Root Cause Analysis Blog

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

Kay Gallogly, Founder of The 42 Group will be presenting IEEE Root Cause Analysis Standard at the 2008 TapRooT® Summit on Wednesday, June 25 at 10:30 a.m.

This segment will provide an update on IEEE Recommended Practice for the Investigation of Events at Nuclear Power Plants. At present a working committee of nuclear industry representatives is composing a guide to conducting and reporting event investigations. The update will include an overview of the process and the practices that have been identified as key elements of an investigation in this important initiative.

Marco Flores will be presenting the following case study during the Spanish Sessions at the 2008 TapRooT® Summit. The sessions will be held on Friday, June 27.

Ken Reed, Equifactor® Program Manager, and Mark Olson, TapRooT® Instructor, will be presenting “Maintenance Best Practices” on the Equipment Reliability and Maintenance Best Practices track at the 2008 TapRooT® Summit. The session will be held on Friday, June 27, at 9:15 a.m.

From Ken:

Times, they are a-changin’! Discuss how the shift in manufacturing and training philosophy has affected the way we view our maintenance departments, including the way they are organized and utilized. This is an interactive discussion on current trends in maintenance practices, so plan on bringing your own observations to the table.

Ken Reed

Mark Olson

Neil Roberts will be presenting “Advanced Behavioral Management: Developing a Modern Safety Culture” on the Safety and Risk Management and Human Error Reduction & Behavior Change Best Practices Tracks at the TapRooT® Summit on Thursday, June 26 at 9:15 a.m.

The session will have the following objectives:

1. To demonstrate the benefits and limitations of safety climate and safety culture surveys as a precursor to the introduction of a safety culture change programme.

2. To outline and demonstrate the benefits of a holistic and advanced approach that would encourage change in an organization’s safety culture. This would include reference to four key areas:

(i) Management Leadership
(ii) Safety Performance Measurement
(iii) Safety Coaching
(iv) Safety Interdependence

3. To demonstrate that habitualization of front line safety behaviors has its limitations, but if we are to make a systemic and long lasting difference to culture we need to identify and encourage a change of management based behaviors.

Although the title includes the word “advanced,” any attendee will benefit.

Jose Gerard will be presenting: Como Evitar Accidentes de Trafico en Monterrey (How to Avoid Traffic Accidents in Monterrey) during the 2008 TapRooT® Summit Spanish Speaking Sessions planned for Friday, June 27.

Es una descripcion de las observaciones hechas durante muchos años de servicio en ambulancias y camiones de rescate urbano de los servicios medicos oficiales de emergencia en Monterrey y su area metropolitana, mientras tratamos de resolver los problemas que ya tiene la persona involucrada en un accidente de automovil.

This presentation includes Jose’s observations during his many years of service in ambulance and urban rescue trucks of the official emergency medical services in the metropolitan Monterrey area. Jose’s work includes resolution of problems encountered by persons involved in a car accidents.

A pesar de que la presentacion esta hecha para el area de Monterrey, las observaciones hechas aplican para casi cualquier ciudad en la que pueda pensar.

Jose’s observations apply to almost any other city you may think of (not just the Monterrey area).

Ken Bloch will be presenting “Using TapRooT® to Solve Complex Equipment Problems” at the 2008 TapRooT® Summit. This presentation is on the Equipment Reliability and Maintenance Best Practice Track and is scheduled for Thursday, June 25 at 2:40 p.m.

To solve a complex equipment problem you need to know what information to look for and where to find it. With over one hundred information sources in a typical production facility, this task is easier said than done. The session uses case histories to explain how TapRooT® is being used to isolate the evidence you need to solve complex equipment problems.

Heinz Bloch and Ken Bloch will be presenting “Examples of Extreme Equipment Failure Investigations” on the Equipment Reliability & Maintenance Best Practices Track at the 2008 TapRooT® Summit. This session with be held on Thursday, June 26 at 1:00 p.m.

A special failure category represents a combination of extremes (”Extreme Failures”). These failures have severe consequences, yet provide little (if any) physical evidence. You will examine several extreme failures to identify their similarities and shared anatomy. This understanding is being used to measure Extreme Failure Investigation effectiveness.

Heinz Bloch will be presenting “How to Become Best of Class in Equipment Reliability by Maximizing Uptime” and “Best of Class in Equipment Reliability Part II” on the Equipment Reliability & Maintenance Best Practices Track at the TapRooT® Summit. The presentations are scheduled for Thursday, June 26, 9:15 a.m. to 10:25 a.m. and 10:40 a.m. to noon, respectively.

