Root Cause Analysis Blog

See:

http://www.foxnews.com/story/0,2933,338209,00.html

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

Senate Confirms John Bresland as Chairman of the Chemical Safety Board

Washington, DC, March 14, 2008 - Acting by unanimous consent early this morning, the U.S. Senate confirmed John S. Bresland to a five-year term as chairman and chief executive officer of the U.S. Chemical Safety Board.  Mr. Bresland previously served as a CSB board member from August 2002 until August 2007.

For details, see:

http://www.boston.com/news/local/articles/2008/03/14/acela_train_kills_worker/

Next week I’ll be at the IOSH Conference in Telford, England.

Why am I attending?

To hear some interesting talks and to promote advanced root cause analysis to improve safety in the UK.

If you want to talk about root cause analysis, drop by our booth (A 12 - near the entrance) and say Hi!

Hope to see you there…

Mark

Agricultural/food accidents aren’t all that uncommon. In this case an auger claimed a life. When I was in college, a friend lost his leg in an auger accident. He was trapped for hours in a remote field before anyone found him and he almost died.

Could agricultural companies apply advanced root cause analysis to improve performance and reduce deaths and injuries? You bet. Some already have.

For details on this accident, see:

http://news.theage.com.au/nsw-winery-shocked-by-worker-fatality/20080313-1z6d.html

See:

http://www.chron.com/disp/story.mpl/business/5615204.html

It’s rare to see an audit or evaluation be this blunt. See:

http://www.smokymountainnews.com/issues/03_08/03_12_08/fr_hrmc_power.html

Could this audit be performed by an internal auditor?

Would it be possible to conduct an audit like this if the Hospital Administrator was still there? (He quit before the audit was conducted.)

Could the Board be more independent and should have they found the problems and forced the Administrator to Change (or fired him) before it came to the point of losing Medicare certification?

What do you think?

For more information, see this article in the Houston Chronicle.

A diesel fuel spill is moving away from land after a fishing boat hit a tanker off the coast of South Korea. For details, see:

http://www.abc.net.au/news/stories/2008/03/12/2187944.htm

CNN reports that the FAA has required air carriers to install improved black boxes to collect more flight data and longer periods of voice communication. The requirement call for the devices to be installed by March 7, 2012.

The requirement comes 9 years after it was requested by the National Transportation Safety Board.

The FAA did not require cockpit cameras as requested by the NTSB. The FAA said the cameras were not justified by a cost/benefit analysis.

IF YOU ARE NOT in the aviation industry, why do you care?

You should think about automatic data recording for your facility (in case of an accident).

Things to think about include:

1. Recording radio communications.
2. Videos in the control room.
3. Data recording.
4. Security camera recordings.
5. Security access data (swipe card data to see who went where).

Don’t wait until it is too late! Think through your data recording requirements before an accident occurs.

Rich Fairfax, OSHA’s Director of Enforcement, says that the National Emphasis Program to inspect refineries will continue. 17 of 81 refineries have been inspected resulting in 146 violations and $896,300 in fines. He said:

“I have no intention of ending it after two years based on what we’re finding.”

(He didn’t say that it was a money maker, but its seems like they are producing a pretty good return on their audit time investment.)

But beyond that, he wants to expand the program to chemical plants.

The program was started after OSHA was criticized for not preventing the BP Texas City explosion even though there had been previous deaths at Texas City. BP refineries accounted for 20 of 29 refinery deaths that occurred from 2005-2008. Fifteen of those were due to the BP Texas City explosion.

Not all refineries are scheduled to be audited because some refineries are in programs (like VPPPA STAR) that exempt them from these inspection and others are in states with their own programs.

This job oportunity includes an interesting application of root cause analysis. Manager needs to perform root cause analysis of scope changes in projects to reduce the likelihood of future scope changes. Great idea.

