Root Cause Analysis Blog

A story in CIO magazine says that a survey (by the consulting firm Deloitte of 100 technology, media, and telecommunications firms worldwide) listed “Human Error” as the leading cause (75% of the time) of security failures.

If this is even remotely true, these firms need advanced root cause analysis - TapRooT® - to analyze their human error incidents and find the real root causes of “human error.”

As we see it, human error isn’t a root cause. It is a starting point to dig into the cause of the human error. We see most human errors as Causal Factors and use the Root Cause Tree® to dig into the real, fixable root causes of the problems that cause the human error.

Unless you find the real root causes of human error, it’s doubtful that you will develop effective fixes. Without effective fixes, the problem will continue to trap people even if they are trying to be careful.

So don’t get caught in the “human error” trap. learn to find and fix the real root causes of human error by attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.

The 5-Day Course really gets into the causes and investigation of human error. It is based on advanced human factors knowledge derived from research from around the world. Where are these courses held? Here are some upcoming locations and dates:

Charleston, SC          March 3-7
Galveston, TX            March 10-14
Amsterdam                March 10-14
San Antonio, TX        March 31 - April 4
Knoxville, TN            April 21-25
Singapore                  May 5-9
Aberdeen, Scotland  June 9-13

For a complete course list, see:
http://www.taproot.com/courses.php?d=2

A line of storms and a tornado may have set off a huge fire at a natural gas pumping plant in Tennessee.

(Not a sunrise, that’s the glow from the fire!)

Would this qualify as a “Sabotage/Natural Disaster” category on the Root Cause Tree®? check your Root Cause Tree® Dictionary before you answer!

For the story about the fire, see:

http://www.chron.com/disp/story.mpl/nation/5517482.html
http://www.wtopnews.com/?nid=104&sid=1339964

http://tennessean.com/apps/pbcs.dll/article?AID=/20080206/NEWS01/80206104

For information, see:

http://www.computerweekly.com/jobs/job/network-engineer–10338586.htm

Holcim (US) Inc has an immediate opening for a Reliability Engineer in Clarksville, Missouri.

Specific responsibilities include management of the preventive/predictive maintenance programs (Inspection, Vibration, Oil Analysis, NDT, thermography) to ensure optimum equipment availability; preventative maintenance work order system with coordinated execution of the maintenance teams; analysis and elimination of repetitive problems through root cause analysis, Pareto analysis, statistical review, FMEA and similar techniques; and facilitation of continuous improvement processes around equipment availability and reliability.

For more info see:

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

Article about an actual event written by Mark Sharp:

What Was I Thinking?

“… former senior reactor operator who mistakenly entered incorrect information into a plant computer during a maintenance operation on Nov. 8, 2006, and subsequently attempted to cover up the mistake by falsifying the record…” NRC news release, October 22, 2007

After 25 years of working in the nuclear power industry in both operations and operations training, you would think that I would have had a handle on operator fundamentals. Self-checking, placekeeping/logging, and error reduction techniques were a part of my every day activities. One of these fundamentals, the trustworthiness and honesty of the employees, became a stumbling block for me one night in the early hours of the morning. Before I can talk about that, I need to give you some background information, including some aspects of human performance/operator fundamentals that need to be reviewed and that could be applied to all nuclear plants.

The multi-unit site I was working at requires a few manual inputs into the plant computer(s) for maintaining the secondary calorimetric up to date. One of these inputs is to account for the Steam Generator Blowdown flowrate from each steam generator. Every time you change the flowpath, and thereby the flowrate, you have to update the computer with the Engineering supplied flowrate constant. This maintains the secondary calorimetric indicated power equal with actual power level. Optimum plant power levels can then be maintained without exceeding limits.

So, what happened that night shift back in November 2006? Following maintenance, our crew was tasked with restoring piping associated with the Steam Generator Blowdown heat exchanger. This would require realigning the blowdown flowpath. Following the required alignment, I made an error in pulling the Steam Generator blowdown constant number off of the operator aid (multiple column/multiple rowed 3” x 4” card) taped to the side of the computer screen and inputting this wrong number into the computers. I also logged this same incorrect number into the constant change log book. The person performing the independent verification (IV) of the action failed to identify my mistake.

