Author Archives: Ken Reed

Have a Plan! Using the TapRooT® Tools to Plan Your Investigation

Posted: June 22nd, 2016 in Investigations, Root Cause Analysis Tips, TapRooT

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Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?

Unfortunately, most systems kind of leave you hanging.  They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt.  Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!

Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process.  We have recently tweaked this guidance to make it even easier to quickly progress through the investigation.  Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.

Some of these tools are required for every investigation; some are optional data-gathering tools.  Let’s first take a look at the required tools.

Mandatory Tools

SnapCharT®:

One of the first things you need to do is get a good understanding of exactly what happened.  Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred.  By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out.  It helps you figure out what questions to ask and who to ask.  Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason.  There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask.  It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.

Root Cause Tree®:

Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process.  However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®.  In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation.  You’ll need the answers to these questions once you get to the root cause analysis phase.  Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?

The tools I listed above are used during EVERY investigation.  However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®.  Let’s look at the non-required tools.

Optional Tools

Change Analysis:  This is a great tool to use to help you ask thought-provoking questions.  It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances.  The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident.  It is actually an extremely easy tool to use, and yet it is very powerful.  I find this to be my most-used optional tool.  The results of this analysis are now added to your SnapCharT® for later root cause analysis.

Critical Human Action Profile (CHAP):  Sometimes, you need help understanding those “dumb” mistakes.  How can someone be walking down the stairs and just plain fall down?  The person must just be clumsy!  This is a great time to use CHAP.  It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task.  What tools were they using (and supposed to be using)?  How did we expect them to perform the individual steps in the task?  This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing.  The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.

Equifactor®:  If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure.  You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem.  For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring.  Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration.  The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure.  These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure.  Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.

The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with.  The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations.  If you need some help getting started, the TapRooT® tools will get you going!  Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.

Which Pump is Best? Evaluating Pump Curves

Posted: June 13th, 2016 in Equipment/Equifactor®

PumpCurve

There are quite a few variables that must be taken into account when selecting the correct pump for a particular application. For centrifugal pumps, the pump curves for a specific pump contain a lot of data. Here are some ideas to help you decide which pump would be best for a particular application, based on the pump curve for various pumps.

Equipment Maintenance and Troubleshooting – Calculating pump run time and duty cycle

Posted: June 9th, 2016 in Equipment/Equifactor®

image

When discussing pump maintenance, we often forget about the electrical side of the equation. Mechanics think about the mechanical side, and we’ll let the electricians worry about the power side. However, it is critical that we take a more holistic view of the entire pump system to make sure we’re not exceeding manufacturer specs when we are using our equipment.

There are several measures we need to keep in mind when we look at equipment lifetime calculations. For example:
– # start/stop cycles in a given period
– Run time after starting
– Overall duty cycle

I read this interesting article about why these items are important.  The author also had a calculator spreadsheet that helps you figure out appropriate run times for pumping out a sump or tank.  That calculator is here.

Electrical Equipment Troubleshooting – Don’t Be Scared!

Posted: May 31st, 2016 in Equipment/Equifactor®

schematic

I found this article about troubleshooting electrical failures in heavy equipment. It discussed some pretty concise nuggets of info I thought were pretty interesting. In many cases, troubleshooting an electrical fault is more a case of figuring out “What is working?” as opposed to “What is broke?”.

Equifactor® Equipment Troubleshooting Basics

Posted: May 25th, 2016 in Equipment/Equifactor®, Root Cause Analysis Tips

afterburner-inspection-897513_1280

Equifactor® is designed to be used to help your equipment maintenance and reliability people figure out the root causes of mechanical or electrical equipment failures.

I thought I’d take the opportunity to take us back to the basics for a moment. I’d like to describe how the Equifactor® Equipment Troubleshooting module of TapRooT® is designed to be used.

What is Equifactor®?

When performing a root cause analysis using TapRooT®, it is critical that you gather the right information for the problem at hand.  This can be safety information, environmental procedures, policies and work instructions for a particular task, etc.  It is usually pretty obvious what types of data you need for the type of investigation you’re performing.

Sometimes, additional TapRooT® data-gathering tools are required for specific types of problems.  Equifactor® is one of those tools.  It is designed to be used to help your equipment maintenance and reliability people figure out the root causes of mechanical or electrical equipment failures.

Why use Equifactor®?