For job posting info, see:

http://jobs.nwsource.com/careers/jobsearch/detail/jobId/7898906/viewType/rss?rssref=pilocal_bellevue

See:

http://www.fiercebiotech.com/jobs/jobs/show/872

A TapRooT® User is looking for a Senior Reliability Analyst. See:

http://maintenancetalk.com/blog.php/viblog/senior_reliability_advisor/

See:

http://health-care-jobs.advanceweb.com/search/Fullresults.aspx?A=6&SOI=0&IL=949896

As a follow-up to the blog posting about the FAA fine of $10.2 million, Here is a memo that was sent to all Southwest Frequent Fliers:

Southwest Airlines: We take Safety Seriously

You may have heard that Southwest Airlines was fined by the FAA regarding recent aircraft inspections. First and foremost, we want to assure you this was never and is not a safety of flight issue.

From our inception, Southwest Airlines has maintained a rigorous Culture of Safety—and has maintained that same dedication for more than 37 years. It is and always has been our number one priority to ensure the Safety of every Southwest Customer and Employee. “We’ve got a 37-year history of very safe operations, one of the safest operations in the world, and we’re safer today than we’ve ever been,” said Southwest CEO Gary Kelly.

Receipt of the FAA letter of penalty gives us the chance to present the facts which we feel will support our actions taken in March 2007. The FAA penalty is related to one of many routine inspections on our aircraft fleet involving an extremely small area in one of the many overlapping inspections. These inspections were designed to detect early signs of skin cracking.

Southwest Airlines discovered the missed inspection area, disclosed it to the FAA, and promptly reinspected all potentially affected aircraft in March 2007. The FAA approved our actions and considered the matter closed as of April 2007.

The Boeing Company has stated its support of Southwest’s aggressive compliance plan. Southwest acted responsibly and the safety of the fleet was not compromised, Boeing said.

Former National Transportation Safety Board Inspector-in-Charge Greg Feith said after a review of the available data and information that it’s apparent that there was no risk to the flying public in March 2007 while Southwest Airlines performed their program to re-inspect the small area of aircraft fuselages identified.

Southwest consistently maintains a Leadership role in developing maintenance programs for the Boeing 737 aircraft.

As always, we commit to keeping you informed. Please check southwest.com for periodic updates.

This short newspaper article starts to provide the information needed to draw a SnapCharT® that would have many Causal Factors. Read the story and then try drawing a SnapCharT®.

Link to story:

http://www.news.com.au/heraldsun/story/0,21985,23323474-29277,00.html

For details, see:

http://www.abc.net.au/news/stories/2008/03/07/2183092.htm?section=australia

There was an interesting article in the Houston Chronicle. It discusses a maintenance problem (overdue inspections) on Southwest jets.

The FAA is proposing $10,2 million in fines. The article says:

The FAA alleged that between June 18, 2006, and March 14, 2007, Southwest operated more than 59,000 flights without complying with a 2004 order requiring repetitive inspections of fuselage areas to detect fatigue cracking.

Further, the FAA charged that the airline flew nearly 1,500 more flights using the same planes in March 2007, even after it determined that it had not done the necessary inspections.

“The FAA is taking action against Southwest Airlines for a failing to follow the rules that are designed to protect passengers and crew,” Nicholas Sabatini, the FAA’s associate administrator for aviation safety, said in a prepared statement.

The fine is the largest levied against an air carrier, FAA spokeswoman Laura Brown said.

The missed inspections were discovered by Southwest and self-reported to the FAA. The missed inspections were then performed in the month of March 2007. Cracks were found and corrected in 6 or the 46 jets that were inspected.

What were the root causes of the missed inspections and have they been corrected?

Fines do little good if the problems root causes aren’t effectively addressed.

My hope is that both the FAA and Southwest thought of this. Why didn’t the reporter dig deeper to find this out and include it in the story?

Reporting on the politics of a fine is one thing, but assuring passengers of their safety by verifying that an effective root cause analysis was performed is quite another.