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In a recent press release, the CSB announced that they are requesting $10,600,000 for FY 2009. That’s a $1,637,000 increase (17.7%).

The press release says that the increase is to be used to sponsor more investigations (done by more people) and more safety videos.

This request comes as the CSB this year completed it’s most expensive investigation - the BP Texas City Refinery Explosion. That investigation took almost 3 years and cost over $2.6 million dollars to complete.

Seeing such big numbers may make you think …

How much have we budgeted for personnel, consulting help,
training, and software for investigations?

You might not work with government budgets, but you may want to think about budgeting for investigation needs.

For TapRooT® Users, here are some items to remember to budget for:

1. Training (see 2-Day, 3-Day, and 5-Day Public Course or call 865-539-2139 for an on-site TapRooT® Root Cause Analysis Course quote)

2. Summit attendance (and don’t forget the pre-Summit courses) and travel

3. Investigation assistance (help with difficult investigations)

4. Software (license, maintenance fee, individual user license)

5. People (don’t plan to perform investigations in your spare time)

If you aren’t doing 2009 budgets yet, put these ideas away until later in the year. Then be prepared to ask for what you need to make your reactive improvement program (incident and accident investigations based on root cause analysis) work.

Six months of NTSB investigation and the politics of failure are starting to heat up.

A recent article claimed that a “design flaw” was the root cause of the I-35W Bridge collapse. But a more recent article suggests that “premature jumping to conclusions” may be politically motivated and that the root causes are still under investigation.

For more info see:

http://minnesota.publicradio.org/display/web/2008/01/31/ntsbsixmo_stachura/

Politics, politics, politics …. certainly politicians have nothing to do with the failure of public roads.

Investigations - either at companies or involving the government - can get tricky when the focus is on who to blame.

India, Pakistan, Egypt, Qatar, Saudi Arabia, the United Arab Emirates, Kuwait and Bahrain suffered internet problems when a cable was cut by a ships anchor. The ship was anchored off the coast of Egypt.

Instead of discussing the root cause of the ship cutting the anchor, lets think about the Safeguards that were in place to protect the cable.

So what keeps a ship from dropping an anchor and cutting a cable? Luck?

Any better ideas?

Use the comments field to provide your ideas.

The accident occurred at Humax Peat Works near Nutberry in England. The UK HSE is investigating the cause.

For more information, see bthe BBC story:

http://news.bbc.co.uk/2/hi/uk_news/scotland/south_of_scotland/7219501.stm

A steelwork was killed in an accident at the Severstal’s plant in Cherepovets, Russia.

For the complete story, see:

http://www.reuters.com/article/rbssIndustryMaterialsUtilitiesNews/idUSL3170342620080131

Interesting “incident” that probably needs some root cause analysis.

It seems an Air Canada flight was diverted to Shannon when one of the pilots “went nuts” and had to be restrained. The pilot was taken to a hospital in Ireland for treatment.

An Air Canada spokeswoman said:

“At no time was safety compromised.”

Neat. I guess pilots aren’t really that important to modern day air transportation!

For more info see:

http://www.nydailynews.com/news/us_world/2008/01/30/2008-01-30_copilot_dragged_screaming_off_flight-1.html

The judge didn’t immediately accept the BP guilty plea. However, she said that she can only consider a plea agreement presented to her:

“I must not evaluate a hypothetical plea that has not been presented.”

Rosenthal delayed a ruling to allow plaintiffs’ attorneys and prosecutors to submit filings on complicated legal issues that dominated several hours of arguments after the victims had their say. The judge didn’t set a date for another hearing.

She said the company can withdraw its guilty plea if she rejects the agreement

For more, see:

http://www.chron.com/disp/story.mpl/business/5513462.html

Assist in the development and implementation of the internal H&S compliance and management system.

