Root Cause Analysis Blog

We reported on the Sayano-Shushenskaya Hydro Accident previously at:

http://www.taproot.com/wordpress/2009/08/17/incident-at-russian-hydroelectric-plant-kills-8/

http://www.taproot.com/wordpress/2009/09/01/very-interesting-powerpoint-about-russian-dampower-plant-disaster/

The accident resulted in 74 deaths and losses in the billions of dollars.

A TapRooT® User sent me some new information that I found interesting.

First, here is a pdf with lots of pictures and some analysis:

AccidentRussiaHydroPlant.pdf

Here are a few of the pictures…

Second is a DOE web page with lessons learned. See:

http://oesummary.wordpress.com/2010/02/04/russian-hydroelectric-plant-accident-lessons-to-be-learned/#more-510

This looks like they should have been applying Equifactor® before the accident to handle the equipment reliability problems they were having.

Also, see the lessons learned at the end of the “AccidentRussianHydroPlant.pdf” that is linked to above. Do you think they were based on a through root cause analysis?

Wouldn’t it have been nice to see a real TapRooT® Investigation of this accident…

Imagine a good, complete summer SnapCharT®. And root causes identified for each Causal Factor by using the Root Cause Tree®. And corrective actions developed using the Corrective Action Helper® Module and SMARTER.

How much knowledge is lost because we don’t effectively investigate problems?

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Some accidents are so historic that every accident investigator should know about them. The Challenger is one of those. It happened 24 years ago today. Dana Barclay, one of our TapRooT® Instructors with an Navy flight background, assisted with this massive investigation. Here is a link to the Report of the Presidential Commission:

http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/table-of-contents.html

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The US Nuclear Regulatory Commission has issued a draft Safety Culture Policy Statement for comment.

The draft requires all nuclear material licensees (companies that operate reactors and that use or manufacture nuclear material) should demonstrate a positive nuclear safety culture. But how?

Here’s an idea…

One of the characteristics of a positive safety culture outlined in the draft policy statement is:

“The organization maintains a continuous learning environment in which opportunities to improve safety and security are sought out and implemented.”

The policy statement then includes examples. One example is:

“Personnel seek out and implement opportunities to improve safety and security performance.”

One great opportunity to demonstrate a site’s commitment to a positive safety culture is to have a team attend the TapRooT® Summit and implement best practices that they learn at the Summit. This demonstrates that personnel are seeking out and implementing “opportunities to improve safety and security performance.” Especially if you bring a couple of security folks with your Summit improvement team.

So, if you are planning how you can demonstrate to the NRC that you have a positive safety culture, don’t forget to explain how your improvement team attending the Summit is an example of efforts to maintain a continuous learning environment.

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For details, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/091214_R332009_North_Rode.pdf

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The PowerPoint below was sent to me several years ago by a TapRooT® User.

I’m sure all of the tips come from accidents and are lessons learned that could be shared with your employees.

If you have a good Holiday Safety PowerPoint with lessons learned that you would like to share, e-mail me at “info” @ “taproot.com”.

Thanks

Mark

SafeHolidayWish.ppt
(click to download a Holiday Tips PowerPoint)

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Here are links to the documents:

Accident at Dalston Junction

Double Fatality at Bayles & Wykies Footpath

Container Door Hits Passenger Trains

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How does TapRooT® Work?

Here’s a paper that outlines an environmental incident and how TapRooT® helped the investigator dig into the problem.

Just click on the paper below to download the pdf…

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Mistake proofing is an excellent way to reduce or eliminate human error.

For information on apply mistake proofing in the healthcare industry, see:

http://www.ahrq.gov/QUAL/mistakeproof/

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The UK Rail Accident Investigation Branch (RAIB) has released its annual report which covers the operational period of 2008. The RAIB published 27 investigation reports and 3 bulletins in 2008. This total includes one report into an investigation opened in 2006; 21 reports into investigations opened in 2007 and 5 reports into investigations opened in 2008. In total, these reports contained 181 recommendations. For the complete report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/090930_AR_AnnualReport2008.pdf

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Back in 1979, I spent a long six months in Idaho at the S1W reactor learning to be a Navy Nuc.

There’s lots I remember about the experience and these pictures and a few of Rickover’s sayings brought back lots of memories.

The pictures came from a history of the Idaho national Laboratory that is available for download at:

http://www.inl.gov/proving-the-principle/

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For a pdf of the report, see:

http://www.raib.gov.uk/cms_resources.cfm?file=/090914_R242009_Leigh_on_Sea.pdf

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See the link to the Word (Docx) document newsletter below.

pandemic newsletter 9-14-09.docx

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Below is a link to a free pdf from the UK HSE that provides a simple mini-risk assessment tool.

Risk Assessment.pdf

Want to go beyond the most basic risk assessment? Maybe you should learn from an expert. Jim Whiting, a risk assessment/risk management expert from Australia will be teaching a 2-Day Risk Analysis and Risk Management Best Practices Course before the TapRooT® Summit. For more information, see:

http://taproot.com/courses.php?d=8

The course will be held in Nashville, TN, on October 5-6 and the Summit is in Nashville on October 7-9.

Hope to see you there!

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Ladder safety is a tough issue. In the UK there have been rumors that the UK H&SE has banned the use of all ladders. The Ladder Book tries to dispell these rumors and help people start learn how to choose the right ladder for the right job.

Here’s a link to downlaod a PDF of this mini-book:

PDFofLadderBook.pdf

It’s a start, but of course there is training that is a follow on.

What do you do to train your employees about ladder use?

How do they know what ladders to use for what jobs?

