Root Cause Analysis Blog

The new TapRooT® Book is titled: TapRooT® - Changing the Way the World Solves Problems.

I’ve had several people ask me what’s new in the book and how can they find out more about the contents. Therefore, I’ve decided to post the Table of Contents as a pdf here so that readers can view it…

Just click on it to download the pdf.

By the way, the authors (Mark Paradies & Linda Unger) will be doing a book signing at the TapRooT® Summit Reception in Las Vegas on June 25.

As a TapRooT® and Equifactor® instructor for System Improvements, I get the opportunity to meet quality, engineering, safety, manufacturing, operations and medical company experts from around the world. In two or five days these experts learn the basics of the TapRooT® System for finding the root causes of problems PLUS some attend one day of Equifactor® Equipment Troubleshooting Technique for root cause failure analysis of equipment problems. These are grueling days of lecture and hands on application that does not allow much time to teach people the science behind good root cause analysis. Just as important, I do not get to show people why being an expert in your field of work can actually impede your investigation due to “tunnel vision” of the mind.

Experts who are now using TapRooT®, have learned how to investigate with an open mind based on tons of research in human and workplace system interactions. But with all the knowledge our experts bring to the table why was this a limiting factor before TapRooT® use? After presenting at the ASQ Automotive Conference in Michigan this February, audience members wanted to know more about root cause tool limitation and expert use of rules-of-thumb. So if you want to understand more of our thinking processes in problem solving and why we have a tendency to assume we know why an incident occurred before we really know what occurred, link to the paper below.

“Why ask why when you should be asking what?”

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

To download, click on:

http://www.hss.energy.gov/CSA/CSP/camp/reports/Camp_1stQtrFY08.pdf

Download the report from the UK Rail Accident Investigation Branch:

http://www.raib.gov.uk/cms_resources/080131_R022008_KEB.pdf

The report has four recommendation to reduce risk and improve performance.

For a report on the July 2007 derailment near Mile End Station in the London Underground, see:

http://www.raib.gov.uk/cms_resources/2008-01-31-R032008-MileEnd.pdf

to download a PDF.

There are five recommendations for improvement in the report.

Want to see past issues of the Root Cause Network Newsletter?

Read about:

• New TapRooT® Book (Issue 87 - January)
• Trending: Doing it Wrong? (Issue 87 - January)
• Rule Breakers (Issue 87 - January)
• A Perfect Corporate Safety Conference  (Issue 86 - November)
• Bullet-Proof Root Cause Analysis (Issue 86 - November)
• BP Not Alone? (Issue 86 - November)
• Lean Root Cause Analysis (Issue 84 & 85 - May/September)
• Repeat Failure (Issue 85 - September)
• Instant Root Cause Analysis (Issue 85 - September)
• Spotlight on Refinery Safety (Issue 85 - September)

OR see past issues of the TapRooT® Friends/Experts e-Newsletter and read about:

• What to do when the facts don’t agree. (January 08)
• Making plans for the new year. (December 07)
• Press Access to In-Progress MSHA Investigation (November 07)
• “Safety First” history. (October 07)
• What’s a CAPER? (September 07)
• Tips from Summit Attendees (June-September 07)
• Applying Lean to Root Cause Analysis & Corrective Action Programs

To see a complete archive, go to:

http://www.rootcause.net/

NASA has posted the controversial Aviation Safety data in Excel format. It is available at:

http://www.nasa.gov/home/hqnews/2008/jan/HQ_M0808_NAOMS_Excel_Data.html

For a story about the report see:

http://www.chron.com/disp/story.mpl/nation/5454046.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

Some posts don’t go out of style…

Here’s a link to an old blog post where you can download a PowerPoint with holiday safety tips:

http://www.taproot.com/wordpress/2005/11/22/powerpoint-holiday-safety-tips/

The following is an excerpt from Appendix B in the upcoming TapRooT® - Changing the Way the World Solves Problems - book. The material is copyrighted and is used here with permission of System Improvements.

Comparing TapRooT® to 


Other Root Cause Tools

Price is what you pay. Value is what you get.…

Risk comes from not knowing what you’re doing.

Warren Buffett 

Choosing the tools you will use to improve performance is one of the most important choices that a business can make. The tools you choose and the systems you set-up, along with the people who use them, will determine your company’s performance in the future. By Warren Buffett’s theory, you need to know what you are doing or you will be taking unnecessary risk.

