Ed Skompski (VP hear at SI) had this story sent to him. Perhaps it’s even true…
During a private “fly-in” fishing excursion in the Alaskan wilderness, the chartered pilot and fishermen left a cooler and bait in the plane. And a bear smelled it. This is what he did to the plane…
The pilot used his radio and had another pilot bring him 2 new tires, 3 cases of duct tape, and a supply of sheet plastic. He patched the plane together and FLEW IT HOME!
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?
The Associated Press reported that Chief Electrician’s Mate John G. Conyers suffered a severe electrical shock and was later pronounced dead at Sharp Coronado Hospital.
The AP reported that the Chief was conducting “routine work” when he was killed.
Normally, Chiefs are supervising, not performing, work. And there is nothing “routine” about working with electricity aboard a ship. Complacency (routine) with electricity on a ship is a deadly combination.
One of my early shipboard jobs in the Navy was being the Electrical Division Officer aboard USS Arkansas (a nuclear powered cruiser). One of the first “performance improvement” programs I ever attempted was to re-instill respect for electricity and get 100% compliance with our lock-out/tag-out program to isolate and check dead all sources of voltage during electrical maintenance work.
People who work with any hazard (for example, electricity), tend to become complacent over time. I’m not sure if this happened on the USS Ronald Reagan, but it certainly is a problem that every manager/supervisor who supervises people who work with a hazard has to confront head-on.
Also, supervisors can frequently be tempted to do work and even take shortcuts to get a job done. This takes them out of their roll to supervise a job and make sure it is done safely and puts them into a dangerous situation where no one is looking over their shoulder to make sure the job is done safely. Once again, I have no evidence that this happened aboard the USS Ronald Reagan, but I’ll be interested in what the eventual accident report has to say.
What can we learn from this fatality BEFORE the investigation is even completed?
First, TapRooT® Users would be getting a complete picture of WHAT happened before they started analyzing WHY it happened. As you can see from my background, there are several problems that I would automatically look for. But, TapRooT® requires the investigator to look at the evidence first before starting the root cause analysis. They have to have a good, complete, accurate, detailed SnapCharT® before they identify the accident’s Causal Factors and find each Causal Factor’s root causes.
Second, TapRooT® Users have a systematic root cause analysis technique, called the Root Cause Tree®, that helps them be sure to check for the many different potential root causes of a problem (Causal Factor). The tree helps guide them to areas they may not have thought of to investigate before. It helps the investigator get beyond blame to find real, fixable root causes that, when fixed, can prevent future accidents.
Third, once the root causes are identified, TapRooT® has a module called the Corrective Action Helper® that helps the investigator develop effective corrective actions. This helps the investigator and management develop corrective actions that might be “outside the box” as far as their experience with corrective actions is concerned.
If you are a TapRooT® User, you have already learned these lessons (but it is good to have them reinforced).
If you are NOT a TapRooT® User, get to a TapRooT® Course NOW! Investigating smaller accidents, incidents, and near misses, as well as using the TapRooT® techniques proactively, can help you avoid major accidents and keep your employees safe.
For more TapRooT® information, including success stories from TapRooT® users, see:
The Mercury News reported that Cal-Osha fined the Department of Water Resources $140,000 after an accident caused by failing to replace an energy dispersion ring in a valve (the report said that they didn’t have time to replace the ring because of the upcoming season) and failure to inspect/maintain a steel wall for 40 years.
Does your facility have standards for maintenance and repairs?
What happens when a part related to safety isn’t available?
Who makes the decision what to do?
Has becoming “Lean” created spare parts shortages?
What old equipment needs safety inspections to make sure that wear or corrosion hasn’t made it unsafe?
When equipment failures lead to bad press, management gets interested. At least the management of EUROSTAR, the high speed train service beneath the English Channel, became interested enough to have an “independent” review of the failure of 5 trains on December 18-19.
Unfortunately, according to some reports, they had missed chance to learn from previous experience. If they had learned, they might have avoided this PR disaster.