The recent BP Annual Report (page 26), BP increased the reserve to settle legal claims from the Texas City Refinery explosion from $1.6 Billion to $2.125 Billion.

Also, the Houston Chronicle reported that a Federal Appeals Court must rule on whether the blast victims were properly consulted before a federal Judge can rule on the $50 million EPA Clean Air Act violation settlement agreement between BP and the EPA.

A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.

Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.

What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).

Bill Sirois, VP and COO of Circadian Technologies, will be presenting three sessions on fatigue and the investigation of fatigue as the cause of accidents. The sessions are:

Human Error Reduction & Behavior Change Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Investigation & Root Cause Analysis Best Practices Track:

• FACTS - Computerized Analysis of Fatigue as a Cause of an Incident

Medical Error Reduction Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

For additional Summit information, see:

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

“An Eagle Rock schoolteacher doesn’t want any bugs squashed in her classroom, so she’s appointed a student insect monitor to take wiggling, creepy critters outside.” The Los Angeles teacher is getting an award for her be-kind-to-bugs effort and thinking outside the box. Does this corrective action to remove bugs give you a creepy crawly feeling or what? Could you think of some the consequences that could occur once put in place?

How often do you review your corrective actions for unintended consequences? If you see “bugs” in your corrective action board, think about attending one of our TapRooT® root cause analysis system courses, training that helps solve problems both reactively and proactively. We can show a proven SMARTER process before a corrective action becomes another incident.

For more info, see:

http://www.signonsandiego.com/news/state/20080229-1927-wst-columbiarivernavigation.html

The Food and Drug Administration (FDA) found that a Chinese plant is at the center of a controversy over the safety of Baxter’s blood thinning drug heparin. Changzhou SPL has problems with impurities, the quality and use of its equipment, and overall quality control. These problems were found in a preliminary inspection by the FDA.

You may remember that in a previous blog entry, the FDA had declined to inspect the plant because of a name mix-up in the FDA’s manufacturer database.

For more information, see:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/28/AR2008022803046.html?hpid=moreheadlines

Conducts root cause analysis on specific project areas. Monitors quality of software products, processes, and standards. Performs in-process and phase end assessments. Establish and the successful execution of Supplier Development Plans.

For complete info, see:

http://www.hotgigs.com/logged_in/search/index.cfm?profileid=Ji5RVipYTlYnCg%3D%3D&userid=JS5BWixYXkQgCg%3D%3D&id=Ji5RVipYTlYnCg%3D%3D&page=viewsearchresults&Mode=G&override=true&jobview=yes

On February 25th, the Federal Deposit Insurance Corporation (FDIC) made public their January Enforcement Actions. Of course my first thoughts were… “where’s my money? is it safe in my bank?” Evidently my bank is doing fine because it did not make the hit list… or is it? So what kind of errors were the financial institutes making?

The core statement in all the findings seemed to be “unsafe or unsound banking practices”. Lower down the chain of complaints were comments such as no independent reviewer, management not certified, no internal audits conducted, and inadequate transactions which did not follow FDIC regulations. For TapRooT® root cause analysis system users, these words sound quite familiar: procedure and policy not used, independent quality control needs improvement, worker selection needs improvement. So the question is what is the tie between FDIC failed audits and an incident investigation…. the answer is none.

The incident or scope of the analysis (investigation) for the FDIC audit could be “Completed Commercial Loan Applications did go through an external review per regulation”. In a safety incident we start with a sequence of events. In the Loan Application we start with the transaction such as customer applies for loan. See below for an example of a SnapCharT® - “What Happened?”, combined with a Six Sigma Tool Called a Swimlane. Had the the financial institutions performed a proactive analysis using this process could they have prevented the audit failure? Keep in mind that once SnapCharT® was developed for this investigation, problems would be grouped, causal factors would be identified, and then effective corrective actions would be developed using TapRooT®’s SMARTER Checklist.

