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?
CNN reports that Captain Chesley “Sully” Sullenberger, the pilot who landed a disabled passenger plane on New York’s Hudson River in 2009, piloted his last flight for US Airways on Wednesday.
Did you know that his co-pilot, Jeff Skiles, will be one of the Keynote Speakers at the 2010 TapRooT® Summit in San Antonio, Texas?
Jeff will be the closing speaker so be sure to book your flight to stay until the end of the Summit.
While performing your PROACTIVE TapRooT® Root Cause Analysis, you observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. He lifts 30 pipes an hour 3 times a day from a rack waist high to a pallet placed on timbers floor level. This task used to be performed by two loaders before recent lay offs, so you go to the Root Cause category of Excessive Lifting and see these two questions in the Root Cause Tree Dictionary:
* Was the issue related to excessive lifting or force to move an object?
* Did the task require repetitive motion (lifting, twisting, bending, etc.) that lead to a musculoskeletal problem?
Since this is a Proactive Assessment there are no issues yet, so your are asking what is the worse issue that could occur by the lifting movements above? Now what does excessive mean? What would excessive lifting, twisting and bending be? We could bring in an external Ergonomic Expert… or we can use a simple calculation ourselves first?
NIOSH 1991 Lifting Calculator. Centers for Disease Control and Prevention (CDC), National Institute of Occupational Safety and Health (NIOSH), 208 KB ZIP*.
As you start doing these calculations, you should also see another Root Cause under Human Engineering start becoming very apparent: Arrangement / placement.
A question that comes to mind from the Root Cause Dictionary is:
* Did poor arrangement, placement, or situation of equipment, displays, or controls contribute to an issue?
So with these new found calculators and a better understanding of just a little bit of the Root Cause Tree Dictionary is this task a risk or not:
” You observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. This task used to be performed by two loaders before recent lay offs.”
A TapRooT® user sent me these photos and said that the driver was “lucky.”
I really can’t tell what is holding that truck up there … Maybe that’s why they think the driver is “lucky.” But I can’t help but think if they really were “lucky”, they wouldn’t have had the wreck in the first place! I guess it is all in your perspective…
I saw an interesting article at nuclearmatters.co.uk about a speech given by Judith Hackitt discussing the potential to have process safety accidents with multiple fatalities because of short-term business pressures. I thought it was a good speech that the article was based on, but that there were a couple of inaccurate impressions that needed to be corrected. So I left this comment:
I like Judith’s statement but there two slightly incorrect facts in her comments …
1) Judith said: “… lack of injuries and near misses is no guide whatsoever that all is well in process safety terms…”
BP Texas City DID NOT have a good safety record.
They were killing people almost every year. They may have kidded themselves into believing that they were improving safety (a little under-reporting can go a long ways) but they had an unacceptable rate of fatalities. These fatalities were proof that something was wrong.
Also, they had previous process safety incidents and near-misses on the very process that exploded that indicated problems and that were not corrected.
Thus, at least for BP Texas City, they should have seen this accident coming and prevented it. They had warnings. All they had to do was listen, find the root causes, and act.
2) Judith said: “Short-term business pressures drove BP to cut capital expenditure at its Texas City plant by deferring projects and failing to monitor the subsequent impact of this. This had a dramatic impact on the repair and maintenance programme at the site and was a significant factor in the catastrophic explosion in 2005.”
The cost cutting at the Texas City refinery was not short term.
It started before BP bought the refinery. BP should have known that they would have to INCREASE spending to make up for cuts prior to the Amoco sale to BP. Instead, BP continued to cut spending right up until the accident. That makes it five, six, or perhaps even seven years or more of underfunding safety and maintenance.
The Texas City refinery under Amoco/BP had backlogged safety corrective actions that were a decade past due when the accident occurred. Therefore, this was not just a one or two year budget cut problem. It was historical underfunding of a high risk process. Short-term business pressures may have caused this underfunding in any one year but the impact was long-term and establish a culture of shortcuts and a “make it work” mentality.
Reasonable management should have been able to see that this game of process safety Russian roulette can’t go on forever. Eventually, someone has to “pay the piper.”