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The Department of Energy’s Nuclear Weapons Labs do important and sometimes dangerous research on many topics including nuclear weapons. A report released yesterday by the General Accounting Office claims that weak safety management and weak oversight has kept safety at the labs from improving.

Read the report at:

http://www.gao.gov/new.items/d0873.pdf

Having experienced a GAO audit, I know the feeling the day after a GAO report is released. The GAO tends to take your external and internal investigations and reports, take the most sensational findings and recommendations, and then use the critiques to make the picture look as bleak as possible. Sometimes the bleak outlook is justified. Seldom does the report mention any positive initiatives and improvements. The reports, requested by congressmen looking for controversy, tend to look at past history (rather than future performance). Managers - even if they are new to the job - must live with the whirlwind of criticism that follows the reports release. Often, the “culture change” programs that follow are similar to nuclear weapons … they destroy everything in their path. Often the massive improvement efforts throw out the baby with the bath water. Since these types of massive improvement programs have been tried since the mid-80s with only limited success, my guess is that the root causes of the problems either aren’t being fixed or … the problems get “unfixed” after a number of years. Certainly these types of problems would be more organizational (which INCLUDES congressional funding issues) rather than just managerial.

Management at Lawrence Livermore, Los Alamos, and Sandia National Labs and their oversight (the National Nuclear Security Administration) are, no doubt, scrambling to respond to the GAO critique and develop appropriate improvement initiatives. After living through such difficult times, my comment is … Good Luck!

Click on the links below to download the investigation reports:

Derailment of Freight Train at Washwood Heath

Incident at Wellesley Roaf on Croydon Tramlink

Last Monday I published an article titled:

Monday Accidents & Lessons Learned: Third Accident in 2 Months - When is an Accident a Repeat Failure?

The Danish Accident Investigation Board has published a report that suggests that this third Dash-8 Q400 accident was NOT a Repeat Failure but rather a failure of the landing gear from a totally separate cause.

To see the Danish Accident Investigation Report go to:

http://www.hcl.dk/graphics/Synkron-Library/hcl/dokumenter/Redegorelser/2007/510-000449%20LN-RDI%20Preliminary%20Report%20UK_03112007.pdf

The investigation shows that this accident could have been caused by an o-ring failure and prior landing gear replacements (although the investigation is not complete).

Lesson Learned: You can’t assume that a failure is a Repeat Failure until the investigation is complete and you are sure that the cause is indeed the same.

One more note: The o-ring failure might be a Repeat Failure. The difference is that this time they moved a component from one system to another that allowed the failed o-ring to enter the landing gear system. (See the report for more info.)

Drawing from Report

Click here to see the UK RAIB’s 2007 report (pdf).

The Rail Accident Investigation Branch (RAIB) has released its report into a fire on a HGV shuttle in the Channel Tunnel on August 21, 2006. The RAIB has made sixteen recommendations as a result of the report.

To download the report, click here.

How safe are the skies? Not as safe as we think according to a secret NASA study. See:

http://www.cnn.com/2007/TRAVEL/10/22/nasa.air.safety.ap/index.html

Earlier this year someone wrote me with the question, “Where does the accident pyramid come from?” I thought that others might be interested so I am posting the answer here.

H.W. Heinrich was the source. In his book, Industrial Accident Prevention, 3rd edition, 1950, he published the following figure:

As I understand it, this came from his experience in the insurance industry in the 1920 and early 1930s. (Not exactly a recent source of research.)

Note that the original pyramid from the 30’s has changed to the one we see today with “unsafe acts” at its base.

Here is an article that takes issue with Heinrich’s the accident pyramid:

http://concreteproducts.com/mag/concrete_reevaluating_incident_pyramid/

Once source actually had the following statement:

Heinrich reclassified 15% of the records originally classified as unsafe conditions to unsafe acts.  By adding that 15% to the 73% that were initially recorded as unsafe acts, he concluded that 88% of all industrial accidents were caused primarily by unsafe acts of persons. During the same period of time the National Safety Council published a study that indicated that 87% of the industrial accidents were caused by unsafe acts and 78% by mechanical hazards. (The National Safety Council study allowed cases to be classified with multiple causes.) One can conclude from the National Safety Council that many industrial accidents of this era involved recognized mechanical hazards.

I like the concept that the pyramid represents - small problems can cause big accidents. I’m not sure that the concept should totally drive a safety program.

What do you think?

