Category: Human Performance

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

 

Top Root Causes of Accidents

November 15th, 2017 by

 

TapRooT® has been used for root cause analysis in industries around the world for almost 30 years. When talking incidents and near misses with our customers, there are certain root causes that come up more than others. It is interesting to take a closer look, and think about what can be done about them.

Supervision: Many incidents are due to lack of supervision during work, and lack of job preparations. Verbal communications are often not heard or understood correctly, sometimes due to noise or PPE.
Human-Machine Interface: Operators often have difficulties interacting with equipment due to its design, or because the interface like screens, gauges or signals are not easy to use.
Ineffective Training or Lack of Training: These cause incidents in a surprising number of cases.
Human Engineering: Many workers are faced with systems that are too complex. Poor physical work environments also cause fatigue, and it becomes difficult to stay alert.
Procedures: There are many instances over the years where procedures are not used or are so outdated that they no longer reflect process reality and need improvement.

The TapRooT® system is effective in identifying root causes of a problem, and with deciding corrective action. As a matter of fact, the dedicated Corrective Action Helper® is part of the methodology, and helps generate effective solutions. It is included in the different “Investigations…” book sets available here http://www.taproot.com/store/

Monday Accidents & Lessons Learned: Review of a Comprehensive Review

November 6th, 2017 by

ComprehensiveReview_Final.pdfReportScreenShot

What will it take for the US Navy surface fleet (or at least the 7th Fleet) to stop crashing ships and killing sailors? That is the question that was suppose to be answered in the Comprehensive Review of Recent Surface Force Incidents. (See the reference here: Comprehensive+Review_Final.pdf). This article critiques the report that senior Navy officials produced that recommended changes to improve performance.

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If you find yourself in a hole, stop digging!!
Will Rogers

The report starts with two and a half pages of how wonderful the US Navy is. The report then blames the crews for the accidents. The report stated:

In each incident, there were fundamental failures to responsibly plan, prepare and execute ship activities to avoid undue operational risk. These ships failed as a team to use available information to build and sustain situational awareness on the Bridge and prevent hazardous conditions from developing. Moreover, leaders and teams failed as maritime professionals by not adhering to safe navigational practices.

It also blamed the local command (the 7th Fleet) by saying:

Further, the recent series of mishaps revealed weaknesses in the command structures in-place to oversee readiness and manage operational risk for forces forward deployed in Japan. In each of the four mishaps there were decisions at headquarters that stemmed from a culturally engrained “can do” attitude, and an unrecognized accumulation of risk that resulted in ships not ready to safely operate at sea.

Now that we know that more senior brass, the CNO, the Secretary of the Navy, the Secretary of Defense, the Congress, or the President (current or past) have nothing to do with the condition of the Navy, we can go on to read about their analysis and fixes.

The report states that individual root cause analysis of US Navy crashes were meant to examine individual unit performance and did NOT consider:

  • Management Systems (Doctrine, Organization, Leadership, Personnel)
  • Facilities and Material
  • Training and Education

The “Comprehensive Report” was designed to do a more in-depth analysis that considers the factors listed above. The report found weaknesses in all of the above areas and recommended improvements in:

  • Fundamentals
  • Teamwork
  • Operational Safety
  • Assessment
  • Culture

The report states:

The recommendations described in this report address the skills, knowledge, capabilities, and processes needed to correct the abnormal conditions found in these five areas, which led to an accumulation of risk in the Western Pacific. The pressure to meet rising operational demand over time caused Commanders, staff and crew to rationalize shortcuts under pressure. The mishap reports support the assertion that there was insufficient rigor in seeking and solving problems at three critical stages: during planning in anticipation of increased tasking, during practice/rehearsal for abnormal or emergency situations in the mishap ships, and in execution of the actual events. This is important, because it is at these stages where knowledge and skills are built and tested. Evidence of skill proficiency (on ships) and readiness problems (at headquarters) were missed, and over time, even normalized to the point that more time could be spent on operational missions. Headquarters were trying to manage the imbalance, and up to the point of the mishaps, the ships had been performing operationally with good outcomes, which ultimately reinforced the rightness of trusting past decisions. This rationalized the continued deviation from the sound training and maintenance practices that set the conditions for safe operations.

The report mentions, but does not emphasize, what I believe to be the main problem:

The findings in chapters four through eight and appendix 9.10 underscore the imbalance between the number of ships in the Navy today and the increasing number of operational missions assigned to them. The Navy can supply a finite amount of forces for operations from the combined force of ships operating from CONUS and based abroad; this finite supply is based both on the size of the force as well as the readiness funding available to man, train, equip and sustain that force. Headquarters are working to manage the imbalance. U.S. Navy ships homeported in the continental United States (CONUS) balance maintenance, training and availability for operations (deployments and/or surge); the Pacific Fleet is re-examining its ability to maintain this balance for ships based in Japan as well. Under the Budget Control Act of 2011 and extended Continuing Resolutions, the ability to supply forces to the full demand is – and will remain – limited.