Implement and lead self-assessments and audit programs and prepare briefings for management

Requirements

A Bachelor’s Degree in Science (or equivalent)

Additionally, a strong background in operations and knowledge of Health and Safety regulations are essential.

You must be willing to travel up to 50% of the time.

Enterprise Products offers a competitive wage and benefits package.

Pre-employment screens required.

For consideration, please e-mail your resume and salary history to:

rrleclair@teppco.com

(Richard LeClair) with the job title (Safety/PSM Assessment Specialist) in the subject heading.. No phone calls. EOE.

Company Description

Established in 1968, privately held EPCO, Inc. and its affiliates own significant equity interests in five publicly traded partnerships with a combined enterprise value of approximately $48 billion. The EPCO family of partnerships comprises one of North America’s largest midstream energy networks, providing a variety of services, including transportation, gathering, storage, processing, fractionation, and terminaling, to producers and consumers of natural gas, natural gas liquids, crude oil, refined products, liquefied petroleum gases, and petrochemicals.

Recipient: Mark Paradies mark@taproot.com

For complete job posting, see:

http://www.theengineer.co.uk/Jobs/97884/Quality+Engineer+-+Defence++Aerospace.htm

FDA News Reports: Stryker Recalls Hip Implants After WarningFor more information see:http://fdanews.com/newsletter/article?issueId=11268&articleId=103627

For more info, see:

http://www.theengineer.co.uk/Jobs/98014/Quality+Manager+-+Precision+Engineering.htm

Few details on an accident at BAE Systems in San Diego. For preliminary info, see:

http://www.signonsandiego.com/news/metro/20080202-1302-bn02dock.html

THIS POSTING HAS EXPIRED.

Southern California Edison
Internal Employee Investigator  (Job Ref# JP31116-TF)

Location: Rosemead, CA

Job Requirements:
Candidates for the Internal Employee Investigator position will be experienced in planning and conducting investigations of problem situations, incidents, allegations of violations of policy, regulations and/or law. A Bachelor’s Degree in Human Resources, Psychology, Business, Engineering, Public Administration, Criminal Justice, Law Enforcement or Police Science; or an equivalent combination of education, training, and experience is also required. Candidates must have a minimum of ten years experience in areas which include: planning and conducting investigations of problem situations or incidents (e.g., performing HR investigations, conducting root cause analyses, conducting internal employee investigations, conducting investigative audits, or investigating violations); obtaining factual information through interviews and reviews of documentary material; analyzing developed information to determine issue, violation, cause, and corrective action; and preparing oral and written investigative reports. Expert knowledge of general investigative techniques and methodologies is required. Demonstrated proficiency in developing information through computer databases. Demonstrated experience at managing multiple cases or projects to timely resolution. Demonstrated experience at working collaboratively and effectively in a team environment. Must be able to maintain the confidentiality of information and identities.

Typical Responsibilities:
The Internal Employee Investigator will report to the Manager of Investigations and Helpline within the Ethics and Compliance Office, carrying out the following responsibilities: leading or individually conducting highly sensitive, critical, confidential, and time sensitive investigations of alleged or potential violations of the Ethics and Compliance Code; providing accurate and timely oral and written reports of investigative activity to senior management and executive leadership; providing subject matter expertise and consulting in investigative process and matters, as requested; reviewing proposed case closures and corrective actions submitted as a result of Ethics and Compliance Office investigations, and making appropriate closure recommendations; analyzing information developed from single and multiple investigations to identify trends, patterns, or common causes, and formulating effective corrective action recommendations; participating in teams or projects designed to promote the goals and objectives of the Ethics and Compliance Program.

If you are interested in this position, please submit your resume in confidence by visiting http://www.edisonjobs.com.

Edison International is an Equal Opportunity Employer.

According to the StarTribune, a UPS delivery truck driver was killed when he ran into a moving freight train.

Imagine that you were assigned to investigate the accident. What problems do you face?

One issue you would need to look into is how the driver could miss seeing a freight train?

A more subtle issue is: How many Safeguards were there to keep traffic from hitting the train? Are they sufficiently strong enough?

