Root Cause Analysis Blog

How much can a service outage cost? It’s costing Rackspace between $2.5 to $3.5 million because they guarantee reliability and provide credits if their service is out for more than a specified period of time.

With millions on the line, let’s hope they perform an adequate root cause analysis. The information in their preliminary release points to a series of electrical equipment failures. (They should have an Equifactor® Troubleshooting Chart for these.)

Here’s an article about the costs:

http://www.datacenterknowledge.com/archives/2009/07/02/rackspace-expects-credits-of-25-million/

Here’s information about the failure:

http://www.rackspace.com/downloads/pdfs/DFWIncidentReport6-29-2009.pdf

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See:

http://www.raib.gov.uk/publications/investigation_reports/reports_2009/report182009.cfm

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Rackspace, a web hosting company, had a 45 minute outage on June 29th. An Article in Web Host Industry Reviews says that they are going to perform a root cause analysis of the event.

Analyzing the root causes of web outages can be very similar to other outage analyses that people do using TapRooT®.

For example, BellSouth used TapRooT® to review 911 outages, long distance network outages, and local service outages.

Another high reliability computer service provider, Tandem Computers who was later bought by HP, used tapRooT® to analyze network and computer reliability issues/outages.

It really is amazing how even with different technologies, the same proven techniques can be used to find the root causes of human error and equipment failure.

If you would like to learn advanced root cause analysis to analyze service problems, attend a TapRooT® Course. For more information, see:

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

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Here is the story:

http://news.yahoo.com/s/ap/20090701/ap_on_re_af/yemen_plane_crash_7

This will make the investigation much easier and more likely to reach good conclusions; hopefully they find the other one.

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See:

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

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Here is the story:

http://news.yahoo.com/s/ap/ml_yemen_plane_crash

It is pretty amazing that they were able to rescue a small child from the ocean; I’d like to hear more about that.

After the Air France crash and this, I can hear the kneejerkers now; Airbus can’t fly in bad weather!  Hopefully they can find the black box on this one.

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Here is the story:

http://cityroom.blogs.nytimes.com/2009/06/29/3-workers-hurt-in-sewage-hole-collapse-in-queens/?hp

Sad story.  What is troubling is that they had a previous fatality at the plant and appear not to have learned much from that experience as evidenced by the recent violations:

“Records from the most recent OSHA inspection, conducted earlier this year, show that the federal agency identified several serious violations at the plant, including violations concerning floor and wall openings and holes, industrial stairs, respiratory protection, medical services, and oxygen-fuel gas welding and cutting.”

How many fatalities does it take before people get the message?

Don’t get caught in this trap - attend a TapRooT® course and learn how to find the root causes of problems after they occur and proactively identify and address issues BEFORE they occur.  See the course schedule HERE.

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Did a series of computer failures lead to the recent Air France Crash in the Atlantic? here’s an interesting article from the Wall Street Journal:

http://online.wsj.com/article/SB124605948270463623.html

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Here is the story:

http://www.latimes.com/news/nationworld/world/wire/sns-ap-as-china-building-collapse,1,2363085.story

I posted a blog a few weeks ago with a similar story; a construction accident in a developing country where someone is “being held.”  The common theme is that blame is the focus with no mention of actually fixing the problem.  In this story, officials are “embarrassed.”  Can you say SCAPEGOAT?

They should be embarrassed.  They should be embarrassed that they don’t have good systems to prevent such incidents.  Meanwhile people are being hurt and killed. 

I’m not sure I would want to be a construction supervisor or safety manager in this environment; you might end up in jail!

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TapRooT® Instructors, Chris Vallee and Dave Janney, teach a record attendance Equifactor® course in Houston last week. Chris is wearing the loud red shirt. So who attended this class you may ask?

Medical…. Power Generation…. Petro-Chemical equipment reliability leaders and safety leaders sat in the class this day. Wait, did you read safety? Just ask the safety leader sitting next you and ask how many times a piece of equipment DID NOT BREAK during a major incident. Now you as an EH&S person may not be able to answer the equipment questions asked in Equifactor® but if you were given a structured way to ask competent equipment questions to your equipment experts would you use it?