How many accidents are being investigated by the UK Marine Accident Investigation Branch? See the list at:

http://www.maib.gov.uk/latest_news/current_investigations.cfm

To see the completed preliminary investigations from 2007, see:

http://www.maib.gov.uk/publications/comlpleted_preliminary_examinations/completed_preliminary_examinations_2007.cfm

And to see the Annual Recommendation Reports, Accident Flyers, and Investigation Reports, see:

http://www.maib.gov.uk/publications/recommendations_reports.cfm

http://www.maib.gov.uk/publications/accident_flyers.cfm

http://www.maib.gov.uk/publications/investigation_reports.cfm

If you are in the marine industry, there’s lots to learn and discuss at safety meeting. If you are not in the marine industry, there are still general lessons learned that might make an interesting safety meeting.

The UK Rail Accident Investigation Branch (RAIB) has released a investigation report into a collision between a train and a road vehicle on the M20 overline bridge at Aylesford on 5 February 2007. The report contains six recommendations. For details see:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report362007.cfm

Marine Safety Alert 4-07
United States Coast Guard Headquarters
Washington, DC

Hammar Manual Remote Release System Pneumatic Pump Units

An investigation into the circumstances surrounding a recent passenger ship grounding revealed difficulties the crew had in manually deploying the vessel’s liferafts from their mounting cradles.  The liferafts were fitted with individual Hammar Manual Remote Release System (MRRS) pneumatic vacuum pump units.  When the pumps are manually operated a vacuum is quickly and easily created that actuates a corresponding Hammar H20 hydrostatic release unit. In this case a large number of those pumps failed to activate the hydrostatic release units and, ultimately, the crew had to manually cut the liferaft canister lashings.  The crew was able to launch all of the vessel’s liferafts successfully in this manner.

The casualty investigation is not complete and additional recommendations are likely to follow.  However, in the interim, the United States Coast Guard strongly recommends that Hammar MRRS pneumatic pump units, as well as all other survival equipment, be maintained in accordance with the manufacturer’s recommended maintenance schedules.

MRRS pump units are clearly marked in black letters on a yellow background on the cylinder housing, “Lubricate piston every second year.”  The pumps that failed had not been lubricated as required. The malfunctioning MRRS pumps were replaced in kind with new units; USCG inspection showed that the new units operated properly.  Owners, operators, port engineers, inspectors and others involved in vessel safety should ensure that all appropriate steps are taken to properly maintain survival equipment.

Questions or comments regarding this safety alert may be addressed to Mr. George Grills of the U.S. Coast Guard Headquarters Lifesaving and Fire Safety Standards Division at 202.372.1385 or george.g.grills@uscg.mil.

This safety alert is provided for informational purposes only and does not relieve any domestic or international safety, operational or material requirement.

Released by: Office of Investigations and Analysis http://marineinvestigations.us

The September e-Newsletter has been posted at www.rootcause.net.

The topics in this month’s e-Newsletter include:

• 5-Why Example & Comments
• Top Tips from Summit Attendees
• Get a Success Story Award for Your Company
• Choose or (Always) Lose by George Burk
• TapRooT® Courses for the rest of 2007
• What is a CAPER?

If you would like to subscribe to get this newsletter by e-mail see:

http://www.taproot.com/contact.php?news=1

The September edition (Newsletter 84) of the Root Cause Network™ Newsletter is posted at:

http://www.rootcause.net/

What are the topics in this edition?

• Refinery Safety in the Spotlight
• Instant Root Cause Analysis
• ‘08 TapRooT® Summit News
• Repeat Failure (funny story)
• Lean Root Cause Analysis Part II
• TapRooT® Courses for the rest of 2007
• TapRooT® Consulting
• 1-Day Equifactor® Courses in 2007 (for previous TapRooT® Course attendees only)

If you would like to subscribe to get this newsletter by e-mail see:

http://www.taproot.com/contact.php?news=1

If you aren’t getting the TapRooT® Friends & Experts e-Newsletters with all sorts of info on TapRooT® and Root Cause Analysis, see:

http://www.rootcause.net/

to download the July and August editions.

To register for them to be delivered by e-mail, see:

http://www.taproot.com/contact.php?news=1

To download the articles (pdf’s) click on these links:

http://www.fra.dot.gov/downloads/safety/fatiguewhitepaper112706.pdf

http://www.fra.dot.gov/downloads/Research/ord0621.pdf

Above is a pdf of an independent report sponsored by the Army Corps of Engineers. Very interesting reading.

Digging in to it made me want to draw a SnapCharT®, define the Causal Factors, and start through the Root Cause Tree®. The problem is that the information is so extensive and the sequence of events is so long that it would takes weeks - or maybe months - to do a good, thorough root cause analysis. Then we would be ready to analyze Generic Causes and start developing corrective actions.