Think about it…. how often in your business are you auditing your business risk processes to identify possible Significant Issues before they happen? Do you have engineering gateways such as IPDS that are failing? In your integrated supply chain what processes are failing? If you fail an audit are your investigating the transaction or process using TapRooT®? If you use Six Sigma for Root Cause Analysis are you using the most effective process accepted by businesses worldwide? If not Call us at System Improvements, Inc. at 865.539.2139. Register for the Summit in Las Vegas in June, where we will be discussing how to improve your Lean Six Sigma Root Cause Analyses.

The UK Rail Accident Investigation Branch has released two new accident investigation reports.

The first is about the derailment at Hooley Cutting, near Merstham, Surry. The report includes seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/2008-02-28_R052008_Merstham.pdf

The second report is about a track worker fatality at Ruscombe Junction. It also has seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/080228_R42008_Ruscombe.pdf

IMO’s Maritime Safety Division’s Maritime Safety Committee is considering amending SOLAS (Safety of Life at Sea  Convention) at their May meeting. The amended standard would become effective in 2009.

The amended code would make it mandatory for flag states to carry out investigations and will make a distinction between establishing what happened and apportioning liability.

To meet the new requirements flag states will have to establish investigation bodies, such as the UK’s Marine Accident Investigation Branch, or use third party investigators.

For more info, see:

http://www.gadball.com/jobs/details.aspx?query=13049456/manager-electrical-reliability.aspx&AspxAutoDetectCookieSupport=1

The following is news release by Oregon’s Occupational Safety and Health Division:

The Oregon Department of Consumer and Business Services, Occupational Safety and Health Division (Oregon OSHA) has fined Siemens Power Generation Inc. a total of $10,500 for safety violations related to an Aug. 25, 2007 wind turbine tower collapse that killed one worker and injured another.

“The investigation found no structural problems with the tower,” said Michael Wood, Oregon OSHA  administrator. “This tragedy was the result of a system that allowed the operator to restart the turbine after  service while the blades were locked in a hazardous position. Siemens has made changes to the tower’s engineering controls to ensure it does not happen again.”

The event took place at the Klondike III Wind Farm near Wasco, where three wind technicians were performing  maintenance on a wind turbine tower. After applying a service brake to stop the blades from moving, one of the  workers entered the hub of the turbine. He then positioned all three blades to the maximum wind resistance  position and closed all three energy isolation devices on the blades. The devices are designed to control the  mechanism that directs the blade pitch so that workers don’t get injured while they are working in the hub.

Before leaving the confined space, the worker did not return the energy isolation devices to the operational  position. As a result, when he released the service brake, wind energy on the out-of-position blades caused an  “overspeed” condition, causing one of the blades to strike the tower and the tower to collapse, the Oregon  OSHA investigation found.

Chadd Mitchell, who was working at the top of the tower, died in the collapse. William Trossen, who was on  his way down a ladder in the tower when it collapsed, was injured. The third worker was outside the tower and  unharmed.

During the investigation, Oregon OSHA found several violations of safety rules:

• Workers were not properly instructed and supervised in the safe operation of machinery, tools,  equipment, process, or practice they were authorized to use or apply. The technicians working on the  turbine each had less than two months’ experience, and there was no supervisor on site. The workers  were unaware of the potential for catastrophic failure of the turbine that could occur as a result of not  restoring energy isolation devices to the operational position.

• The company’s procedures for controlling potentially hazardous energy during service or maintenance  activities did not fully comply with Oregon OSHA regulations. Oregon OSHA requirements include developing, documenting, and using detailed procedures and applying lockout or tagout devices to secure hazardous energy in a “safe” or “off” position during service or maintenance. Several energy  isolation devices in the towers, such as valves and lock pins, were not designed to hold a lockout device, and energy control procedures in place at the time of the accident did not include the application and removal of tagout devices.

• Employees who were required to enter the hub (a permit-required confined space) or act as attendants to employees entering the hub had not been trained in emergency rescue procedures from the hub.

