Category: Accidents

Monday Accident and Lesson Learned: Have we learned anything from famous downtime fiascos?

September 4th, 2017 by

 

Finding root causes is important not only to keep our workplaces safer but also to avoid costly incidents. IT systems downtime can cost companies millions of dollars in lost production.

This article examines the massive power outage in Silicon Valley last April as well as the August outage at Delta Airlines and asks the important question: What have we learned.

Read:

Have We Learned Anything from Famous Downtime Fiascos?

on Inc.

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

August 30th, 2017 by

NewImage

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 understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

NewImage

Monday Accident and Lesson Learned: Arcing and Fire at Windsor & Eton Riverside

August 28th, 2017 by

A train barely made it 400 meters from the Windsor & Eton Riverside station before the sixth carriage caught fire, which caused severe electrical arcing. For the full story and what happened next, click here.

(Resource: https://www.gov.uk/raib-reports/arcing-and-fire-at-windsor-eaton-riverside)

Remembering and Accident: Sayano–Shushenskaya Power Station Accident

August 25th, 2017 by

In August 2009, the Sayano-Shushenskaya hydroelectric power station had a turbine completely fall apart causing a significant flood with major collateral damage. Not only were 9-10 turbines broken, the building destroyed and a widespread power outage, but there were 75 fatalities.

So, what happened? Long story short, when the turbines were in installed in 1979, multiple problems with the seals appeared and were fixed. Similar problems occurred again in 2000 and were again worked on and reconditioned. In March 2009, the plant performed scheduled maintenance, repair and modernization on the turbine, but did not properly rebalance the runner causing increased vibrations, which causes damage to turbine seals over time. The night of the accident, the vibrations were out of control, and despite multiple attempts to stop the turbine, it still erupted violently.

For more details of the accident, click here.

Interesting Story – Was Quarry Employee Responsible for His Own Death?

August 24th, 2017 by

Jim Whiting, one of our TapRooT® Instructors in Australia, set me this article:

MCG Quarries blames Sean Scovell, 21, for his own death in 2012

NewImage

Read the article. What do you think? Where does self responsibility end and management responsibility start? What would your root cause analysis say?

Second Navy Ship Collides – What is going on?

August 23rd, 2017 by

First, god bless the missing and dead sailors and their families and shipmates who experienced this, the second crash in the past two months.

I’ve waited a couple of days to comment on this second Navy collision with fatalities because I was hoping more information would be released about what happened to cause this collision at sea. Unfortunately, it seems the Navy has clamped down on the flow of information and, therefore, no intelligent comments can be made to compare the collision of the USS John S. McCain with the earlier collision of the USS Fitzgerald.

NewImage

What do we know?

  • They are both similar Navy DDG’s with the same staffing levels (only 23 officers).
  • They were both in a shipping channel.
  • They both hit (or were hit by) a merchant ship.
  • The crew was trained to the same Navy standards.

That’s about it.

Of course, we know what they did to those involved in the previous accident (see my previous article HERE).

Was the timing of this second collision just bad luck?

We could use the Navy’s collision statistics to answer that question. Of course, you would have to agree about what is a collision. Would a grounding count? Would there have to be injuries or a fatality?

We would then use the advanced trending techniques that we teach in our pre-Summit trending course to see if the second collision was so close in time to the first that it indicated a significant increase in the collision frequency. To learn about these techniques, see:

http://www.taproot.com/taproot-summit/pre-summit-courses#AdvancedTrendingTrending

Since we don’t have facts (and will probably never get them), what is my guess? The things I would consider for this accident are the same as for the last. Look into what happened including:

  1. Fatigue
  2. Where was the CO?
  3. What did the CIC watch team do?
  4. Experience/training of the bridge and CIC team.

What should the Navy do? A complete, detailed TapRooT® Investigation.

Admiral Richardson (formerly the head of the Navsea 07 – the Nuclear Navy) has the right words about the analysis the Navy is performing. What is missing? A systematic guide for the investigators and prevent them from jumping to conclusions.

In a TapRooT® Investigation, we would start collecting facts and developing a SnapCharT® to truly understand what happened. Next we would identify all the causal Factors before we started analyzing their root causes using the Root Cause Tree® Diagram. Next, we would consider the generic causes and then develop effective (SMARTER) corrective actions. Unfortunately, this will be hard to do because of the Navy’s tradition of blame.

Some of my friends have been asking if I thought that some type of sabotage was involved. Some sort of hacking of the combat systems. In my experience, unless it was extremely foggy, you should be able to use your eyes and the simple bridge radar to navigate. You don’t need fancy technology to keep you from colliding. Simple “constant bearing decreasing range” tells you a collision is coming. To prevent it you turn or slow down (or perhaps speed up) to get a bearing rate of change to bring the other ship down whichever side is appropriate (use the rules of the road).

The trick comes when there are multiple contacts and restricted channels. That’s when it is nice to have someone senior (the Commanding Officer) on hand to second check your judgment and give you some coaching if needed.

Most of the time you spend of the bridge is boring. But when you are steaming in formation or in a shipping channel with lots of traffic, it quickly goes from boring to nerve-racking. And if you are fatigued when it happens … watch out! Add to that an inexperience navigation team (even the Commanding Officer may be inexperienced) and you have an accident waiting to happen.

Is that what happened to the USS John S. McCain? We don’t know.

What we do know is that the Navy’s typical blame and shame response with a safety stand down thrown in won’t address the root causes – whatever they may be – of these accidents.

The Navy seldom releases the results of their investigations without heavily redacting them. What we do know is that previous  investigations of previous collisions were heavy on blame and included little in the way of changes to prevent fatigue or or inexperienced watch standers. The fact is that the corrective actions from previous collisions didn’t prevent this string of collisions.

What can you do? Advise anyone you know in a position of responsibility in the Navy that they need advanced root cause analysis to improve performance. The young men and women that we send to sea deserve nothing less. Navy brass needs to end the blame game and coverup and implement truly effective corrective actions.

Monday Accident and Lesson Learned: Aviation Safety Callback

August 21st, 2017 by

As a Tower Controller, your role is vital to ensure the pilots have the information and guidance they need when descending and landing their aircrafts. One Tower Controller was working alone on midday shift when an aircraft was coming in for landing while experiencing minor turbulence. The Tower Controller cleared him for landing and gave instruction, but also had to leave his station to record a PIREP for moderate turbulence on the AISR website. When he returned, the pilot had descended past the assigned altitude, which could have been avoided if the Tower Controller could do two things at once, submit the PIREP to the AISR website and the FSS at the same time.

The suggested corrective action is to allow the Tower Controllers to enter the PIREP to just the FSS allowing them to focus on the current operation.

What do you think?

(Resource: ASRS Callbacks)

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

August 18th, 2017 by

USS Fitzgerald

The 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 were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“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.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

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

NewImage

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.

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

In this short period of time interesting problems were uncovered and difficult issues were…

Huntsman

Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company
Contact Us