The fact that management can get away with underfunding safety and maintenance for several years without an accident is what makes taking shortcuts so tempting. This is especially true when managers are quickly promoted so that they don’t stick around to see the impact of their business decisions on performance at a complex facility (like the Texas City refinery). The wrong lessons (we can cut costs without noticeable impact) are reinforced as the market (and benchmarking surveys) rewards those with the highest production and the lowest costs. Management is not required to understand or face the long-term impact of their decisions.
Therefore, I still believe that many executives have not learned the lessons that:
1) You must work diligently to learn from your experience (they think Texas City was a surprise when it should not have been a surprise).
2) There is a point below which you should not cut the budget on a high-risk enterprise.
You must have strict standards that can’t be compromised and you have to say, “No - We won’t continue to operate without support for these safety initiatives.”
If management (especially senior management and corporate boards of directors) fails to learn these lessons and continues to operate high risk facilities as if they were any standard manufacturing plant, we (society) are doomed to see accidents with causes like those that caused the explosion at Texas City again.
Lest one thinks that this is only a problem for refineries and chemical and oil industry facilities, look no further than the Davis-Besse reactor vessel hole for a near-miss that was only prevented by the regulator saying “No” to a utility request to cut inspection requirements again.
No high hazard industry is immune to the temptation to get buy with less and the failure to listen to the warnings of operating experience.
Best Regards,
Mark Paradies
What do you think?
Has management learned the budget and operating experience lessons from Texas City?
Have they established strict standards and drawn a funding line that can’t be crossed?
Are they interested and actively promoting analysis of operating experience, advanced root cause analysis, and prompt implementation of corrective actions?
Or have things gone back to business as usual?
After all, the five year anniversary of the Texas City refinery explosion is just around the corner.
From the “facts” in the story, on a dark, rainy night, a person crossed against the light and stepped in front of a car that was not speeding and had a green light. The driver’s lawyer says the driver was not texting at the time of the accident.
However, the Gwinnett police disagree and say that the outcome of the “accident” could have been different is the driver had not been texting. They say her use of the cell phone was a contributing factor and have charged Lori Reineke, the driver, with vehicular homicide.
(Police photo of Lori Reineke)
What do you think? Are we going too far in criminalizing accidents?
I thought that I would provide the guidance by breaking up the suggestions by the 7-Step TapRooT® Reactive Investigation Process that is detailed in Chapter 3 of the TapRooT® Book (Copyright 2009, used here by permission).
NOTE: If you don’t understand the terminology or reasons for the management actions below, it could be that you need more TapRooT® Training!
TapRooT® 7-Step Reactive Investigation Process
STEP 1
So let’s start with Step 1: Planning the Investigation - Getting Started.
Since we are just getting started, there is nothing for management to review. However, management does have several responsibilities.
a. Management needs to set criteria for what gets investigated. This should be documented in the site’s incident investigation procedure. Management should then make sure that all incidents are reported and investigated. Occasionally, management will identify an incident that doesn’t meet the criteria, but still, in their opinion, deserves a complete investigation and root cause analysis.
b. Management should make sure that their site is prepared for investigations. This includes having an investigation procedure, trained investigators, and investigation review process, and trained management. See the TapRooT® Book (Chapters 3 and 6 and Appendix A and C) for more information.
c. Management should ensure that evidence is preserved for the team.
d. Management should make sure they they have assigned an adequate investigative team to perform the investigation and that the team has all the resources and support that they need. Depending upon the seriousness of the investigation, the team may include independent facilitators or coaches to help the team and outside experts for technical guidance. Management should assign an independent (not from the organization involved in the incident) Team Leader for all but the most minor investigations. The Team Leader should be thoroughly trained (probably in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course).
e. Management should agree to an initial investigation scope (although the team should have the freedom to enlarge the scope based on the facts discovered during the investigation).