After the accident it will be easy to ascertain facts like:

• Was there a guard (gate) at the crossing. Did the gate work?
• Were there flashing lights and a bell signal at the crossing? Did they work?

Some things will be harder to find out:

• Was the windshield clean?
• Was the driver on a cell phone or distracted by some other activity?

Some things are impossible to find out:

• What was the driver thinking?

Frequently, traffic accidents have very few Safeguards to prevent a crash. Many times, the goodness and alertness of the driver is the only Safeguard.

Also, investigating a fatality is difficult because you can’t interview the person who died.

One way to make these types of investigation more productive is to require data collection devices (let’s call them black boxes) to help an investigator “see” what happened. Imagine if the UPS truck had been equipped with three simple “web cams” that save visual data. One facing forward, one facing the driver, and recording the traffic behind the truck. How much more would the investigator know?

Have you thought about where you need video and audio recordings to help with your next major accident investigation?

Finally, the other issue to consider is the post-accident factors that could make an accident survivable. This brings into question the crash-worthiness of the vehicle, the use of seat belts, the deployment of airbags, etc.

Also, the accident response (emergency response) may play a factor.

Any deficiencies will need o be corrected. But many corrective actions in this type of accident may beyond the investigators ability to change.

For example, if the investigator was a UPS representative, he might decide that the railroad crossing needs a better warning system. However, he can’t make the railroad implement this corrective action. Even if he decided that the UPS truck should be built stronger and have airbags, implementing this corrective action might be difficult.

Why? Certainly changing the whole UPS fleet would be expensive. And making a truck more crash-worthy might ad weight. This added weight would cause the truck to burn more fuel. This might constribute to global warming. Thus a corrective action might have unintended, negative consequences. (Just as requiring higher gas mileage in cars to avoid global warming might lead to lighter, less crash-worthy cars that cause the death toll on the highway to increase.)

One last note. Many see a vehicle incident as a simple investigation. You simply find out who was a fault (usually one of the drivers) and you issue the appropriate ticket. TapRooT® Users know that they need to look at much more than who is at fault. They need to look at root causes and the adequacy of Safeguards if they are going to develop effective corrective actions.

Exelon, a licensed TapRooT® User, is looking for an Instrumentation & Controls Planner with Root Cause Analysis Skills. For more info, see:

http://www.nukeworker.com/job/view.php?job_id=5887

Topics:

Pursuing Process Excellence – What’s Holding You Back?

Process Excellence from the Inside Out – Who Needs Top-Down Support?

For more info see:

http://www.asqstlouis.org/membership_meeting/

For more about Kevin’s work see:

http://www.greatsystems.com/

The Judge deciding on the BP Texas City explosion criminal settlement could hear from survivors asking for a bigger penalty. For more in the Houston Chronicle, see:

http://www.chron.com/disp/story.mpl/business/5500858.html

The building boom has a human cost. Another fatal construction accident in New York. For details see:

http://www.newsday.com/news/local/wire/newyork/ny-bc-ny–constructionaccid0130jan30,0,7640304.story

For more info, see:

http://www.ukjobs.net/job-1475522-joEkS.html

Here’s a differet job that requires root cause analysis skills:

http://www.hotgigs.com/logged_in/search/index.cfm?profileid=Ji5RUi5YXkYlCg%3D%3D&userid=JS8hUihYLlAgCg%3D%3D&id=Ji5RUi5YXkYlCg%3D%3D&page=viewsearchresults&Mode=G&override=true&jobview=yes

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

Washington, DC, January 30, 2008 - On the first anniversary of a fatal propane explosion at a West Virginia convenience store, the U.S. Chemical Safety Board (CSB) today announced that testing has been completed on a key propane valve and outlined other issues that will be examined in the final investigation report.

The accident on January 30, 2007, at the Little General Store in Ghent killed four people and injured six others when propane gas was suddenly released through a liquid withdrawal valve during a changeover between two propane tanks.  A volunteer firefighter and an EMT who responded to reports of the leak were among those killed when the propane cloud ignited, destroying the store.

The CSB has examined and tested the valve and found that on the day of the accident the valve was stuck in an open position.

