Wow. Quite an eye-opening Washington Post article describing a report published in the BMJ. A comprehensive study by researchers at the John Hopkins University have found that medical mistakes are now responsible for more deaths in the US each year than Accidents, Respiratory Disease, and Strokes. They estimate over a quarter million people die each year in the US due to mistakes made during medical procedures. And this does NOT include other sentinel events that do not result in death. Researchers include in this category “everything from bad doctors to more systemic issues such as communication breakdowns when patients are handed off from one department to another.” Other tidbits from this study:
- Over 700 deaths each day are due to medical errors
- This is nearly 10% of all deaths in the US each year
What’s particularly alarming is that a study conducted in 1999 showed similar results. That study called medical errors “an epidemic.” And yet, very little has changed since that report was issued. While a few categories have gotten better (hospital-acquired infections, for example), there has been almost no change in the overall numbers.
I’m sure there are many “causes” for these issues. This report focused on the reporting systems in the US (and many other countries) that make it almost impossible to identify medical error cases. And many other problems are endemic to the entire medical system:
- Insurance liabilities
- Inadequate reporting requirements
- Poor training at many levels
- Ineffective accountability systems
- between patient care and running a business
However, individual health care facilities have the most control over their own outcomes. They truly believe in providing the very best medical care to their patients. They don’t necessarily need to wait for national regulations to force change. They often just need a way to recognize the issues, minimize the local blame culture, identify problems, recognize systemic issues at their facilities, and apply effective corrective actions to those issues.
I have found that one of the major hurdles to correcting these issues is a lack of proper sentinel event analysis. Hospitals are staffed with extremely smart people, but they just don’t have the training or expertise to perform comprehensive root cause analysis and incident investigation. Many feel that, because they have smart people, they can perform these analyses without further training. Unfortunately, incident investigation is a skill, just like other skills learned by doctors, nurses, and patient quality staff, and this skill requires specialized training and methodology. When a facility is presented with this training (yes, I’m talking about TapRooT®!), I’ve found that they embrace the training and perform excellent investigations. Hospital staff just need this bit of training to move to the next level of finding scientifically-derived root causes and applying effective corrective actions, all without playing the blame game. It is gratifying to see doctors and nurses working together to correct these issues on their own, without needing some expensive guru to come in and do it for them.
Hospitals have the means to start fixing these issues. I’m hoping the smart people at these facilities take this to heart and begin putting processes in place to make a positive difference in their patient outcomes.
“We are going to find out who is to blame because that is the frustrating part about health and safety accidents such as this. When we go back, when we read the report, we find out each and every time that it was preventable. That’s why we need to learn from this,” Kevin Flynn, Ontario’s labour minister, told reporters Tuesday afternoon.
That’s a quote from CP 24, Toronto’s Breaking News. See the story and watch the video interview about the accident here:
Is there a lesson to be learned here?
Interestingly, the “contractor” performing the work in this accident was a branch of the Ontario government.
On April 3rd, an Amtrak passenger train collided with a backhoe that was being used by railroad employees for maintenance. Two maintenance workers were killed, and about 20 passengers on the train were injured. For those that are not familiar with the railroad industry, I wanted to discuss a system that was in place that was designed to help prevent these types of incidents.
Many trains are being back-fitted with equipment and software that is collectively known as positive train control (PTC). These systems include sensors, software, and procedures that are designed to help the engineer safely operate the train. It is designed to allow for:
- Train separation and collision avoidance
- Speed enforcement
- Rail worker safety
For example, as the train approaches a curve that has a lower speed limit, a train with PTC would first alert the engineer that he must reduce speed, and then, if this doesn’t happen, automatically reduce the speed or stop the train as necessary to prevent exceeding tolerance. Another example is that, if maintenance is known to be occurring on a particular section of track, the train “knows” it is not allowed to be on that particular section, and will slow / stop to avoid entering the restricted area. The system can be pretty sophisticated, but this is the general idea.
Notice that I described the system as a series of sensors, software, and procedures that make up PTC. While we can put all kinds of sensors and software in place, there are still procedures that people must follow for the system to operate properly. For example, in in order to know about worker safety restrictions on a particular piece of track, there are several things that must happen:
- The workers must tell the dispatcher they are on a specific section of track (there are very detailed procedures that cover this).
- The dispatcher must correctly tell the system that the workers are present.
- The software must correctly identify the section of track.
- The communications hardware must properly communicate with the train.
- The train must know where it is and where it is going.
- The workers must be on the correct section of track.
- The workers must be doing the correct maintenance (for example, not also working on an additional siding).
- If being used, local temporary warning systems being used by the workers must be operating properly. For example, there are devices that can be worn on the workers’ bodies that signal the train, and that receive a signal from the train.
- Proper maintenance must be performed on all of the PTC hardware and software.
As you can see, just putting a great PTC system in place involves more than just installing a bunch of equipment. Workers must understand the equipment, its interrelation with the train and dispatcher, how the system is properly initialized and secured, the limitations of the PTC system, etc. People are still involved.
For the Washington Amtrak crash, we know that there was a PTC system in place. However, I don’t know how it was being employed, if it was working properly, were all the procedures being followed, etc. I am definitely not trying to apportion any blame, since I’m not involved in the investigation. However, I did want to point out that, while implementation of PTC systems is long overdue, it is important to realize that these systems have many weak points that must be recognized and understood in order to have them operating properly.
Humans will almost always end up being the weak link, and it is critical that the entire system, including the human interactions with the system, be fully accounted for when designing and operating the system. Proper audits will often catch these weak barriers, and proper investigations can help identify the human performance issues that are almost certainly in play when an accident occurs. By finding the human performance issues, we can target more effective corrective actions than just blaming the individual. Our investigations and audits have to take the entire system into account when looking for improvements.
For the 25th year, the AFL-CIO has produced a report about the the state of safety and health for American workers. The report states that in 2014, 4,821 workers were killed on the job in the U.S., and approximately 50,000 died from occupational diseases. This indicates a loss of 150 workers each day from hazardous conditions.
READ the full report.
Read story here.
The following sequence is from the Clarence Bee …
First, an air conditioning unit for a power supply room failed.
No big deal … There’s an automatic backup and a system to notify the engineer.
Oops … It failed too.
Well, at least there is a local temperature alarm. The local maintenance guy will do the right thing … Right?
Sorry. In the “heat” of the moment, he pushed the “kill” button.
Unfortunately, this was for fire emergencies and it cut off all the power to the 911 system. And nobody knew how to reset it.
Finally, the tech rep from Reliance Electric arrived and the system was restored – 3.5 hours after the kill switch was pushed.
What can you learn from this incident?
- Do your people know what to do when things go wrong?
- Do you do drills?
- Are things clearly labeled?
- Are there response procedures?
- How long has it been since people were trained?
The CSB press release starts with:
“Washington, DC, April 13, 2016 – Offshore regulatory changes made thus far do not do enough to place the onus on industry to reduce risk, nor do they sufficiently empower the regulator to proactively oversee industry’s efforts to prevent another disaster like the Deepwater Horizon rig explosion and oil spill at the Macondo well in the Gulf of Mexico, an independent investigation by the U.S. Chemical Safety Board (CSB) warns.”
For the whole report, see:
On April 16, 1947, the Texas City Disaster occurred in the Port of Texas City. It is considered one of the deadliest industrial accidents in the U.S. history. This incident killed a minimum of 581 people and there were 8,485 victims. It even claimed some of the lives of the rescue workers. Because of this disaster it was the first time a class action lawsuit was filled against the United States government under the the Federal Tort Claims Act (FTCA).
The French-registered vessel SS Grandcamp that was docked in the Texas port caught fire. It was carrying 2,300 tons of ammonium nitrate, which is extremely explosive. Once the SS Grandcamp exploded it caused a chain-reaction of fires and explosions through out the port and other near by oil-storage facilities.
To read more about this disaster please click on the link below.
Did you know our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training is for those who want to learn the essential and advanced TapRooT® Techniques and to use the TapRooT® Software (by using it in training). TapRooT® can be used proactively before a major incident happens! Learn more about the 5-day at:
Press reports that the ex-CEO of Massey Coal faces a year in prison as a result of Upper Big Branch Mine explosion. As a CEO, putting the safety of your workers at risk to improve profits can be costly.
Here’s the article …
They have already fired the Commanding Officer … so don’t worry … they won’t start up gears without lube oil again. More video below.
If you are in the Navy … it looks like this!
Notice how happy sailors look when they aren’t to blame! (Bet they don’t look that happy on the bridge.)
Just needs some duct tape for repairs!
The following is the summary of a report from the UK Rail Accident Investigation Branch.
Serious accident involving a passenger trapped in train doors and
dragged at Clapham South station, 12 March 2015
At around 08:00 hrs on Thursday 12 March 2015, a passenger fell beneath a train after being dragged along the northbound platform of Clapham South station, in south London. She was dragged because her coat had become trapped between the closing doors of a London Underground Northern line train.
The train had stopped and passengers had alighted and boarded normally, before the driver confirmed that the door closure sequence could begin. The train operator, in the driving cab, started the door closure sequence but, before the doors had fully closed, one set encountered an obstruction and the doors were reopened. A passenger who had just boarded, and found that the available standing space was uncomfortable, stepped back off the train and onto the platform, in order to catch the following train. The edge of this passenger’s coat was then trapped when the doors closed again and she was unable to free it.
The trapped coat was not large enough to be detected by the door control system and the train operator, who was unaware of the situation, started the train moving. While checking the platform camera views displayed in his cab, the train operator saw unusual movements on the platform and applied the train brakes. Before the train came to a stop, the trapped passenger fell to the ground and then, having become separated from her coat, fell into the gap between the platform and the train. The train stopped after travelling about 60 metres. The passenger suffered injuries to her arm, head and shoulder, and was taken to hospital.
As a result of this accident, RAIB has made one recommendation, addressed to London Underground, seeking further improvements in the processes used to manage risks at the platform-train interface.
RAIB has also identified one learning point for the railway industry, relating to the provision of under platform recesses as a measure to mitigate the consequences of accidents where passengers fall from the platform.
For the complete report, see:
IOGP SAFETY ALERTDROPPED OBJECT: 1.3 POUND LINK PIN FELL 40 FEET
A drilling contractor was tripping pipe out of the hole and a link pin came loose from the hook, falling 40 feet (12.2 metres) to the deck below. The pin bounced and struck a glancing blow to the left jaw/neck area of a worker. The link pin is 1 inch by 5 inches (2.5cm x 12.7cm) and weighs 1.3 pounds (0.6 kg).
What Went Wrong?
The type of keeper pin used on the dropped object did not adequately secure the pin. The link pin is threaded and uses a cotter pin to prevent the pin body from backing out. The pin was secured with a coil “diaper pin” instead of a cotter pin.
Corrective Actions and Recommendations:
Safety pins that can be knocked out must not be used for lifting operations or securing equipment overhead.
Follow cotter pin installation guidelines:
- Both points on a cotter pin must be bent around the shaft.
- Cotter pins are a single-use instrument and should never be re-used.
safety alert number: 271
IOGP Safety Alerts http://safetyzone.iogp.org/
Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.
This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.
What’s worse than a fatal accident? A fatal accident followed by fatalities to first responders or rescuers.
Six rescuers were recently killed while trying to save 26 miners after a coal mine explosion in Russia. The rescuers were killed when the methane exploded again during their rescue attempt. See:
Can you learn something about your emergency response and rescue efforts from this example?
How much does an equipment failure cost? Washington Metro, after having a repeat failure on power distribution jumpers (2 in the past year, with one fatality), decided to shutdown the entire Metro system for a full day. Lost revenue (counting only lost fares) is estimated to be $2 million. This doesn’t count inspectors’ pay, cable replacements, etc.
Effective root cause analysis is critical to maintaining equipment reliability. It’s not good enough to have equipment fail, and then just replace the equipment. Your RCA must look at other possible human performance issues:
– Maintenance procedures
– Inspection periodicity
– Inspection requirements and procedures
– Inspector training
– Reasons for having a repeat of a supposedly corrected failure
– Generic cause analysis
These are the types of things that must go into an equipment failure analysis. Repeat failures cost money, convenience, and possibly lives.
Monday Accident & Lessons Learned: Report by UK RAIB – Serious accident as a passenger left a train and became trapped in the train doors at West Wickham station last AprilMarch 14th, 2016 by Mark Paradies
At around 11:35 hrs on 10 April 2015, a passenger was dragged along the platform at West Wickham station, south London, when the 11:00 hrs Southeastern service from London Cannon Street to Hayes (Kent) departed while her backpack strap was trapped in the doors of the train.
As it moved off, she fell onto the platform and then through the gap between the platform and train, suffering life-changing injuries.
The backpack strap became trapped when the train doors closed unexpectedly and quickly while she was alighting.
Testing showed that this potentially unsafe situation could only occur when a passenger pressed a door-open button, illuminated to show it was available for use, within a period of less than one second beginning shortly after the train driver initiated the door closure sequence.
RAIB identified this door behaviour, which was not known to the owner or operator, and issued urgent safety advice. In response to this, the railway industry undertook a review which identified 21 other types of train that permit passenger doors to be opened for a short period after door closure is initiated by train crew. The industry is now seeking ways to deal with this risk.
The train was being driven by a trainee driver under the supervision of an instructor. The service was driver only operation, which meant that before leaving West Wickham station, and after all train doors were closed, drivers were required to check that it was safe to depart by viewing CCTV monitors located on the platform. Two of these monitor images showed that a passenger appeared to be trapped but, although visible from the driving cab, neither the trainee driver nor the instructor was aware of this. Although the RAIB has not been able to establish why the trapped passenger was not seen before the train departed, a number of possible explanations have been identified.
As a result of this accident, RAIB has made two recommendations. The first, addressed to operators and owners of trains with power operated doors, is intended to identify and correct all train door control systems exhibiting the unsafe characteristics found during this investigation. The second, addressed to RSSB, seeks changes to guidance documents so that, where practicable, staff dispatching trains watch the train doors while they are closing, in addition to checking the doors after they are closed.
RAIB has also identified five learning points relating to: releasing train doors long enough to allow passengers to get on and off trains safely; effective checking of train doors before trains depart (and not relying on the door interlock light); design of door controls; and use of train driving simulators to raise drivers’ awareness of circumstances when it is not safe to depart from a station.
For the entire report, see:
Here’s a short video that doesn’t share much. But nuclear plants are much safer today as a result of learning lessons from accidents and incidents.
Root cause analysis has helped nuclear plants perform at record levels of safety.
On March 10, 1906, the worst European mining disaster occurred killing 1,099 workers. An underground fire caused a massive coal dust explosion, causing a chain reaction through out the vast mine.
Around 3pm on March 9, a fire began in the Cecil pit. The workers tried to extinguish the fire but nothing was working. They decided to close the pit outlets and starve the fire of all its’ oxygen. Believing the mine was safe to enter 1,795 workers entered the mines. Later that morning a huge explosion came from the Cecil pit. The fire was still smoldering and there were fissures in the walls that let in flammable gases that became ignited by the fire.
When the gases ignited flames and debris shoot out of the tunnels opening. Many of the miners suffered sever burn injuries. It wasn’t until the flames subdued when a rescue party of 40 men descended into the tunnels. Unfortunately, the rescue men paid the ultimate price. While descending into the mines tunnels the shaft collapsed killing all 40 men.
To read more about this unfortunate disaster please click on the link below.
Learn more about how to find and fix root causes of potential accidents here:
Here’s the press report about an incident at a west coast refinery …
They think that someone working in the area accidentally hit a button that shut down fuel to a boiler. That caused a major portion of the refinery to shut down.
At least one Causal Factor for this incident would be “Worker accidentally hits button with elbow.”
If you were analyzing this Causal Factor using the Root Cause Tree®, where would you go?
Of course, it would be a Human Performance Difficulty.
When you reviewed The Human Performance Troubleshooting Guide, you would answer “Yes” to question 5:
“Were displays, alarms, controls, tools, or equipment identified or operated improperly?”
That would lead you do evaluating the equipment’s Human Engineering.
Under the Human-Nachine Interface Basic Cause Category, you would identify the “controls need improvement” root cause because you would answer “Yes” to the Root Cause Tree® Dictionary question:
“Did controls need mistake-proofing to prevent unintentional or incorrect actuation?”
That’s just one root cause for one Causal Factor. How many other Causal Factors were there? It’s hard to tell with the level of detail provided by the article. I would guess there was at least one more, and maybe several (there usually should be for an incident of this magnitude).
At least one of the corrective actions by the refinery management was to initially put a guard on the button. Later, the button was removed to eliminate the chance for human error.
Are there more human-machine interface problems at this refinery? Are they checking for them to look for Generic Causes? You can’t tell from the article.
Would you like to learn more about understanding human errors and advanced root cause analysis? Then you should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See public course dates at:
And click on the link for the continent where you would like to attend the training.