savings ahead of safety.

- – -

In a different context, BP had questioned the impact of its cost-cutting in the Gulf. After the 2008 incident on the Atlantis platform, BP’s internal report warned of lax safety oversight and tight budgets.

It concluded: ‘A key question to ask, especially with apparently minor and disconnected defects, is ‘What’s the worst thing that could happen?””

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