Of course aside from major Incidents why would Equifactor® be useful for the EH&S leader….. after all a 30 cent O-Ring that frequently gets replaced on a shutoff valve located in a confine space doesn’t need to be analyzed does it? See below for upcoming Equifactor® courses close to you.

Location Dates
Chicago, ILLINOIS - Sep 17
Calgary, CANADA - Oct 16
Halifax, CANADA - Nov 5
Dallas, TEXAS  - Nov 6
Aberdeen, SCOTLAND - Nov 11
Salt Lake City, UTAH - Nov 12
Edmonton, CANADA - Nov 25
(more…)

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Download the PDF at:

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

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Here’s an article from Abu Dhabi about a second fatal accident involving a child and a school bus. It’s interesting because the writer discusses the hierarchy of Barriers (we call them Safeguards in the TapRooT® System) and how they can be used when developing corrective actions. You usually don’t see this level of understanding of root cause analysis in a newspaper article or letter to the editor.

To read the article, see:

http://www.khaleejtimes.com/DisplayArticleNew.asp?col=&section=opinion&xfile=data/opinion/2009/June/opinion_June135.xml

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Read the story:

http://news.yahoo.com/s/ap/20090626/ap_on_bi_ge/us_nestle_recall

In my previous life, I have a great deal of experience dealing with regulators.  While I have had limited dealings with the FDA, I think the kind of approach Nestle is taking (if the article is accurate) is not very smart.

My experience is that you must develop partnerships with your regulators so problems can be solved together.  Making life difficult for them will only come back to haunt you later.

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Here is the story:

http://www.cnn.com/2009/TRAVEL/06/26/airbus.problems/index.html

While we are far from reaching conclusions on what brought down Air France 447, there is at least some indication that air speed may have been a factor. 

Air France is replacing the air speed indicators (pitot tubes) on its fleet of A330  aircraft.  What we cannot tell from the article is whether the same exact type of pitot tubes are on the other aircraft mentioned, so let’s no jump to any conclusions.

One thing I would like to mention is that airlines do have processes for the crew to follow in the event of an airspeed discrepancy.  Why the Air France crew was not able to respond is a key question that is still unanswered, although we do know weather like they encountered requires a great deal of extra work on the part of the crew.

There are still more questions than answers.  Until we have those answers, I’ll be more than happy to step onto an Airbus.  I have confidence that the NTSB will do all possible to determine if this is a generic issue.

This situation brings up an interesting question - how do different companies in your industry share information about events?  In the case of the airline industry, the aircraft manufacturers share information with those that operate their aircraft, and entities like the NTSB do as well.  Not every industry has this type of feedback mechanism however.  Food for thought.
      

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Here is the story:

http://www.dallasnews.com/sharedcontent/dws/dn/latestnews/stories/062709dnmetdiver.bef91d9.html

OSHA is investigating.

It is hard to believe it is cost effective to hire someone to retrieve balls.  Then again, I guess you can’t leave them in there forever.  Sad story.

This just goes to show that no profession is immune to injury/death. 

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I’ll post the links here so that people can review the report.

The Executive Summary:

http://www.tva.gov/kingston/rca/Executive%20Summary-for%20VI-062409.pdf

The presentation slides:

http://www.tva.gov/kingston/rca/aecom.pdf

The independent review letter:

http://www.tva.gov/kingston/rca/letter.pdf

The complete report site:

http://www.tva.gov/kingston/rca/index.htm

I reviewed the slide show and the Executive Summary and I couldn’t find anything that I would call “root causes.”

I did see a good failure scenario that would make a good SnapCharT® and then could be used to identify Causal Factors (which are similar to the “Failure Conditions” in the presentation pdf). Their failure conditions were:

• Increased Loads Due to Higher Fill
• Hydraulically Placed Loose Wet Ash
• Fill Geometry & Setbacks
• Inusually Weak Slimes Foundation

But they didn’t analyze these factors to find the root causes behind them and they certainly didn’t look for Generic Causes.

