Root Cause Analysis Blog

Breaking News – Another Gulf Platform Explosion

Dave Janney — Thu, 02 Sep 2010 16:06:31 +0000

Here is the story:

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

Sounds like from initial reports that there were no fatalities. If that is true that is good news.

My first reaction when I heard this was: I hope there will be ample time for a thorough investigation before any “knee-jerk” decisions are made to suspend drilling.

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Ferrari Fires on You-Tube

Mark Paradies — Thu, 02 Sep 2010 13:50:19 +0000

Expensive cars catching fire gets lots of attention. Here are the You-Tube videos …

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Root Cause Analysis Day One at Golden Pass LNG, Sabine Pass Texas

Chris Vallee — Thu, 02 Sep 2010 02:56:35 +0000

Golden Pass LNG Terminal LLC, the owner of the Golden Pass LNG Terminal, is 70 percent owned by an affiliate of Qatar Petroleum, 17.6 percent owned by an affiliate ExxonMobil, and 12.4 percent owned by an affiliate of Conoco Phillips.

Taking the lead before their first shipment of LNG, Golden Pass LNG started the Root Cause Analysis process and training early on. Below are just of few pictures from the first hands-on exercise.

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Root Cause Analysis Tip: “Death by Data” also known as “Data Paralysis”

Chris Vallee — Thu, 02 Sep 2010 02:17:05 +0000

Understanding your process data, filtering the good from the bad and detecting when there are true problems coming to light should not be like hand-sorting grains of rice.

Yet I hear this question frequently, “We have a large database and we would like to ……..?”

When I ask what processes are being measured and what data are tied to the process’ outcome, the answers are often very vague if not delayed with a, “I will get back with you, good question.”

Now most of us our good at tracking outcomes (often because we are required by Regulations) like:

… number of defects

… costumer complaints

… OSHA recordables

… Sentinel Events

With tracking outcomes however, comes the data merging error that hides the fact that all rice does not come from the same fields and cannot always be included in the same analysis. For example:

… we had a wonderful month with lower injuries in July per assigned employees.

Problem: Cannot compare the number of employees assigned in July with the other months because we had a 2 week plant shutdown.

… we count all defect opportunities and perform frequent audits but the leading indicators do not seem to predict the change.

Problem: Not all audits are created equal. Often leading indicator metrics are too global and general. In other words, “just plain rice”. When you see indicators change but there is no correlation to your lagging output metrics, stop and Go Out And Look (GOAL) at the tasks being performed to identify the correct leading metrics.

This is just the tip of the iceberg when looking at wrong data collection thoughts. Just remember just because you collect lots of data does not mean this a good thing…. you just get more grains of salt to sift through.

Below are two presentations to dig a little deeper in this thought process.

http://www.taproot.com/wordpress/2009/10/30/trending-with-the-taproot%C2%AE-v5-software/

http://www.taproot.com/wordpress/2009/10/30/proactively-using-leansix-sigma-with-taproot%C2%AE/

Also, check out our metrics course being offered during our October Pre-Summit. It is the only this year it is offered as a public course: http://www.taproot.com/summit.php?t=pre-summit#advancedtrending

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New York Times Story About the Miners Trapped in Chilean Mine

Mark Paradies — Wed, 01 Sep 2010 20:07:55 +0000

See:

http://www.nytimes.com/2010/09/01/world/americas/01chile.html?_r=1&th&emc=th

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Entergy Vermont Yankee to do Root Cause Analysis of Mysterious Blow Fuses

Mark Paradies — Wed, 01 Sep 2010 19:58:01 +0000

Blown fuses on two of five control room room panels will prompt Entergy Vermont Yankee to do a root cause analysis of the incident.

The blown fuses caused the nuclear plant to declare a low-level emergency which lasted until the fuses were replaced.

Sometimes even a blown fuse can lead to a root cause analysis.

Do you have any “unusual incidents at your plant that you could share? If you do., leave a description of them here.