The report does not say how many more ships the 7th Fleet or the US Navy needs.

The report also stated:

The risks that were taken in the Western Pacific accumulated over time, and did so insidiously. The dynamic environment normalized to the point where individuals and groups of individuals could no longer recognize that the processes in place to identify, communicate and assess readiness were no longer working at the ship and headquarters level.

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This could be used as a definition of normalization of deviation. To read more about this, see the article about Admiral Rickover’s philosophy of operational excellence and normalization of deviation by CLICKING HERE.

Normalization of deviation has been common in the US Navy, especially the surface fleet, with their “Git er Dun” attitude. But I’m now worried that the CNO (Chief of Naval Operation), who was trained as a Navy Nuke, might not remember Admiral Rickover’s lessons. I also worry that the submarine force, which has had its own series of accidents over the past decade, may take shortcuts with nuclear safety if the emphasis on mission accomplishment becomes preeminent and resources are squeezed by Washington bureaucrats.

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The military has been in a constant state of warfare for at least 15 years. One might say that since the peacekeeping missions of the Clinton administration, the military has been “ridden hard and put up wet” every year since that mission started. This abuse can’t continue without further detrimental effects to readiness and performance in the field.

The report summary ends with:

Going forward, the Navy must develop and formalize “firebreaks” into our force generation and employment systems to guard against a slide in standards. We must continue to build a culture – from the most junior Sailor to the most senior Commander – that values achieving and maintaining high operational and warfighting standards of performance. These standards must be manifest in our approach to the fundamentals, teamwork, operational safety, and assessment. These standards must be enforced in our equipment, our individuals, our unit teams, and our fleets. This Comprehensive Review aims to define the problems with specificity, and offers several general and specific recommendations to get started on making improvements to instilling those standards and strengthen that culture.

This is the culture for reactor operations in the Nuclear Navy. But changing a culture in the surface fleet will be difficult, especially when any future accidents are analyzed using the same poor root cause analysis that the Navy has been applying since the days of sail.

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After the summary, the report summarizes the blame oriented root cause analysis that I have previously reviewed HERE and HERE.

Another quote from the report that points out the flaws in US Navy root cause analysis is:

Leadership typically goes through several phases following a major mishap: ordering an operational pause or safety stand down; assembling a team to determine what happened and why; and developing a list of discrete actions for improvement. Causes are identified, meaningful actions taken, and there has been repeated near- term success in instilling improved performance. However, these improvements may only have marginal effect in the absence of programs and processes to ensure lessons are not forgotten. Still, all levels of command must evaluate the sufficiency of internal programs and processes to self-assess, trend problems, and develop and follow through on corrective actions in the wake of mishaps.”

Instead of thinking that the lessons from previous accidents have somehow been forgotten, a more reasonable conclusion is that the Navy really isn’t learning appropriate lessons and their root cause analysis and their corrective actions are ineffective. Of course, admitting this would mean that their current report is, also, probably misguided (since the same approach is used). Therefore they can’t admit one of their basic problems and this report’s corrective actions will also be short lived and probably fail.

The 33 people (a large board) performing the Comprehensive Review of Recent Surface Force Incidents were distinguished insiders. All had either previous military/DoD/government affiliations or had done contracting or speaking work for the Navy. I didn’t recognize any of the members as a root cause analysis expert. I didn’t see this review board as one that would “rock the boat” or significantly challenge the status quo. This isn’t to say that they are unintelligent or are bad people. They are some of the best and brightest. But they are unlikely to be able to see the problems they are trying to diagnose because they created them or at least they have been surrounded by the system for so long that they find it difficult to challenge the system.

The findings and recommendations in the report are hard to evaluate. Without a thorough, detailed, accurate root cause analysis of the four incidents that the report was based upon (plus the significant amount of interviews that were conducted with no details provided), it is hard to tell if the finding are just opinions and if the recommendations are agenda items that people on the review board wanted to get implemented. I certainly can’t tell if the recommended fixes will actually cause a culture change when that culture change may not be supported by senior leadership and congressional funding.

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One more point that I noticed is that certain “hot button” morale issues were not mentioned. This could mean that certain factors effecting manning, training time wasted, and disciplinary issues aren’t being addressed. Even mentioning an example in this critique of the report seems risky in our very sensitive politically correct culture. Those aboard ships know examples of the type of issues I’m referring to, therefore, I won’t go into more detail. If, however, certain issues won’t be discussed and directly addressed, the problems being created won’t be solved.

Finally, it was good to see references to human factors and fatigue in the report. Unfortunately, I don’t know if the board members actually understand the fundamentals of human performance.

For example, it seems that senior military leadership expects the Commanding Officer, the Officer of the Deck, or even the Junior Officer of the Deck to take bold, decisive action when faced with a crisis they have never experienced before and that they have never had training and practice in handling. Therefore, here is a simple piece of basic human factors theory:

If you expect people to take bold, decisive action when faced with a crisis,
you will frequently be disappointed. If you expect that sailors and officers
will have to act in a crisis situations, they better be highly practiced
in what they need to do. In most cases, you would be much better off to
spend time and energy avoiding putting people in a crisis situation.