They won’t be reopening this site so this accident won’t be repeated here. But I didn’t come away with lessons that TVA’s Management should be learning to improve their performance.

Am I missing something? Review the materials and see what you think.

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Nine are now confirmed dead after the Washington Metro train collision.

Two stories now speculate about the failure of circuits to detect the train that was approaching the other train stopped at the station. To read more, see:

http://abcnews.go.com/News/story?id=7927243&page=1

http://www.chron.com/disp/story.mpl/ap/top/all/6498184.html

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SAFETY ALERT NO. 212:

WORKERS INJURED USING DAMAGED LIFTING EQUIPMENT

Country: CANADA

Release Date: 22 June 2008

Type of Activity: Lifting, crane, rigging, deck operations

Type of Injury: Struck by

Two workers were injured when a lift sling dislodged from a winch hook that did not have a properly operating safety latch.

A service rig crew was in the process of laying down the working floor when they realized that the floor would not be able to come down all the way because a pressure switch was in the way. The operator began to raise the floor so the pressure switch could be turned. As the floor was raised to approximately 45 degrees, the winch hook came unlatched and the floor fell. To save time and speed up the operation, the floorhand and the derrick hand had stepped underneath the floor to pass a 36″ pipe wrench. This placed both individuals directly in the fall path of the floor. Both workers were contacted by the falling floor.

What Went Wrong?

The rig was equipped with two winch lines, the first of which had a damaged Kuplex hook. At the time of the incident the second winch line, which was not used, was fully operational.

The rig crew identified “overhead loads, swing paths, and pinch points” in a safety meeting.

The rig manager was aware that the safety latch on the winch hook was damaged and could not be properly secured. This was verbally communicated to all crew members and documented the hook in a hazard report.

The winch hook was taken out of service for repair after it had been identified as damaged.

A winch hook repair kit had been ordered and was on location at the time of the incident.

After the hook repair kit had been received, the rig manager had attempted to fix the winch hook but was unable to install the new latch locking mechanism.

Believing it would be “OK” for the task of positioning the work floor, the winch hook was returned to service.

When the rig operator began running the winch controls, the floor hand and derrick hand were standing out of the fall path of the rig floor.

At the time of the incident, both workers had moved below the fall zone of the rig floor before the rig floor was in position.

The winch hook was attached to the centre pad and an engineered sling was attached to the work floor. As the floor was raised, the weight of the floor transferred from the center pad sling to the work floor sling. Without the latch lock mechanism, the D-ring pushed out of the winch hook allowing the rig floor to fall.

Corrective actions and Recommendations:

Important hazard identification and control recommendations include:

Never use damaged equipment: Although all members of the rig crew were aware that the winch hook was damaged, the hook was returned to service and used to raise the rig floor.

Always give careful thought about your proper position for the task: In this case, both the derrick hand and the floor hand moved below the rig floor while it was being hoisted by the winch line and were standing directly below an overhead hazard.

Consider the need for design changes before an incident happens: In this case, the company initiated a review the work floor design after the incident and made changes to eliminate the necessity of having the winch hook on the work floor centre pad making lifting operations much safer.

A final thought: Efficiency is important and something we all take a lot of pride in. Always take an extra moment to consider your actions whenever attempting to save time or effort. Make sure your decision is a safe one.

DISCLAIMER:

This Safety Alert is designed to prevent similar incidents by communicating the information at the earliest possible opportunity. Accordingly, the information may change over time. It may be necessary to obtain updates from the source before relying upon the accuracy of the information contained herein. This material is presented for information purposes only. Managers and supervisors should evaluate this information to determine if it can be applied to their own situations and practices.

Source Contact:

This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).

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Read this story about the finding of a recent audit report about the TVA ash spill in Tennessee:

http://www.chron.com/disp/story.mpl/nation/6483719.html

In this cases, there was a “Causal Factors” after the “Incident” (circle) on the SnapCharT®.