Siemens Power Generation has 30 days to appeal the citation.

Here are some links for more information:

http://www.reuters.com/article/domesticNews/idUSN2664121920080227

http://ap.google.com/article/ALeqM5hHI4Ql8XfZuPMktRM7fQxHjXbz1QD8V2O01O0

http://www.miamiherald.com/news/breaking_news/story/434132.html

http://www.ktvu.com/news/15424754/detail.html

http://www.cnn.com/2008/US/02/26/florida.power/index.html

Software written internally by HSBC caused an intermittent failure (don’t you hate those) of Mastercard’s Maestro system last weekend. This caused thousands of HSBC’s customers to be unable to make purchases or withdraw cash.

The bank is now conducting a “major incident review” that should be completed by Friday. The review will look at the problems with the software and why recovery took so long (four hours after the offending software was removed).

How is a root cause analysis of a software failure different than the root cause analysis of a equipment failure or a human error that causes an explosion or plant shutdown? Really, there isn’t a difference in the tools to use. The only difference is the technology involved.

I found this out back in the 90’s when working with Gerald Starling at BellSouth. He used TapRooT® to investigate telecommunications incidents (network reliability, 911 outages, etc.). These were often software issues. And using TapRooT®, he found fixable root causes that improved performance.

The technology (network reliability) was very different than the types of investigations I had perviously performed. Even though I am an electrical engineer, the terminology of network reliability was completely foreign to me. Yet the reasons for human errors and system failures were in the Root Cause Tree® (part of the TapRooT® System).

The reason for this is that the causes of unreliable human performance (mistakes - human errors) are the same no matter what type of technology the human is involved with. Therefore, the ways to achieve reliable human performance are a basic part of the analysis that TapRooT® helps an investigator perform.

A man was struck and killed by the red line Luas Tram last weekend. The tram operator, Veolia Transport, is conducting an investigation in coordination with the Irish Railway Safety Agency. This is the first fatal accident since the tram was inaugurated in 2004. There were 17 “contact” incidents between people and the tram in 2007. A December 2007 incident caused serious head injuries to another man.

For a video report see:
http://www.rte.ie/news/2008/0225/luas_av.html

For complete details, see:

http://my.jobstreet.com/jobs/2008/2/default/10/576976.htm?fr=R

The Air Force has declared a “temporary pause” to review safety procedures for flying the B-2 after a crash at a Guam air base.

This is the first time a B-2 had crashed. However, even a single crash is significant because each B-2 is worth more than $1 billion. Perhaps that is why all B-2’s will be grounded (oops - I mean temporarily paused) while safety reviews are conducted.

Air Force officials were careful to explain that this action was not a “stand-down” or “grounding” and that the planes could return to service at any time they were needed. A stand-down or grounding occurs only if senior Air Force commander order it. Officials said that has not happened.

What happens when you lie to the Coast Guard during an investigation of a maritime accident? You end up facing federal charges! See this story from the San Francisco Chronicle:

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/02/23/BAVTV7DN8.DTL

Root cause analysis can help you improve performance. Sometimes at little or no cost. But the article linked below takes a different view. They think that increased reliability isn’t worth the cost.

Of course, Research in Motion has assigned engineers to investigate the problem to make sure it doesn’t happen again (this was the second outage in 10 months). An opportunity for better root cause analysis or a waste of time?

What do you think?

Article Link:

http://www.computerworld.com/action/article.do?command=viewArticleBasic&taxonomyName=mobile_and_wireless&articleId=312950&taxonomyId=15&intsrc=kc_feat

For details, see:

http://www.theengineer.co.uk/Jobs/101454/Quality+Engineer+-+DFMEA.htm

International Cooling Tower pleaded guilty to a violation of the Occupational Health and Safety Act after a July 2005 accident. An apprentice carpenter fell through an uncovered opening in platform and suffering serious spinal injuries that left him paralyzed.