During your investigation, you may find that one of your problems relates to an equipment malfunction.  For example, you might find that a compressor is vibrating above expectation.  You can put this fact into your SnapCharT®, but now what?  What do you do with this piece of information?  To get past this point in the SnapCharT®, you really need the answer from your troubleshooting team:  “Why is the compressor vibrating?”  Unfortunately, if you knew that, you wouldn’t need to put the question on your SnapCharT® in the first place!  You need to know the physical cause of the vibration in order to progress to a more detailed SnapCharT® with Causal Factors.

Equifactor® in detail

This is where Equifactor® comes in.  To help your equipment experts figure out the physical cause of the vibration, they will probably rely on their experience and local manuals for troubleshooting advice.  They’ll look at the possible causes they are familiar with, and hopefully find the problem.  However, we can’t rely on hope.  What happens when they check the items they are familiar with, and the problem is not found?  This is when they can turn to the Equifactor® troubleshooting tables for help.  The tables give a comprehensive list of possible causes of compressor vibration.  Your experts can review these tables to identify all the possible causes that apply to your compressor, and then use that list of possible causes to devise a detailed troubleshooting plan to identify the issue.  Theses tables give your maintenance team some great guidance on things to look at during their troubleshooting.  These items are quite often things that they have never seen before, and therefore did not think to look for.

Equifactor® – a TapRooT® Tool

Once your team finds the physical cause of the compressor vibration (for example, maybe the wrong coupling bolts were used, throwing off the balance of the machine), we’re not done.  Equifactor® is NOT a separate, independent tool.  It is designed to be used as a data-gathering tool for your TapRooT® investigation.  Therefore, the problem that was found (wrong coupling bolts) is now added to the original SnapCharT®, and we can now move forward with our normal TapRooT® investigation.  I’m pretty sure the bolts didn’t magically install themselves; a human was involved.  We can now discover the human performance issues that lead the mechanics to use the wrong bolts.  We continue adding information to our SnapCharT®, until we can run all of the Causal Factors (one of which will probably be, “Mechanics assembled the coupling using the wrong bolts”) through the Root Cause Tree®.  We can now apply effective corrective actions to the problem.  Instead of blaming the mechanic (“Counselled the mechanic on the importance of using the authorized repair parts during coupling assembly”), we can now target our corrective actions at the reason the mechanic used the wrong bolts (correct bolts not available, common use of “parts bins” to repair equipment, wrong part number on repair order, etc.).

Equifactor® is a terrific tool to assist your maintenance and reliability folks in finding the physical cause of a machinery problem.  It is a tool to assist you in performing your TapRooT® investigation when an equipment problem is part of that investigation.  Learn to use these tables to save you time and effort when troubleshooting your equipment issues.

LEARN MORE about Equifactor®.

CONTACT US about a course.

Common Wind Turbine Equipment Failure Modes

Posted: May 19th, 2016 in Equipment/Equifactor®

Turbine failure

I found this article discussing some common failure modes for wind turbines. While not completely new, it does give you some things to consider when performing maintenance on turbine equipment.

Heavy Equipment Maintenance Tips

Posted: May 13th, 2016 in Equipment/Equifactor®

3D-Repair-Men

I saw this entry today, highlighting some great ideas on maintaining your heavy equipment. I think what caught my eye was the very first tip: “Stay on top of large machinery operator training.” Any plan to keep your equipment operating at top performance must include the operators and maintenance personnel. It doesn’t matter if you have the very best maintenance plans and schedules if the operators don’t understand how to properly start, operate, and secure the equipment. And maintenance techs must also be properly trained; otherwise, the best preventative maintenance plan will be poorly implemented.
Training of your staff should ALWAYS be a top priority!

Medical Errors – 3rd Leading Cause of Death in the US

Posted: May 4th, 2016 in Accidents, Current Events, Medical/Healthcare

Medical Death Chart

Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death.  Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.”  Other tidbits from this study:

  • Over 700 deaths each day are due to medical errors
  • This is nearly 10% of all deaths in the US each year

What’s particularly alarming is that a study conducted in 1999 showed similar results.  That study called medical errors “an epidemic.”  And yet, very little has changed since that report was issued.  While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.