I already have so much to do that I just can’t find the time to dig in, find the root causes, and answers to fix the problems. To tell the truth, I barley had time to read the report (ah - great vacation reading).

Plus, my guess is that the Management System causes (of which there seem to be many) would require the government - local and national - and even Congress to change. Sometime you shouldn’t start a root cause analysis if you aren’t ready (or able) to fix the problems you find because root cause analysis without the ability to implement corrective actions is a waste of time.

When a patient in injured or killed by a sentinel events, the doctor may also suffer. To download a copy of an interesting article, see:

http://www.bmj.com/cgi/reprint/320/7237/726

When I saw this article I thought it was new. Then I looked at the date at the bottom of the page. The article was from 2000! That made me think …

What has actually changed in the past 7 years in the efforts to achieve greater patient safety and quality of care? Have most of our solutions just been “band-aids”? Have we really made significant change in the reporting, root cause analysis, and correction of the causes of medical errors across the industry?

What do you think? Click on the title word “comment” below to leave your ideas…

RAIB reports released

The Rail Accident Investigation Branch (RAIB) has released its report into a runaway permanent way trolley incident at Notting Hill Gate on 24 May 2006. The RAIB has made nine recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report122007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a locomotive runaway near East Didsbury on 27 August 2006. The RAIB has made eight recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report132007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a fatal accident involving a train driver at Deal on 29 July 2006. The RAIB has made nine recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report142007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a derailment at Starr Gate on the Blackpool Tramway on 30 May 2006. The RAIB has made two recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report152007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into two near misses at Crofton Old Station No. 1 level crossing near Wakefield on the 01 and 18 May 2006. The RAIB has made six recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report162007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into a tram collision at Soho Benson Road on Midland Metro on 19 December 2006. The RAIB has made three recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report172007.cfm

The Rail Accident Investigation Branch (RAIB) has released its report into the collision between a tram and a road vehicle at New Swan Lane level crossing on Midland Metro on 08 June 2006. The RAIB has made two recommendations. Full report here:

http://www.raib.gov.uk/publications/investigation_reports/reports_2007/report182007.cfm

RAIB investigation update

The RAIB is carrying out an investigation into a fatal accident at Ruscombe… see:

http://www.raib.gov.uk/publications/current_investigations_register/070429_ruscombe.cfm

The RAIB is carrying out an investigation into a collision at Pickering, North Yorkshire… see:

http://www.raib.gov.uk/publications/current_investigations_register/070505_pickering.cfm

The RAIB is carrying out an investigation into a derailment at King Edward’s Bridge, Newcastle upon Tyne… see:

http://www.raib.gov.uk/publications/current_investigations_register/070510_king_edwards_bridge.cfm

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Below is a note I received from Summit Speaker, Bill Sirois. (Bill Sirois is Senior Vice President and Chief Operating Officer of Circadian Technologies, Inc. (CTI). You may contact him through his website: www.circadian.com.) ~ Barbara

While we all know intuitively that fatigue is frequently a root cause of today’s accidents and injuries, it is still being grossly under-reported as a causative factor. This is because we are not collecting the necessary data to identify fatigue as the real culprit. Plus, it is much easier to blame “behavior” as the cause of human error. For example, the truck driver who recently crashed into the Bay City Bridge in Oakland at 4:30am was cited for speeding, rather than the more likely scenario that he simply nodded-off during the low point on the human biological scale. Moreover, his entire life’s history is being scrutinized to find just cause that he was simply a “bad apple” to begin with. Yet, the fact remains that there is a 15 times greater likelihood of an accident between 3am and 6am than at any other time of day (DOT, 1995). It has to do with our human design specifications (i.e. circadian rhythms), and most of us have known that for a long time. Just how to prove it in an industrial or transportation accident is another matter. That’s where FACTS comes in.

In the meantime, please let me know if you have any questions on the FACTS System, or if you have any incidents that you would like to have analyzed for fatigue as part of the research and development effort.

[Please click the icon below to view Bill’s Summit presentation.]

Here are a few more ideas shared at the TapRooT® User Best Practices session (with Linda Unger, Michele Lindsay and Jade Washmon):

“If an incident appears to be easy to resolve, immediately assign one person to investigate. If the assigned person finds the incident is more complicated, then form a team.”

“Follow through with corrective actions. We developed a system with e-mail notification. Three individuals are assigned to follow-up to make sure corrective action is implemented.”

