See this article in the Houston Chronicle:

http://www.chron.com/disp/story.mpl/business/5487314.html

See:

http://seattletimes.nwsource.com/html/businesstechnology/2004143439_web777crash24.html

Press release from the Chemical Safety Board:

Washington, DC, January 25, 2008 - Investigators from the U.S. Chemical Safety Board (CSB) today concluded the initial field investigation of the fatal accident at T2 Laboratories Inc. Among investigators’ findings thus far is that that the number of people injured was more than double what was known immediately after the accident.

Investigators say that 33 people were injured in the massive explosion and fire at the Jacksonville, Florida, chemical plant on December 19. Many of these injuries resulted from flying and falling debris due to structural damage to offsite buildings. The team plans to return to Washington, DC, later today to continue the investigation of the causes of the accident.

The explosion resulted in the death of four workers; preliminary findings indicate that the accident occurred as a result of a runaway chemical reaction during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl (MCMT or Ecotane®).  The loss of control of the reaction probably occurred during the first step of the process where more than half a ton of metallic sodium was reacted in a steel vessel with other raw materials, producing hydrogen gas as a byproduct.  T2 is a small company with about a dozen employees and the single production site in Jacksonville.

The reactor eventually overpressured and ruptured at a pressure of several thousand pounds per square inch.  The contents of the reactor immediately ignited creating a fireball and mushroom cloud rising approximately 2000 feet high.

CSB Supervisory Investigator Robert Hall, P.E., said, ‘As a result of our interviews, the CSB has discovered that over 30 people were injured, versus the 14 reported the first few days following the accident.’ After conducting over 50 interviews CSB investigators determined the significantly higher number of injuries. Initial media reports of 14 injuries did not count individuals who sought medical attention on their own.  Most of the injuries occurred off-site when a powerful blast wave swept through surrounding businesses; only 9 people were at the T2 site when the accident occurred.

Mr. Hall said, ‘We will conduct laboratory testing to quantify the amount of heat and pressure released by the reaction.  Our goal is to discover what went wrong on December 19 and to prevent a similar accident from happening again.’

For more information, please contact Public Affairs Specialists Hillary Cohen at (202) 261-3601 or Jennifer Jones at (202) 261-3603.

See this BBC report:

http://news.bbc.co.uk/1/hi/england/london/7208126.stm

A story in The Mail on Sunday, a UK paper said:

Elizabeth Ward, of the British Kidney Patients Association, said: “I’m quite sure it’s the first time this has happened in this country. It’s hard to understand how this could have happened.”
What was she talking about? A kidney transplant patient was forced to have the new organ removed after just a few hours – when it was discovered that the patient’s blood type had been incorrectly recorded on a computer database.

The incident, which was only revealed in response to a Freedom of Information request, comes just days after Gordon Brown called for a system in which individuals are presumed to consent to the use of their organs for transplant unless they specifically stipulate otherwise.

The error took place three years ago and would have remained secret had The Mail on Sunday not seen a confidential report into the “profound error”.

The internal investigation did not name the hospital involved. The report concluded that the initial data entry mistake was “human error” but said “there was no means of identifying” who did it, or where the incorrect information had been entered.

Although the mistake was made by Hospital Trust staff, the report blamed UK Transplant for failing to set up a standard nationwide system for entering patient details. It said: “During this investigation it became apparent that any number of professionals could have entered the blood results on to the computer.

“UK Transplant do not have a uniform system in place. [They] have not been prescriptive in dictating practice, and have allowed local Trusts the freedom to adopt whatever systems they deem fit.”

But a spokeswoman for UK Transplant said the report was “misleading” as the organization had no responsibility for the way Trusts entered information. “We need to be clear that the mistake here was not with UK Transplant,” she said.

“Information that Trusts provide is what goes into the national database. In this case, we have correctly recorded incorrect data. Our system has been in place for several years and can be viewed by Trusts at any time to check the data we’re holding.”

Once again, BLAME (rather than a fix for the problem) seems to be a major issue.

A source at UK Transplant said the mistake was “extremely rare” as fewer than five of the 20,000 organ transplants in the past seven years were made in error.

Hmmm … 5 in the past seven years? That sounds like more than “This has never happened before.” And if the reports aren’t made public, how can this error rate be verified?

For the complete article, see:

http://www.mailonsunday.co.uk/pages/live/articles/news/news.html?in_article_id=509289&in_page_id=1770

Car accidents usually are NOT funny. but add a little music, and speed it up to sound like the chipmunks, and … anything can be funny.

