Category: Accidents

Stop the Sacrifices

July 30th, 2015 by

NewImage

Over a decade ago, I wrote this article to make a point about stopping construction fatalities. I’ve reposted it because it is missing from the archives. Does it still apply today? Perhaps it applies in many other industries as well. Let me know by leaving a comment.

StopSacrifices.pdf (click to open the pdf)

When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?

July 29th, 2015 by

NewImage

I think we all agree that a fatality is a very unfortunate event. But it may not be a criminal act.

When one asks after an accident if a crime has been committed, the answer depends on the country where the accident occurred. A crime in China may not be a crime in the UK. A crime in the UK may not be a crime in the USA. And a crime in the USA may not be a crime in China.

Even experts may disagree on what constitutes a crime. For example, University of Maryland Law Professor Rena Steinzor wrote an article on her blog titled: “Kill a Worker? You’re Not a Criminal. Steal a Worker’s Pay? You Are One.” that her belief is that Du Pont and Du Pont’s managers should have faced criminal prosecution after an accident at their LaPorte, Texas, facility. She cited behavior by Du Pont’s management as “extraordinarily reckless.”

OSHA Chief David Michaels disagrees with Professor Steinzor. He is quoted in a different article as saying during a press conference that Professor Steinzor’s conclusions and article are, “… simply wrong.”

The debate should raise a significant question: Is making an accident – especially a fatal accident – a corporate crime a good way to change corporate/management behavior and improve worker safety?

Having worked for Du Pont back in the late 1980’s, I know that management was very concerned about safety. They really took safety to heart. I don’t know if that attitude changed as Du Pont transformed itself to increase return on equity … Perhaps they lost their way. But would making poor management decisions a crime make Du Pont a safer place to work?

Making accidents a crime would definitely making performing an accident investigation more difficult. Would employees and managers cooperate with ANY investigation (internal, OSHA, or criminal) IF the outcome could be a jail sentence? I can picture every interviewee consulting with their attorney prior to answering an investigator’s question.

I believe the lack of cooperation would make finding and fixing root causes much more difficult. And finding and fixing the root causes of accidents is extremely important when trying to improve safety. Thus, I believe increased criminalization of accidents would actually work against improving safety.

I believe that Du Pont will take action to turn around safety performance after a series of serious and sometimes fatal accidents. I think they will do this out of concern for their employees. I don’t think the potential for managers going to jail would improve the odds that this improvement will occur.

What do you think? Do you agree or disagree. Or better yet, do you have evidence of criminal proceedings improving or hindering safety improvement?

Let me know by leaving a comment below.

 

Monday Accident and Lessons Learned: FAA Lessons Learned from Transport Airplane Accidents

July 20th, 2015 by

NewImage

What can you learn from transport aircraft accidents? See the FAA Lessons Learned from Transport Plane Accidents page and find out. See:

http://lessonslearned.faa.gov/index.cfm

Monday Accident & Lessons Learned: Graniteville Train Accident

July 13th, 2015 by

Have you ever seen this video about the 2009 train derailment in Graniteville, SC? 

Could have we learned these lessons before people were killed?

What were the Safeguards?

July 9th, 2015 by

I love to use Safeguard Analysis to examine incidents and determine Causal Factors. 

What were the Safeguards keeping this officer safe and how did they fail? (A failed Safeguard is usually a Causal Factor.)

Watch and leave a comment about your ideas …

Robot Made a Human Error and a Worker was Killed

July 8th, 2015 by


_83994885_getty_robot_pic

The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.

A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.

Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?

http://www.bbc.co.uk/newsbeat/article/33359005/man-crushed-to-death-by-robot-at-car-factory

 

Monday Accident & Lessons Learned: Lessons Learned from 5 Chemical Accidents

July 6th, 2015 by

Lessons learned from five accidents reported by EU and OECD Countries. See:

http://ec.europa.eu/environment/seveso/pdf/mahb_bulletin2.pdf

Read insights on lessons learned from accidents reported in the European Major Accident Reporting System (eMARS) and other accident sources.

47 accidents in eMARS involving contractor safety issues in the chemical or petrochemical industries were examined. Five accidents were chosen on the basis that a contract worker was killed or injured or was involved in the accident.