“Corrective Actions Team: take your corrective actions back to management before the final report is complete.”

“Review process for each investigation. Use a TapRooT® quality checklist - making sure leadership is trained in TapRooT® so when management reviews the checklist, they know what they are looking for.”

“Be efficient with utilization of investigative teams. Establish a goal of the investigation that is thorough, efficient and objective. Cover all bases on data collection: 1) Go see the equipment/facility involved (example, walk to the pothole, check visability); 2) Collect all paper for the incident (example: reports, records); 3) Meet all people involved (conduct interviews); 4) Review recordings (request security videos). Last but not least, recognize your team’s work!”

Jim Whiting discussed different risk analysis methods used to estimate hazards in his Summit talk, “Using Risk Analysis as a Pre-Job Evaluation/Pre-Job Briefing Tool” (as well as how to choose the most effective risk control option!). Click below to download a copy of Jim’s papers:

All safeguards are not created equal.

In Jim Whiting’s Summit talk, he showed attendees how to identify and strengthen safeguards for proactive improvement. For more information about using safeguard analysis, download Jim’s presentation below:

After writing hundreds of reports, Mike Rodriguez shared an experienced based presentation at the Summit, “Writing the Report - Do’s and Don’ts.” Take this opportunity to download a copy of his handout below to keep as a handy report writing reference:

Single User, Multi-User, Corporate Multi-User — choices, choices — how do you weigh your options? Ed Skompski’s presentation at the Summit helped attendees make an informed decision. But if you missed Ed’s presentation at the Summit, “Comparing Individual User, Workgroup, and Enterprise TapRooT® Software - Which is Best for Your Company?” — you can view his papers below:

Six Sigma methodology focus is implementation of a measured-based strategy that focuses on process improvement and variation reduction through the application of Six Sigma improvement project. But any process improvement in healthcare demands knowledge of how its systems affect patient care. Harry Wetz and David Davis presented “Six Sigma/Lean Healthcare” at the Summit. To view their papers, see the icon below:

Six Sigma Quality

Kaizen Event Summary - Medication Administration

System Improvements has been working since the mid-90’s to help healthcare facilities perform better root cause analysis and adopt advanced strategies to stop human error. Continuing that work, David Davis, Tommy Garnett and Ed Skompski presented and facilitated ideas for “Healthcare Best and Worst Practices for Root Cause Analysis” at the TapRooT® Summit. Below is David and Tommy’s handout for the presentation:

If you are at a healthcare facility and need to learn advanced root cause analysis or would like to learn best practices to stop medical errors, see our course info and our upcoming announcements about the 2008 TapRooT® Summit on this blog.

Summit attendees who signed up for the “Stopping Medical Error” track learned best practices in infection control. David Davis and Dr. Will Sawyer presented “Stopping Nosocomial Infections” at the TapRooT® Summit. If you missed this excellent presentation about infection-control, click below to view David’s papers:

Lessons from History . . . Modern Day Techniques . . . Marco Flores presented all in his Summit presentation, “Becoming Creative - Techniques from Great Thinkers.” Find out the techniques used by great thinkers to drive their creativity by viewing Marco’s handout:

In your company, is retraining the employee the frequent answer to Corrective and Preventive Actions (CAPA)? Are CAPAs often viewed as an afterthought to conducting Root Cause Analysis (RCA)?

Summit attendees learned what the FDA expects from the Biological Pharmaceutical (Bio Pharma) industry in the area of CAPAs. In Lisa Smith’s Summit presentation, an example of an adequate CAPA versus a robust CAPA was discussed and the benefits of each was compared.

Attendees learned about:

• FDA requirements

• Criteria for effective CAPAs

• The difference between adequate versus robust CAPAs

• The concept of mistake-proofed CAPAs

• The importance of using cross-functional improvement teams to solve nagging problems systemically

• The importance of assessing the post-implementation effectiveness of CAPAs

Click the link below to download a copy of Lisa’s presentation.

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How many times have you had an equipment failure occur, only to have the operators tell you:

Oh, yeah, it never has worked right.

Many would say this is a nuisance issue, sometimes costing a little extra for repeat repairs, but not worth a full investigation. At the Summit, Ken Reed presented how implementation of this philosophy is a roll of the dice, sometimes resulting in disastrous consequences.

Click below to receive a download of Ken’s handout at this presentation.