For the story from ABC see:

http://www.wjla.com/news/stories/0108/490262.html

For a video report, see:

http://www.wjla.com/news/stories/0108/490262_video.html?ref=newsstory

Watch this and then think about the accident investigation …

You know it’s a bad day when your plane carrying people back from an aviation safety conference crashes. For the whole story see:

http://www.cnn.com/2008/WORLD/europe/01/23/poland.crash/index.html

The BP Texas City Refinery explosion case drags on (since 2005). An AP story about the BP plea agreement with Federal Prosecutors says:

“Federal prosecutors took the harshest option available in brokering a $50 million fine proposed as criminal punishment for BP PLC’s deadly 2005 Texas City refinery explosion, the company and the government said in court filings Tuesday.”

For the whole story see:

http://www.chron.com/disp/story.mpl/ap/fn/5476163.html

U.S. District Judge Lee Rosenthal is expected to make a decision on the plea agreement by Febuary 4.

Back in December, I wrote about an accident investigation that was never completed because the “facts” didn’t agree. I asked “How would readers complete the investigation” and asked for comments. The comments can be seen at:

http://www.taproot.com/wordpress/2007/12/10/monday-accident-lessons-learned-what-to-do-when-the-facts-dont-agree/

Having conflicting information is a common problem when investigating an accident.

The best way to detect conflicting information (facts that don’t match) is to put the information collected on a SnapCharT®.

Using a SnapCharT® to display the information sometimes will make the non-factual information obvious (it doesn’t agree with the other stories or the physical evidence). Other times, either story is possible, and you can display how each set of facts is plausible.

What do you do when you have two sets of plausible stories? I try to analyze each possibility, develop causal factors for both stories, analyze each stories root causes, and then look at the potential corrective actions. If I can develop corrective actions that correct the root causes for BOTH stories, I don’t have to know which one is right. If I can’t develop effective corrective actions that will prevent the recurrence of both stories, then I need two sets of corrective actions, one for each story.

In my experience, the main reason (although not the only reason) for conflicting stories is that people are trying to avoid blame and are are either:

1. Telling the investigator a story that won’t get them in trouble.

OR

2. Telling the investigator what they think the investigator wants to hear (to keep the interviewee out of trouble).

The best way to avoid people “telling stories” is to develop a “just culture” or “no blame” environment where accident/incident investigations are seen as performance improvement opportunities rather than witch-hunts. Making this change requires senior management support.

WHAT DO YOU THINK?

Are my suggestions a practical way to deal with conflicting “facts.”

Leave a comment and let me know what you think.

A lifting accident at the Reliance Refinery in Mumbai, India killed a construction laborer.

For more details see:

http://in.reuters.com/article/businessNews/idINIndia-31484720080119

A blast caused by leaking Oxygen was described by Armand Arreza, Administrator of the Subic Bay Metropolitan Authority, as: “Just an Industrial Accident.”

I additional comments he said:

“What is important is for workers to be aware of the potential occupational and health hazards and report these.”

This was the third fatal accident at the shipyard in less than a month.

Does it sound like they need a little root cause analysis training???

For more information see:

http://newsinfo.inquirer.net/breakingnews/regions/view/20080119-113504/Early-probe-result-in-shipyard-blast-Its-an-accident

Kochi, India: Just four weeks ago, five workers were killed in a landslide at a quarry near Mannur. Now, just 10 km away at the G.K. Granite quarry near Oorakkad in Kizhakkambalam Panchayat, another person was killed in a similar incident.

For more information, see:

http://in.reuters.com/article/businessNews/idINIndia-31484720080119

A Navy mine sweeping MH-53 Sea Stallion apparently hit a broadcast tower and crashed last Wednesday. For more info see:

http://www.chron.com/disp/story.mpl/metropolitan/5462015.html

A construction accident at a resort being built in Singapore killed a construction worker when a wall collapsed.

For more information see:

http://www.channelnewsasia.com/stories/singaporelocalnews/view/322997/1/.html

CSB Announces Investigations into Acetylene Trailer Fires Will Be Carried Forward by the National Transportation Safety Board

Washington, DC, January 18, 2008 - The U.S. Chemical Safety Board (CSB) today announced that due to the National Transportation Safety Board’s investigation of the incidents, the CSB will discontinue its investigations into the July 2007 fire and explosions at Southwest Industrial Gases Inc. in Dallas, Texas and the August 2007 trailer fire at Hughes Christensen in The Woodlands, Texas. The investigation being conducted by the National Transportation Safety Board (NTSB) will thoroughly deal with all aspects of trailer design and operating procedures.