Investigators are continuing their examination of regulatory and code compliance as well as West Virginia’s gas safety practices.

‘This investigation is about more than figuring out what went wrong with the valve, it is about getting to the root cause of this accident and preventing a similar incident from occurring,’ said CSB Lead Investigator Jeffrey Wanko, P.E., C.S.P.

On the day of the accident, a technician working for Appalachian Heating (a company that had a business arrangement with Thompson Gas) was preparing to switch propane service to Thompson Gas from a previous propane vendor, Ferrellgas. As part of the process, the technician was to transfer propane from the Ferrellgas tank to the newly installed one.

The Ferrellgas tank was located against the store’s outside rear wall. The Thompson Gas tank was located about ten feet away.  While preparing for the transfer, propane began flowing out of the liquid withdrawal valve on the Ferrellgas tank located next to the store.

Lead Investigator Jeffrey Wanko said, ‘The placement of the tank facilitated gas entering the building and the ignition of the flammable gas and contributed to the high number of injuries and fatalities.’ The tank did not comply with National Fire Protection Association or Occupation Safety and Health Administration siting specifications which require that a propane tank be placed 10 feet from the building.

Investigators believe personnel involved in the installation of a new propane tank at the store removed a metal screw cap on the liquid withdrawal valve, in preparation for removing propane from the old tank.  The malfunctioning withdrawal valve leaked, resulting in an uncontrollable release.  The technician was unable to stop the flow and placed a 9-1-1 emergency call at 10:40 a.m.

CSB investigators found that in common with many states, West Virginia does not require technicians who install propane tanks to receive any formal training.  The CSB is also examining the practices of 9-1-1 emergency call centers to provide basic emergency instructions for flammable gas incidents such as proper evacuation procedures. In this instance, Little General employees stayed in the building during the gas release.

The CSB’s final report and safety recommendations are expected to be complete in mid-2008.
 
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) 261-7613, or Public Affairs Specialists Hillary Cohen at (202) 261-3601, or Jennifer Jones at (202) 261-3603.

Snow in Gaza -

Accidents sure to follow!

I saw an article about a bus accident near ARCO, Idaho. It reminded me of my time (six months as a student) at S1W (west of Idaho Falls) at the INL site.

It still looks cold in the winter. (I bet the bus drivers are looking forward to global warming!)

I remember getting a foot a snow several days in a row and never having a snow cancellation. The average temperature was BELOW zero in January.

I also remember great skiing. (And difficult driving getting there on black ice.)

I climbed the Great Southern Butte in the early spring. It was still snow capped and we used show shoes to climb up and then slid down.

I really enjoyed my time in Idaho … But I’m glad I don’t face that weather every day.

An 86-year-old woman (under anesthesia and not conscious) was dropped from a surgery table when a safety belt was released in preparation for transferring her to a mobile hospital bed. She died as a result of the head injury.

The family is suing. The article about the death said:

“The investigative report said the hospital did its own root cause analysis and determined that the doctors and nurses in the operating room were preoccupied with their own tasks and that the ‘removal of the . . . safety belt from the patient was not verbally communicated.’”

“The hospital has adopted a protocol requiring all nurses and doctors put their hands on the patient before removing the safety belt and making sure that there are people on both sides of the table.”

I know this isn’t a complete Sentinel Event Report, but what do you think of “communication” and a policy of “putting their hands on the patient and having people on both sides of the bed before removing the safety belt” as the Safeguards to prevent future accidents? Are these Safeguards strong enough? Will they be effective?

Leave a comment and let me know what you think…

ADDITION:

Here’s what the table looks like (I think):

Here’s another example:

Or another:

Read the Associated Press story at:

http://ap.google.com/article/ALeqM5jCUZUyqz41WcLXfHXqfWu3cIWLFgD8UF75KO0

It was December 7th.

Samsung, an industrial giant, was responsible for a crane on a barge that was being towed by two tug boats.

The weather was bad.

The seas were rough.

The barge broke loose from the tugs.

Now for the bad news … there was an oil supertanker anchored nearby.