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Job Opening: Aurora, CO – Raytheon – Quality Assurance Eng I – Needs Root cause Analysis and Corrective Action Development Skills

Mark Paradies — Wed, 01 Sep 2010 18:47:19 +0000

See:

http://jobview.monster.com/Sr-Quality-Assurance-Eng-I-Job-Aurora-CO-US-90442024.aspx

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Root Cause of this Accident?

Mark Paradies — Tue, 31 Aug 2010 12:14:11 +0000

I think this fits in the Natural Phenomenon / Sabotage category …

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Wisdom Quote

Barb Phillips — Tue, 31 Aug 2010 11:00:05 +0000

“I’d rather live with a good question than a bad answer.” ~ Aryeh Frimer

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Safety & Risk Management

Barb Phillips — Mon, 30 Aug 2010 15:55:32 +0000

Come and learn best practices in Safety & Risk Management at the 2010 TapRooT® Summit. Sign up for this track and be part of these remarkable best practice sessions. (Read bios of the presenters on the Summit website):

How Does Your Corporate Culture Effect Your Investigations? The culture that exists within your company greatly effects the success of any investigation and subsequent corrective actions..

Brian W. Tink and Brian A. Tink will show you some ways to quantify & identify your current corporate culture. The session will conclude by suggesting how you can use this information to strengthen your organizational/safety culture, allowing you to develop and execute more effective corrective actions that will, in turn, lead to desired and significantly improved business results.
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Communicating with Management About Risk: Effectively communicating HSE risks to senior management is critical. Their support for resources (time and money) is necessary to implement actions that reduce risk. Strong visual communications and other techniques are needed to get the message across in a way that leads to action and increased credibility for HSE issues. One of the keys is to present HSE information from a business perspective.

In this session, Dennis Osmer, former Worldwide Head of HSE will review development of several risk communication techniques (risk assessment in terms of organizational impact & degree of control vs. probability & severity, use of site risk analysis, score cards, involvement in accident notifications, etc.).

Ahead of the Law: OSHA Enforcement Problems & Solutions: What is the latest in the world of safety compliance? Join Dave Janney and learn what OSHA has been citing, current inspection emphasis programs, the A-Z’s of the Site Specific Target Program, and inspection and citation handling tips..

Using TapRooT® for Regulatory Safety Compliance: Learn how one of the world’s most sucessful airlines is driving safety compliance by using TapRooT®. Dave Janney, System Improvement’s Senior Associate and former FAA Liason at Delta Air Lines will provide framework for the regulatory compliance environment in the industry, and Rick Diamond and Joe Fresquez from Southwest Airlines will discuss how SWA is using TapRooT® in the regulatory oversight function in its aircraft maintenance division.

Improving Incident Investigation and Safety in the BW Fleet: BW Fleet Management are responsible for the management of a large fleet of Bulk Carriers, Oil and Gas Tankers. Although they are a recognized leader in the Shipping Industry, in 2008 they decided more needed to be done..

Capt. Vibhas Garg and Malcolm Gresham will present how BW Fleet Management’s search for a better way to analyze incidents resulted in them implementing TapRooT®. This presentation will discuss the challenges overcome when implementing the system. It will also cover how the introduction of a company Risk Management Framework will contribute to future improvements.

Advanced Ideas for Corrective Actions: In this best practice session, Dan Damaan will present how to use risk to rank corrective actions. The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization.

Richard Mesker will also talk about using extent of condition/common cause/generic cause analysis to build complete corrective actions during this session.

Be a Safety STAR: How a VPP Program & TapRooT® Can Be Combined for Excellent Safety Performance: Learn how some leading companies used TapRooT® to improve their OSHA VPP (Voluntary Protection Programs) processes and get some ideas how you can leverage the capabilities of TapRooT® with Melva Luckie-Oni, Dave Janney and Dan Phillippe..

Quality in Life and Work: Quality Improvement can be applied to your personal life and your business. It’s sequential—inside out, not outside in. George Burk was critically burned and severely injured, the sole survivor of 14 passengers in a military plane crash.

Learn how several of W. Edward Deming’s 14 Points for Quality Improvement assisted him in his recovery, rehabilitation and transformation from victim to survivor. Hear and learn how you can apply several of Deming’s points—to help you and help you assist others to achieve success in life and business.

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