The CSB deployed a team to the serious fire and explosions at Southwest Industrial Gases Inc. in Dallas on July 25 that caused three injuries, destroyed the facility, and forced the temporary closure of major highways. On August 9 investigators were deployed to a similar incident at the Hughes Christensen Co. manufacturing facility in The Woodlands, Texas. Both fires were found to originate from acetylene trailers owned and operated by Western International Gas and Cylinders Inc, a supplier of industrial welding gases based in Bellville, Texas.

‘Since these accidents relate to transportation and are being investigated by the NTSB we are curtailing our investigation to avoid a duplication of effort,’ said Board Member William E. Wright. ‘The CSB plans to turn over all relevant data gathered during the initial deployments to the NTSB, and we offer our support in their investigation.’

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 CSB 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, please contact Public Affairs Specialists Hillary Cohen at (202) 261-3601 or Jennifer Jones at (202) 261-3603.

Press Release from the Chemical Safety Board:

Washington, DC, January 17, 2008 - An investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the BP refinery in Texas City, Texas, where an employee was killed in a process-related accident in an ultracracker unit on Monday.

BP officials today informed the Board that a chemical explosion may have been involved in the overpressure event leading to the death of the employee. Earlier reports had suggested that water pressure was responsible.

CSB Supervisory Investigator Don Holmstrom, who led the CSB’s two-year investigation of the 2005 fatal explosion at the Texas City refinery, will head the team. The team is expected to arrive at the site on Friday.

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 Director of Public Affairs Dr. Daniel Horowitz, 202-441-6074 (cell) or Hillary Cohen at 202-446-8094 (cell).

The Houston Chronicle reported that William Garcia, shift foreman at the BP site,  was killed by an accident at the BP Texas City Refinery on Monday. This is the third fatality in the 3 years since the explosion that killed 15 people in 2005. For more information see:

http://www.chron.com/disp/story.mpl/business/5458362.html

and

http://www.chron.com/disp/story.mpl/ap/business/5458808.html

See:

http://ap.google.com/article/ALeqM5hgPDc7ZMFo7noK7Z74MJpwiUsXAAD8U69T080

See the AP story on the CNN web site:

http://www.cnn.com/2008/US/01/15/bridge.collapse.ap/index.html

Photo of damage.

For the complete story from the San Francisco Chronicle, see:

http://www.sfgate.com/flat/archive/2008/01/11/chronicle/archive/2008/01/11/MNGQUDOT1.html

Link to AP Story:

http://www.newsday.com/news/local/wire/newyork/ny-bc-ny–trump-constructio0114jan14,0,2930921.story
Link to casasugar Blog Post:

http://casasugar.com/956128

For complete story see:

http://www.cnn.com/2008/WORLD/africa/01/12/nigeria.crash/index.html

Making muffins doesn’t sound very hazardous. But an Australian woman had two fingers amputated in an accident at a Cripps Nubake factory in Glenorchy, Tasmania.

This is just another example of the types of accidents that need thorough root cause analysis to make sure that the problems that caused the accident get fixed.

But let lesson from this accident might not be obvious to everyone. Why did this accident have to happen? A good proactive improvement program could have spotted this hazard and fixed it before anyone was hurt.

Proactive use of root cause analysis is a much more efficient and effective way to improve. It’s much better than waiting for accidents to point out safety problems for reactive root cause analysis.

If you are interested in proactive root cause analysis, there are two ways to learn more.

First, attend a 2-Day or 5-Day TapRooT® Course. You will learn to apply the highly acclaimed TapRooT® System to find root causes of accidents (reactively) or to find the causes of problems before accidents happen (proactive improvement).

The AP reports that two hydrofoils ferrying passengers between the Chinese territories of Hong Kong and Macau collided Friday night in heavy fog, seriously injuring 19 people.

For more info see the CNN web site:

http://www.cnn.com/2008/WORLD/asiapcf/01/11/hk.ferry.ap/index.html

The UK RAIB has released its report into a collision at Willington, near Burton on Trent.

The RAIB has made four recommendations.