I’m sure there are many “causes” for these issues.  This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases.  And many other problems are endemic to the entire medical system:

  • Insurance liabilities
  • Inadequate reporting requirements
  • Poor training at many levels
  • Ineffective accountability systems
  • between patient care and running a business

However, individual health care facilities have the most control over their own outcomes.  They truly believe in providing the very best medical care to their patients.  They don’t necessarily need to wait for national regulations to force change.  They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.

I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis.  Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation.  Many feel that, because they have smart people, they can perform these analyses without further training.  Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology.  When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations.  Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game.  It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.

Hospitals have the means to start fixing these issues.  I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.

 

Rail Accidents: It’s the Entire System that Matters

Posted: May 2nd, 2016 in Accidents, Equipment/Equifactor®, Investigations

amtrak

 

On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance.  Two maintenance workers were killed, and about 20 passengers on the train were injured.  For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.

Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC).  These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train.  It is designed to allow for:

  • Train separation and collision avoidance
  • Speed enforcement
  • Rail worker safety

For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance.  Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area.  The system can be pretty sophisticated, but this is the general idea.

Notice that I described the system as a series of sensors, software, and procedures that make up PTC.  While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly.  For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:

  • The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
  • The dispatcher must correctly tell the system that the workers are present.
  • The software must correctly identify the section of track.
  • The communications hardware must properly communicate with the train.
  • The train must know where it is and where it is going.
  • The workers must be on the correct section of track.
  • The workers must be doing the correct maintenance (for example, not also working on an additional siding).
  • If being used, local temporary warning systems being used by the workers must be operating properly.  For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
  • Proper maintenance must be performed on all of the PTC hardware and software.

As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment.  Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc.  People are still involved.

For the Washington Amtrak crash, we know that there was a PTC system in place.  However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc.  I am definitely not trying to apportion any blame, since I’m not involved in the investigation.  However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.

Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system.  Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs.  By finding the human performance issues, we can target more effective corrective actions than just blaming the individual.  Our investigations and audits have to take the entire system into account when looking for improvements.

Conveyor Belt Maintenance Tips

Posted: April 25th, 2016 in Uncategorized

belt fire

We sometimes take conveyor belts for granted. “Just a motor, some rollers, and a big flexible belt.” But for those of us that use conveyor belts as a critical part of our business, we know how impactful a belt system failure can be.  Additionally, a failure can cause more than just an inconvenience; failures in your belt system can lead to overheating and serious fires.
Here are some good ideas to help keep your conveyor belts running smoothly and safely.

Heavy Equipment Maintenance Tips

Posted: April 21st, 2016 in Equipment/Equifactor®

Detail

I ran across these tips for keeping your heavy equipment operating at peak performance. Some may seem obvious, but it is amazing how many times I’ve seen these simple maintenance actions ignored, especially at smaller companies. Larger companies often have staff dedicated to their maintenance programs, but smaller companies sometimes just don’t feel they have the resources.  I was working with a company just recently who had had a near miss due to a missing equipment guard.  As we dug a little deeper, we realized that there was no formalized maintenance system in place for there basic equipment.  They expected the operators to notice, report, and oftentimes actually fix any issues with their equipment on their own.  That was the extent of the maintenance program!

Please take a look at your equipment maintenance programs.  If you have planned maintenance in place for most of your equipment, take a hard look at your other, ancillary equipment.  You may find the big stuff has a good program, but the smaller (yet still critical) equipment is missing required maintenance and inspections.

Nudging Human Behavior in the Rail Industry

Posted: April 20th, 2016 in Human Performance, Performance Improvement, Uncategorized

rail

A colleague at a recent Rail Safety conference pointed me to this article on how to change people’s behavior on rail lines in London. How do we influence people to:
– put trash in trash bins
– be courteous while playing music
– keep feet off the train seats

They’ve tried signs and warnings. I think we can all agree those have limited effect. There are audible reminders. The escalators in Atlanta Airport talk to you continuously on the way down to the trains.

Here are some other (gentler) ways the London Underground is trying to influence passengers to do what is required.

3 Things that Separate the “Best of the Best” from the Rest

Posted: April 14th, 2016 in Investigations, Performance Improvement

Are you getting the results you are looking for?

There are some companies out there who “get it.”  We see it all the time at our courses.  Some companies just seem to be able to understand what it takes to not just have an incident investigation program, but actually have an EFFECTIVE program that can demonstrate consistent results.  As a comparison, some companies write great policies, say all the right things, and seem to have a drive to make their businesses better, and yet don’t seem to be able to get the results they are looking over.  By contrast, great companies are able to translate this drive into results.  They have fewer injuries, less downtime, fewer repeat incidents, and happier employees.  What is the difference?

