Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis: As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond. You […]
Read MoreThe Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is: Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish? After all, they knew who the CO, XO, and Command Master Chief […]
Read MoreAs a root cause analysis expert and former US Navy Officer who was qualified as a Surface Warfare Officer (SWO) and was qualified to stand underway steaming Officer of the Deck watches, I’ve had many friends ask me what was the root cause of the collision of the USS Fitzgerald. Of course, the answer is […]
Read MoreVideo of an Accident in 1969 I was still in high school when this accident happened… But the accident seems strikingly similar to more recent accidents where junior officers made mistakes in the middle of the night resulting in ships colliding. Common Factor: Discipline What is one of the US Navy’s swiftest actions after a […]
Read MoreSome Things Never Change Every year, some of the lessons I learn at the Summit are repeats. Just because they are repeated lessons doesn’t mean they aren’t important. I think of them as reinforcement of important lessons learned. Read the following sections about lessons relearned at the 2023 Summit and see if you agree… Specific […]
Read MoreWhat To Do Before Starting a Major Accident Investigation? Having a major accident at your company is a nightmare. But it is even worse if you are assigned to lead a major accident investigation. What do you do??? This post explains: What is a major accident? When do you start planning? How do you handle […]
Read MoreDo You Make Conservative Decisions? Learn How… Conservative Decision Making … often people take shortcuts and make non-conservative decisions to save time or moneyn when faced with a tough decision. Incident investigators often find non-conservative decisions after major accidents. For example the: BP Deepwater Horizon well blowout and explosion Chernobyl reactor core meltdown Shuttle disasters […]
Read More2020 & 2021 Were Tough – How Will 2022 Be? If you would have asked me in 2019 how the next two years would turn out, I couldn’t have come close to guessing how rough the years would be. That’s why I think everyone needs to be revitalized, refreshed, and motivated in 2022 to make […]
Read MoreWhat is a Weak Signal? Weak Signals … What are they? There are many articles that define the term weak signals. Here are two… EHS Today Terry Mathis – Safety & Performance Excellence: Weak Signals…“… being sensitive to subtle and less obvious aspects of safety.” SITRAMikko Dufva – What is a weak signal?A weak signal […]
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