For the complete report see:

http://www.raib.gov.uk/cms_resources/080110_R012008_Willington.pdf

Did you know that the Chief Inspector at the UK RAIB, Carolyn Griffiths, will be a Keynote Speaker at the TapRooT® Summit in Las Vegas (June 25-27, 2008)?

Carolyn will be speaking about her experience forming an independent investigation authority and her experience with the RAIB’s investigations.

For more information about the Summit see:

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

For some interesting pictures and commentary about recent accidents (dropped loads from cranes) at the Bank of America construction project, see:

http://curbed.com/archives/2007/10/17/breaking_curbedwire_construction_accident_at_b_of_a_tower.php
http://curbed.com/archives/2008/01/09/another_b_of_a_accident.php

You know you are in trouble when your regional safety authorities can’t keep up with the investigations of accidents that have 10 or more fatalities. That’s the situation in China where in the past two years there’s been 3,245 serious workplace accidents that caused at least 10 deaths in each accident.

For more info see:

http://www.chinadaily.com.cn/china/2008-01/10/content_6383316.htm

An Edinburgh, Australia chicken factory was evacuated after an Ammonia leak. 20 people were affected by the fumes.

The food processing industry is a great place to put TapRooT® to work finding the causes of all sorts of events including industrial safety issues, food safety issues, and equipment reliability problems.

In this case, there was a combination of equipment reliability and industrial safety issues.

For more information about learning about TapRooT® in Australia, see these two web sites:

Practical Solutions Group

Capability Resources

This fits into one of the “strange but true” stories.

A hunting dog stepped on a loaded shotgun and shot the hunter.

For details see the Reuters story:

http://www.reuters.com/article/domesticNews/idUSN0853532820080109

The Chemical Safety Board has completed their root cause analysis of the explosion at the Synthron facility at Morganton, North Carolina. The report is available at:

http://www.csb.gov/completed_investigations/docs/Synthron%20Final%20Report.pdf

In addition to the report, the CSB has produced a video titled:

Reactive Hazards: Dangers of Uncontrolled Chemical Reactions

It is available by clicking on the safety video link at:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=389#

What do you (or should you) be video taping to have documentation after an accident occurs? get your systems in place now and be ready after an accient occurs. Here is an example to get your planning started…

Head-on Train Collision

Posted Sep 04, 2007

Look carefully to see people jumping from the oncoming train just before impact.

(QuickTime Movie of Explosion from a Coast Guard Camera.)

(Aerial view of facility after explosion.)

CSB Investigation Press Release:

Statement by CSB Investigator-in-Charge Robert Hall Updating the Public on the Investigation of the T2 Laboratories Explosion and Fire

Jacksonville, FL, January 3, 2008 - Good afternoon.  I am Robert Hall, Investigator-in-Charge for this U.S. Chemical Safety Board (CSB) investigation.  The CSB is an independent federal agency that investigates major chemical accidents at industrial sites.

We are currently conducting an investigation to determine causes of the fatal chemical explosion that occurred on December 19th at T2 Laboratories Inc. here in Jacksonville.  The Board does not issue fines or citations but does produce investigative reports and recommendations that are widely used to prevent future accidents.

The team of CSB investigators from Washington, D.C., worked here through the holiday week and remains in Jacksonville interviewing survivors and surveying damage.

T2 is a small company with about a dozen employees and the single production site in Jacksonville.  The explosion at T2 occurred at about 1:30 p.m. on December 19th and killed four workers.

One worker remains in the hospital, and a number of other people were injured both on and off site.  The blast at T2 was among the most powerful ever examined by the Chemical Safety Board.  In addition to the tragic loss of life among T2 workers, injuries off-site requiring medical attention occurred as far as away as 750 feet from the reactor site.

The explosion occurred during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl.  This additive was first developed in the 1950s and is widely used to boost the octane rating of gasoline.  The company began producing the chemical for commercial sale a few years ago, using a batch reactor.

(more…)

Here’s a video of an accident. A jet clips a parked truck while taxiing. Are your ready to perform a root cause analysis?

http://view.break.com/423733 - Watch more free videos

Will the results of your root cause analysis be more of the same? You know what I mean … More Training, More Firings (or demotions), and/or More Procedures.

Or will you find the real root causes and develop effective corrective actions?

If you haven’t attended our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, you need to soon to be ready to investigate accidents, incidents, quality problems, equipment failures, and other operational issues and find and fix their true root causes.