My father was a fighter ace in World War II. One of the things he learned as he watched a majority of the young fighter pilots die in their first month or even first week of combat was that there was no substitute for experience in arial combat. Certainly early combat experience led to the death of some poor pilots or those who just couldn’t get the feel of leading an aircraft with their shots. But he also observed that inexperienced good pilots also fell victim to the more experienced Luftwaffe pilots. If a pilot could gain experience (proficiency), then their chances of surviving the next mission increased dramatically.

An undertrained, undermanned, fatigue crew is a recipe for disaster. Your best sailors will decide to leave the Navy rather than facing long hours with little thanks. Changing a couple of decades of neglect of our Navy will take more than the list of recommendations I read in the Comprehensive Review of Recent Surface Force Incidents. Until more ships and more sailors are supplied, the understaffed, undertrained, under appreciated,  under supported, limited surface force that we have today will be asked to do too much with too little.

That’s my critique of the Comprehensive Review. What lessons should we learn?

  • You need to have advanced root cause analysis to learn from your experience. (See About TapRooT® for more information.)
  • Blame is not the start of a performance improvement effort.
  • Sometimes senior leaders really do believe that they can apply the same old answers and expect a different result. Who said that was the definition of insanity?
  • If you can’t mention a problem, you can’t solve it.
  • People in high stress situations will often make mistakes, especially if they are fatigued and haven’t been properly trained. (And you shouldn’t blame them if they do … You put them there!)
  • Just because you are in senior management, that doesn’t mean that you know how to find and fix the root causes of human performance problems. Few senior managers have had any formal training in doing this.

Once you have had a chance to review the report, leave your comments below.

Human Factors Issue in USS John S McCain Crash Not Specifically Identified in Navy Report

November 3rd, 2017 by

The report issues by the US Navy had enough details to identify a human factors issue in the steering system of the USS John S McCain. However, the report identified the main issue as a training problem. I think they missed a significant human factors issue in this investigation. The following details explain what I mean.

Here is a quote from the report:

“At 0519, the Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty maintaining course while also adjusting the throttles for speed control. In response, he ordered the watch team to divide the duties of steering and throttles, maintaining course control with the Helmsman while shifting speed control to another watchstander known as the Lee Helm station, who sat directly next to the Helmsman at the panel to control these two functions, known as the Ship’s Control Console. See Figures 3 and 4. This unplanned shift caused confusion in the watch team, and inadvertently led to steering control transferring to the Lee Helm Station without the knowledge of the watch team. The CO had only ordered speed control shifted. Because he did not know that steering had been transferred to the Lee Helm, the Helmsman perceived a loss of steering.”

McCainHelm

“Steering was never physically lost. Rather, it had been shifted to a different control station and watchstanders failed to recognize this configuration. Complicating this, the steering control transfer to the Lee Helm caused the rudder to go amidships (centerline). Since the Helmsman had been steering 1-4 degrees of right rudder to maintain course before the transfer, the amidships rudder deviated the ship’s course to the left.Additionally, when the Helmsman reported loss of steering, the Commanding Officer slowed the ship to 10 knots and eventually to 5 knots, but the Lee Helmsman reduced only the speed of the port shaft as the throttles were not coupled together (ganged). The starboard shaft continued at 20 knots for another 68 seconds before the Lee Helmsman reduced its speed. The combination of the wrong rudder direction, and the two shafts working opposite to one another in this fashion caused an un-commanded turn to the left (port) into the heavily congested traffic area in close proximity to three ships, including the ALNIC. See Figure 5.”

McCainCollision

“Although JOHN S MCCAIN was now on a course to collide with ALNIC, the Commanding Officer and others on the ship’s bridge lost situational awareness. No one on the bridge clearly understood the forces acting on the ship, nor did they understand the ALNIC’s course and speed relative to JOHN S MCCAIN during the confusion.Approximately three minutes after the reported loss of steering, JOHN S MCCAIN regained positive steering control at another control station, known as Aft Steering, and the Lee Helm gained control of both throttles for speed and corrected the mismatch between the port and starboard shafts. These actions were too late, and at approximately 0524 JOHN S MCCAIN crossed in front of ALNIC’s bow and collided. See Figure 6.”

McCainCollision2

Also, from the report:

“Because steering control was in backup manual at the helm station, the offer of control existed at all the other control stations (Lee Helm, Helm forward station, Bridge Command and Control station and Aft Steering Unit). System design is such that any of these stations could have taken control of steering via drop down menu selection and the Lee Helm’s acceptance of the request. If this had occurred, steering control would have been transferred.”