Whenever accident get this much press, you know that lawsuits will follow. That’s a “lesson learned” that shouldn’t be forgotten. If Toyota had found the root causes of these accidents and fixed them two years ago, they wouldn’t be facing these serious lawsuits.
One more thing. How serious are these lawsuits? I saw one blog posting saying that he wouldn’t be surprised if Toyota declared bankruptcy because of the lawsuits. I don’t think that’s possible … how many suits would it take to make Toyota go bankrupt? But the fact that somebody might suggest it makes one think twice about what the final cost of this quality/safety issue will be.
They question Toyota’s management, organization, and cost cutting efforts.
Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.
Why should you have been in this equipment troubleshooting class in New Orleans?
1. You are a Saints fan… that would add two more people
2. People in your company use equipment in day to day activities…. that would be everyone
3. You are a safety leader and need a way into the equipment operator’s world (you can help them and get a better understanding of what they do)
When should you register for the Equifactor® Course?
1. Before the class (this makes sure we have enough course materials for you and you don’t have to pull your hair out to find a last minute hotel room)
2. Let us know during the 2-day class that you want to stay for the third day. (Like the three guys from ATEC below)
Here is the schedule for the upcoming Equipment Troubleshooting Courses:
Malcolm Gresham, TapRooT® Instructor from PSG in Australia, sent the pictures below from a TapRooT® Course for Fluor Rail Services. Fluor Corporation is a licensed TapRooT® User and Fluor Rail Services maintains and constructs track infrastructure that links Rio Tinto’s Iron Ore operations in the Pilbara Region. Malcolm says that it is the largest privately owned Rail Network in the world.
The pictures below show teams working on their final exercise in the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
When using the Equifactor® module of the TapRooT® Software, you have the opportunity to store some very specific data in each Symptom or Possible Cause that can help your equipment experts with their troubleshooting efforts. Each of these Equifactor® items has an associated Equifactor® Reference area that allows you to store your own custom data.
For example, if I want to add a new Equifactor® item for troubleshooting a diesel engine that hesitates, you would start with the System Configuration - Equifactor Maintenance, and adding your own custom Diesel Engine troubleshooting table. You might start with this:
You could then add any extra information about that item by clicking “Edit” and adding your custom information:
You can even add a picture of your problem by clicking on “Image.”
Once you are done, you could then start a new incident and open your Equifactor® tables. You can access the Equifactor® Reference section either by right-clicking on the item, or clicking the Equifactor® Reference button at the bottom:
The new information is now available, including the picture you attached:
This information will make a great tool for your new troubleshooters!
Seems like a very simple evolution: drain the excess liquid out of a rail car tank. What could go wrong with that?
It depends on how you “drain” the car. In this case, maybe your workers decided to do a really good job, and hooked up a vacuum truck to the tank, instead of just draining excess. This video shows the results of this type of mistake.
What safeguards would you put in place to prevent this type of problem?
As part of the Maintenance / Equipment Reliability Track at the TapRooT® Summit in Nashville last week, Heinz Bloch gave some terrific presentations. During one of these talks, he impressed upon all of us the importance of always learning. You can’t just assume you know everything you need to know to be successful; you must keep reading and learning to improve your professional knowledge.
In keeping with the ideals of the Summit, we don’t just throw ideas out there and then let you try to figure it out how to implement. We give you concrete methods to move forward with your improvement ideas. So to help you improve your equipment troubleshooting and reliability knowledge, Heinz was kind enough to send us his suggested reading list. A library of must-reads from the foremost equipment reliability expert. It doesn’t get much better than that!
Here’s a link to the list: http://www.taproot.com/wordpress/wp-content/uploads/2009/10/hpb-essential-reliability-library.pdf
Perhaps an Equifactor® checklist for troubleshooting M4 problems could help collect data?