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Try to build a nuclear power plant in someone’s back yard, and you’ll witness how communities come together to fight something they perceive as extremely dangerous. And yet, at the submarine base in Groton, CT, there may be as many as 18 nuclear reactors within a quarter mile of each other, in various stages of operation and maintenance. Why is there no public outcry over this “dangerous” situation? Admiral Rickover has put in place a program that has endured over 30 years. In his Summit presentation, “Rickover’s Legacy - Safety & Equipment Reliability,” Ken Reed told us what made Admiral Rickover’s program endure, while the civilian program has, until quite recently, languished.

Click below for a download of Ken’s presentation.

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Equipment troubleshooting is an art. It requires logic, focus, and system expertise to successfully conduct equipment fault analysis and repair. Troubleshooting electrical and electronic devices takes this one step further. Ken Reed’s presentation at the Summit, “7 Step Method for Electronic Troubleshooting,” reviewed troubleshooting strategies that can be employed when faced with electronic equipment failures. Click the link below to download a copy of Ken’s presentation.

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For the complete story see:

http://www.chron.com/disp/story.mpl/business/4774310.html

To read the internal BP report see:

http://partners.ibctv.com/Bonse%20Main%20Report.pdf

The article starts out saying:

“An internal BP investigation, detailed for the first time Thursday, recommended that four executives be fired for management shortcomings in a “culture of risk taking” leading up to the 2005 explosion that killed 15 people at BP’s Texas City refinery.

The two-part report of the “management accountability” probe also chastised John Manzoni, the London-based company’s chief executive of refining and marketing, but didn’t call for his termination.

The plant blast investigation, led by BP group vice president Wilhelm Bonse-Geuking, was finished in February but remained under wraps until Thursday, after a Texas appeals court upheld a state district judge’s order that it be made public. BP fought to prevent public identification of the men recommended for firing.”

For the complete article, see the link above.

Why is it important to get management involved in your investigation program?

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Hazard Identification and Risk Analysis are internationally recognized pro-active safety tools that can take an organization’s safety program to the next level. Job Safety Analysis is one way to translate that hazard and risk information into task specific steps that help the employee recognize and avoid the risks inherent in certain jobs. The challenge has always been to provide an end product that is useful enough that employees not only understand it and use it but also know how to revise it when situations change.

Dan Stevenson’s Summit presentation, “Combining Process Mapping of Procedures with Job Safety Analysis,” outlined one organization’s successful effort to develop immediately available procedures for all critical tasks that provide useable information about the risks of the task and the tools needed to reduce the likelihood of personal injury or damage to equipment. This Procedure Mapping process proactively uses the familiar TapRooT® tools and introduces other simple tools to provide a very, user-friendly process that is easily used by all employees.

Click the link below for a presentation of Dan’s 6-step overview of this process.

~ Barbara

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Ken Scott presented “Analyzing Human Performance Problems” at the TapRooT® Summit. I asked him about his thoughts on solutions to human error (besides training and more training!). Ken replied:

“I used to use some information on analyzing performance problems that was published by Robert F. Mager and Peter Pipe. The text was titled Analyzing Performance Problems Or ‘You Really Oughta Wanna.’ What I did in the presentation was compare Mager’s work with the TapRooT® process.

Mager was concerned that we often apply training solutions to many problems that are not rooted in training, especially motivational problems. He presented a Model on how to analyze a performance discrepancy to determine if it is based in a skill deficiency or motivational problem. I used to use this model in some safety management training I did for the mining industry. If you would want to get a copy of the text, you can find it on Amazon.com.”

Thanks Ken!

To view Ken’s presentation click the link below! ~ Barbara

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Mark Paradies and Kevin McManus taught TapRooT® Summit attendees how to cut waste and gain efficiency in the root cause analysis process at the “Lean Root Cause Analysis” breakout. Ideas for lean root cause analysis discussed at the session include:

Building a team of experts by selecting those who know the subject matter.

Training people to use a documented investigation process.

Making sure to analyze good causal factors.

Preparing the initial SnapCharT® before meeting.

Avoiding excess wordsmithing (group around rule).

Moving meetings off shift - improving meeting scheduling.

Collecting all documents prior to meeting (using technology when possible).

Having a plan for collecting information prior to incident (and preserving evidence).

If you missed this informative session, here is a copy of the presentation:

From the desk of Dan Verlinde we bring you the Summit Presentation entitled “The Path to Version 5″, detailing the method of going from version 3 or 4 to version 5, what you need to take into consideration, and more.

To see the slides, just look inside…

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Click on the PDF below to see the slides for the Summit opening session.