These type of Causal Factors don’t “cause” the incident, they do “cause” the accident to have worse consequences.

If you would like to learn more about advanced root cause analysis and incident investigation techniques, here are three ideas to consider:

1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Pick from course in:

• Niagara Falls, Canada (July 6-10)
• Melbourne, Australia (July 6-10)
• San Antonio, USA (July 13-17)
• Perth, Australia (July 20-24)
• Seattle, USA (July 27-31)
• Newcastle, Australia (Aug 3-7)
• Brisbane, Australia (Aug 3-7)
• Hong Kong, China (August 31 - September 4)
• Edmonton, Canada (September 7-11)

For complete course information, schedule of courses, and registration, see:

http://www.taproot.com/courses.php?d=2

2. Already attended a TapRooT® Course but want to learn the latest improvements in the techniques? Attend the 2-Day TapRooT® Advanced Techniques Course that is being held on October 5-6 in Nashville, Tennessee. For more information and registration, see:

http://www.taproot.com/summit.php?t=pre-summit#taproot_advanced

3. If you want to learn best practices from around-the-world, attend the Investigation and Root Cause Analysis Track at the TapRooT® Summit on October 7-9 in Nashville, Tennessee. In addition to the great Keynote Speakers, you will also attend the following Best Practices sessions:

• Accident Analysis Presentations (Attack on the USS Stark, Crandall Canyon Mine, 230 Environmental Incidents)
• Success Stories from the Field (common cause analysis of multiple aviation accident investigations and proactive use of Safeguard Analysis for manufacturing quality improvement)
• DISCover How To Communicate After an Accident
• The Good, The Bad, and The Ugly: Which Describes Your Investigations and Reports and What Can You Do To Improve?
• TapRooT® User’s Best Practice Forum
• How To Prove That Fatigue Was the Cause of an Incident
• Advanced Ideas for Defining Causal Factors
• Lessons from Tennessee OSHA Fatality Investigations

For more Summit information or to register, see:

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

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For more info, see:

http://www.philly.com/philly/wires/ap/news/state/pennsylvania/20090619_ap_ohiomankilledinwesternpadrillingaccident.html

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People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator. But there can be times when an investigator needs to ask for help. This posting will provide some examples that could help you decide when to ask for help.

LEGAL

Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.

CUSTOMER DISPUTE

It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.

UNION ISSUE

Ever had an investigation that gets contentious with a union? This may be time to ask for help.

An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.

JUST LEARNING

TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.

INDEPENDENT INVESTIGATION/NEW SET OF EYES

Sometimes management may want fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and get beyond group think.

CONTROVERSIAL INVESTIGATION

I’ve seen investigations that might result in someone in upper management loosing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.

COACHING

Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.

OVERWHELMED

Too many accidents to investigate? Augment your staff with outside facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Want more info? Use the “Contact Us” button above or call 865-539-2139.

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Here’s an article that follows up on a previous post here at the Root Cause Analysis Blog.

The WSBTV story reports on the results of an OSHA investigation that does not include a root cause analysis.

Click here to see the OSHA report.

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An Article in the The Pratt Tribune says that cracks on wind farm turbine blades in Flat Ridge, Kansas, are due to a “manufacturing defect” and a “quality control defect in the manufacturing process.”

The problem was discovered during the root cause analysis of cracks at another wind farm. Since the same manufacturing process was used for the blades at the Flat Ridge site, the manufacturer has decided to replace the blades under warranty rather than waiting to see which ones start to crack.

First, if I am a manufacturer, a manufacturing defect is not a root cause. It is a causal factor that needs to be investigated. Since they have found out how the cracks occur (”During the manufacturing process numerous layers of laminate are used to make the fiberglass blades. During that process little folds develop that build up in a very defined location on the blades that will eventually lead to small cracks in the blades and cause pealing.”).

The “little folds developing” needs to be examined. It is probably the causal factor that needs to be examined to find it’s root causes.

