Category: Presentations

Jeff Skiles – Co-Pilot of “Miracle on the Hudson” Landing – To Tell His Story at the Summit

September 7th, 2010 by

Skiles Jeff-1

I just got off the phone with Jeff Skiles who was the co-pilot of the US Airways flight that made an emergency landing in the Hudson River. It was a flight that could have had a tragic end but instead, everyone made it off the plane. After the conversation, I know we are going to have another great Keynote Speaker at the Summit.

Jeff said that he tells his story but provides some of the behind the scenes information that most people don’t know about. Information that helped them be successful that day but also might help you at your facility. The lessons aren’t just about aviation. They can be applied in any industry where things can go wrong and consequences can be severe.

So make sure that when you plan your trip, you plan to stay until the end of the Summit to hear Jeff’s talk. He’ll be speaking from 10:35-11:55 (followed by the TapRooT® Summit Charity Golf Tournament).

For the complete Summit schedule, see:

http://www.taproot.com/summit.php?t=schedule

Mark’s Talk About the Heinrich Pyramid (Safety Pyramid) at the European Safety Committee of the Conference Board

June 1st, 2010 by

That’s me and the interested participants at the Conference Board…

P1020056.JPG

Below is a copy of a PDF of the PowerPoint that I used.

ConfBoardPrint2.pdf

BP/Tranocean Rig BOP Failure: The Smoking Gun Paper

May 7th, 2010 by

Little is known (or at least has been released) about the actual failure of the Blowout Preventer on the Deepwater Horizon. However, a technical paper (2003) has surfaced that may be a “smoking gun” if it is found that maintenance was deferred on the BOP to reduce costs of drilling.

Here’s a link to the paper (Earl Shanks, Transocean, presented at the Offshore Technology Conference, 2003):

BOPReliabilityPaper.pdf

Here’s one of the “smoking gun” quotes:

Because of the pressure on getting the equipment back to work, root cause analysis of the failure is generally not performed.”

Ah … a failure to perform root cause analysis to save time (and big bucks) during drilling.

Another quote:

In general, operating reliability (of the BOP) is maintained on rigs mostly through regular maintenance intervals rather than specifying a reliability of a system or a component to minimize maintenance.”

The article also said:

“… this is a very expensive approach, and it is also an opportunity to introduce human error into the system.”

Most of the paper is about ways to improve the design and reliability of Blowout Preventers. But the vultures are circling. And the smoking gun quotes above will mean trouble if it is found that any maintenance was skipped or if the BOP had a poor reliability record.

If maintenance was skipped and/or if the BOP had a poor reliability record, you will hear the cry that BP is once again trading lives (as at the BP Texas City explosion) and the environment (as at the corrosion related oil leaks in their pipeline at Prudhoe Bay). Actually, many don’t need evidence. They will start saying it already!

Could these Answers Affect your Investigations – Live Q&A Session with OSHA

April 29th, 2010 by

This is a link to an April 26 chat session with OSHA. Interesting answers.

http://www.dol.gov/regulations/chat-osha-201004.htm

Here is just one question and answer:

[Comment From Greg Hellman, BNAGreg Hellman, BNA: ]
OSHA has placed an injury and illness prevention program rule on its agenda for the first time. Could such a rule address musculoskeletal disorders in some way?
Monday April 26, 2010 1:27 Greg Hellman, BNA
1:27

David (OSHA):
The i2p2 standard is not a substitute for other OSHA standards. It provides a mechanism to achieve the culture change needed in this country to effectively address workplace safety and health issues. It will be the employer’s responsibility to identify all hazards in their workplace, which may include ergonomics, falls, amputations, electrocutions, work-related respiratory disease (such as occupational asthma), etc. The i2p2 standard simply provides a mechanism for employers to identify hazards; however, the control of those hazards will be required by existing OSHA standards and the general duty clause, as is currently the case.

New Approach to Root Cause Analysis Can Help Clear Up Misconceptions

April 26th, 2010 by

Quality Progress Magazine published a new article written by System Improvements’ President, Mark Paradies which can be read on the Quality Progress website: http://www.asq.org/quality-progress/2010/04/quality-tools/under-scrutiny.html

You don’t have to be a member to access the article — free registration allows you access to ASQ’s “open-access” articles and case studies.

You can also find this article on page 32 of the April edition of Quality Progress magazine.

Article highlights:

• Cause and effect analysis has inherent limitations that may result in root cause analysis misconceptions and hinder problem-solving efforts.

• Problem solvers need help analyzing human performance issues.

• A new definition of root cause could help people realize a systematic process beyond cause and effect is needed for root cause analysis.

Monday Accident & Lessons Learned: TN OSHA Fatality Investigations

October 12th, 2009 by

“Lessons from TN OSHA Fatality Investigations” was a best practice session presented by Steve Hawkins at the 2009 TapRooT® Summit.


Taproot part 1 Hawkins

Keys to Successful Safety Culture Change

October 11th, 2009 by

“Keys to Successful Safety Culture Change” was a best practice session presented by Michele Lindsay and Mike Kelly at the 2009 TapRooT® Summit.


Keys to Successful Safety Culture Change

Healthcare Root Cause Analysis Presentations: CSI Stanly

October 11th, 2009 by

“CSI Stanly” was a 2009 TapRooT® Summit best practice session presented by Debra Smith.



CSI_Stanly

Ideas for Reliability Improvement

October 11th, 2009 by

“Ideas for Reliability Improvement” was a best practice session presented by Tim Thompson at the 2009 TapRooT® Summit .


TapRoot2009Presentation1

Persistent Equipment Failures and their Solutions

October 11th, 2009 by

“Persistent Equipment Failures and their Solutions” was a best practice session presented by Ken Bloch at the 2009 TapRooT® Summit.


KBloch TapRooT 2009

How to Become Best in Class in Equipment Reliability by Maximizing Uptime

October 11th, 2009 by

“How to Become Best in Class in Equipment Reliability by Maximizing Uptime” was a best practice session presented by Heinz Bloch at the 2009 TapRooT® Summit.


TapRooT Summit Nashville 2009_2_

Spanish Track at the 2009 TapRooT® Summit

October 9th, 2009 by

Here are best practice presentations from the Spanish speaking Track at the 2009 TapRooT® Summit.

From presenter, Marco Flores:


analis de tendencias avanzado A Marco Flores


AUDITORIAS DISPARADAS POR TAPROOT®

From presenter, Piedad Colmenares:


SESION MEJORES PRACTICAS


HERRAMIENTAS PARA EL DESARROLLO DE ACCIONES Piedad Colmenares CORRECTIVAS Piedad Colmenares

From presenter, Jose Grisi:


jgf_De la Intención a la Acción

How Fatigue Impacts Human Error

October 9th, 2009 by

“How Fatigue Impacts Human Error” was a best practice presentation presented by Bill Sirois at the 2009 TapRooT® Summit.


Impact on Fatigue on Behavior and Human Error

How to Prove Fatigue was the Cause of an Accident

October 9th, 2009 by

“How to Prove Fatigue was the Cause of an Accident” was a best practice presentation presented by Bill Sirois at the 2009 TapRooT® Summit.


2009 Taproot Presentation

Implementing TapRooT® Across Sisters of Mercy Health System

October 9th, 2009 by

“Implementing TapRooT® Across Sisters of Mercy Health System” was a 2009 TapRooT® Summit best practice session presented by Susan Sinclair.


TapRooT_Presentation_compressed _2

Using TapRooT® to Review Emergency Drills

October 9th, 2009 by

“Using TapRooT® to Review Emergency Drills” is a 2009 TapRooT® Best Practice Presentation presented by Heidi Reed.


Getting_Ahead_of Hindsight

Combine a Super Resume with Social Networking to Find Your Next Job

October 9th, 2009 by

“Combine a Super Resume with Social Networking to Find Your Next Job” was a 2009 TapRooT® Summit best practice session presented by Barb Phillips.


Social_Media_ Presentation

Troubleshooting Plant Process Upsets

October 9th, 2009 by

“Troubleshooting Plant Process Upsets: The Application of Customizable Equifactor® Troubleshooting Tables to Capture the Knowledge of Your Sages and Wiz Kids” was a best practice session presented by Jason Laws at the 2009 TapRooT® Summit.


Troubleshooting Plant Process Upsets

What is Your Career Plan?

October 9th, 2009 by

“What is Your Career Plan?” was a 2009 TapRooT® Summit best practice session presented by Dave Janney.


What_is_your_career_plan

Making a Business Case for Improvement

October 9th, 2009 by

“Making a Business Case for Improvement” was a presentation by Dave Janney at the 2009 TapRooT® Summit.


Making_a_Business_Case_for_Improvement

Finding Time for Process Excellence – No Fuel, No Progress

October 9th, 2009 by

“Finding Time for Process Excellence – No Fuel, No Progress” was presented by Kevin McManus at the 2009 TapRooT® Summit.


Finding_Time_for Improvement_Presentation

What’s New in the ISO 31000 Risk Management Standard

October 8th, 2009 by

Here is Jim Whiting’s presentation for “What’s New in the ISO 31000 Risk Management Standard” from the 2009 TapRooT Summit.

(Color version)


What’s New in the ISO 31000 Risk Management Standard

(Black and white version)


What’s New in the ISO 31000 Risk Management Standard B&W

Pursuit of World Class EH&S

October 8th, 2009 by

“Pursuit of World Class EH&S” was a 2009 TapRooT® Summit best practice session presented by Dennis Osmer.


Pursuit of World Class EH&S

8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement

October 8th, 2009 by

“8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement” was presented by Kevin McManus at the 2009 TapRooT® Summit.


8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement

Practical Tools to Stop Worker Error

October 8th, 2009 by

2009 TapRooT® Summit best practice session “Practical Tools to Stop Worker Error” presented by Ralph Brickey, Jeff Hubbart and Chris Vallee. (Click the “Full Screen” button at the top right of the document to view the document in its entirety.)


Practical Tools to Stop Human Error

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