STEPS 2 & 3
Next, come Steps 2 & 3. I include these together because the main aspect that management will be reviewing is the team’s SnapCharT® with the incident’s Causal Factors. Management should make sure that:
a. The team has a detailed, logical SnapCharT® that is based on the evidence (facts) about the incident. Each Event and Condition should have a factual bases and not be an assumption (unless the reason for not verifying the assumption is adequately explained).
b. The evidence cannot support alternative scenarios.
c. All facts (not just those that supported this sequence of events) were considered.
d. Each Event includes the “Who did what” or “What did what” to clearly indicate the action that occurred.
e. ALL Causal factors have been identified (including those that were a “catch” for an error). May want to consider the using Safeguard Analysis to check the completeness of the Causal Factors.
f. The Causal Factors are the big picture causes of the incident and are not root causes. (They meet the definition of a Causal Factor and are at the “most general” end of the “So What?” chain.)
g. All Causal Factors have the associated information about them grouped together under the Causal Factor.
h. Only job positions (not people’s names) are used on the SnapCharT®.
i. Emphasis adjective are not used on the SnapCharT® (just state the facts - quantified when possible).
j. The Causal factors are repeatable and sufficient to cause the Incident.
STEPS 4 & 5
Next come Steps 4 & 5 - finding the incident root and generic causes. For these two steps, management should ensure that:
a. The team took each Causal Factor though the Root Cause Tree®.
b. Each root cause has evidence to support the finding and that the evidence provides a “Yes” answer to one of the questions in the Root Cause Tree® Dictionary.
c. The evidence is on the team’s SnapCharT®.
c. Management System root causes were considered.
d. The team checked for previous similar incidents and previous ineffective corrective actions.
e. Generic causes were considered for each root cause that was discovered.
f. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) was considered in analyzing the root causes’ generic causes.
g. There is evidence to support the finding of generic causes.
STEPS 6 & 7
The final management jobs in Steps 6 & 7 are to ensure that sufficient corrective actions are adopted and implemented to prevent recurrence of this incident and, if applicable, similar incidents. Therefore, management should ensure that:
a. Each root cause/generic cause has a corrective action.
b. The corrective action is SMARTER.
c. The investigation team considered the recommendations in the Corrective Action Helper® (check their recommendations against the Corrective Action Helper®).
d. For a significant incident’s root causes, Type 1-4 corrective actions are used (see below). Preference should be given to removing the hazard if possible, next removing the target, and then guarding the target.
(From the TapRooT® Book. Copyright 2008. Used by Permission.)
e. Any corrective action that includes a “re” should be questioned. (For example: retrain, remind, and re-emphasize.) “Re” corrective actions are just repeating actions that didn’t work in the past. Why do we expect them to work now? Also, note that if the corrective action is counseling an employee to remind them about rules or procedures, this is “re” corrective action and should not be used alone, but must be combined with other behavior change techniques.
f. Reject any corrective action that includes these words - Ensure, Assure, Insure, Make Sure - unless the team can explain how they will make sure that the change occurs (and this additional information should be included in the corrective action to make it specific).
g. Corrective actions that are studies be carefully evaluated to see why the study has to be delayed and can’t be completed before the investigation is concluded. (Examples of studies are: Investigate, Evaluate, Consider, Analyze.)
h. Any corrective actions that require behavior to change have considered what factors are causing current behavior and how these will be removed and what rewards/incentives and punishment will be clearly linked to the desired behavior to make it occur.
i. Training is not used as punishment or to embarrass an employee.
j. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) were considered in developing corrective actions and are documented on the SnapCharT®.
k. The people responsible for implementing the corrective actions and the people impacted by the corrective actions agree that the corrective action will be effective.
l. Corrective action will be sufficient to eliminate significant risk or if additional Safeguards or process redesign need to be considered because the risk is so significant.
m. Corrective actions are assigned to the appropriate individual/organization for implementation.
n. The organization responsible for corrective actions has adequate resources to implement the corrective action by the assigned due date.
o. The corrective actions are tracked, and if significant enough, verified, and validated. Management should periodically be updated on corrective action status, especially overdue corrective actions.
p. Significant corrective actions are periodically checked (audited) to ensure their continued effectiveness.
q. Significant corrective actions that may impact other facilities are shared within a corporation.
r. Names of employees are not used in the report.
s. Emphasis adjective are not used in the report (just state the facts).
t. Pictures are used effectively to help explain what happened in the report and presentation.
u. Rewards are given for good investigations.
v. Evidence and reports are retained to meet any legal requirements.