Next, should these “little folds” have been caught in the design/manufacturing testing process?

Finally, how long have reports of these “little cracks” been coming in?

Because these cracks seem to occur across the manufacturing process (all the blades seem to have them), the root causes will be Generic Causes that apply to all blades manufactured. But are the problems with the design/manufacturing/testing process also present in other parts of the manufacturing process (not just the “little folds” on these blades)? That is a much bigger generic cause question.

What do you do to find the real fixable causes of manufacturing problems?

Do you look beyond the immediate causes to find root causes and then probe further to see if there are Generic Causes?

If you would like to learn a process that is used by industry leaders around the world, see:

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

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From Yahoo’s space news section, “a 14-year old German boy was hit in the hand by a pea-sized meteorite that scared the bejeezus out of him and left a scar.”

“When it hit me it knocked me flying and then was still going fast enough to bury itself into the road,” the boy said.

Now as a TapRooT® Root Cause Analysis Instructor and incident investigation facilitator, I do not want to ever hear our clients say this incident was just bad luck. It was a one of a kind occurrence that never happened before. In reality it would be pretty hard to substantiate those types of findings.

In this case however it appears to be pretty much bad luck but it has happened a few times before. Now I don’t plan on issuing a “Chicken Little” the sky is falling report but I will look up every now and then.
(more…)

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Washington, DC, June 9, 2009— The U.S. Chemical Safety Board (CSB) today sent an investigation team to the site of an explosion, fire and roof collapse at the ConAgra Foods plant in Garner, North Carolina.

According to media reports, at least 20 people have been transported to area hospitals and at least two were reported as unaccounted for following the explosion which occurred shortly before 11:30 a.m. today. The explosion caused the roof to collapse on one side of the building, knocked down walls, and blew debris about the area.

The CSB team will be headed by Investigations Supervisor Don Holmstrom. Board Member William Wark will accompany the team.

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 Public Affairs Specialist Hillary Cohen (on location) cell 202.446.8094; or Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074.

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Kevin Palardy and I are in Calgary this week teaching a 2 day course.  See the pictures:

As you can see, we have a large group; in fact, we even had a waiting list for the course. 

But wait!  The economy is bad and we can’t afford to send people to training!

What does this group know that others do not?  They know that cutting back on improvement during hard times is the worst thing you can do if you want to survive!

Join us for a course soon.  Click HERE for the schedule.

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Update: Missile was NOT LIVE….. does this now condone the actions taken? No, all weapons are considered live until proven otherwise. The questions below still stand.

Here are some questions following a live catch of a missile while fishing.

1. What kind of bait do you use for missiles … little fishing boats?

2. What do you do if you catch a LIVE MISSILE that is corroded and unstable?…. I know, keep it on your boat for ten days and then turn it in to the authorities.

3. What do you do if a live missile gets loose and runs away? …. I might need a little help on this one.

Wow, I don’t know the charge in the missile, but this could have turned out really bad. The question is what type of investigation would this need to keep it from happening again. After all, no property damage or injury… it might just get an “Apparent Cause” analysis. That works, right?
(more…)

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Can a corrective action cause a bigger problem than the one it solves?

In TaprooT® Courses we teach people to use a technique called SMARTER.

SMARTER stands for:

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

This root cause analysis tip focusses on the Reviewed part of SMARTER.

Here’s the story.

Up in the state of New York, they had a good idea.

People sometimes fell asleep and ran off the road.

If they cut groves in the pavement outside the white line on the road, the “rumble” could wake up the snoozing drive.

So, they started cutting grooves all over.

This included a section of road frequented by cyclists.

One day while riding his bike home at night (low visibility), Richard Wilt, a New York police sergeant, came across a new set of rumble strips.

He was riding outside the white line to avoid the hazard of automobiles when he hit the rumble strips while coasting (not very fast) down a hill.

The groove - hidden in the dark - “grabbed” his tire and he flew over the handlebars … landing face first on the road.

Others have been injured in similar accidents when bikes hit rumble strips.

Which brings me make to a personal experience.