With the whole ocean available for the barge to float in, what happens? It hits the supertanker that is at anchor, makes three holes, and spills 10,900 tons of oil.

But what can we all learn from this accident? Read about the protests and even suicides in the wake of the oil spill:

http://afp.google.com/article/ALeqM5gTFYqvDI0TxGOYZK66K9pBC7FAkQ

Also: http://www.energycurrent.com/?id=4&storyid=8266

Click Read More to see video and another story link.

(more…)

A story about how an accident happens:

http://newsinfo.inquirer.net/inquirerheadlines/metro/view/20080125-114613/Oil-tanker-explosion-an-accident

See this article in the Houston Chronicle:

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

Farmer hides castle from building inspectors behind a wall of hay bales. Now I have heard of searching for a needle in a haystack but wow, a castle? But think about it , can you find the “castle” in your root cause analysis when it is right in front of your eyes? Unfortunately, this is the problem we have when using cause and effect diagrams and 5 why’s where you fill in the questions needed to be asked. If you are not familiar with human factors engineering and human behavior in systems, you might as well be looking for a “needle”.

Why are these other root cause tools ineffective you ask? WITHOUT getting technical, our own “rules-of-thumb” prevent us from seeing or recognizing anything that does not match our current understanding of the world we live in. Look at the picture above, do you see a young woman or an elderly woman? The mind prevents us from seeing one image over the other at the same time. A good root cause analysis prevents us from investigating an incident or reoccurring problem using our past understanding of limited subject matter expert experience. When I say limited, the implication is that the operator, safety officer, manager, and quality inspector only understand their part of the company processes; while good at what they do, total system influences on human performance is usually limited. A good root cause analysis should ask questions at the system level creating a new way of looking at the “castle”. This is why TapRooT® is a root cause analysis system and training that helps solve problems both reactively and proactively. Call us at 865.539.2139 if you are tired of looking for the “needle”.

Just finishing up another successful 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Edmonton, I saw this headline, “Fire Eases at Vegas’ Monte Carlo”. First question, does the hotel on fire perform proactive Safeguards Analyses? Second question, does the hotel scheduled for the TapRooT® Summit in June perform proactive Safeguards Analyses? Watching news before I fly to San Diego for another 5-day TapRooT® course, the news reported recent remodeling may be a clue for the fire. Will the Monte Carlo perform a Change Analysis I wonder? If this was your hotel, do the analyses listed above sound familiar? If not, contact us at System Improvements, Inc. at 865.539.2139.

An interesting story from American Samoa points out that hospitals can’t release information on a healthcare root cause analysis unless the patient consents.

See:

http://www.pacificmagazine.net/news/2008/01/25/lbj-medical-center-wont-release-information-on-governor

for the whole story.

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

Exelon, a long-time Licensed TapRooT® User, was honored when their CEO, John Rowe, was named Best Electric Utility CEO by Institutional Investor.

John said: “Exelon has been one of the most consistently profitable companies in the electricity industry, having grown our operating earnings an average of about 12 percent per year over the past seven years. I’m honored to be recognized by the financial community and Institutional Investor for our success. It’s my job and the job of Exelon’s management team to deliver sustainable value to our shareholders, and I believe Exelon is uniquely positioned to continue on a successful path in the years ahead.”

To arrive at its list of Best U.S. CEOs, Institutional Investor surveyed portfolio managers, analysts and other investment professionals. It asked these individuals to name the best U.S. CEOs in the sectors in which they invest. Some 900 people at 425 institutions responded, offering first, second and third place votes in each of the sectors with which they were familiar. These votes were weighted to produce a score for each executive that Institutional Investor used to compile the rankings.

Additional information can be found at www.iimagazine.com and in the January issue of the magazine.

Exelon Corporation is one of the nation’s largest electric utilities with more than $15 billion in annual revenues. The company has one of the industry’s largest portfolios of electricity generation capacity, with a nationwide reach and strong positions in the Midwest and Mid-Atlantic. Exelon distributes electricity to approximately 5.4 million customers in northern Illinois and Pennsylvania and natural gas to approximately 480,000 customers in the Philadelphia area. Exelon is headquartered in Chicago.

