Root Cause Analysis Blog

Link to AP Story:

http://www.newsday.com/news/local/wire/newyork/ny-bc-ny–trump-constructio0114jan14,0,2930921.story
Link to casasugar Blog Post:

http://casasugar.com/956128

Sanjay Gandhi (TapRooT® Instructor on the left) sent the picture below from the 5-Day Course we just did for KPO in Kazakhstan.

These folks are ready to find the root causes of problems and improve performance.

Would you like more information about holding a TapRooT® Course at your site? Contact us at this link:

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

The AP reports that two hydrofoils ferrying passengers between the Chinese territories of Hong Kong and Macau collided Friday night in heavy fog, seriously injuring 19 people.

For more info see the CNN web site:

http://www.cnn.com/2008/WORLD/asiapcf/01/11/hk.ferry.ap/index.html

but it didn’t wake the dead.

The UK RAIB has released its report into a collision at Willington, near Burton on Trent.

The RAIB has made four recommendations.

For the complete report see:

http://www.raib.gov.uk/cms_resources/080110_R012008_Willington.pdf

Did you know that the Chief Inspector at the UK RAIB, Carolyn Griffiths, will be a Keynote Speaker at the TapRooT® Summit in Las Vegas (June 25-27, 2008)?

Carolyn will be speaking about her experience forming an independent investigation authority and her experience with the RAIB’s investigations.

For more information about the Summit see:

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

For some interesting pictures and commentary about recent accidents (dropped loads from cranes) at the Bank of America construction project, see:

http://curbed.com/archives/2007/10/17/breaking_curbedwire_construction_accident_at_b_of_a_tower.php
http://curbed.com/archives/2008/01/09/another_b_of_a_accident.php

The Chemical Safety Board has completed their root cause analysis of the explosion at the Synthron facility at Morganton, North Carolina. The report is available at:

http://www.csb.gov/completed_investigations/docs/Synthron%20Final%20Report.pdf

In addition to the report, the CSB has produced a video titled:

Reactive Hazards: Dangers of Uncontrolled Chemical Reactions

It is available by clicking on the safety video link at:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=389#

I think a second sign checker is needed here. Or maybe this is a post holiday clearance? I wonder if they take babies and children on consignment? Stock up everyone!

(QuickTime Movie of Explosion from a Coast Guard Camera.)

(Aerial view of facility after explosion.)

CSB Investigation Press Release:

Statement by CSB Investigator-in-Charge Robert Hall Updating the Public on the Investigation of the T2 Laboratories Explosion and Fire

Jacksonville, FL, January 3, 2008 - Good afternoon.  I am Robert Hall, Investigator-in-Charge for this U.S. Chemical Safety Board (CSB) investigation.  The CSB is an independent federal agency that investigates major chemical accidents at industrial sites.

We are currently conducting an investigation to determine causes of the fatal chemical explosion that occurred on December 19th at T2 Laboratories Inc. here in Jacksonville.  The Board does not issue fines or citations but does produce investigative reports and recommendations that are widely used to prevent future accidents.

The team of CSB investigators from Washington, D.C., worked here through the holiday week and remains in Jacksonville interviewing survivors and surveying damage.

T2 is a small company with about a dozen employees and the single production site in Jacksonville.  The explosion at T2 occurred at about 1:30 p.m. on December 19th and killed four workers.

One worker remains in the hospital, and a number of other people were injured both on and off site.  The blast at T2 was among the most powerful ever examined by the Chemical Safety Board.  In addition to the tragic loss of life among T2 workers, injuries off-site requiring medical attention occurred as far as away as 750 feet from the reactor site.

The explosion occurred during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl.  This additive was first developed in the 1950s and is widely used to boost the octane rating of gasoline.  The company began producing the chemical for commercial sale a few years ago, using a batch reactor.

(more…)

Peace on Earth. Good will toward men.

Track Santa on Google Earth.

Merry Christmas to all and to all a good night!

Linda, Chris, Ken and I are teaching two 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Las Vegas this week. Ken will also be teaching the Equifactor® Equipment Troubleshooting techniques.

Teaching great courses isn’t all that we are doing in Las Vegas. Katherine, our meeting planner, also is here and we are planning the details of the TapRooT® Summit (Las Vegas on June 25-27, 2008).

I thought that I should let readers know what we are doing so that you can start your planning for the Summit. This isn’t planning for the technical sessions (that’s done and I’ll share that next month). This is planning for the location and the fun we are going to have.

First, we are at the Westin Casuarina at 160 East Flamingo in Las Vegas. The hotel is just a block and a half off one of the busiest intersections on the strip. An easy walk and you are at Bally’s, the Bellagio (and their fountains), and Caesars Palace.

The hotel is nice - great soft beds, double-headed showers, and a friendly staff. And the TapRooT® Summit rate ($155/night) is a good value.

The hotel has a small casino (compared to some of the mega-casinos). It will be easy to network with others attending the Summit.

What is there to do in the area at night after the Summit concludes? Tons.

Every time I come to Las Vegas I marvel at how much there is to do. The shows are amazing. Of course, there are the standard Vegas shows. But there are also Broadway shows, famous entertainers, magic, and comedy, including:

Toni Braxton

Cirque de Soleil (”O”, Mystere, Zumanity, KA, The Beatles-LOVE)

Bette Midler

Momma Mia!

Lance Burton

Penn & Teller

The Producers

The Amazing Jonathan

Blue Man Group

Spamalot

Andrew Lloyd Webber’s Phantom

Barry Manilow

Rita Rudner

Carrot Top

And that’s just the start!

Next, there’s shopping. Within walking distance from the hotel are the Forum Shops (designer stuff at designer prices) and the Fashion Mall (everything).

Also, there’s a never ending list of casinos. Bally’s, the Bellagio, Caesars, Harrahs, Rio, MGM Grande, Bill’s, Las Vegas Hilton, The Orleans, Flamingo, Excalibur, Paris, Luxor, Mandalay Bay, Mirage, New York-New York, Planet Hollywood, Hooters, Venetian, Wynns, … it goes on and on. You could spend a week just visiting them all.

And the food is great. Every major casino has one, two, three, or four 4 start restaurants. The Forum Shops has several of my favorites including the Cheesecake Factory.

And we have our own entertainment at the Summit - the Wednesday night reception and exhibit.   

Elvis (Greg Miller) will sign us a couple of songs.

Olympic Gold Medal winner Nikki Stone

An iPod Shuffle prize for best costume (come in 50s/60’s attire to win).

An iPhone drawing for timely attendance (must get timely attendance tickets during the day plus must be at the drawing to win).

And there will be some surprises (I’ll announce these as the Summit gets closer).

One last note. I’m going out to The Revere Golf Club - the Concord course - later today. I’ve heard the course is great, but I wanted to see it for myself. On Friday of the Summit, we’ll have a scramble golf tournament that’s great fun and a great way to meet more people.

I’m looking forward to the Summit. I hope you are starting your planing and looking forward the the valuable information you will learn and the fun you will have.

Hope to see you there.

The Summit web site is:

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

Some posts don’t go out of style…

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

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

A recent article stated that the Canadian Transportation Safety Board was due to do release the crash report for an Airbus A340. The aircraft came in too high and too fast in bad weather and “simply” ran out of runway. Not seeing the full report yet, I have to ask what root cause analysis process was used in this accident investigation?

With the advanced instrumentation and glass cockpits of today, how and why did this accident occur? I can’t prevent bad weather so the corrective action based on the report must be don’t attempt to land in bad weather…If this seems wrong to you then I suggest that you try the TapRooTç root cause analysis process.

I think Training NI is the cause…

The third strike for wrong site operation during brain surgery, could it have been prevented? What changes for those who did not die were made in these patients’ personalities and thought processes? “While the hospital has made improvements in the operating room, they have not extended these changes to the rest of the hospital,” stated the director of health for this facility. How often we as a company struggle to fix the system without involving all that touch it. If you would like to change the system look through the TapRooTç success stories, see how it is possible to operate with the right and left side of the brain using our human factors driven process.

Mark recently spoke at the 33rd ESReDA Conference (The Future of Accident Investigation Conference) at the European Commission’s Joint Research Centre in Ispra, Italy. Mark’s talk was “GETTING BEYOND SWISS CHEESE IN ACCIDENT INVESTIGATIONS - Modeling and Improving Human Performance.”

Here’s a picture of Mark and the conference attendees.

If you would like to learn to find human performance, system, and organizational root causes of accidents and incidents, consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. For more information, click on the Courses link above.

AFP reports on a mining disaster in the Ukraine. 90 have been confirmed dead and 10 are still missing. For the complete story see:
http://afp.google.com/article/ALeqM5jnxMxWdxKy4XLFaGpSw6Z9LKOYZQ

Your realtor describes this feature as “well lighted driveway for extra home security” . . . 

You think … “Root Cause Analysis needed!”  

Dave Thompson and Malcoml Gresham recently taught a successful TapRooT® 2-Day Incident Investigation and Root Cause Analysis Course in Kuala Lumpur. Dave stayed on to teach the thitd day to complete the 3-Day Equifactor® / TapRooT® Equipment Troubleshooting and Root Cause Analysis Course.

Here’s the class photo:

If you are interested in Public TapRooT® Training see the Courses link above.

If you are interested in a course at your site, contact us at 865-539-2139 or use the Contact Us link above.

(System Improvements, Inc. is the company that provides TapRooT® Root Cause Analysis Training and Consulting Services.)

The NTSB has developed two simulations of “very close” near-misses that happened when:

• a plane landing almost hit a plane taxing and

• a plane taking off almost hit a plane taxing.

These are available at CNN’s wen site (I couldn’t find them on the NTSB web site). See:

http://www.cnn.com/2007/US/11/09/runway.safety/index.html

People look on as ship is driven ashore.

Reports say that as many as ten ships sank or ran aground in the Strait of Kerch and in nearby areas of the Black Sea in a fierce storm. Up to 11 sailors are dead or missing. For more information see:
http://www.chron.com/disp/story.mpl/world/5293205.html

Picture of damage to ship

I love reading newspaper accounts of accidents. An Associated Press story had the following two quotes:

“Investigators were focusing on possible communication problems between the ship’s crew, the pilot guiding the vessel and the Vessel Traffic Service, the Coast Guard station that monitors the bay’s shipping traffic.”

“A language barrier between the vessel’s pilot, Capt. John Cota, and the ship’s all-Chinese crew was not likely a factor in the crash, since the ship’s captain and officers are required to speak English, officials said.”

I wonder what official said that a Chinese crew speaking English was not likely a factor because they are REQUIRED to speak English?

CNN reports that 5 rail cars carrying coal were dumped into the Anancostia River when a CSX freight train struck another train that was parked on a bridge.

For the complete story from CNN, see:

http://www.cnn.com/2007/US/11/09/train.derailment/index.html

Human Factors Series 1: Taking Signal Detection Theory (SDT) out of the Laboratory and into the Workplace

Everyday we have to make decisions about uncertain events. Signal Detection Theory is a model of how people make uncertain decisions. To put it simply, can you single out one object (beep, light, defect…) from the surrounding workspace? How important is it not to miss the object you are searching for (correct hit) and how detrimental to you is it if you indicate the object is there when it isn’t (false alarm)? What does senior leadership reward?

An article published in http://www.latimes.com/ stated that 75% of the fake bombs and explosives sent through LAX Airport security screeners during an undercover terrorism drill passed through undetected.

Airport authorities were not surprised. The simulated devices were not “sticks of dynamite” but “more like caps on a pen….a piece of metal with a wire in it. TSA’s remedy is to send poorly performing screeners into remedial training until their screening scores get better or remove the employee. To see Signal Detection Theory used to assist training for security screens see this SDT Simulation.

A former security director at LAX cited in the article stated that authorities could: purchase more advanced screening equipment, fund the proper number of screeners at each airport and ensure that screeners who consistently fail covert tests are removed.

The question I ask is how does one get from the incident of missing the explosives in the screening process to corrective actions such as remedial training, possible firing, hiring more employees, and purchasing better equipment? This is where the human factors science such as Signal Detection Theory behind TapRooT® could have helped with the root cause analysis.

Use a structured root cause analysis like TapRooT® that asks questions tied to human engineering such as were errors (targets) detectable? Are choices made by the person subject to knowledge-based decisions? Are the safeguards or barriers dependent on human action?

While types of human error are subject to change, human factors science continues to be introduced into the workplace with increasing usability. Replacing “common sense” with a structured root cause analysis based on science will continue to improve corrective actions.

Human Factors Series 2 will discuss Management Systems influence on correct hits and false alarms.

The Associated Press reported that 14 railway officials, including the Deputy Chairman of the Railways Authority, were sentenced to one year in jail for their part in a 2006 train accident that killed 58 people. At least part of the cause of the accident was reported to be poorly maintained switching equipment.

Below is a sample of Mid-East TV coverage from the accident (some graphic accident footage included) from the web.

QuickTime Format (.mov)

QuickTime Format (.mov)

Last Monday I published an article titled:

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

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

To see the Danish Accident Investigation Report go to:

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

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

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

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

Drawing from Report

Cleanup of Spill Underway

Not much information has come our about the PEMEX drilling rig accident. A new article says that 21 people were killed and that production should be resuming soon. Most reports seem to blame the weather. That doesn’t seem to be an adequate root cause analysis. Perhaps more information will be released later.

Here are some of the participants from ESB in Dublin participating in the 2-Day course.

If you want to hold a course for folks at your facility, click on the “Contact Us” button above.

How do six sailors give the entire Nuclear Navy a black eye? Simple … Falsify the results of required chemistry checks for a nuclear reactor. And do it not just once or twice … but for an entire month.

The negative press reports appeared all over:

http://hosted.ap.org/dynamic/stories/N/NAVY_NUCLEAR_PROBE?SITE=CAVIC&SECTION=US&TEMPLATE=DEFAULT&CTIME=2007-10-22-11-38-27

http://www.msnbc.msn.com/id/21418417/

http://www.foxnews.com/story/0,2933,303861,00.html

http://www.forbes.com/feeds/ap/2007/10/22/ap4246036.html

http://seattletimes.nwsource.com/html/nationworld/2003967171_webnukesub22.html

I spent 7 years in the Nuclear Navy (back in the late 70’s and early 80’s). I find the idea of not sampling the reactor chemistry for a month … amazing!  Admiral Rickover is probably spinning in his grave!

From the story it sounds like they were somehow caught during their ORSE (Operational Reactor Safeguards Exam). Surely this resulted in a failed ORSE. The Commanding Officer and Engineer will be looking for new jobs (probably outside the Navy - their naval careers are ruined).

Once again, if lax enforcement of standards (especially sampling of reactor chemistry) can happen in the Nuclear Navy … poor enforcement of SPAC can happen anyplace.

What are you doing to enforce important policies?

Are you just using late-uncertain-negatives?

Have you tried soon-certain-positives?

If you don’t know what I’m talking about you should consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. It has a section on changing behavior that will teach you what you need to know.

For course information, dates/locations, and registration see:

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

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

To download the report, click here.

Here’s the class photo:

See:
http://hscweb3.hsc.usf.edu/health/now/?p=272

Here’s a class picture from the latest TapRooT® Course in Mexico.

Marco, the instructor, is on the right.

Las Vegas is a great place to hold the TapRooT® Summit. Be there from June 25-27, 2008, and learn best practices and have fun!

And on Wednesday Night, attend the Exhibit and Reception and meet and hear ELVIS!

See what I mean by going to this link:

http://www.elvisinvegas.net/media/qt/high/gregpromo.mov

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

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

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

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

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

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

Once source actually had the following statement:

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

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

What do you think?

Marco Flores, one of the instructors, sent me this class photo for the Root Cause Analysis Blog:

And the root cause of opening the wrong valve is?

Operator should have been moire careful! And should have self checked. And should have used STAR (Stop-Think-Act-Review).

And the Corrective action is:

Tell them to be more careful next time!

Michele Lindsay, one of the instructors, passed along these pictures of people learning and having a good time at our beautiful course location in Edmonton.

Last week Steve Swarthout, TapRooT® Instructor, taught a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course for miners in Lima, Peru. He sent the following picture of people hard at work learning ways to understand and solve problems and improve performance by using TapRooT® …