“When taking control of steering, the Aft Steering Helmsman failed to first verify the rudder position on the After Steering Control Console prior to taking control. This error led to an exacerbated turn to port just prior to the collision, as the indicated rudder position was 33 degrees left, vice amidships. As a result, the rudder had a left 33 degrees order at the console at this time, exacerbating the turn to port.”

“Several Sailors on watch during the collision with control over steering were temporarily assigned from USS ANTIETAM (CG 54) with significant differences between the steering control systems of both ships and inadequate training to compensate for these differences.”

“Multiple bridge watchstanders lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations. Contributing, personnel assigned to ensure these watchstanders were trained had an insufficient level of knowledge to effectively maintain appropriate rigor in the qualification program. The senior most officer responsible for these training standards lacked a general understanding of the procedure for transferring steering control between consoles.”

The Navy report concludes that this problem was related to training. Although training may have been an issue, training was made much more difficult (complex) by a poorly human factored design. The design didn’t consider the user.

In my experience (I was a 1st Lieutenant on a cruiser – the USS Arkansas, CGN-41), Seaman who are Boatswains Mates are the least technically inclined sailors on the ship. These are the people who stand this type of watch. The job of guiding a long heavy ship, turning it, and keeping it on course using a rudder mounted on the stern can be a thing of beauty when an experienced helmsman knows what they are doing. But not everyone standing the watch is that good. Obviously this sailor was having trouble compensating for current (obvious when you see how far he was steering off the ordered track in Figure 6 above).

On the ships that I served aboard (30 years ago), the steering and helm systems appeared quite simple. There was only one console on the bridge to steer from and only one place on the bridge to indicate the ships speed input that was communicated to the throttleman in the engine room. You could shift steering to aft steering, but this was mainly a process of them manually taking over from the bridge. You would then communicate helm orders via sound powered phones.

Also, speed orders could be manually communicated from the lee helm to the throttleman in engineering via sound powered phones.

In the old days, the lee helm was always manned and there would be no “shifting of controls” as occurred in this collision. Instead, if the helmsman was having problems, the Boatswain Mate of the Watch (the supervisor of these watch stations) could step in to provide advice, or, if needed, take over for the less experienced helmsman. In theory, the Boatswain Mate of the Watch was a more experienced helmsman and could be counted on to correct any problem the helmsman had experienced.

However, on these modern cruisers there is an addition order of difficulty. They have made the Navy ships much more like commercial ships that can be steered from various locations. Also, the two jobs of helmsman and lee helmsman can be performed by a single individual. In theory, this can reduce the number of watch standers and perhaps make the steering of the ship easier.

I think the reality is quite different. The computerized controls have reduced the control that a helmsman has and added complexity that can lead to errors. I would like to do a complete human factors review of the system, but I would bet that the steering modes, locations of control, and the controls used to change control locations are not obvious and, thus, contributed to this accident. That is a human factors problem … NOT a training problem.

This is just one specific example of the lack of thorough root cause analysis that I saw in the US Navy report on the collision (that I wrote about yesterday). It shows the need for better US Navy root cause analysis to fix the real system problems.

If you would like to learn a system that includes an expert system to help investigators identify human factors issues, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Training Courses. See our upcoming public course dates and locations by CLICKING HERE.

Navy Releases Reports on Recent Collisions and Provides Inadequate Information and Corrective Actions

November 2nd, 2017 by

Punish

At the end of the cold war, politicians talked of a “peace dividend.” We could cut back our military funding and staffing.

Similar action was taken by the USSR Government for the Soviet fleet. I watched the Soviet Fleet deteriorate. Ships weren’t maintained. Training was curtailed. What was the second best navy in the world deteriorated. I thought it was good news.

What I didn’t know was that our fleet was deteriorating too.

Fast forward to the most recent pair of collisions involving ships in the 7th Fleet (The USS Fitzgerald and the USS John S McCain). If you read the official report (see the link below) you will see that the Navy Brass blames the collisions on bad people. It’s the ship’s CO’s and sailors that are to blame.

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The blame for the ship’s leadership and crews includes (list shortened and paraphrased from the report above by me):

USS Fizgerald

  • The Officer of the Deck (OOD) and bridge team didn’t follow the Rules of the Road (laws for operating ships at sea).
  • The ship was going too fast.
  • The ship didn’t avoid the collision.
  • Radars weren’t used appropriately.
  • The lookout (singular) and the bridge team was only watching the port side and didn’t see the contacts on the starboard side.
  • The Navigation Department personnel didn’t consider the traffic separation lanes when laying out the proposed track for navigating the ship (and this should have been well known since this ship was leaving their home port).
  • The navigation team did not use the Automated Identification System that provides real time updates on commercial shipping positions.
  • The Bridge team and the Combat Information Center team did not communicate effectively.
  • The OOD did not call the CO when required.
  • Members of the Bridge team did not forcefully notify and correct others (including their seniors) when mistakes were suspected or noted.
  • Radar systems were not operating to full capability and this had become accepted.
  • A previous near-collision had not be adequately investigated and root causes identified by the ship’s crew and leadership.
  • The command leadership did not realize how bad the ship’s performance was.
  • The command leadership allowed a schedule of events which led to fatigue for the crew.
  • The command leadership didn’t assess the risk of fatigue and take mitigating actions.