A quote from the article:
“Battlefield surveys show that nearly 90 percent of soldiers are satisfied with their M4s, according to Brig. Gen. Peter Fuller, head of the Army office that buys soldier gear. Still, the rifle is continually being improved to make it even more reliable and lethal.“
I bet those with jammed weapons in a firefight aren’t among the satisfied.
“How to Become Best in Class in Equipment Reliability by Maximizing Uptime” was a best practice session presented by Heinz Bloch at the 2009 TapRooT® Summit.
“Troubleshooting Plant Process Upsets: The Application of Customizable Equifactor® Troubleshooting Tables to Capture the Knowledge of Your Sages and Wiz Kids” was a best practice session presented by Jason Laws at the 2009 TapRooT® Summit.
I’m getting behind on my Summit reporting because of all the amazing talks and amazing discussions I’m having. I just can’t keep up.
Here are some of the highlights…
Success Stories: I attended a session with two success stories yesterday. Ron Pryor (Alcoa) and Theresa Guay (Irving Oil) presented their stories of how they were using TapRooT® to get significant improvements in environmental, quality, and safety performance. We’ll post the Success Stories at http://www.taproot.com/about.php when we get back from the Summit, so you can look for the details there. But what you can’t get from the written word is the Q&A that occurs at the session. For that, you must attend the Summit.
Personal Development: Next, I went to a great presentation by Jennifer Mounce that was very interactive. She taught us about coaching ourselves to get better and bring our personal performance to the next level. Once again, you had to be there to participate and learn. It really gave me some good ideas to act on to improve my own performance.
(E.D. signing books. Mark, E.D., & Linda just before the 70’s themed party.)
Lessons from Success: Then we had an inspiring General Session talk by E.D. Hill. Wow! E.D. is smart, insightful, and a great speaker about lessons from the success of others and her own career. After her talk she spent and hour and a half with us signing her book and talking to people one-on-one. She even came to our reception where the band Entice entertained Summit participants.
Lessons from an Accident: This morning I heard an amazing talk about an injury, the aftermath, and the investigation that changed the standard of care for electrical injuries in the province of Ontario. Jim Thompson, Brian Tink, and Dr. Joel Fish shared their story which was very impressive. We had to cut off the Q&A and let people continue the discussion at the break.
Equipment Failure Lessons Learned: I’m now in a talk about “Persistent Equipment Failures” by Ken Bloch. He’s talking about equipment failures that cause process safety incidents. One neat detail so far … He quoted a statistic that process plants could expect one fire per 1000 pump repairs.
More later.
Plant to attend the 2010 Summit so that you can learn, improve, and share best practices with some of the best companies in the world.
When will it be?
October 20-22, 2010, in San Antonio.
Planning has already started and I’ll let you know more when things are confirmed.
The Bonhomme Richard was stranded pier-side while 3 of it’s 5 service turbine generators were repaired by Norfolk Naval Shipyard workers and ship’s force personnel. For details, see an article in Navy Times:
When troubleshooting an equipment failure, it is often tough to figure out exactly where to start. You’ve probably already eliminated the easy possibilities, and you now find yourself confronted with a list of crossed-off troubleshooting steps. Now what?
Just like in a normal TapRooT® investigation, ALWAYS START WITH A SNAPCHART®. In fact, the more complex the problem, the important it is to make sure you understand the sequence of events that lead to the failure. Luckily, machinery normally breaks for very specific reasons, so understanding this sequence can get you a long way towards resolving the problem.
Build that Spring SnapCharT®. You may find that you don’t have much to start with, so just record what you know. Next, pull out the Equifactor® tables. Run through your symptom, find your possible causes, and hand these off to your mechanics. Have them report what they find. You’ll collect new information about your failure, some of which you may not be sure really applies to your particular problem. Just add your findings to your SnapCharT®, and review what you have. You’ll find that you have lots of new questions regarding your sequence of events that will lead your investigators down the path to a final result.
The SnapCharT® (in conjunction with Equifactor®) is the key. Use this tool to keep your thoughts organized. If your sequence of events is not totally clear, try moving the events around to try out different scenarios until you have a sequence that fits your facts.