My daughter was riding a bike down a hill and didn’t notice the speed bump intended to cause cars to slow down.

When she hit it, it threw her off her bike.

She had a helmet on and received minor cuts and bruises. But it could have been worse.

So what does this have to do with root cause analysis?

Your corrective actions may have unintended consequences.

Nobody at the New York Department of Transportation thought about the dangers of rumble strips to bicycles.

How can you guard against this in your corrective actions?

Get them to be REVIEWED for unintended consequences by operators, mechanics, and others to help spot unintended consequences.

You might not spot every complication, but you will catch many problems before they are implemented.

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Click here for the story.

$6 Million in damages - ouch!  And there may be an “inquiry!”

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Here is the story:

http://www.southcoasttoday.com/apps/pbcs.dll/article?AID=/20090604/NEWS/90604003/-1/NEWSMAP

We don’t know much, other than the fact that this did not have to happen.  The first of many questions I have is why is someone under a load from a forklift?  What policies and safeguards are in place?

Excerpt:

“The Occupational Safety and Health Administration was notified of the accident and opened an investigation to see if there were any violations.”

At the very least, it appears that the general duty clause could be cited.

Do you have the policies, safeguards, procedures, training, and management system best practices in place to avoid such incidents in your facility?  If you want to learn more, you should attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course.

We have courses in the near future in Gatlinburg, Jakarta, Niagara Falls, Melbourne, and San Antonio to name just a few.  To see the schedule and to register, click here.

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Here is the story:

http://www.dglobe.com/event/article/id/23380/

Interesting; the second major event and repeated attention by OSHA.  While the fines may not be much, shutting down the plant and paying all these medical bills must be quite costly at this point. 

Excerpt:

“The second violation pertained to the employer’s investigation report following the ammonia leak in January 2008. The report said JBS did not adequately address … several factors that may have contributed to the accident.”

So they’ve had all these problems, OSHA told them that their report last year did not dig deep enough, and now they have had another major incident.  Had they taken action the last time this event would not have happened.

I would love to know the final cost of these two major incidents and the fallout from all these inspections.  I would bet it is enormous.  And that does not consider public perception, which is hard to measure but very real and a bad public opinion about an organization can be very damaging to the business.  

Do not fall into this trap.  Send your investigators to advanced root cause analysis training so they can find ALL the REAL root causes and so they can correct them effectively, protect your employees, and save big $$$$$$.

Here is the schedule of TapRooT® courses.     

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This title got my attention, “Driver ‘dozes off’ on India train.” Problem is that I did not expect to read these next lines from the article:

When some of the passengers managed to reach the engine, they apparently found the driver snoring away.

Now I understand the role of damage control and the need to investigate this incident. What I don’t agree with is how the Authority handled the public and media response. Either there was a medical condition, he was asleep, or this was inattentiveness. Regardless of the final investigation report, this should be considered a Near Miss. (more…)

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Surely something a heavy as a rail cargo container can’t just blow off of a train…in 2 separate incidents.

Here’s the RAIB report:
http://www.raib.gov.uk/publications/investigation_reports/reports_2009/report122009.cfm

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Here is the story:

http://news.yahoo.com/s/nm/20090601/ts_nm/us_france_plane

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Two Stories:

http://www.chinadaily.com.cn/china/2009-06/01/content_7957666.htm

http://www.shanghaidaily.com/sp/article/2009/200906/20090601/article_402703.htm

Excerpts:

“Zhao Tiechui, director of the State Administration of Coal Mine Safety, said yesterday that an excessive amount of explosives triggered the accident. Coal mine owners put the emphasis on accelerating construction instead of work safety, he told Xinhua News Agency.”

——————————————

This is an all too common story in the mines of developing countries.  They’ve already started telling people the cause of the accident and they have “detained” management, including the safety manager.  I don’t think they’ve had time to do a proper investigation!  I wonder if these detainees will cooperate or has their fate already been sealed?