NewImageFired (reassigned) CO of USS Fitzgerald

USS John S McCain

  • Then training of the helm and lee helm operators was substandard in at least part because some sailors were assigned temporarily too the ship and didn’t have adequate training on the differences in the ships rudder control systems.
  • The aft steering helmsman failed to verify the position of the rudder position on his console and made a bad situation worse.
  • Senior personnel and bridge watch standers on the USS John S McCain seemed to have inadequate knowledge of the steering control system.
  • The ship’s watch standers were not the most qualified team and Sea Detail should have been set sooner by the Commanding Officer.
  • The OOD and Conning Officer had not attended the navigation brief held the previous day that covered the risk of the evolution.
  • Five short blasts were not sounded when a collision was immanent giving the other ship a chance to avoid the collision.
  • The CO ordered an unplanned shift of the propulsion control from one station to another without clear notification of the bridge watch team. This order occurred in a shipping channel with heavy traffic.
  • Senior officers and bridge watch standers did not question the report of loss of steering by the Helmsman or pursue the issue to resolution.

NewImageCO & XO of USS John S McCain that were fired (reassigned).

That’s a significant blame list. Can you spot what is missing?

First, the factors that are listed aren’t root causes or even near-root causes. Rather they are Causal Factors and maybe a few causal categories.

Second, the report doesn’t provide enough information to judge if the list is a complete list of the Causal Factors.

Third, with no real root cause analysis, analysis of Generic Causes is impossible. Perhaps that’s why the is no senior leadership (i.e., the Brass – Admirals) responsibility for the lack of training, lack of readiness, poor material condition, poor root cause analysis, and poor crew coordination. For an idea about Generic Cause Analysis of these collisions and potential corrective actions, see: http://www.taproot.com/archives/59924.

Here is a short recreation of the USS Fitzgerald collision to refresh you memory…

The US Navy did not release the actual accident investigation report (the Command and the Admiralty investigations) because the Chief of Naval Operations, “… determined to retain the legal privilege that exists with the command Admiralty investigations in order to protect the legal interests of the United States of America and the families of those Sailors who perished.” I believe the release of the actual investigation reports has more to do with protecting Navy Admirals and an inadequate training and manning of US Navy ships than protecting the US Government legally.

It seems to me that the US Navy has sunk (no pun intended) to the same low standards that the Soviet Navy let their fleet deteriorate to after the cold war ended. Bad material condition, low readiness, and, perhaps, poor morale. And the US Navy seems to have the same “transparency” that the USSR had during the communist hay day.

But I was even more shocked when I found that these problems (Training, manning, material condition, …) had been noted in a report to senior US Navy leadership back in 2010. That’s right, military commanders had known of these problems across the fleet for seven years and DID NOT take actions to correct them. Instead, they blame the Commanding Officers and ship’s crews for problems that were caused by Navy and political policy. Here is a link to that report:

https://www.scribd.com/document/43245136/Balisle-Report-on-FRP-of-Surface-Force-Readiness

Why didn’t senior leadership fix the problems noted in the report? One can only guess that it didn’t fit their plans for reduced manning, reduced maintenance, and more automated systems. These programs went forward despite evidence of decreased readiness by ships in the fleet. A decreased state of readiness that led two ships to fatal collisions. This cutting of costs was a direct response to budget cuts imposed by politicians. Thus “supporting our troops” is too expensive.

It seems from the reports that the Navy would rather punish Commanding Officers and the ship’s crews rather than fix the fleet’s problems. No accountability is shared by the senior naval leadership that has gone along with budget cuts without a decrease in the operating tempo and commitments.

NewImageChief of Naval Operations who says these types of accidents should “never happen again.”

More blame is NOT what is needed. What is needed is advanced root cause analysis that leads to effective corrective actions. The report released by the Navy (at the start of this article) doesn’t have either effective root cause analysis or effective corrective actions. I fear the unreleased reports are no better.

What can we do? Demand better from our representatives. Our sailors (and other branches as well) deserve the budget and manning needed to accomplish their mission. We can’t change the past but we need to go forward with effective root cause analysis and corrective actions to fix the problems that have caused the decline in mission capabilities.

KISS and Root Cause Analysis

November 1st, 2017 by

I’ve heard many “experts” claim that you need to apply the KISS principle when it comes to root cause analysis. You may hear this too and I want you to understand where these experts lead many people astray.

First, what is KISS? Keep It Simple Stupid! The acronym implies that simple solutions are better solutions. And when simple solution work (are effective) KISS is a dream come true. But remember Einstein’s quote:

Make things as simple as possible, but not simpler.

So let’s start with some of the reasons that these experts say you need to use simple techniques and debunk or demystify each one. Here’s a list of common expert advice.