Here are the presentation highlights:

How to Become BEST-OF-CLASS in Equipment Reliability by Maximizing Uptime 

(a) Bearing protection issues that are vastly misunderstood
(b) Lube application issues the vendors will not admit
(c) Dual seal component improvements your “alliance partner” will not tell you about
(d) Resourcefulness practiced by BEST-OF-CLASS companies
(e) Cultivating vendor contacts

BEST-OF-CLASS in Equipment Reliability Part II

(a) Bid evaluation concepts your design contractor knows little about
(b) How to effectively manage reliability on New Projects
(c) Grooming talent and skills - why the contractor can not do this for you
(d) Little-known reliability management strategies that make a big difference 

Heinz Bloch is a worldwide recognized equipment reliability expert with over 20 books on equipment reliability and maintenance topics. 

If your improvement ideas include improving equipment reliability and maintenance at your facility, then you should plan to attend!  

Bill Sirois will be presenting FACTS - Computerized Analysis of Fatigue as a Cause of an Incident to the Investigation & Root Cause Analysis Best Practice Track at the TapRooT® Summit.

The developmental progress of this long awaited tool for qualifying fatigue as a causal factor in accidents and incidents has been presented in previous Summits. Now comes the final validation of this analytical software for both Industrial and Transportation application. At long last, companies will now be able to determine which of their incidents are fatigue related, and thus what level of priority should be attached to addressing this increasing problem.

Darby Allen will be presenting Senior Executive Involvement in Safety: What the Corporate Board Needs to Know About Safety at the 2008 TapRooT® Summit. This session will be held on Friday at 9:15 a.m. (in both the Safety & Risk Management and Management & Measuring Performance Tracks).

From Darby: “Safety has to come from the top . . . develop that commitment! Learn tips for the Safety Team on what turns them on or off and explore issues which will help grab the attention of Senior Executives including the personal liability and financial aspects. Understand the role of Senior Executives as guardians of the company reputation and some examples of where this has gone very wrong. What should Senior Executives be doing to lead on safety? This session offers simple tools which can be used to assist Senior Executives set world class standards.”

On Friday, June 27, we are pleased to present a day of Spanish sessions at the TapRooT® Summit for our Spanish speaking clients.  Arturo de la Garza will be presenting Como Disminuir los Errores Humanos Sobrevivir (How to Reduce Human Error . . . and Survive).  Que es un error humano? What is human error?

Aprende categorias, causas, y los cuestan de los errores humanos y mas! Learn the categories, causes and costs of human error and more!

On Friday, June 27, we are pleased to present a day of Spanish sessions at the TapRooT® Summit for our Spanish speaking clients.

Marco Flores will be presenting: Lecciones Aprendidas en 3 Decadas en el Desarrollo de la Tecnologia en Reduccion Directa y Arranque de Plantas (Lessons Learned in 3 Decades in the Development of Technology in Direct Reduction and Plant Start-up).

Here is the course description in Spanish (followed by English):

Treinta años en Reducción Directa

1. Investigación
2. Desarrollo de Equipos Especiales Desarrollo de Estándares de Prueba
3. Escalamiento de Datos de Planta Piloto
4. Arranque de Plantas y Solución de Problemas
5. El Problema Humano del Desarrollo Tecnológico en los Dos Extremos
6. De la Creación a la Implementación Industrial y al Mercado Mundial

Treinta años de experiencia técnica en el desarrollo de procesos de reducción directa y equipos auxiliares,

El Escalamiento – un Concepto de Percepción

Desde la concepción de la idea, hasta la operación de plantas industriales de Millones de Toneladas anuales.

El Factor Humano

La integración y conservación de un equipo de trabajo eficiente, con capacidad de análisis y respuesta rápida y la interacción humana dentro del contexto particular del mercado, no es una tarea fácil.

El concepto, Las patentes, el diseño y el hombre

Analizaremos algunos de los puntos relevantes de las patentes existentes y de cómo el concepto original se vio afectado por estilos de gestión y las consecuencias que esto tuvo.

Veremos las lecciones aprendidas. Todo esto envuelto en el contexto humano comercial y multicultural.

* * * * * * * * * *

Thirty Years Hands-On in Direct Reduction

1. Concept
2. Research and Development
3. Special Equipment Development and Testing Standard Development
4. Scale‐up
5. The Human Problem of Technological Development on Both Sides
6. From the Creation to the World Market

Thirty years of technical experience in the concept, research, development and industrial implementation of Direct Reduction Processes and still learning from them the tough lessons and the simple ones.

Scale‐up and the Perception Concept

From the conception of the idea, to the installation of mega modules; the solutions for a pilot plant might not be suitable for a mega module.

The Human Factor

Building and preserving a competitive working team, capable of fast analysis and response, and the human interaction within the particular market context, is not an easy task.

The concept, the patents, the design, the man

We will analyze some of the available patents, its relevant points and how the original concept was affected by management, market and fads. We will see the lessons that have been learned all this involved in a human, commercial and multicultural context.

If you want more information about the Spanish sessions, please contact us!