There are four best practice entries published on this weblog in the success story contest (view all entries here).  Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner.  In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.

Entry #2:  Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

Submitted by: James Watson, Regional Specialist, System Safety Branch
FAA, Alaska

Challenge

TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors to cause a future accident.

Action

These factors that the thorough analysis of TapRooT® helped identify are included in the presentation to management at the end of the talk (after the root cause analysis and corrective actions have been reviewed). This review includes explaining and discussing each of these potentially adverse factors with management. At a minimum, management is aware of these potentially adverse factors and the review often leads to discussion of additional corrective actions to address these issues.

Result

Accidents that might have happened are avoided by implementing corrective actions for problems identified during a root cause analysis that didn’t cause that accident but could have cause additional accident and were corrected by proactive corrective actions.