  1. It’s a waste of time to use full root cause analysis on every problem.
  2. People can’t understand complex root cause analysis techniques.
  3. Learning simple techniques will get people to start thinking deeper about problems.
  4. Simple is just about as good as those fancy techniques.
  5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.
  6. You can apply those complicated techniques to just the most serious accidents.
  7. The data from the simple investigations will help you identify the more complex issues you need to solve.

I see these arguments all the time. They make me want to scream! Let me debunk each one and then you too can dismiss these “experts” the next time they try one or more of these arguments on your management team.

1. It’s a waste of time to use full root cause analysis on every problem.

I actually sort of agree with this statement. What I don’t agree with is the answer they arrive at. Their answer is that you should apply some “simple” root cause analysis technique (let’s just say 5-Whys as an example) to “solve” these problems that don’t deserve a well thought out answer.

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First, what do I have against their ideas of simple root cause analysis? If you’ve been reading this blog for a while you know what I’m going the explain, so just skip ahead. For those who don’t know what’s wrong with most “simple” root cause analysis techniques, I would suggest start reading from the top of the links below until you are convinced that most expert advice about “simple” root cause analysis is root cause analysis malpractice. If you haven’t been convinced by the end of the links … perhaps you are one of the experts I’m talking about. Here’s the list of links:

What happens when root cause analysis becomes too simple? Six problems I’ve observed. 

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Wrong with 5-Whys??? – Complete Article 

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

I believe that one of the biggest root cause analysis problems that companies face is that they are performing “root cause analysis” on problems that don’t need to be analyzed.  YES – I said it. Not every problem deserves a root cause analysis.

What problems don’t need to be analyzed? Problems that aren’t going to teach you anything significant. I call these “paper cut problems.” You don’t need to investigate paper cuts.

But some people would say that you do need to investigate every loss time injury and medical treatment case. Maybe … maybe not.

You do need to investigate an incident if it could have caused an outcome that you are trying to prevent and there are worthy lessons learned. Some medical treatment cases fall into this category. They got a cut finger but they could have lost their whole arm.

Two similar examples are provided in the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. One is a sprained ankle and one is a sprained wrist. Both came from falling down. One was judged worthy of a full but simple root cause analysis using the essential features of the TapRooT® Root Cause Analysis System. One was judged not worthy of a full investigation after a simple SnapCharT® was developed. Interested in how this works? Read the book. It’s only 100 pages long and seeing how to judge if a root cause analysis is worthwhile is worth it. (And you will learn how to apply TapRooT® simply to low-to-medium risk incidents.)

Once you know how to do a real “simple” investigation with an effective technique, you won’t need to do bad root cause analysis with an ineffective technique.

2. People can’t understand complex root cause analysis techniques.

I don’t know every “complex” root cause analysis technique but I do know that this statement does NOT apply to TapRooT®. Why? Because we’ve tested it.

One “test” was at a refinery. The Operation Manager (a good guy) thought that TapRooT® was a good system but wasn’t sure that his operators would understand it. We decided to run a test. We decided to teach a basic class to all his union stewards. Then refinery management did a focus group with the shop stewards.

I was one of the instructors and from the course examples that they analyzed, I knew that they were really enjoying finding real root causes rather than placing blame.

They did the focus group (with us in another room). I could hear what was going on. The first question the facilitator asked was: “Did you understand the TapRooT® Root Cause Analysis Technique?” One of the shop stewards said …

“If I can run a Cat Cracker I can certainly understand this! After all, it’s not rocket science!”

And that’s one of the great parts about TapRooT®. We’ve added expert systems for analysis of equipment and human performance problems, but we’ve kept the system understandable and made it easy to use. Making it seem like it isn’t rocket science (even though there is a whole bunch of science embedded in it) is the secret sauce of TapRooT®.

3. Learning simple techniques will get people to start thinking deeper about problems.

Learning to count is required before you learn calculus BUT counting over and over again does not teach you calculus.

If you don’t understand the causes of human performance problems, you won’t find the causes of the problems by asking why. And I don’t care how many times you ask why … it still won’t work.

For years we did a basic poll at the start of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. We asked:

“How many of you have had any formal training in human factors or the causes of human error?”

Only about 2% of the attendees had ANY training on the causes of human error. But almost everybody that attended our training said that they had previously been assigned to find the causes of human errors. I wonder how well that went? (I can tell you from the student feedback, they said that they really DID NOT address the real root causes in their previous investigations.)

So, NO. Learning simple techniques DOES NOT get people to “think deeper” about problems.

4. Simple is just about as good as those fancy techniques.

NO WAY.

First, I’ve never seen a good example of 5-Whys. I’ve seen hundreds of bad examples that 5-Why experts thought were good examples. One “good example” that I remember was published in Quality Progress, the magazine from the American Society for Quality (ASQ). I couldn’t stand it. I had to write a reply. When I sent the letter to the editor, they asked me to write a whole article … so I did. To see the example and my article that was published in Quality Progress, see page 32 of the link below:

Under Scrutiny: A Critical Look at Root Cause Analysis.