What do you think? Leave your comments below.

BP to Pay $18.7 Billion for Environmental Damage Caused by the Deepwater Horizon Oil Spill

July 3rd, 2015 by

It is the largest environmental settlement ever.

BP will pay the US Government,Alabama, Florida, Louisiana,Mississippi, and Texas $18.7 billion to compensate for environmental damage done by the Deepwater Horizon spill.

For more info, see: http://www.nytimes.com/2015/07/03/us/bp-to-pay-gulf-coast-states-18-7-billion-for-deepwater-horizon-oil-spill.html?emc=edit_th_20150703&nl=todaysheadlines&nlid=60802201&_r=0

Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

Monday Accident & Lessons Learned: Broken Leg caused by Fall From Ladder Cost Company $2.4 Million

June 29th, 2015 by

The Chicago Tribune reported “Fall from ladder nets Merrillville man $2.4 million jury verdict.”

Part of the reason that the company was found liable is that the ladder was “out of code.” It had been produced before standards for ladders were developed. 

Have any old ladders out there that need to be replaced?

Monday Accident & Lessons Learned: Complacency?

June 22nd, 2015 by

Is thinking that you are the best a sign of potential problems? (Especially for “routine” work?)

By any measure, the X-31 was a highly successful flight research program at NASA’s Dryden Flight Research Center, now the Armstrong Flight Research Center. It regularly flew several flights a day, accumulating over 550 flights during the course of the program, with a superlative safety record. And yet, on Jan. 19, 1995, on the very last scheduled flight of the X-31 ship No. 1, disaster struck.

View the video below or read about it here:  http://www.nasa.gov/centers/dryden/news/X-Press/stories/2004/013004/new_x31.html

Leave your comments below. Complacency? Leave your comments below.

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

Monday Accident & Lessons Learned: Forklift Accident

June 15th, 2015 by

A tragic workplace accident.

A life lost.

You see the resolve on the faces in this video to never lose a co-worker … a friend … to this type of accident again.

What do you think about “paying attention” for preventing potential tragedies such as this?  Leave your comments below and let’s share ideas to find and fix root causes.

Monday Accident & Lessons Learned: Fire Truck Accident & Lessons Learned

June 1st, 2015 by

What do you think of this accident investigation and lessons learned?

Monday Accident & Lessons Learned: 1964 Army Aviation Accident Lessons Learned

May 25th, 2015 by

What can you learn from a 1964 video?

How they viewed human performance was certainly different.

What do we know that helps us do better today?

Could better root cause analysis have helped them then? After all, an engine failure in a helicopter is a serious accident to blame on the pilot.

Monday Accident & Lessons Learned: Hunting Accident

May 19th, 2015 by

Could root cause analysis help learn more from this accident? How about a Safeguards Analysis before you hunt?

FASTEST WAY TO GET FIRED

May 14th, 2015 by

pablo(1)

When a major accident happens, look out. The tradition is for “heads to roll.”

That’s right, people get fired.

Who get’s fired? Those that are seen as “part of the problem.”

You need to be part of the solution.

How?

Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.

Then you are part of the answer … Not part of the problem.

Or you could just sit around and wait to get fired.

The choice is yours.

Get trained to use TapRooT® root cause analysis to solve problems. See:

http://www.taproot.com/courses

Monday Accident & Lessons Learned: Root Cause Analysis Failure at Blue Bell Ice Cream?

May 11th, 2015 by

NewImage

I read an article in the Houston Chronicle about failed corrective actions at Blue Bell® Ice Cream.

It made me wonder:

“Did Blue Bell perform an adequate root cause analysis?”

Sometimes people jump tp conclusions and implement inadequate corrective actions because they don’t address the root causes of the problem.

Its hard to tell without more information, but better root cause analysis sure couldn’t have hurt.

Find out how TapRooT® Root Cause Analysis can help find and fix the root causes of problems by reading about TapRooT®’s history at:

http://www.taproot.com/products-services/about-taproot

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski

Medical

Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed

Equifactor®

Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

An improvement plan was developed and implemented. Elements of the improvement plan included process…

Exelon Nuclear

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

Hydro One
Contact Us