A Labour Ministry investigation found the worker was wearing a full-body harness with a single lanyard that wasn’t attached to a fixed support or lifeline. The ministry’s also found the worker was unaware of the opening because lighting was inadequate and that the worker was inadequately trained in safety procedures.

The Labour Ministry has finally fined the company $150,000.

The 10th person died from burns received from the blast at Imperial Sugar’s plant in Georgia. Thirteen are still in critical condition. For more details see:

http://www.chron.com/disp/story.mpl/business/5563790.html

For details, see:

http://www.chron.com/disp/story.mpl/business/5563715.html

For more info, see:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=132635

Another data point on the cost of an accident.

We noted the accident at the Trump Hotel in SoHo on a blog entry on January 14.

Today I saw an article that said the construction contractor at the Trump Hotel SoHo was just allowed to resume work on the first 23 stories of the building, but is NOT being allowed to use cranes, resume pouring concrete, or work above the 23 floor.

Imagine the costs of this construction delay.

Yes, this was a fatality. The first concern should be for the lives (health and safety) of employees. But one of the overlooked costs of an accident is the regulatory consequences (in this case a stop work order by the New York Department of Buildings).

Construction accident prevention, proactive risk reduction, and good root cause analysis of problems can help companies avoid the unexpected and costly constructions delays that a major accident can cause.

I wrote about this amazingly stupid government decision to stop research into imporving patient care by using a checklist, but I came across this link to the New Yorker magazine article, so I thought I should include it here:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

If you agree that this is outrageous, write the White House, your Congressman, and your Senator.

Use these links:

Contact the President and Vice-President about this at:

http://www.whitehouse.gov/contact/

Write your Congressman about this by using the following link:

https://forms.house.gov/wyr/welcome.shtml

Write your Senator at this link:

http://www.senate.gov/general/contact_information/senators_cfm.cfm

The Air Accident Investigation Branch’s official web page for the investigation of the 777 crash at Heathrow is:

http://www.aaib.dft.gov.uk/publications/special_bulletins/s1_2008___boeing_777_236_er__g_ymmm.cfm

The International Herald Tribune had an interesting article on the progress of the investigation into the crash of the 777 landing at Heathrow. See:

http://www.iht.com/articles/ap/2008/02/19/europe/EU-GEN-Britain-BA-Crash-Landing.php

Legal representatives of those injured or the loved ones of those who were killed, are asking Judge Lee Rosenthal to reject the $50 million dollar fine for BP. They say the fine should be between $400 million and $3.2 billion.

For additional information, see:

http://www.chron.com/disp/story.mpl/business/5550899.html

Two different plants. Two similar names. Oops! Wrong plant!

If you’ve been following the FDA investigation of allergic reactions to Baxter’s heparin blood thinner, you know that a Chinese manufacturer is supplying a key ingredient. The supplier that produces the ingredient was not previously inspected by the FDA because the FDA went to the wrong plant. It seems there are two plants with similar names in the agency’s database.

Joseph Famulare, Deputy Director of the Compliance Department at the FDA’s Center for Drug Evaluation and Research said that the wrong factory had a history of positive inspections and wasn’t re-inspected. This month, they discovered their error. Famulare says that as far as the FDA knows, this is an isolated error. FDA inspectors will travel to China this week to check the right plant.

The FDA has notified Doctors to stop using Baxter’s heparin because of 350 reports of adverse reactions (including deaths) this year.

For more information see the Associated Press story at:

http://www.chron.com/disp/story.mpl/world/5550954.html

For more information, see:

http://ph.jobstreet.com/jobs/2008/2/default/20/1764885.htm?fr=R

TapRooT® user GE is looking for a Field Engineer with root cause analysis skills. For information see:

http://smechapter21.org/board/?p=16

Initial reports are that five people were hurt by the blast and fire. One person was injured by flying debris that landed on her car. One worker was hospitalized with burns.

