Jeff's Programs
Deepwater Horizon Oil Spill in the Gulf of Mexico
(1.25 Hours)
This Presentation reviews the actions of the operators of the oil rig and the engineering support staff as they designed and drilled the well that eventually led to the largest offshore oil spill. This focus is upon:
• How a team of people get use to a very hazardous environment that is right below their feet
• The real forces of time, money, and schedule, and the short-sighted decisions that are made when under pressure
• The importance of sharing Operating Experience
• The necessity of a strong regulator when a money-making operation is performing hazardous work
Onagawa Response to the Great Japan Earthquake and Tsunami
(1 Hour)
On 3/11/2011, the Onagawa Nuclear Power Plant was the closest to the 9.1 Magnitude Earthquake and Tsunami that caused the meltdowns at the Fukushima Daichi Nuclear Power Plant. However, the damage was mitigated and the reactors were saved by design decisions and made years prior and the teamwork of the operators combatting the casualty. This presentation will show:
• How design decisions and the extra design margin afforded during the construction of the plant saved them from a catastrophic event
• The heroic actions of the plant operators during the event
• The current state of Japanese Nuclear Power and the recovery that the Onagawa Plant is making to return to operations
Upper Big Branch Mine Explosion (1 hour)
Upper Big Branch Mine Explosion (1 hour)
On the day after Easter in 2010, the Upper Big Branch Mine exploded, resulting in the death of 29 miners during a routine shift change. Despite a safety culture, production pressures caused shortcuts. We will explore:
• Our ISQO Safety Culture, and if we would choose to be less than truthful to maintain production
• The importance of maintenance on routinely used equipment, especially that equipment that makes the money…. balancing production vs. production capability
• How we need each other to maintain our safety awareness
Space Shuttle Challenger Accident
(1.5 Hours)
Space Shuttle Challenger Accident (1.5 Hours)
The most complex engineering equipment going into the most extreme environment developed by a top-notch engineering organization was declared as operational, not developmental, and resulted in the loss of 7 lives and the shock of a nation. Although several engineers tried to stop the launch on its eve, the organization moved forward, resulting in tragedy.
• The Paradigms we develop because of our work and how they focus our decisions
• The Normalization of Deviation causes us to accept a poor design
• How our Engineering Society affects our decisions
• The need to have room for “gut” level decisions when the data is incomplete
• How material is presented will affect a decision
Space Shuttle Columbia
(1.5 Hours)
This Presentation will look at a lesson that was learned twice, and how upon the second lesson, it was finally learned. Following Challenger, the Space Shuttle Program learned its lesson and improved the power of the Quality Control organization and made important changes to the communication within the organization. As time went by, the production pressures returned in an environment of budget cutting, and the management team became stressed beyond the point of looking and listening for safety signals within the organization. Unfortunately, this accident was a contributor in the retirement of the Space Shuttle Program.
• Complex systems fail in complex ways, and simple explanations of failure are not helpful
• The Paradigm contained in the initial design is difficult to change as a product matures
• Repetitive problems become organizational norms that become discounted with tragic effects
• The Procedures in an organization are no substitute for Engineering Rigor
• The “Engineering Manager” is no oxymoron, but rather the best technician and the best leader
Boeing 737 8 Max
(1 Hour)
Market forces are always in play when a for-profit business is working with an unforgiving technology. In the airlines business, they are trying to make money by defying gravity. In our business, we harness the incredible power of the atom. Both defy natural physics, and need to be done safely, to serve the interest of the public. This presentation will explore:
Complex systems fail in complex ways, and simple explanations of failure are not helpful
• Design changes and their impact to equipment operation
• The market pressures that impact engineering decisions
• The engineering processes that help us drive towards safety
• How you can be safe in “unthinkable” situations
Chernobyl Nuclear Accident
(1.5 Hours)
An accident is defined as “an unfortunate event that has unexpected and unfortunate consequences.” The most devastating Nuclear accident in the history of the world will be explored and the steps/events that led to the accident. In addition, we will ask the question “what were they thinkin’” and what did the operators not know about their reactor design that would have been helpful. The lack of an open society and the need to “keep secrets” for fear of consequences for their mistakes were contributing factors that will be examined.
Volkswagen Emissions Scandal
(1.25 hours)
In this seminar, we will look at a corporate culture at VW that drove employees, working feverishly in pursuit of difficult sales targets, towards illegal methods. Unable to build cars that could meet emissions standards in the United States, engineers felt they were left with no choice but to cheat. Volkswagen then compounded the fraud by spending millions marketing "clean diesel", only to have the lie exposed by a handful of researchers on a shoestring budget, resulting in years of cover-up followed by a guilty plea to criminal charges in a landmark Department of Justice case.