Part of Exelon’s success is due to their efforts to improve performance both reactively and proactively by finding the root causes of human performance and equipment problems. As part of the TapRooT® Summit, Exelon will be sharing one of their performance improvement programs - Exelon’s Error Free Performance Tool.

For more information about the TapRooT® Summit, see:

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

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 …

Marine Information Notice (MIN) 315 published December 2007describes MCA research project 555 which is a study into the safety of davit-mounted, side launched ships’ lifeboats and their launching systems. The primary objective of the study was to make proposals for measures to improve the hardware performance of lifeboats and contribute to the prevention of accidents.

For more info see:

http://maritimeaccident.wordpress.com/2008/01/24/lifeboat-hooks-not-fit-for-purpose-worldwide/

For complete details, see:

http://jobboard.asme.org/jobdetail.cfm?job=2789544

ISO certified small manufacturing company is looking for a Director of Quality that has Six Sigma and Root Cause Analysis skills. For more information, see:

http://www.asqstlouis.org/job_postings/2008/01/director-of-quality-st-louis-area.html

To get advanced root cause analysis training, see:

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

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.

Job opening requires knowledge of radar systems. For more information, see:

See the job posting here.

For job posting, see:

http://www.bayt.com/job/job.adp?xid=769096

Sometimes you read stories and you just can’t believe what you are reading.

For example, a New York Times story explained that a government office - the Office for Human Research Protection - shut down a John Hopkins University research project.

The project was using checklist to reduce post-operative infections. Using 5-step checklist had cut the rate of bloodstream infections acquired in the I.C.U by two-thirds. Over 18 months, the program saved 1,500 lives and $200 million dollars.

So why did the government shut it down? The study was breaking the rules. What rules?The NY Times article said that:

“…by introducing a checklist and tracking the results without written, informed consent from each patient and health-care provider, they had violated scientific ethics regulations.”

Here is the logic for the finding reported by the NY Times:

“A checklist is an alteration in medical care no less than an experimental drug is. Studying an experimental drug in people without federal monitoring and explicit written permission from each patient is unethical and illegal. Therefore, it is no less unethical and illegal to do the same with a checklist. Indeed, a checklist may require even more stringent oversight, the administration ruled, because the data gathered in testing it could put not only the patients but also the doctors at risk — by exposing how poorly some of them follow basic infection-prevention procedures.”

By this tortured logic, I’m surprised that any study or improvement efforts are allowed in the medical field. No wonder improvement in the medical industry progresses so slowly.

“Canada ranks 23rd out of 30 countries surveyed in “consumer friendliness” of its health-care system” cites a report by European and Canadian researchers in the Canadian Press. Having more in common with publicly financed and governed European health-systems, the “think tank” researchers wanted to compare Canada with like populations in this first annual “consumer index”. Not including publicly-commercially financed countries such as the United States would provide a better base-line of performance for Canada.

What will the affect of this study be? Canada performed well in survival rates of heart attack, cancer, and other medical procedures, but failed in areas such as treatment waiting times, range of services available, and access to new diagnosis tools and new medicine. First question to ask is whether there were countries that performed well in the latter categories but failed in survival rates? As a medical consumer, what is more important to you, survival rate or “friendliness”? As a medical business, what is important, survival rates or “friendliness indexes” that would bring new customers to your business or longer term survival rates? If business operation policy is changed to perform well in this survey, this will also affect how you perform future sentinel investigations.

As a medical health-system provider, should you chance changing your policy and procedures based on this survey? When business risk assessments and hazard risk assessments diverge this is bad practice. This practice tends to split quality, safety, and operation personnel reducing a one-company mission. How can you prevent this company split? Ensure sentinel investigations and corrective actions are based on accurate human performance and equipment root cause analyses? If you see this bad practice occurring in your medical health service, you may find TapRooT® an effective solution. Contact us from this site to learn what medical health providers have taken on this challenge with TapRooT®.