For details, see the article at Fox News:
http://www.foxnews.com/story/0,2933,331039,00.html

The following press release is from the UK Rail Accident Investigation Branch:

The RAIB is carrying out an investigation into a fatal level crossing accident at West Lodge level crossing, near Haltwhistle, Northumberland, on 22 January 2008.

The accident occurred at 17:13 hrs, when English, Welsh and Scottish Railways freight train 6E62, from Carlisle to Middlesbrough, struck and killed a young man delivering coal to a house adjacent to the West Lodge user worked level crossing on Network Rail’s Carlisle to Newcastle line.

The RAIB’s preliminary examination indicates no issues with the condition or operation of the train or the signalling system that could have contributed to the accident.

The RAIB’s investigation into the accident is proceeding independently of any parallel investigations by the safety authority.

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website.

It was a bad day at the rail yard in DC.

An Amtrak MARC Train from Baltimore was still unloading passengers when an Amtrak rail yard locomotive decided to hook up to move the train for maintenance. Amtrak spokeswoman Katrina Romero said that the yard locomotive “…came in to fast.” One car of the train was derailed and 7 people were injured with bumps, bruises, and minor head/neck injuries.

What were the Safeguards that should have kept this from happening?

What Safeguards could be added to make this operation safer for passengers?

Leave comments to let me know what you think.

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

Statement of CSB Investigations Manager Stephen Selk, P.E., Updating the Public on the Investigation of the Imperial Sugar Company Explosion and Fire, Savannah, Georgia –  February 17, 2008, 1 p.m.

Good afternoon and welcome to this first U.S. Chemical Safety Board briefing on the Imperial Sugar Company explosion and fire.

I will begin this afternoon by explaining the Chemical Safety Board’s role.  Following that I will present a primer on dust explosions.  And then I will show you a pair of large photographs and describe some of the devastation to the Imperial sugar refinery.  Finally, I will try and answer any questions you may have.

(more…)

For more info, see:

http://www.chron.com/disp/story.mpl/metropolitan/5547297.html

Medical device industry experience required. Needs root cause analysis and CAPA experience. For more info, see:

http://www.gadball.com/job/12816340/manager-quality-assurance–quality-control.aspx

A seal failure led to a small oil spill in the Terra Nova oil field. The immediate cause reported in the article was a seal failure. This seems like a good opportunity to apply Equifactor® to help analyze the root causes of the seal failure.

The approach discussed in the article (link below) seems similar to Change Analysis. What are the differences in lots of the drug that lead to adverse patient reactions?

To read about this problem see:

http://www.nj.com/business/index.ssf/2008/02/heparin_probe_finds_us_tie_to.html

For more info, see:

http://www.theengineer.co.uk/Jobs/99723/QA+Engineers+(x2)+++Workshop+Turbine+Overhauls.htm

The following job openings are being offered through, Paul Shrenker, a recruiter. Contact him directly at 413-267-4271; email address pshrenker@comcast.net.

Link to their web site: http://www.psassociatesinc.com

Director of Safety (Philadelphia, PA area) for this 5000 employee nationwide company.  This position reports to the VP of Operations and will have 8 or 9 direct reports (mostly Regional Safety Managers). The ideal candidate should have 15+ years of safety experience to include fleet safety, supervisory experience and multi-site experience.  A BS in Safety, Engineering or related is required and they prefer the person to be certified (CIH, CSP or PE).

Corporate Safety Director (Southeastern PA) for this specialty commercial and industrial construction company.  The company has 35 branch locations across the U.S. with approximately 2500 employees.  The ideal candidate will have 10+ years of safety, health and environmental experience in the construction industry, a BS in Safety or related, previous supervisory experience and certification preferred.  There will be approx. 35% travel.  This position has 3 regional safety, health and environmental managers reporting into it.

Environmental Manager (Portland, OR) for this heavy manufacturer.  This position will be promotable to a Corporate EHS position within a couple years.  The person will initially “s