Simple is not “almost as good” as real root cause analysis (TapRooT®). If you would like another example, see Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

That’s it – Case Closed. Those “simple” techniques are NOT just about as good as TapRooT® Root Cause Analysis.

5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.

Once again, I’m reminding of a saying:

Why is there never enough time to do it right,
but there is always enough time to do it over? 

How many times have I seen managers misdiagnose problems because they didn’t find the root causes and then have bigger accidents because they didn’t fix the near-misses and small accidents?

The percentage of managers trained in the causes of human error is very similar to the statistics I previously provided (2%). This means that managers need an effective root cause analysis technique … just like investigators need an effective technique. That’s why the standard corrective actions they use don’t solve the problems and we have accidents that happen over and over again.

So if you don’t have time, don’t worry. You will make time to do it over and over again.

That reminds me of a quote from a plant manager I knew…

“If we investigated every incident, we’d do nothing but investigate incidents!”

6. You can apply those complicated techniques to just the most serious accidents.

I’ve seen companies saving their “best” root cause analysis for their big accidents. Here are the two problems I see with that.

FIRST, they have the big accidents BECAUSE they didn’t solve the precursor incidents. Why? because they didn’t do good root cause analysis on the precursor incidents. Thus, applying poor root cause analysis to the lessor incidents CAUSES the big accidents.

SECOND, their investigators don’t get practice using their “best” root cause analysis techniques because the “most serious” incidents are infrequent. Therefore, their investigators get rusty or they never really develop the skills they need by using the techniques on smaller incidents that could give them practice.

The key here is to learn to use TapRooT® Root Cause Analysis to investigate smaller problems. And that’s why we wrote a book about using TapRooT® for simple incidents: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Don’t wait for big accidents to find and fix the causes of your biggest risks. Find and fix them when they give you warnings (the precursor incidents).

7. The data from the simple investigations will help you identify the more complex issues you need to solve.

Why do people think that analyzing lots of bad data will yield good results? I think it is the misconception about mathematics. A good formula doesn’t provide knowledge from bad data.

If you don’t really know how to analyze data, you should attend our pre-Summit course:

Advanced Trending Techniques

As W. Edwards Deming said:

“Without data, you’re just another person with an opinion.”

And if you know much about Deming, you know that he was very interested in the accuracy of the data.

If you aren’t finding the real root causes, data about your BAD ANALYSIS only tells you what you were doing wrong. You now have data about what was NOT the causes of your problems. Go analyze that!

So data from BAD simple investigations DOES NOT help you solve your more complex issues. All it does is mislead your management.

THAT’S IT. All the bad advice debunked. Now, what do you need to do?

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

You will learn the theory behind performance improvement and you will be well on your way to understanding what management needs to do to really improve safety, quality, equipment reliability, and operational/financial performance.

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

You will know how to implement a real, effective root cause analysis system for low-to-medium risk incidents as well as major accidents.

3. If you haven’t done it already, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the list of our upcoming public 5-Day TapRooT® Courses held around the world at this link:

http://www.taproot.com/store/5-Day-Courses/

And don’t take any more bad advice from experts who don’t know what they are talking about!

PS: If you have questions or want to discuss what you read in the books, contact me (Mark Paradies) at 865-539-2139 or by e-mail by clicking HERE.

Why do people jump to conclusions?

October 10th, 2017 by

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?

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And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Why is Root Cause Analysis Applied Reactively More Than Proactively?

October 3rd, 2017 by

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

September 26th, 2017 by

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First, let me state that the reason I seem to be carried away by the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much. Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

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What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet. And if you know me, you know that I think they should be using TapRooT® to do this.

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In TapRooT®, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® and see if there is a generic causes using a three step process. The three steps are:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?
  3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these question.

TapRooT® Users know about the Root Cause Tree® and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions. If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

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Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information we can get a hint at the generic causes for these accidents.

Before I list the generic causes we are guessing at and discuss potential fixes, here is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

GENERIC CAUSES

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade if there is the will to invest in a capable fleet. All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

  • Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
  • Conduct the training for all ships on a prioritized basis.
  • Integrate the training into junior officer training courses and department head and perspective XO and CO training.
  • Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staffs.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

  • Develop a standard watch rotation schedule to minimize fatigue.
  • Review underway requirements and prioritize to allow for adequate rest.
  • Allow daytime sleeping to reduce fatigue.
  • Minimize noise during daytime sleeping hours to allow for rest.
  • Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
  • Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
  • Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for CO’s when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

This corrective action is difficult because a through training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented that are not listed above.

