Category: Accidents

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

August 16th, 2017 by

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

Monday Accident and Lesson Learned: Unsecured Load Falls Onto Worker

August 14th, 2017 by

Just a couple of days ago at Pacific Northwest National Laboratory in Washington, a worker backed into a cart that had a large, heavy cylinder loaded on it. He soon figured out the cylinder was not secured properly as it tipped over slightly hitting the workers back. Luckily he walked away unharmed, but large, heavy objects should be secured well to avoid any major injuries. Another lesson learned is to always check your surrounding well before you begin working.

 

(Resource: https://opexshare.doe.gov/lesson.cfm/2017/8/9/14769/Unsecured-Load-Falls-onto-Staff-Member-from-Wheeled-Cart)

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

August 11th, 2017 by

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

August 8th, 2017 by

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

Monday Accident and Lesson Learned: Collision of Trains at Plymouth Station

August 7th, 2017 by

In April of last year a train collided with an empty, still train that was waiting at Plymouth Station. The train that caused the accident was going 15 mph when it collided, and the conductor stated that he “misjudged” the amount of space he had to pull in behind the other train. He had also never operated a train so closely to another so he lacked the experience needed to complete the procedure. There were no fatal injuries, but 48 passengers were hurt and the two trains were damaged.

Corrective action: improve the training and assessment of new drivers, look at emergency door release controls, check procedure for permissive movements between trains

(Resource: https://www.gov.uk/raib-reports/collision-at-plymouth-station)

 

What does a bad day look like?

August 1st, 2017 by

When the pothole repair truck falls into the pothole.

Monday Accident & Lesson Learned: Overpressure of Explosion Proof Enclosure

July 31st, 2017 by

This past May, as an engineer unscrewed the cover off of an explosion-proof enclosure, a mass amount of pressure inside forced the cover to propel towards the engineer giving him a fatal head injury.  Two problems were found: the pressure was caused by leaked sample gas or instrument air components and there is no outer pressure meter to read before attempting to open.

 

(Resource: IOGP Safety Alert #288)

Is There Just One Root Cause for a Major Accident?

July 26th, 2017 by

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Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

http://www.taproot.com/store/Courses/

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

Monday Accidents and Lesson Learned: Retrofitted Busses

July 24th, 2017 by

This week’s Lesson Learned isn’t necessarily coming from an accident, but from something that was caught that could have resulted in fatalities if an accident occurs. Ultimately, the lesson here is proactivity. If you’re proactive in your investigations, you can create corrective actions to prevent accidents from ever occurring.

In Russia, it was found that the seats on busses were not bolted down effectively. Although the transportation companies complied with the regulations for seat anchoring when they were manufactured, the regulations have changed due to old seat anchoring practices being unsafe. Previously, the bolts were not properly securing the seats, therefore if there was a collision, the bolts could easily be pulled from the floor allowing the passengers to be injured or even killed.

The corrective action for this proactive investigation is to inspect all public transportation vehicles and ensure that they comply with current safety regulations. If they don’t, they need to be fixed immediately.

How Long Should a Root Cause Analysis Take?

July 18th, 2017 by

How long should a root cause analysis take? This is a question that I’m frequently asked. 

Of course, the answer is … It DEPENDS!

Depends on what?

  • How complex is the incident?
  • Are there complex tests that need to be performed to troubleshoot equipment issues?
  • Is everyone available to be interviewed?
  • Is there regulatory coordination/interference (for instance … do they take control of the scene or the evidence)?
  • How far do you want to dig into generic causes?
  • What level of proof do you need to support your conclusions?

However, I believe most investigations should be completed in a couple of weeks or at most a couple of months.

Now for the exceptions…

REGULATORY DELAYS: We helped facilitate a major investigation that was progressing until the regulators took the evidence. They stated that they needed it for their investigation. Their investigation dragged on for over a year. Finally, they announced their findings and released the evidence back to the company. It turned out that none of the evidence sequestered by the government had anything to do with the reason for their investigation being delayed (they were doing complex modeling and videos to demonstrate their conclusions). After about an additional two months, the company investigation was completed. The companies investigation was delayed for over a year unnecessarily. 

SLOW INVESTIGATION DELAYED BY UNCOOPERATIVE PARTICIPANTS: One of the longest root cause analyses I’ve ever seen took four years. The agency performing the investigation is notoriously slow when performing investigations but this investigation was slow even by their standards. What happened? The investigation had multiple parties that were suing each other over the accident and some of the parties would not comply with a subpoena. The agency had to take the unwilling participant to court. Eventually, the evidence was provided but it took almost a year for the process to play out.

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SLOW INVESTIGATION PROCESSES: The most recent bad example is the Alison Canyon Natural Gas Storage leak root cause analysis. The investigation started when the leak was stopped 18 months ago. But the root cause analysis still is not finished. Why? Is seems the process is mired in public hearings. The spokesperson for the California Public Utilities Commission said that the “study” was in the third phase of a five phase process. What was slowing the “study” (root cause analysis and corrective actions) down? Public hearings. Here is what an article in NGI Daily Gas Prices said:

A California Public Utilities Commission spokesperson said the study remains in the third of a five-phase process that is to take more than three years. The third phase is expected to take up to nine months, and the fourth phase more than two months, before the final phase of “integration and interpretation” of the results is issued.

The process is scheduled to take three years! That definitely makes any kind of timely root cause analysis impossible. 

CONCLUSION: Many people complain about the time it takes for a good root cause analysis. But most excessive delays have nothing to do with the root cause analysis process that is chosen. Excessive delays are usually political, due to uncooperative participants, or regulatory red tape. 

Spin A Cause

Don’t try to save time on an investigation by picking the fastest root causes analysis tool (for example … Spin-a-Cause™), rather pick an advanced root cause analysis tool (TapRooT®) that will get you superior results in a reasonable amount of time and effort. 

One more idea…

Learn from smaller but significant incidents to avoid major accidents that have huge public relations and regulatory complications. Learning from smaller incidents can be much faster and save considerable headaches and money. 

What does a bad day look like?

July 18th, 2017 by

 

It could look like this but objects may be closer than they appear.  Read the story behind this photo on the Times Colonist.

What is the Root Cause of the USS Fitzgerald Collision?

July 17th, 2017 by

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As 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 that all the facts aren’t yet in. But that never keeps us from speculation…

But before I speculate, let’s honor the seven crew members who died as a result of this accident: Dakota Kyle Rigsby. Shingo Alexander Douglass. Ngoc T Truong Huynh. Noe Hernandez. Carlos Victor Ganzon Sibayan. Xavier Alec Martin. Gary Leo Rehm Jr.

Also, let’s note that the reason for good root cause analysis is to prevent fatalities and injuries by solving the problems discovered in an accident to keep a similar repeat accident from happening in the future.

Mia Culpa: It’s been a long time since I stood a bridge watch. I’m not familiar with the current state of naval readiness and training. However, my general opinion is that you should never turn in front of a containership. They are big. Even at night you can see them (commercial ships are often lit up). They are obvious on even a simple radar. So what could have gone wrong?

1. It was the middle of the night. I would bet that one thing that has not changed since I was in the Navy is FATIGUE. It would be interesting to see the Oficer of the Deck’s and the Conning Officer’s (if there was one) sleep schedule for the previous seven days. Fatigue was rampant when I was at sea in the navy. “Stupid” mistakes are often made by fatigued sailors. And who is to blame for the fatigue? It is built into the system. It is almost invisible. It is so rampant that no one even asks about it. You are suppose to be able to do your job with no sleep. Of course, this doesn’t work.

2. Where was the CO? I heard that the ship was in a shipping lane. Even though it was the middle of the night, I thought … where was the Commanding Officer? Our standing orders (rules for the Officer of the Deck) had us wake the CO if a contact (other ship) was getting close. If we had any doubt, we were to get him to the bridge (usually his sea cabin was only a couple of steps from the bridge). And the CO’s on the ships I was on were ALWAYS on the bridge when we were in a shipping lane. Why? Because in shipping lanes you are constantly having nearby contacts. Sometimes the CO even slept in their bridge chair, if nothing was going on, just so they would be handy if something happened. Commander Benson (the CO) had only been in his job for a month. He had previously been the Executive Officer. Did this have any impact on his relationship with bridge watchstanders?

3. Where was the CIC watch team?  On a Navy ship you have support. Besides the bridge watch team, you are supported by the Combat Information Center. They constantly monitor the radars for contacts (other ships or aircraft) and they should contact the Officer of the Deck if they see any problems. If the OOD doesn’t respond … they can contact the Commanding Officer (this would be rare – I never saw it done). Why didn’t they intervene?

4. Chicken of the Sea. Navy ships are notorious for staying away from other ships. Many Captains of commercial shipping referred to US Navy ships as “chickens of the sea” because they steered clear of any other traffic. Why was the Fitzgerald so close to commercial shipping?

5. Experience. One thing I always wonder about is the experience of the crew and especially the officers on a US Navy ship. Typically, junior officers stand Officer of the Deck watches at sea. They have from a two to three year tour of duty and standing bridge watches is one of many things they do. Often, they don’t have extensive experience as an Officer of the Deck. How much experience did this watch team have? Once again, the experience of the team is NOT the team’s fault. It is a product of the system to train naval officers. Did it play a factor?

6. Two crews. The US Navy is trying out a new way of manning ships with two crews. One crew is off while the other goes to sea. This keeps the ship on station longer than a crew could stand to be deployed. But the crew is less familiar with the ship as they are only on it about 1/2 the time. I read some articles about this and couldn’t tell if the USS Fitzgerald was in this program or not (the program is for forward deployed ships like the Fitzgerald). Was this another factor?

These six factors are some of the many factors that investigators should be looking into. Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.

Monday Accident and Lessons Learned: Injured Spotter from Outrigger Incident

July 17th, 2017 by

Backing cranes into position requires multiple workers, the operator and the spotter. At a drill site in February 2015, a spotter was guiding the operator into position, but when he reached for his radio to alert the operator to “stop”, he lost balance causing him to not give the command. The lack of instruction to the operator meant he continued in reverse. By the time the operator realized the mistake, the spotter was already stuck between the outrigger and a well house causing injuries to his wrist. Luckily that was the only harm done.

What are some corrective actions to ensure this sort of incident doesn’t happen again? Ensure there are clear communication protocols in place before starting the job, choose different place for spotter to stand while guiding the operator to avoid being in the line of fire, and instruct both operator and spotter to stop all operations if any communication is lost between them.

Do you agree with these? Is there more they can do?

(resource: IOGP Safety Alert #286)

Should Helicopter Go Back in Service Before the Root Cause Analysis of a Crash is Finished?

July 12th, 2017 by

NewImage

Finishing a root cause analysis before returning the Super Puma to service in the North Sea is the issue that the Unite union is upset about.

The UK and Norwegian Civil Aviation Authorities have authorized the flights but several oil companies are reluctant to resume using the helicopters before the root cause analysis is complete.

For the whole story, see: http://www.bbc.com/news/uk-scotland-north-east-orkney-shetland-40567877

What does a bad day look like?

July 11th, 2017 by

It looks like when the secret of happiness seems so close but is actually so far away.

Causal Factors and remembering one of the worst incidents in American history

July 5th, 2017 by

We just returned from enjoying our Independence Day Holiday here in the US.

There were many good shows over the weekend about American History and during one I watched I was reminded of one of the worst events in our history (from a workplace safety standpoint); the Triangle Shirtwaist Fire in 1911.

Most safety professionals know of this incident as the Life Safety Code was partially born from the tragedy. I started to think about the incident in terms of TapRooT®, Causal Factors in particular. In our courses, we teach the concept of initiating errors, and chances to stop/catch/mitigate. There were many failures that day and many lost opportunities to stop and mitigate the event.

Possible causal factors that would be identified if TapRooT® would have been used:

CF – fire started (initiating error)

CF – egress blocked/not sufficient for the number of people to escape

CF – exit doors locked

CF – fire escapes collapsed

CF – fire hoses did not work

CF – ladders from fire department did not reach higher floors

I am sure there are more, but these are the ones that jumped out at me while watching the show.

It is a real shame that so many had to die for better conditions to become the norm.

Triangle Shirtwaist Factory fire escape collapsed during the March 15, 1911 fire. 146 died, either from fire, jumping or falling to the pavement.

For more on Causal Factors and stop/catch/mitigate, see this earlier POST

What does a bad day look like?

July 4th, 2017 by

A bad day is when you plan a nice family picnic, but this is the only picnic table available.

Monday Accident and Lessons Learned: Flooding and Sinking of Fishing Vessel, Capt. David

July 3rd, 2017 by

In February 2016, off the coast of Oregon Inlet, North Carolina, a vessel, Capt David, was disabled and flooded. The vessel was attempting to help another disabled vessel and direct contact caused serious damage. Luckily, the US Navy had a dock landing ship, USS Carter Hall, nearby that was able to provide assistance. The crew from both vessels were unharmed, but those on the unnamed vessel opted to remain on their vessel as it was towed, while the Capt David climbed aboard the USS Carter Hall. The Navy could obviously see that there was too much damage and no time for repairs to Capt David so the best they could do was rescue the crew and abandon the ship to sink.

It is noted that Capt David had not been inspected prior to setting out to sea. Investigators found that there was engine cooling water leak that was likely to have contributed to the incident.

So, what did they learn? What can we all learn form this?

(Resource: https://www.ntsb.gov/investigations/AccidentReports/Reports/MAB1712.pdf)

“Human Error” by Maintenance Crew is “Cause” of NYC Subway Derailment. Two Supervisors Suspended Without Pay.

June 29th, 2017 by

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The New York Daily News says that a piece of track was left between the rails during repair of track on the NYC subway system. That loose track may have caused the derailment of an eight car train.

The rule is that any track less than 19.5 feet either be bolted down or removed. It seems that others say that the “practice” is somewhat different. This piece of track was only 13.5 feet long and was not bolted down.

But don’t worry. Two supervisors have been suspended without pay. And workers are riding the railed looking for other loose equipment between the rails. Problem solved. Human error root cause fixed…

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