Where can you attend a course in the near future? You can have a course at your site (contact us by clicking here). Or you can attend one of our public courses:

Edmonton, Canada    January 21-25
San Diego, CA    January 28-February 1
London, England    February 4-8
New Orleans, LA    February 4-8
Singleton, Australia    February 4-8
Halifax, Canada    February 25-29
Vancouver, Canada    March 3-7
Charleston, SC    March 3-7
Galveston, TX    March 10-14
Amsterdam, The Netherlands    March 10-14
San Antonio, TX    March 31-April 4
Knoxville, TN    April 21-25

For complete course info see:

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

What does a major accident cost?

The Houston Chronicle reports that production levels at BP Texas City won’t reach 2005 levels until sometime in 2008.

Without thinking about the lost lives and legal issues, just imagine the financial losses that could have been avoided if BP management had applied advanced root cause analysis and acted to correct problems before the explosion in 2005. Management System problems really do have big dollar impacts.

If you are a Senior Manager, are you insisting that investigators look for Management System problems? You are either a part of the solution or a part of the problem.

For the complete story see:

http://www.chron.com/disp/story.mpl/business/5414694.html

For complete story see:

http://sportsillustrated.cnn.com/2007/football/nfl/12/30/bc.fbn.giantsstadium.es.ap/?eref=mostpop

A recent article published indicated that pilot error for U.S. air carriers is down 40%. Pilot error has been a “prominent contributor” to aircraft mishaps as stated by the author of the study published in the January 2008 edition of “Aviation, Space and Environmental Medicine”. The author attributes improvements in Cockpit Resource Management (CRM) techniques, pilot training, and flight deck technology for reduction in pilot error. With that said, I have one question:

1. The accident rate did not drop with a 40% reduction in pilot error. If pilot error was the primary root cause why not?

If you find yourself blaming the the pilot, operator, or doctor in your company repeatedly for failures, you may need to a reassess your investigation robustness. You can always find data to support your conclusion of blame, but this comes with a price. You ignore data that is in conflict with your initial cause assessment. Unfortunately feedback for this error comes too late. If you would like additional information for removing the blame factor in order to conduct a proper incident investigation, contact us at System Improvements, Inc to discuss TapRooT®.

Houston Chronicle story available at:

http://www.chron.com/disp/story.mpl/business/5405484.html

If you’ve attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, you’ve used TapRooT® to find the root causes of the crash of Eastern Flight 401 that happened on December 29, 1972.

Would you like to learn more about the rescues after the crash? Then see this article:

http://www.cnn.com/2007/US/12/25/jet.crash.memorial.ap/index.html

An accident waiting to happen (but not waiting too long).

Wii Bat Accident

Posted Today

A Nintendo Wii bat slams straight through a home theater system (with slo-mo replay included!)

The Navy Times reported that that several submarines and nuclear powered aircraft carriers could have substandard welds.

The corrective action? According to the article, a change in a policy and more training.

Are these strong corrective actions or weak ones? How will shipyard management know if the policy change is being followed?

What can you learn from this quality incident?

Four accidents in a year? Two near death. Is this a lucky dog (as the vet seems to think) or an accident prone dog?

For more info, see:

http://www.thenorthernecho.co.uk/news/topstories/display.var.1907339.0.accidentprone_dog_whipped_by_cat_in_his_latest_mishap.php

If dogs can be accident prone, can people?

Last week one window washers was killed and one seriously injured in an accident in New York.

This week the union members of Local 32 BJ received more safety training.

For complete info see:

http://www.ny1.com/ny1/content/index.jsp?stid=8&aid=76589

Accident a school with tragic results. See:

Fatal Accident Causes Death – Company Fined

See:

http://www.crainsnewyork.com/apps/pbcs.dll/article?AID=/20071214/FREE/71214003/-1/rss01&rssfeed=rss01

Having a major accident is a good start for getting on this list:

1. Cintas Corp - OSHA Fine: $2,782,000

2. Thomas Industrial Coatings Inc. - OSHA Fine: $2,362,500

3. Southland Forming Inc. - OSHA Fine: $328,025

4. Davis Wire Pueblo LLC - OSHA Fine: $287,500

5. Crescent Manufacturing - OSHA Fine: $272,900

6. American Airlines - OSHA Fine: $262,500

7. Koch Foods - OSHA Fine: $253,500

8. St. Marys Foundary Inc. - OSHA Fine: $253,300

9. Provident Pharmaceuticals - OSHA Fine: $251,500

10. Abbyland Foods Inc. - OSHA Fine: $248,000

This is the list of the top ten OSHA Fines as of September 30, 2007 (the end of the government year).