Not every one of these “management must” items must be performed by a manager for each investigation. Management can set up systems , review teams, or review boards to help ensure the quality of investigations.
- - - -
Now for your comments … What do you think? Additions? Deletions? Modifications?
And how is your site doing to make sure the TapRooT® Process is being used correctly, efficiently, and effectively?
By the way, many of the points above originally were shared as best practices at the TapRooT® Summit. If you would like to keep up with the latest TapRooT® best practices, attend the 2010 TapRooT® Summit in San Antonio on October 27-29.
The Workers’ Compensation Board of British Columbia do a great job of sharing lessons learned after an investigation. Watch the video in this link to learn where Controls NI, Plant/Unit Differences, Arrangement/Placement, and Fatigue Root Causes come into the picture during a fatality investigation. Do you think this was the first time the wrong switch has been selected?
We introduce these root causes in our TapRooT® Root Cause Analysis Courses, however seeing the impact of muscle memory and an almost reflex like movement in this fatality really adds strength to why these Root Causes are part of our analysis process. To help people get a better understanding of a person’s ability to feel, see, hear, smell, and move in his/her environment, I added hands on exercises in our Stopping Human Error course last year, which will be taught again in San Antonio this October at the Pre-Summit. For those students who took the course last year and asked for additional behavior changing techniques, this request was heard and will be added in this year.
So looking at the fatality above and after reviewing the video what could have been done when the two trucks were introduced to the workforce:
1. Inexpensive fix: Turn the toggle switches to match the movement of the container (↑ Up, ↓ Down, ← Out, → In); even with muscle memory from driving one truck or another, the person would get feedback when the switch did not move and the label would not need to be the only indicator.
2. Little more expensive fix: Put more space in between the switches which according to Fitt’s Law will improve speed and accuracy trade off.
Remember to use SMARTER, Corrective Action Helper®, and Root Cause Dictionary to help develop achievable and sustainable corrective actions.
Here’s some pictures taken during an exercise during a recent class we held for Rio Tinto in Brazil (Ken Turnbull and Boris Resnic were the instructors) …
Part 2, as promised, is a discussion on our TapRooT® Users and Friends LinkedIn Group. This begins with a question asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.
“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”
My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.
Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don't put in don't dead head or run a pump dry. I've been doing this too long to expect that.]
That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.
Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.
Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.
ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!
First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!
At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.
The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.
First attack at the problem:
1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM
2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)
3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?
4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.
So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.
After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.
Posted 1 month ago | Delete comment
Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.
For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.
Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?
That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:
- Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
- Was he using the right tool? Did we provide him with the right tool?
- Was the right person performing this job?
- Was this job really required in the first place?
- Do supervisors ever watch their people do this particular job? Why not?
- Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
- Was the worker properly trained for this task?
- since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?
I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.
I also know that sometimes we think that people should already know these things. There are 2 possibilities:
1. The person really didn’t know (to cut away from himself)
- Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
- This is when my discussion above comes into play.
Hope this helps a little.
Posted 1 month ago | Reply Privately | Delete comment
Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.
I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.
My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.
Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.
So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.
The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.
Once again. Thanks guys. I appreciate the feedback.
Posted 1 month ago | Reply Privately | Delete comment
Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.
As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?
Steps of the process:
1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.
Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.
2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).
Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.
3. Shops have floating experts identified for employees who need a little help.
Problem: The new are training the new. The senior employees are too busy to.
So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .
Have senior employees attend training with new employees to help all do right.
Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.
We are just finishing a Spanish 5-Day course in Bogotá. Looks like they are having a great time improving performance. Looks like a great meal, too! Great job by Marco Flores, the instructor in the first picture. Diana Munévar (in the third picture) from T&PS Certified Training partnered with us to set up the course.
So I looked into my bathroom at the hotel, and I think, hey, a little small, but OK…
Then I looked a little closer, and noticed something doesn’t look quite right…
Hmm, THIS could be interesting!