We often see three common threads in these successful world-class companies:

1.  Their investigation teams are given the resources they need to actually perform excellent investigations.  The team members are given time to participate in the process.  This doesn’t mean that they have time during the day, and then (after work) it is time to catch up on everything they missed.  They are truly given dedicated time (without penalty) to perform quality investigations.  They are also given authority to speak to who they need and gather the evidence they need.  Finally, they are given management support throughout the process.  These items allow the team members to focus on the actual investigation process, instead of fighting hurdles and being distracted by outside interference.

2.  The investigation teams are rewarded for their results.  This doesn’t mean they are offered monetary rewards.  However, it is not considered a “bad deal” to have to perform the investigation.  Final reports are reviewed by management and good questions are asked.  However, the team does not feel like they are in front of a firing squad each time they present their results.  Periodic performance reviews recognize their participation on investigation teams, and good performance (both by the teams and by those implementing corrective actions) are recognized in a variety of ways.  Team members should never dread getting a call to perform an investigation.  They should be made to feel that this is an opportunity to make their workplace better, and it’s management’s job to foster that attitude.

3.  Great companies don’t wait for an incident to come along before they apply root cause analysis techniques. They are proactive, looking for small problems in their businesses.  I often hear people tell me, “Luckily, I only have to do a couple investigations each year because we don’t have many incidents.”  That just means they aren’t looking hard enough.  Any company that thinks that everything is going great is sticking their head in the sand.  World-class companies actively seek problems, before they become major incidents.  Why wait until someone gets hurt?  Go find those small, everyday issues that are just waiting to cause a major problem.  Fixing them early is much easier, and this is recognized by the Best of the Best.

Oh, and actually, there is a #4:

4.  The Best of the Best use TapRooT®!!!

REGISTER for a course and build an effective program with consistent results!

Pump Maintenance Tips

Posted: April 7th, 2016 in Equipment/Equifactor®

pump repair

Here’s an article describing some great tips to keep your pumps operating at peak performance. You can use these tips, in conjunction with the Equifactor® equipment troubleshooting tables, to ensure you’re getting the most out of your pumps.

Equipment Safety Alert: Counterfeit Crosby Shackles

Posted: March 28th, 2016 in Equipment/Equifactor®

Crosby

The problem with fake Crosby shackles has actually been around for quite a while, but companies are still finding these shackles in their inventories. I thought I’d put this out there again and make sure we are still thinking about it.

Additionally, this might be a good time to verify your other lifting gear is meeting your specs.

– Are we using trusted suppliers?

– Are we researching the equipment and making sure there are no safety recalls issued?

– Do you have a program in place to periodically check for safety bulletins in your departments?

Go that extra step to make sure we are giving our teams the very best equipment, and helping them properly maintain it.

Worlds Easiest Equipment Troubleshooting Chart

Posted: March 21st, 2016 in Equipment/Equifactor®

 

 

EngineeringFlowchart

I can’t tell you how many times I used this method in the Navy. Just substitute “EB Green” for “Duct Tape.”  Wasn’t a great permanent fix, though.

We use a slightly more comprehensive set of troubleshooting charts in our Equifactor® Equipment Troubleshooting courses!

Equipment Failure: Washington Metro Shutdown for Emergency Maintenance

Posted: March 18th, 2016 in Accidents, Equipment/Equifactor®

Metro

 

How much does an equipment failure cost? Washington Metro, after having a repeat failure on power distribution jumpers (2 in the past year, with one fatality), decided to shutdown the entire Metro system for a full day. Lost revenue (counting only lost fares) is estimated to be $2 million. This doesn’t count inspectors’ pay, cable replacements, etc.
Effective root cause analysis is critical to maintaining equipment reliability. It’s not good enough to have equipment fail, and then just replace the equipment. Your RCA must look at other possible human performance issues:

– Maintenance procedures
– Inspection periodicity
– Inspection requirements and procedures
– Inspector training
– Reasons for having a repeat of a supposedly corrected failure
– Generic cause analysis

These are the types of things that must go into an equipment failure analysis. Repeat failures cost money, convenience, and possibly lives.