You don’t have to have an accident to make this list … but it helps.

Perhaps your company want to learn from the accidents of others and avoid this list. How can you do it? One tool that can help is learning from near-misses and incidents by applying advanced root cause analysis - TapRooT®.

If you would rather read about Success Stories rather than failures?See what these TapRooT® Users say about success at:

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

The RAIB is carrying out an investigation into a collision between two road rail vehicles at Glen Garry, near Blair Atholl, on 5 December 2007. For more info see:

http://www.raib.gov.uk/publications/current_investigations_register/071205_glen_garry.cfm

I was reading a Houston Chronicle article about a BP civil trial. It said:

“BP has spent more than $1.6 billion settling 2,425 claims, including all involving deaths. The remaining claims involve injuries or property damage.”

Is that all the costs of that accident? No way.

Lost production …. Billions.

Bad PR … Billions.

Management turmoil … Billions.

Hit to the stock price … Billions.

Hit to employee morale … not billions but significant.

So if you are saving pennies and the results may be a major accident, you are making a fool’s bargain.

Penny wise, Pound foolish
Benjamin Franklin

Investing in advanced root cause analysis? A wise use of resources that produces returns for years.

What kind of returns do you get? See the Success Stories at:

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

A South African web site reported on the trial after a refinery accident. The trial took place three years after the accident and the accident investigator admitted under oath that the accident investigation had never been completed.

The story said:

“Kgele Mathiba, the investigator, said the report was never completed because there were too many conflicting versions of events and opinions as to who was accountable.”

How would you complete an investigation with conflicting “facts”.

Read the story and give me your best ideas for how you would handle this type of difficult investigation. (Use the “Comments” link below.)

The International Herald Tribune reports that 105 miners died in the second deadliest mining accident this year in China.

When the second deadliest accident kills 105, you know the Chinese mining industry needs major safety improvements including advanced root cause analysis.

TapRooT® is used to investigate mine accidents around the world. Some mining companies and regulatory agencies that use TapRooT® to investigate accidents, incidents, and near-misses and who use TapRooT® to proactively improve performance include (just to name a few):

- US Mine Safety & Health Administration
- Rio Tinto
- Barrick
- Mimosa Mining Company
- Syncrude
- Cameco
- Interwest Mining
- Alcoa
- PCS
- Arch Coal

To see a mining performance improvement success story, go to:

http://www.taproot.com/about.php?s=1

William Brand and Harry Harris of the Bay Area Newsgroup reported that an accident killed a man at the Port of Oakland this week.

A previous fatality in September has longshoremen worried about port safety.

What caused these fatalities? The story implies that the push for production may be leading to unsafe work practices.

Seems like the Port should be considering advanced root cause analysis to find the real causes of these accidents and develop effective corrective actions.

It is good to note that the fire department responded quickly and there were no fatalities. The supervisor’s response after investigating the accident was to focus on why the waiter did not check before locking the door. If he had been more attentive this accident would have never happened…..I must confess though, while the damage and location are correct this fire actually occurred in someone’s house and a dog was to blame. Authorities say the woman was taking garbage outside Tuesday evening when the dog somehow shut the door behind her. Firefighters arrived to find heavy smoke with flames shooting from the roof of the home.

Had you known that this was a dog instead of a waiter would you have changed your focus to the cook instead during your root cause analysis? Why should this bias your investigation? Is this how your company leads investigations? We can help you avoid this bias with our TapRooT® root cause analysis process.

A recent article stated that the Canadian Transportation Safety Board was due to do release the crash report for an Airbus A340. The aircraft came in too high and too fast in bad weather and “simply” ran out of runway. Not seeing the full report yet, I have to ask what root cause analysis process was used in this accident investigation?

With the advanced instrumentation and glass cockpits of today, how and why did this accident occur? I can’t prevent bad weather so the corrective action based on the report must be don’t attempt to land in bad weather…If this seems wrong to you then I suggest that you try the TapRooTç root cause analysis process.

And the root cause is …

AFP reports on a mining disaster in the Ukraine. 90 have been confirmed dead and 10 are still missing. For the complete story see:
http://afp.google.com/article/ALeqM5jnxMxWdxKy4XLFaGpSw6Z9LKOYZQ