Once you have discovered your physical cause, this will probably be one of your Causal Factors. “Repair Tech used an uncertified bearing during refurbishment.” You now have a good place to start asking your normal TapRooT® questions (training level, procedure use, level of supervision, etc).
Chris Vallee and I are currently attending the Reliable Plant 2009 Conference in Columbus, OH. This conference concentrates on machinery lubrication technologies, so you would expect that the lubrication vendors would be the most popular, right? Amazingly enough, we have had nearly 1/4 of all attendees stop by our booth to discuss equipment troubleshooting and root cause analysis! Everyone seems to understand that correctly lubricating your equipment takes more than just the best oil or grease. You also have to ensure that the human element is taken care of. When machinery problems arise, human error usually plays a starring role.
I noticed on page 3 that this type of crank shaft failure occurs several times each year, but it doesn’t normally result in the entire engine detaching from the vehicle. This time, the failure consequences were more severe than normal.
Don’t wait for your repeat failures to result in more catastrophic results. Come to the Summit and attend the 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis course in Nashville, and learn how to prevent repeat failures before they cause you this much pain.
I’m signed up for just about every root cause analysis, quality improvement, equipment reliability, and problem solving publication there is. What I’m usually surprised about is how much BAD ADVICE I get in many of the publications.
Where does the bad advice come from? People who teach 5 Whys as a root cause analysis tool.
If you’ve read this blog for very long, you have read the theoretical and practical discussions that we’ve had that explain why the “5 Why” method does not promote good root cause analysis. If you haven’t been reading for very long, check out these articles…
Now for the most recent BAD advice … An article claimed that all operators should be trained in “5 Whys.”
Why? Because they need “5 Why” skills to effectively troubleshoot and find the root causes of potential equipment problems and improve asset reliability.
Since the articles above already show that “5 Whys” is only effective if you already know the cause of the problem, I think it is highly unlikely that “5 Whys” will help operators find answers that they don’t already know.
Therefore, you are wasting your time teaching them “5 Whys” when they are only going to find answers that they already know OR they will misdiagnose problems by using “5 Whys” to troubleshoot a problem and make the analysis fit the answers that they are familiar with.
Most operators can already tell you familiar causes for problems without going through the “5 Why” process. What they can’t do is find the answers to problems that are outside their experience and knowledge.
So what technique should operators use to find the causes of problems that are beyond their current understanding?
TapRooT® and Equifactor®.
Equifactor® will help them find the reasons why equipment failed through an expert system based on Heinz Bloch’s proven troubleshooting tables.
TapRooT® has embedded experts systems that will help operators find causes and solutions that are outside their experience and current knowledge.
That’s good root cause analysis advice that’s based on two decades of research and development.
If you want to train your staff in problem solving tools that will help them go beyond their current knowledge, give us a call at 865-539-2139 or CLICK HERE to contact us by e-mail.
It’s critical to your business to fix equipment failures on the first try. Ken Reed, Equifactor® Program Manager, shares details about unique opportunities to become best-in-class in equipment reliability at the TapRooT® Summit.
So you’ve been plagued with a recurring equipment problem, and you’ve decided to use Equifactor® to help you narrow down the possible causes of the failure.You’ve worked your way through the list of Possible Causes, and you’re ready to start troubleshooting. How do you transform this list into a valid, usable troubleshooting plan for your repair team?
First, you should already have the started an investigation in the TapRooT® Software. You’ve drawn a Spring SnapCharT® to understand what actually happened, then used the Equifactor® tool in the software to select your Possible Causes. Your list may look something like this:
Once you have this list, you want to get it out to your troubleshooters. How do you do this? First, you can export your list of options into a report directly from the TapRooT® software. Your report might be similar to this:
This gives you a nice list of possible problems that your experienced troubleshooting team can now take to the field and start narrowing down the problems.