Friday Joke: Equipment Troubleshooting Flowchart

Posted: March 11th, 2016 in Equipment/Equifactor®, Jokes, Pictures

EngineeringFlowchart

This works great for me at home.

Air Compressor Maintenance Tips

Posted: March 10th, 2016 in Equipment/Equifactor®

compressor

Here are some simple tips to protect your investment, whether it is an industrial machine or the compressor in your garage.  Simple maintenance can prevent costly failures and analyses in the future.

Centrifugal Pump Reliability – Heinz Bloch Tips

Posted: March 4th, 2016 in Equipment/Equifactor®

Centrifugal

Here’s a great article by Heinz Bloch on centrifugal process pump reliability. His tips include purchasing strategies, operational considerations, installation ideas, and maintenance requirements. Always a pleasure to read his tips!

 

Equipment vs. Human Performance Failures in Aircraft Accidents

Posted: February 23rd, 2016 in Accidents, Equipment/Equifactor®

sw airlines

Here’s a good discussion of the causes of airline accidents. As aircraft reliability and maintenance practices have improved over the years, the leading cause of aircraft accidents has shifted dramatically away from parts failures and toward human mistakes. Yet, polls have shown that most people think that aircraft accidents are usually caused by a mechanical breakdown.
It’s important to consider the human element whenever we assume a mechanical failure. Make sure you’re looking deeply enough into an equipment malfunction and make sure you understand, even when equipment does fail, how the human was involved.

Equipment Failure Risks Injuries

Posted: February 16th, 2016 in Accidents, Equipment/Equifactor®

Here’s another quick verdict of “crane failure.” I’m guessing the hoist was not designed to fail in this scenario! We probably need to look a little deeper at what allowed this hoist to fail. What safeguards do you think should have been in place here?

Meteorite Casualty: Natural Disaster in TapRooT® Root Cause Analysis

Posted: February 8th, 2016 in Accidents, Root Cause Analysis Tips

meteor

Photo of meteor from Chelyabinsk, Russia in 2013

If confirmed, here is a link to the first recorded fatality due to a meteorite strike in modern history. This would be one of the few appropriate uses of the Natural Disaster category on the Root Cause Tree®.

When doing a root cause analysis using TapRooT®, one of the top-level paths you can follow can lead you to Natural Disaster as a possibility. We note that this doesn’t come up very often. When you go down this path, TapRooT® makes you verify that the problem was caused by a natural event that was outside of your control.

I have seen people try to select Natural Disaster because there was a rainstorm, and a leak in the roof caused damage to equipment inside the building. Using TapRooT®, this would most likely NOT meet the TapRooT® Dictionary® definition of Natural Disaster. In this case, we would want to look at why the roof leaked. There should have been multiple safeguards in place to prevent this. We might find that:

The roofing material was improperly installed.
We do not do any inspections of our roof.
We have noted minor water damage before, but did not take action.
We have deferred maintenance on the roof due to budget, etc.

Therefore, the leaky roof would not be Natural Disaster, but a Human Performance issue.

The case of the meteorite strike, however, is a different issue. There are no reasonable mitigations that an organization can put in place that would prevent injury due to a meteorite. This is just one of those times that you verify that your emergency response was appropriate (Did we call the correct people? Did medical aid arrive as expected?). If we find no issues with our response, we can conclude that this was a Natural Disaster, and there are no root causes that could have prevented or mitigated the accident.

Equipment Failure: Blackout for 46,000 Residents

Posted: February 8th, 2016 in Equipment/Equifactor®

Blackout

Here’s another example of generic “equipment failure.” Not a lot of details, but I’m pretty sure the substation was not designed to fail. We should look at not just the equipment, but what additional safeguards are in place to prevent a single-point failure from blacking out a large section of a city.
Again, we don’t have details yet, but the label of “equipment failure” should make you think about digging a little deeper.

Equipment Failure? Parachuting Accident

Posted: February 5th, 2016 in Accidents, Equipment/Equifactor®

formation

I’m going to be bringing you some examples of accidents and problems that are quickly listed as “equipment failure.” Take a look at these problems and ask yourself:

– Is this really an equipment problem?

– Have we looked deep enough into the actual reason that the equipment did not work as intended?

– Were there any safeguards that were in place that failed, or should have been in place and were not?”

Here’s an example that is just quickly labeled “equipment failure”. List the safeguards that you think should have been in place (and maybe were, maybe weren’t) to prevent the accident’s outcome.

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