I’m not sure I agree with the approach of this particular government agency, we still hear frequent reports of fatalities in China’s mines, so there is at least some evidence that their efforts are not working.  The MSHA here in the US has proven they can work with companies to solve problems and reduce accidents; hopefully China and the other developing countries will someday catch on and develop a process to improve safety.  Just locking people up after an incident is not good enough.

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Want to learn a lesson from some Air Force incidents and an experienced aviation troubleshooter?

Here’s an article by David Chamberlin from Aircraft Maintenance Technology that will help you troubleshoot the causes of FOD more quickly:

http://www.amtonline.com/publication/article.jsp?pubId=1&id=8198

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The Chemical Safety Board has updated their website with a more powerful search function and access to numerous hi-resolution photos of various accident investigations.  The home page is here.
One way to prevent accidents is to learn from your own mistakes.  However, it is even better to learn from the mistakes of others.  The CSB has some outstanding information available for use in your own training and lessons learned programs.   Don’t miss out on this important improvement resource.

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Checking on the news in the town where my daughter lives I saw this article at www.kake.com, “Sno-Cone Mishap Leaves Sedgwick Co. Zoo Visitors Ill.” Turns out that the employees mistakingly used the dark colored degreaser instead of the dark colored blue sno-cone flavoring.

Here are the highlights from the article (see the link in read more to see the video):

Luckily, the bottle mix-up did not end up with any major injuries. Those involved did not ingest enough of the mixture to cause any harm. Still, they are not happy.

“They need to be more careful, especially serving food. Pay attention to what you’re grabbing because this could have turned out tragic,” the victim said.

The zoo says it will now stop serving blue sno-cones completely to make sure this kind of mix up never happens again.
Now do you think that the zoo officials have truly found the causal factors, identified the root causes, and found the failed safeguards? I am surprised they were not fined for having cleaners stored with food products.. that would be a failed safeguard and root cause of arrangement and placement… but everyone seemed to focus on the mistake made by the sno-cone machine attendants.

What about the other sno-cone machines and food service areas, this may be a generic issue. Why was the issue not caught with proactive audits? If you want to reduce the possibility of this type of incident in the food industry come to our TapRooT® Summit in Nashville this October 5-6 (for the Pre-Summit) and October 7-9 (for the Summit). Found out about our proactive risk assessments and industry best practice tracks at this link: http://www.taproot.com/summit.php
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Here is the story:

http://news.id.msn.com/business/article.aspx?cp-documentid=3344849

Interesting; Brazil blames the US pilots and our NTSB finds fault with the Brazilian controllers.  As usual more than one problem led to the tragedy.

Plenty of blame but no mention of how the next accident will be prevented!   

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Here is the information:

http://www.amtonline.com/article/article.jsp?siteSection=1&id=8331

We all learn from reading about the misfortune of other organizations, and this is just one more way we can access good information.

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Here is the story:

http://www.salemnews.com/punews/local_story_147235147.html

This is an interesting article; the focus seems to be getting off the hook and the company hired an independent to dispute the CSB’s findings.  I will never say you should automatically accept a regulator’s findings if you have information to the contrary; however, no cause was found, only a rebuttal was presented.

Whoever happens to be right, this company definatley has a PR problem at this point, and I’m not confident it will not happen again.

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I read a current event today titled, “Mountain Lion Escape At Great Bend Zoo Blamed On Staff Error”. Now for anyone who has ever read our TapRooT® book Changing the Way the World Solves Problems, this should remind you of the Thailand student’s Tiger and safeguards example. For those just purchasing the book it is in Chapter 10 on page 375.

Here are some of the facts as reported:

1. A double-gated entryway was left unsecured.

2. A 150 pound Mountain Lion with unpredictable and aggressive behavior strayed 150 feet from the cage.

3. Authorities shot and killed the Mountain Lion.

With a TapRooT® root cause analysis we would have to define the worst thing that happened as the incident. Would that be the Mountain lion escaping, being shot and killed, or the fact that the park staff left the cage open? I would define it as the Mountain Lion being killed. Next we would list the events before and following the incident and include as many conditions (supporting facts as possible).