Let us know by posting a comment here…

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See:

http://www.raib.gov.uk/cms_resources.cfm?file=/090827_R232009_Stevenage.pdf

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See the report at:

http://www.raib.gov.uk/cms_resources.cfm?file=/090812_R212009_Basingstoke.pdf

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Do you want to search for back issues of the Root Cause Network™ Newsletter, the TapRooT® Friends/Experts e-Newsletter, or the Equifactor® Minute?

The go to:

http://www.rootcause.net/

to see the most recent newsletters and use the search function to find topics in the old newsletters.

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Here’s the press release from BC Safety:

The BC Safety Authority (BCSA) has released its State of Safety Report 2008 which provides an overview of reported incidents related to the technologies that it regulates.

The report also summarizes the outcome of inspections carried out by its safety officers, analyses inspection data and identifies safety risks.

In 2008, there were a total of 456 incidents reported to the BCSA. This represents a 5% decline from the 483 reported incidents in 2007. Only 359 were directly related to regulated equipment or operations under the BCSA’s jurisdiction.

There were fewer minor injuries last year at 80 from 151 in 2007. Major injuries were higher at 58 from 10 in the previous year. The rise in major injuries was largely caused by a single incident that sent 27 people to a hospital for carbon monoxide exposure. Two deaths were also reported due to separate gas-related incidents.

The report also summarizes the enforcement activities conducted by the BCSA. In 2008, a total of 625 enforcement actions were carried out, most of which were compliance orders and suspensions of permit privileges.

The BCSA regulates the following seven technologies:

• Amusement devices (including amusement rides, ziplines, waterslides)

• Boilers, pressure vessels and refrigeration systems

• Electrical equipment and systems

• Elevating devices (elevators and escalators)

• Gas appliances and systems

• Passenger ropeways (including tramways, gondolas and ski lifts)

• Railways

The BCSA considers the data it collects every year as fundamental to its operations.

According to Harry Diemer, the BCSA’s President and Chief Executive Officer, “The data  allows us to identify high-risk areas and create strategies to reduce risk and prevent accidents across our province.”

“Year-over-year safety will improve as we continue to develop tools such as risk control plans, incident investigation skills and root cause analysis to reduce risk and prevent accidents.”

Diemer also pointed out that education was “a major initiative and priority” in 2008.

Here’s a link to the report:
http://www.safetyauthority.ca/files/4286_BCSA_SOS_2.pdf

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I got this from our local ASSE section and thought I would pass it along to TapRooT® Users …

See the pdf attachment for details:

Miller Back-biter.pdf

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The report has nine recommendations.

To download the report, go to:

http://www.raib.gov.uk/publications/investigation_reports/reports_2009/report192009.cfm

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Quotes from the report:

“There must be much wider, and better, use of root-cause analysis, which is an investigative method that seeks to identify the underlying causes of an incident, with a view to preventing its repetition.”

“There are serious deficiencies in the undergraduate medical curriculum, Tomorrow’s Doctors, which are detrimental to patient safety, in respect of training in:

• clinical pharmacology and therapeutics;

• diagnostic skills;

• non-technical skills; and

• root-cause analysis.“

“The apparent paucity of effective root-cause analysis in the NHS, along with other potential drawbacks of self-investigation by NHS organisations, raises the question of whether there ought to be something akin to the Air Accident Investigation Branch for healthcare.“

“There are serious deficiencies in the undergraduate medical curriculum, which are detrimental to patient safety, in respect of training in: clinical pharmacology and therapeutics; diagnostic skills; non-technical skills; and root-cause analysis.“

For the complete report, see:

http://www.publications.parliament.uk/pa/cm200809/cmselect/cmhealth/151/151i.pdf

We’ve had several people from the UK NHS come to TapRooT® Training. All had very positive comments. Perhaps it’s time for wider use of advanced root cause analysis in the UK health system?

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See:

http://www.raib.gov.uk/publications/bulletins/bulletins_2009/bulletin_07_2009.cfm

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Download the PDF at:

http://www.raib.gov.uk/cms_resources/090622_R162009_Deptford%20Bridge.pdf

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Readers of this blog would probably be interested in the three newsletters that we publish. The are the:

1. Root Cause Network™ Newsletter
2. TapRooT® Friends and Experts e-Newsletter
3. Equifactor® Equipment Troubleshooting Newsletter

To see past issues, visit:

http://www.rootcause.net/

To sign up for e-mail delivery of the Root Cause Network™ Newsletter and the TapRooT® Friends and Experts e-Newsletter, see:

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

To sign up for the Equifactor® Newsletter, see:

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

And don’t forget to sign up for RSS feed for this blog at the blog homepage:

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WorkCover a branch of Australia’s New South Wales government, has published a useful document titled:

Preventing Slips, Trips, and Falls

Simply click on the link below to download it.

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I had trouble downloading the report from the UK RAIB web site so I’ve posted the pdf here. Click on it below to download the accident report.

090430_R102009_ForeignOre.pdf

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From the bulletin:

An engineer’s train conveying OCA type wagons was travelling from within an engineering possession on a four track railway.  During this journey the door of an open wagon fell open, fouled the adjacent line and was struck by a High Speed Train (HST).

To download the bulletin, see:

http://www.raib.gov.uk/cms_resources/Bulletin%2005-2009.pdf

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The UK RAIB has released three new investigation reports (click to see pdf):

Morden Hall Park

Moor Street

Eurotunnel

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A funny PowerPoint …

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From the press release:

The Rail Accident Investigation Branch (RAIB) has released its report into a ‘near miss’ incident involving the runaway of a road-rail maintenance vehicle at Glen Garry in Perthshire. The RAIB has made seven recommendations.

See:

http://www.raib.gov.uk/cms_resources/090225_R052009_Glen%20Garry.pdf

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