You might also want to modify your list, giving your team a structured troubleshooting plan, prioritizing the list to take into account ease of component access, cost of replacement parts, order of dis-assembly, etc. Your team can now ensure they are recording the measurements you need, looking for specific symptoms, and retaining the disposable hardware you might need to make a final evaluation of the physical cause of the failure.
Want to learn more about using Equifactor® to give your troubleshooting team an edge? I’ll be teaching a special Equifactor® 2-Day Pre-Summit course in Nashville, TN on October 5-6. Then, stay for the rest of the TapRooT® Summit, and talk to Heinz Bloch about your specific problem. Heinz will be there all day Thursday, giving talks and discussing best-in-class reliability tips to help your facility achieve success. See the full Summit schedule at www.TapRooT.com/summit. I look forward to seeing you there!
“CERN has been working since late last year to repair the damage caused by a faulty electrical joint. The breakdown occurred nine days after the spectacular start up of the $10 billion machine last Sept. 10 when beams of subatomic particles were sent around the accelerator in opposite directions.”
“He (spokesman James Gillies) said the biggest cause of the “bad accident” last year was ‘probably due to human error caused by rushing the project.’”
“‘But I view it as a temporary black eye. We’ll get it up and running,’ Kaku said.”
“CERN expects repairs and additional safety systems to cost about 40 million Swiss francs ($37 million) over the course of several years, covered by the 20-nation organization’s budget.”
If human error could cost your company millions. maybe it’s time to invest in a little training that will help you stop human error. See the course at this link:
They are “leaning” away from human error. “It was just a freak thing that happened.”
I would be willing to bet human error was in fact involved. Possibly they are implying that the two individuals involved did not err, which I would understand; however, if the equipment failed do you think human error may have been involved?
Normally when equipment fails, it is because HUMANS do no operate or maintain the equipment properly, which means what? Human error.
If you are interested in equipment failure, please sign up for our FREE equipment newsletter. See this blog entry for more details.
If you are interested in learning more about human error, attend our Stopping Human Error course on October 5-6. We would also invite you to stay the following three days for the TapRooT® Summit. You can attend the Behavior Change and Stopping Human Error Track, the Equipment Reliability and Maintenance Track, or you can mix it up and attend sessions from both tracks (or the other 10 tracks!) We have something for everyone, so please join us.
By the way, I can’t let you go without making one more comment about the window washer article; the comment about Massachusetts not enforcing OSHA laws is totally misleading. MA falls under Federal OSHA jurisdiction, while some states have state plans which require adherence to the federal guidelines at least, with some guidelines being stricter (CA/OR/UT/KY for example). Most states fall under the federal plan just like Massachusetts.
When I was in the Navy serving aboard the USS Long Beach (back in the early 80’s), we pioneered using ultrasonic detectors to find troublesome leaks on our heat exchangers. (I think it was a first for the application in Navy condensors.) Perhaps that’s why I found this article in Quality Digest so interesting:
What’s the lesson learned? Often before you can find the root causes of an equipment problem, you need to completely troubleshoot the problem to understand it. Every day the troubleshooting tools get better and better. Make sure you keep up with improvements to keep the efficiency and effectiveness of your troubleshooting efforts up to the industry’s best practices.
Are you interested in maintenance and equipment reliability best practices? Then you should consider attending the Maintenance and Equipment Reliability Best Practices Track at the TapRooT® Summit. See a previous post for more information:
Chris Vallee and I are currently attending the Reliable Plant 2009 Conference in Columbus, OH. This conference concentrates on machinery lubrication technologies, so you would expect that the lubrication vendors would be the most popular, right? Amazingly enough, we have had nearly 1/4 of all attendees stop by our booth to discuss equipment troubleshooting and root cause analysis! Everyone seems to understand that correctly lubricating your equipment takes more than just the best oil or grease. You also have to ensure that the human element is taken care of. When machinery problems arise, human error usually plays a starring role.
I’m signed up for just about every root cause analysis, quality improvement, equipment reliability, and problem solving publication there is. What I’m usually surprised about is how much BAD ADVICE I get in many of the publications.