It also helps to determine the hazard (uncontrolled energy), the safeguards (failed, successful, and absent), and the targets. Review the article and see if you can determine these items and what other questions you may have. While the park staff did error in leaving the cage open it took more Causal Factors for this Mountain Lion to be killed.
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Here is the story:

http://www.stuff.co.nz/national/2448672/Worker-reinstated-after-million-dollar-accident

Operator error…..fire the guy….case closed.  Or is it?

What is the real cause of the employee making a mistake?  Apparently the authorities think training is one reason, but there may be others.  When we look for someone to blame rather than investigating and solving the REAL problems, the accidents are bound to repeat; it may be 5 years from now, or it may be tomorrow, but it will happen. 

If you want to do good investigations and eliminate the reasons for human performance problems (errors/mistakes), a good root cause analysis should be done using TapRooT®.  Attend a course today - here is the schedule:

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

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Here is the story:

http://www.miningweekly.com/article/sa-gold-platinum-mines-report-more-deaths-over-weekend-2009-05-25

While any fatality is unfortunate and avoidable, these numbers are truly shocking.  I’m not usually one to suggest government intervention, but clearly something needs to be done; the South African government could learn a great deal from the Mine Safety and Health Administration (MSHA) here in the United States.

Of course, the individual companies could/should take action, and that would include better management systems and a good root cause analysis process.  A process like TapRooT®.

If you would like to learn more, see: http://www.taproot.com/about.php

To attend a course, the schedules and registration link can be found here: http://www.taproot.com/courses.php   

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I saw an article on-line that is a textbook case of how to make what is probably a minor environmental release sound like a major environmental accident.

Here’s the article from the Ashbury Park Press (written by Todd Bates):

“Extent of Tritium Leaks Still Unknown “

Let’s start will the title of the article. Yes, it is true that the extent of the leak is “still unknown” but the extent of the contamination is fairly well known. In the fourth to the last sentence in the article, it says:

“Exelon expects to complete a ‘root cause analysis”
of the tritium issue by June 19, accordng to Sheehan.“

So, perhaps the headline should have read:

“Root Cause Analysis of Tritium Leak 1/2 Done“

But that wouldn’t sound near as dire or exciting - no “unknown”.

The article also starts with quotes from antinuclear group spokes-persons and residents (2 miles away) who are scared. No one explains how the groundwater that is fairly localized is going to spread 2 miles to the man’s well.

The article does provide testing results that show (as far as I can tell) that as the Tritium leakage spreads underground, it is being diluted to levels well below the EPA limits for groundwater. Just plot the contamination yourself on the map at:

http://www.state.nj.us/dep/rpp/bne/occst.pdf

Here are the contamination levels (from the article):

Well MW-15K-1A: 5.3 million picocuries per liter of tritium — 265 times higher than the government limit of 20,000. A picocurie is a measure of radioactivity.

Well MW-50: 2.9 million picocuries per liter.

Well MW-51: 4.5 million picocuries per liter.

Well MW-52: Tritium not detected.

Well MW-53: 15,100 picocuries per liter.

Well MW-54: 9,500 picocuries per liter.

So perhaps the headline should have read:

“Tritium Leak Poses No Threat to Plant’s Neighbors“

Finally, at the very end of the article are these three sentences:

Exelon will work with the state and the NRC to “”determine the best course of action to take” said David Benson, Oyster Creek spokesman.

NRC and state Department of Environmental Protection officials are at the plant daily, Benso said.

“Oyster Creek is a good corporate neighbor, and we want to continue working with the state ust to make sure that this is done correctly,” he said.

Hmmm… Sounds like they are making a good faith effort to clean up a release from an accidental radioactive spill that is contained on-site and is no danger to the community.

Perhaps the headline should have read:

“Anti-Nuclear Groups Try to Get Community Worked Up About Minor Incident“

By the way, Exelon is a TapRooT® User, therefore I have confidence they will find and fix the root causes of this spill.

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