Yes … It is a Tennessee snow emergency at System Improvements.
Here’s proof:
First, there is snow in our parking lot!
Second is a photo of Benna’s driveway (she sent it to me from her phone).
East Tennessee has lots of hills (and a few Mountains too).
East Tennessee has very little snow removal equipment.
So when it snows, it covers the road.
Because snow is so infrequent (once or twice a year), nobody knows how to drive on it. Many drive along like normal and slam on the breaks and skid until they hit something.
So, if you call us at the office this afternoon, we’ll probably be gone because we’ve left early to avoid being on the road.
Maybe tomorrow too!
Sometimes it’s better to avoid an accident than to investigate it!
One of our Australian TapRooT® Users sent this picture…
The text below the picture said …
EVA AIR BOEING 747 TAKING OFF FROM AMSTERDAM
(Taiwan’s National Carrier)
EVA Air Boeing 747-45EM taking off from runway 36L at Amsterdam-Schiphol (Netherlands). The great timing and angle just makes this shot, and the size of the 747, looking quite surreal. Someone must have changed his underwear after this one. The distance to the fence was 145 meters (475ft)!
Sometimes it is difficult to get a 747 off the ground!
Did you get it right? How would the SMART car hold up?
During our TapRooT® course section, I often ask students whether they think Ice is a hazard (uncontrolled energy). The first answer is often yes. The next question then is whether all ice is a hazard and the answer is… only when you walk or drive on it. Now we get to the uncontrolled energy of motion. For years many have used safety checklists looking for daily “hazards” such as no safety glasses, tripping hazards, and no fall protection… just to realize that we were looking for failed safeguards and not the uncontrolled energies that they were to protect us from. So the first tip is to have all employees look for uncontrolled energy daily.
Once you identify a hazard with no safeguard it may seem easy to select a new safeguard… but is it? Follow through is just as important in safeguards as it is in throwing a ball in the right direction. Each step is vital. If you had selected the older heavy car (1959 Bel Air) because it looked stronger what would the unintended consequences of that choice have been? Final tip of the day, make sure you have a knowledgeable person help with the selection of or improvements of safeguards.
Paul Hughes taught this public 5-Day TapRooT® Advanced Root Cause Analysis Course in Singapore last week (pictures below). Want to see our world-wide schedule for TapRooT® Courses in the first half of 2010? Click on the continent that you are most interested in at:
Malcolm Gresham of PSG (one of our Australian TapRooT® Instructors) sent this pictures from an in-house 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course held for Cactus Engineering in Singapore. After just two days of training, student will be able to apply the essential TapRooT® Techniques to find the root causes of accidents, incidents, quality issues, near-misses, and operating problems. In addition, they will learn to use the same techniques proactively to stop incidents before they happen.
If you want information about a course at your site anywhere around the world, contact us by CLICKING HERE.
How can TapRooT® be improved? Combine its great root cause analysis capabilities with the equipment troubleshooting techniques from Heinz Bloch that have been built into the Equifactor® Equipment Troubleshooting Software.
How can you improve your equipment reliability? Apply TapRooT® and Equifactor® to stop repeat equipment failures. Plus, we’ll teach you to use TapRooT® and Equifactor® proactively to improve performance.
Here’s a picture of Chris Vallee teaching the Equifacfor® Course in Las Vegas.
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CSB Issues Urgent Recommendations to CITGO;
Finds Inadequate Hydrogen Fluoride Water Mitigation System during Corpus Christi Refinery Fire Last July
Houston, Texas, December 9, 2009 – The U.S. Chemical Safety Board (CSB) today issued urgent safety recommendations calling on CITGO to immediately improve its emergency water mitigation system in the event of another release of potentially deadly hydrogen fluoride (HF) vapor, as occurred following an explosion and fire July 19, 2009, at CITGO’s Corpus Christi refinery. The Board also called on CITGO to perform third-party audits to ensure the safety of its hydrogen fluoride units at its Corpus Christi, Texas, and Lemont, Illinois, refineries.