I’ve seen accident investigations (not using TapRooT®, of course!) that point to the worker as needing to be more careful. “Inattention to detail” is the root cause. “Worker did not keep eyes on path.” It’s easy to come up with these poor “root causes.” What we really need to do is find out why the worker was “clumsy.” There’s a good chance that there was a poorly-designed piece of equipment, walkway, or room arrangement that made it very difficult to do a job correctly. I’ll try to avoid hurting myself in this room. I’ll “be more careful.”
While dumping the contents of a hydrovac unit, a swamper was killed when he was caught in the closing hydrovac tank door.
What Went Wrong?:
The truck operator and swamper were offloading the contents of the hydrovac truck at a designated area. The hydrovac truck tank had been elevated and the rear door was opened to allow the crew to clean out the tank.
Other relevant incident information:
Photograph of rear door configuration of a typical hydrovac truck. Note crush point.
The workers had cleaned the tank and had both stepped down from the rear tank access platforms (also known as beavertails).
The operator walked around to the drivers side of the truck to access the hydraulic control levers located directly behind the cab of the truck.
Unknown to the truck operator, the swamper had climbed back up onto the right, rear beavertail and became caught in the swing radius of the rear tank door as it was closing.
Corrective actions and Recommendations:
To prevent future incidents, the employer and the hydrovac truck supplier have worked together to implement a number of corrective actions.
Equipment Modifications (Engineering Controls)
The hydrovac truck supplier has altered the hydrovac truck involved in the incident including:
The bank of four control levers for the vacuum tank operation were changed;
Two control levers have been routed to other locations. The removal of these levers may allow for additional room between the remaining control levers to minimize an inadvertent activation due to their proximity; and
The control lever that operates the rear tank door was moved to the rear of the hydrovac tank, which allows the operator to maintain a clear line of sight of the door during opening and closing operations.
Flow restrictors have been installed on the hydraulic lines to the cylinder for the opening and closing of the rear tank door. This alteration slows down and controls the door’s rate of travel;
Hydraulic controls have been tagged with permanent markings to provide clearer identification of the function of the control; and,
Signs warning of the hazardous pinch point have been installed on both sides of the rear of the vacuum tank.
The supplier intends to make similar alterations to all new vacuum/hydrovac truck assemblies and all vacuum/hydrovac trucks, which are returned for service and recertification.
Revisions to Operating Procedures (Administrative Controls)
The employer has modified its hydrovac truck operating procedures to include:
An enhancement and ordering of the steps that will be followed for closing the tank door and lowering of the tank;
Added a requirement that the hydraulic rear door operator visually identifies any workers for whom the closing tank door may be a hazard, before the operator activates the controls; and
Added a provision for the engagement of the tank safety bar when the tank door is open. This provision would include a requirement that, when the tank is clean, the swamper should remove the bar while remaining in the operator’s line of sight and then instruct the truck operator to close the door.
The employer and hydrovac truck supplier involved in this incident believe that the actions summarized above are relevant to the manufacture, supply and associated procedures of similar equipment used at energy and construction work sites. They are urging other companies to reassess their operations in light of the measures identified above and identify if there is a need for similar preventive actions in their operations.
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/).
What happens when an Aviation Evaluator, OIMS Advisor, SHE Pipeline Coordinator, Drilling Superintendent, Field Safety Coordinator, EHS Consultant, Laboratory Project Coordinator, Laboratory Senior Administrator, General Engineer, Safety Engineer,,, just mention to few, sit in the same room? It must be a TapRooT® course! Heidi Reed and I have enjoyed teaching root cause analysis to this lively group.
“WASHINGTON — Accident investigators uncovered such egregious behavior by train operators in the fatal 2008 accident near Los Angeles that they suggested Thursday that all railroads monitor crews with video surveillance.
In a controversial recommendation intended to draw a line in the sand against the rapid rise in accidents triggered by distractions from cellphones and other technology, the National Transportation Safety Board (NTSB) not only endorsed placing video cameras in train cabs, but said railroads should regularly monitor the videos to ensure that engineers follow safety rules.“
These recommendations by the NTSB will not only help improve the accountability for and the enforcement of SPAC (Standards, Policies, and Administrative Controls), they will also make future investigations much easier.
Have you thought about video/audio monitoring of key personnel and workspaces to provide increased accountability, better enforcement of SPAC, and better root cause analysis?
See the accident report at:
