Category: Accidents

Monday Accident & Lesson Learned

December 25th, 2017 by

In Singapore, a car was crushed by two trailers after a passenger bus hit the one behind him, causing a chain collision that left 26 people injured. Read more here.

Friday Joke

December 22nd, 2017 by

‘See, I told you we could make it under that bridge!’

The Georgia State Public Services Commission Demands Root Cause Analysis of Atlanta Airport Blackout

December 21st, 2017 by

ATL

Read about the story in The Atlanta Journal-Constitution: http://www.ajc.com/news/georgia-regulators-demand-answers-about-atlanta-airport-blackout/nDwICT5QFrUyXOvFnZbroM/

It’s hard to believe there wasn’t a redundant transmission line and transformers to such a vital resource.

Hack of safety system causes plant shutdown …

December 18th, 2017 by

Jim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.

There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.

Secretary of the Navy Strategic Readiness Review – Management System Problems Broke the US Navy

December 14th, 2017 by

Yes, “Management System Problems Broke the US Navy” is my headline.

 

The report to the Secretary of the Navy is much worse than I thought. The report outlines how budget restrictions and congressional leadership made the Navy conform to the structures of the Army and the Air Force and de-emphasized the role of providing seapower. That’s how the US Navy was broken. And it will be difficult to fix. (“All the King’s horses and all the King’s men couldn’t put Humpty Dumpty together again!” was a lesson learned in 1648 during the English civil war.)

NewImage

Many of the problems are Management System problems as outlined in a Navy Times article about the Strategic Review report to the Secretary of the Navy. The good news is … the authors of the Strategic Review get the Management System root causes pretty much right! The bad news is that it is less clear that the Navy has the ability to fix the issues because they are a result of Congressional action (funding, ship procurement, the Defense Officer Personnel Management Act, the Goldwater-Nichols Act of 1986, and National Defense Authorization Act provisions) and the Navy’s response to congressional cutbacks (Optimum Manning, the SWOS-in-a-box, modifications to the surface warfare officer sea-shore rotations and assignments, and the 2001 Revolution in Training for enlisted personnel).

The review says that the Navy must cut back their commitments to operational requirements in “peacetime.” But that is unlikely in the near wartime footing that they Navy faces in their forward deployments.

One of the recommendations made by the Strategic Review is for the Type Commanders to implement the “Rickover Letters” that are part of the Nuclear Navy Commanding Officer reporting structure. This will only work if the Type Commanders maintain strict requirements that Admiral Rickover established in the Nuclear Navy. This has not been the culture in the conventional surface Navy – EVER. Thus this would be a dramatic cultural shift.

Navy brass in the 1980’s and 1990’s wished that sailors at sea could do more with less and that “technology” would make that possible. Unfortunately the cuts were made (Optimal Manning and Continuous Maintenance Plan) without proof of concept testing. Now, over two decades later, the chickens have come home to roost.

The USA is an island nation. We can’t exist in our modern economy without sea trade. Thus, the USA must be the premier sea power. This requirement is independent of the “War on Terror,” the “War on Drugs,” or other missions to support land forces. Somehow past Presidents and Congressional leaders have not funded the seapower mission. Thus, we find ourselves in a bind that will be hard to fix.

The people in senior Navy leadership positions have grown up in a broken system. We must now ask them to fix (restore) the system when they have never seen it work properly. The CNO in a Navy Nuke from the submarine fleet that has faced budget reductions but has not faced the same personnel and training issues. He grew up in a different culture.

By making the US Navy the “same” as the Air Force and the Army, the unique requirements of the Navy were overlooked and the Navy was broken. Can it be fixed? The recommendations of the Strategic Review could start the repair process. But it is only a start. Many uniquely “Navy” cultural and readiness issues are not addressed in the report. Plus, this report probably will not get the attention it deserves until a failure of our war-fighting ability at sea produces a major foreign policy fiasco or, even worse, economic collapse at home because our island nation is cut off from overseas supplies.

One last comment.

The Strategic Review calls for the establishment of a “learning culture.” The authors of the Strategic Review call for proactive learning instead of the current culture of punishment based reactive learning. They frequently mention the “normalization-of-deviation” as if it a relatively recent US Navy cultural problem rather than being the state of the conventional surface navy for decades (or centuries?). They should read the article about Admiral Rickover and the normalization-of-excellence to better understand the changes that are needed. Also, establishing a proactive, learning culture isn’t possible until the US Navy understands advanced root cause analysis (which current investigations and corrective actions prove that the Navy does not understand).

The recommendations of section 6.3 of the Strategic Review are putting the “cart in front of the horse.” The FIRST step in correcting the Navy’s culture is for all naval officers (senior commanders through junior officers) to understand advanced root cause analysis. Without this understanding, learning – either proactive or reactive – is impossible. We have worked with industry leaders and we know of what we speak.

I certainly hope the US Navy makes significant progress in correcting the glaring shortcomings outlined in the Strategic Review. The lives of sailors at sea depend on it. But even worse, a failure to fix the root causes of the Management System problems and the poor understanding of advanced root cause analysis will certainly lead to failures of our seapower and serious foreign policy issues that may cause tremendous economic troubles for the US. I’m old and may not see the day when we discover that under-investment in seapower was a gigantic mistake. But if this problem isn’t fixed rapidly and effectively, certainly my children and grandchildren will face an uncertain, dark future.

I would be happy to discuss the improvements in root cause analysis that are needed with any Navy leader concerned that a more effective approach is needed.

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Monday Accident & Lesson Learned: Near Miss Incidents at Camden Junction South London

December 11th, 2017 by

 

The RAIB recently published an investigation report concerning track worker near miss incidents at Camden Junction South, London. Click here to view the report.

Fake News or Real?

December 6th, 2017 by

FakeNews

That’s the headline. Here is the link:

http://www.abcnews-us.com/2017/12/05/morgue-employee-cremated-by-mistake-while-taking-a-nap/

Could it really be true? I guess the funeral home industry needs TapRooT®!

(Editor’s update: After this post was published, Snopes reported this as fake news and the news story was removed. Thank goodness!)

Monday Accident & Lessons Learned: Firm fined after worker severs fingers

December 4th, 2017 by

An employee lost four fingers, broke several bones and dislocated his wrist cleaning steel shafts on a metal working lathe. The investigation found that the company did not ensure the work was carried out safely.  Read the story here.

Avoid scenarios like this by conducting proactive root cause analysis investigations. Protect your people from life-changing injuries that can be avoided. Click here for a list of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings that include training on the proactive use of TapRooT®.

OSHA Top 10 Violations

December 1st, 2017 by

TapRooT® Root Cause Analysis can help with hazard prevention and control.

Sign up for training and learn how to avoid incidents, minimize risks and provide workers with safe working conditions.

How Far Away is Death?

November 28th, 2017 by

 

Did you know that e-cigarettes using lithium batteries can spark explosion dangers? Devastating injuries can result.

The U.S. Fire Administration published a July 2017 report entitled, “Electronic Cigarette Fires and Explosions in the United States, 2009-2016.” According to the report, the number of e-cigarette fires and explosions are increasing over time. Click here to read the report.

Monday Accident & Lessons Learned: Are you prepared for adverse weather?

November 28th, 2017 by

Callback shared reported incidents spawned by typical winter weather. Click here to read the report.

How far away is death?

November 23rd, 2017 by

CCTV captures woman’s near miss on train tracks in Australia.

Click here to view video.

Monday Accident & Lessons Learned: NTSB Reports that “Ignored Safety Procedures, Fractured Safety Program Led to Fatal Amtrak Derailment”

November 20th, 2017 by

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This accident may seem like a simple case of a supervisor failing to make a call. However, the NTSB investigation shows there were many more issues that caused the fatalities.

Here is the press release from the NTSB:

Ignored Safety Procedures, Fractured Safety Program Led to Fatal Amtrak Derailment

11/14/2017

WASHINGTON (Nov. 14, 2017) — The National Transportation Safety Board determined Tuesday the April 3, 2016, derailment of Amtrak train 89 near Chester, Pennsylvania was caused by deficient safety management across many levels of Amtrak and the resultant  lack of a clear, consistent and accepted vision for safety.

A backhoe operator and a track supervisor were killed, and 39 people were injured when Amtrak train 89, traveling on the Northeast Corridor from Philadelphia to Washington on track 3, struck a backhoe at about 7:50 a.m. The train engineer saw equipment and people working on and near track 3 and initiated emergency braking that slowed the train from 106 mph to approximately 99 mph at the time of impact.

The NTSB also determined allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present, the absence of shunting devices, the foreman’s failure to conduct a job briefing at the start of the shift, all coupled with the numerous inconsistent views of safety and safety management throughout Amtrak, led to the accident.

“Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” said NTSB Chairman Robert L. Sumwalt. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”

The NTSB also noted the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to this accident.

Post-accident toxicology determined that the backhoe operator tested positive for cocaine, and the track supervisor and tested positive for codeine and morphine.   The locomotive engineer tested positive for marijuana. The NTSB determined that while drug use was not a factor in this accident, it was symptomatic of a weak safety culture at Amtrak.

As a result of this investigation, the NTSB issued 14 safety recommendations including nine to Amtrak.
The NTSB also made two safety recommendations to the Federal Railroad Administration, and three safety recommendations were issued to the Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen.

The abstract of the NTSB’s final report, that includes the findings, probable cause and safety recommendations is available online at https://go.usa.gov/xnWpg.  The final report will be publicly released in the next several days.

The webcast of the board meeting for this investigation is available for 90 days at http://ntsb.capitolconnection.org/.

Contact: NTSB Media Relations
490 L’Enfant Plaza, SW 
Washington, DC 20594 
Terry Williams 
(202) 314-6100 
Terry.williams@ntsb.gov

 

Monday Accident & Lessons Learned: Passenger train collides with buffer stops

November 13th, 2017 by

A passenger train collided with buffer stops. The RAIB reported that the accident occurred becaue the driver was suffering from fatigue and experienced microsleep. Real the full report here.

How Far Away is Death?

November 9th, 2017 by

A worker was dragged with a chain when a meat hook impaled him through the head behind his ear. The worker remained conscious and “jovial” throughout the 2014 incident. Click here to read the story on “Sunshine Coastal Daily.”

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Investigation Detects Lack of Experience in Experienced Personnel And Leads To Job Simulation To Improve Performance Submitted by: Errol De Freitas Rojas, SHE Coordinator Company: ExxonMobil, Caracus, Venezuela Challenge We investigated a Marine incident where an anchor cable picked up tension during maneuvers and caused a job to be stopped. We needed to find the …

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