The CSB issues urgent recommendations before completion of final investigation reports in cases where CSB Board Members determine an imminent hazard may be present and has the potential to cause serious harm unless rectified in a short timeframe. On the day of the accident last July, hydrocarbons and hydrogen fluoride were suddenly released from the refinery’s HF alkylation unit. The hydrocarbons ignited, leading to a fire that burned for several days. The fire critically injured one employee and another was treated for possible hydrogen fluoride exposure. CSB investigators determined that a blockage of liquid caused by the sudden failure of a control valve led to violent shaking within the process recycle piping. The shaking broke threaded pipe connections resulting in the release of hydrocarbons. The cloud of hydrocarbons reached an adjacent unit and ignited. The ensuing fire caused multiple additional fires and the release of approximately 42,000 pounds of hydrogen fluoride from equipment and piping within the unit. The refinery used a water spray system to absorb the released HF, but the CSB cited scientific literature to conclude that at least 4,000 pounds of HF likely escaped from the unit into the atmosphere and left the facility. Investigators determined that during the first day of response efforts CITGO nearly exhausted the stored water supply for the water mitigation system. Approximately eleven-and-a-half hours after the initial release, before the water supply was completely exhausted, the refinery began pumping salt water from the ship channel into the refinery fire water supply. Multiple failures occurred during the salt water transfer including ruptures of the barge-to-shore transfer hoses and water pump engine failures. CSB Chairman John Bresland said, “It is imperative that refineries have the proper emergency response resources available to control a release of hazardous materials and protect against impact on the surrounding community.” The CSB’s urgent recommendations call on CITGO to develop and initiate plans within thirty days to ensure an adequate water supply to the refinery’s HF mitigation system. The company should also report planned or completed actions to the Refinery Terminal Fire Company and the Local Emergency Planning Committee every thirty days until all planned activities are fully implemented. Investigations Supervisor Robert Hall, P.E., said, “Our investigation closely examined emergency response actions related to this accident. Investigators found that the CITGO water mitigation system serves as the last line of defense to protect the community from an HF release. The CSB’s urgent recommendation aims to improve the reliability of CITGO’s Corpus Christi, Texas, HF water mitigation system.” A second urgent recommendation called on CITGO to commission independent, third-party audits of the safety of its two HF alkylation units at refineries in Corpus Christi and Lemont, Illinois. The audits should compare safety practices at the alkylation units to those recommended by the American Petroleum Institute (API). Investigators said that CITGO had never conducted such an audit of the units, despite an existing industry recommendation for audits every three years. The CSB also released video of the initial pipe failure, release, ignition, and fire as captured by two refinery surveillance cameras. Chairman Bresland noted, “The camera footage shows the release and spread of the flammable vapor cloud and the moment when the flammable vapor was ignited. It shows just how severe the release and fire were during this incident.” Chairman Bresland said, however, that the company had raised objections to the CSB’s release of the video, saying that doing so would “raise substantial issues of national security” and would “only sensationalize this unfortunate accident.” The CSB subsequently received affirmation from the Department of Homeland Security that the video did not fall under certain classifications requiring protection from disclosure. Chairman Bresland said, “We found this claim disturbing and believe that it is contrary to the intent of a recent law passed by Congress, following similar secrecy claims by Bayer CropScience in Institute, West Virginia. This law, the American Communities’ Right to Public Information Act, states that national security classifications may not be used to conceal corporate errors, prevent embarrassment, or improperly delay the release of information to the public. An important part of this CSB investigation is to ensure all relevant information and visual materials regarding this accident are made available to the residents of Corpus Christi.”
Why should you have been in this equipment troubleshooting class in New Orleans?
1. You are a Saints fan… that would add two more people
2. People in your company use equipment in day to day activities…. that would be everyone
3. You are a safety leader and need a way into the equipment operator’s world (you can help them and get a better understanding of what they do)
When should you register for the Equifactor® Course?
1. Before the class (this makes sure we have enough course materials for you and you don’t have to pull your hair out to find a last minute hotel room)
2. Let us know during the 2-day class that you want to stay for the third day. (Like the three guys from ATEC below)
Here is the schedule for the upcoming Equipment Troubleshooting Courses:
Chris Vallee and I (Mark Paradies) are teaching the 2-Day TapRooT® Course in Las Vegas. Here are pictures of teams working on their first SnapCharT® exercise…
Malcolm Gresham, TapRooT® Instructor from PSG in Australia, sent the pictures below from a TapRooT® Course for Fluor Rail Services. Fluor Corporation is a licensed TapRooT® User and Fluor Rail Services maintains and constructs track infrastructure that links Rio Tinto’s Iron Ore operations in the Pilbara Region. Malcolm says that it is the largest privately owned Rail Network in the world.
The pictures below show teams working on their final exercise in the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
I was in Jesup, Georgia this week doing a course for Rayonier. Here are some pictures from the final course exercise:
Our onsite courses provide a cost-effective way to train larger groups of people without having them out of the office traveling and without absorbing travel costs. If you have 10 or more people to be trained, it is likely that an onsite course will be the best choice for you.
If you are interested in a quote for an onsite course, please give us a call at 865.539.2139.
While we were celebrating Thanksgiving in the USA, folks in Australia were learning advanced root cause analysis skills.
TapRooT® Root Cause Analysis Courses teach practical skills and proprietary techniques and then you use them on real life examples to immediately practice and reinforce what you have learned.
Here are pictures taken by the course instructor, Paul Hughes of PSG:
We are working to complete the 2010 Summit before the end of 2009.
Many of the speakers and sessions have fallen into place. I’ll tell you more about those soon.
What is this post about?
Golf!
The 2010 TapRooT® Summit Charity Golf Tournament will be held at The Quarry Golf Club in San Antonio.
We’ve held the Summit tournament there once before (in 2005) and it was a great place to play.
Nine holes are around an old stone quarry. Nine holes are actually down in the quarry. So for clients from the mining industry … it’s like playing at work! (Not really.)
The facilities are excellent, the pro shop is great, and I’m really looking forward to holding the tournament there again.
Of course, golf is not the only reason to sign up for the TapRooT® Summit. But I will be you that this will be the most fun you’ve had at a golf tournament ever.
So start making your plans to attend the TapRooT® Summit on October 27-29, 2010, in San Antonio and the pre-Summit Courses on October 25-26 (at the same location in San Antonio - more information about these courses soon).
Marco, one of our Spanish speaking instructors, sent these “graduation” photos from a class he is teaching in Chile:
I like to see the timer going in the background (second photo). Everybody who has been to a TapRooT® Course knows what this is about. Those who haven’t should attend and learn how to change human behavior.
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See the accident report at:
