April 7, 2006 | Mark Paradies

Summit Report – Friday Morning

2006 Summit

What a day! (Thursday)

I made my first posting yesterday (Wednesday) and never got a chance to make another posting.

Right now I’m trying to get this written before Bob Nelson talks about rewarding employees.

Yesterday I started out giving a talk on human performance models and then Jim Whiting challenged people to STOP staying that they “are safe” or that they support “safety at any cost” and start recognizing that ALL human activity has some amount of RISK. We must assess the risk, manage the risk, decide which risks are unacceptable, …

Next I was the speaker at a session about Critical Human Action Profile and analyzing human error. We looked at a fairly simple valve mis-positioning error using CHAP and Reason’s Model of Slips-Lapses-Mistakes. This “simple” error was one of the major contributors to the Giant Refinery fire. Who would have thought that a simple errors could have ignited the spirited discussion that we had about the RIGHT way to lock out and drain a pump!

After another great lunch, I went to two talks on investigations. One was by Steve Hawkins of TN OSHA about lessions learned from fatality investigations. The next was Mark Kaszniak, a Chemical Safety Board investigator. He talked about the BP Texas City Explosion. After Mark finished talking, I started thinking that the BP Texas City Refinery disaster could have happened to anyone in the refining industry (I’ll write more about this if I get the chance next week).

Next, was an outstanding session on best practices used by TapRooT(R) Users to investigate problems. First four users shared best practices from their facilities. Then all the attendees in the breakout (about 80) got together in groups of 10 and compared best practices at their sites. They then selected a best practice from their group and shared it with the rest of the groups.

Then we went back to hear a keynote speaker – Mike Kelley, VP of TODCO. What an inspiring talk about a Vision for Corporate Improvement! You could feel the emotion, sincerity, and commitment in his voice.

Then there was a Panel Discussion. Topic? “What is the most important factor in leading an investigation.” Each of six panelists (Mark Kaszniak, Ken Turnbull, Brian Locker, Steve Hawkins, Jim Whiting, and Mike Kelley) had to pick one factor that they deemed “Most Important” and explain in five minutes or less WHY they thought it was most important. They then answered questions from the attendees about their opinions. … It turned out to be quite thought provoking.

That was the end of the official day. But I was immediately drawn into a conversation that lasted for an hour. We retired to the hotel’s lobby bar for further discussions that lasted almost two hours until karaoke started. With about 60 Summit attendees in the bar, the party started. We had great fun and more discussions of a wide range of topics. It was 11 PM when I decided that I needed sleep and, for me, the fun had to end.

What a day!

I’ll try to sum up Friday when I get a chance and also post some of the papers presented by the speakers.



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