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class I learned that it was a 2nd or 3rd order control problem and these types of problems are very difficult for humans to solve. Thus ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

  • A seamanship training program be developed based on best human factors and training practices including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
  • Develop ship handing course for junior officers to complete before they arrive at their first ship to learn and practice common ship handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking and avoidance in restricted waters.
  • Develop an advanced ship handing corse for department heads that refreshes/tests their ship handling skills and teaches them how to coach junior officers to develop their ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance.
  • Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters including when to take control if the ship is in extremis (and practice of this skill).
  • Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship handing and supervisory skills to be passed before reporting to a ship.
  • Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

  • Perform a task analysis of required navigation shipboard duties including new technology duties and duties if technology fails (without shipboard computerized aids).
  • Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

  • Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
  • Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
  • Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

  • Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, number of days at sea under certain levels of high operating tempo, number of days at sea without a port call, staffing levels in key jobs, …
  • Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

  • Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current operating tempo.
  • Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
  • Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
  • Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support current operating tempo and create a better nuclear surface fleet carrier path.
  • Establish a new ship building program to support a modern 400 ship Navy by 2030.
  • Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to adopt and apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources needed to keep our young men and women safe at sea.

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Is punishment the best way to improve performance in the Navy?

September 20th, 2017 by

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In my decades of root cause analysis, less than 2% of incidents are caused by some sort of willful action that does not have a system cause. However, in many incident responses, companies discipline people for mistakes that were caused by system problem. This unwarranted punishment leads to:

  • Covering up problems.
  • Lying about what people did.
  • Morale issues when people are punished for things that were not their fault.
  • Mystery incidents that no one seems to know anything about (no one will talk).
  • Poor performance because the root causes of the problems are not being addressed.

Thus, I was disappointed when I saw the US Navy resort to discipline before the root cause analysis was completed after the collision of the USS Fitzgerald. Then again more discipline was used (this time against an Admiral) after the collision of the USS John S. McCain.

I wrote several articles about the collisions:

What is the Root Cause of the USS Fitzgerald Collision?

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

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

Several senior naval officers and others that discipline was needed for Navy personnel when a mission fails or a ship collides with another.

This brought to mind two sayings that I learned in the Navy. The first is:

The beatings will continue until morale improves.

The second is:

Why be fair when you can be arbitrary.

Do people in the Navy really respond to random discipline? The kind of discipline that’s been proven not to work in the civilian world?

I spent 7 years in the US Navy and have had close contacts with many people in the Navy since I left to start my civilian career. What I can tell you is this:

  1. Being at sea is different than working in a civilian job
  2. The Navy generally has a stricter set of operating rules than a civilian workforce does.
  3. There is a wider range of disciplinary actions that are available in the Navy than in the civilian word. (Although flogging and keel-hauling have been eliminated.)
  4. You can’t quit in the Navy if you have a bad boss.
  5. It’s difficult to fire someone that works for you if they are incompetent (you are stuck with those who you are assigned to lead).
  6. People ARE NOT different. They don’t become some sort of robot just because they joined the Navy.

Why did I include point #6 above? Because I’m often told that discipline is needed in the Navy to improve performance (One Admiral told me that it “sharpens the Commanding Officers game”).

It seems that some believe that senior naval officers (people commanding Navy ships – the Commanding Officers or COs) would try less hard, be less alert, and have worse performance if they didn’t have the threat of being relieved of command if they run into another ship or run aground.

Yes – the CO is ultimately responsible. Therefore, how could it NOT be the CO’s fault? They have ultimate authority on their ship … don’t they?

Let’s look at a an example. What if:

  • A ship was assigned a rigorous operational schedule of demanding technical missions.
  • The ship had several key pieces of equipment that that had been reported as broken (because of lack of time, parts, and money to perform maintenance).
  • The ship had many junior, barely qualified personnel serving in key positions because of the Navy’s planned rotation of officers and enlisted personnel and planned reduction of ashore training before new personnel arrived for their tour of duty.
  • The ship was undermanned because new ships were designed with new, smaller, crews but still had the same work to be performed as on older ships with 20-30% more people. This saved the Navy budget money – especially in the time of sequester.
  • The ship had several key personnel left ashore – with no replacement – because they were pregnant.
  • The CO was new to the ship and had little experience with this type of ship because he was assigned wartime duties ashore in Iraq during the Gulf Wars and missed an Executive Officer and a Department Head tours that would have provided more applicable experience and knowledge for this assignment.
  • People were fatigued after several tough evolutions but still had to drive the ship through a narrow, busy straight to get to their next assigned mission.

Is any of this under the CO’s control? Don’t these circumstances contribute to a mission failure if one occurs (like a collision). Would discipline make any of these factors change?

Does telling the CO that you are going to punish him (or her) if he or his crew makes a mistake make ANY difference?

Please leave me your comments. I’d be interested in what you have to say.

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TapRooT® featured on Worldwide Business with kathy ireland®

September 5th, 2017 by

Mark & Kathy discussing root cause analysis and human performance.

Watch the recorded television broadcast below.

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

August 30th, 2017 by

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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.

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Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

“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…

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

Knowing that each year about 900 construction workers do not come home to their families after work, safety on construction work sites must be taken seriously.

AGC, the Associated General Contractors of America recently published a study together with Virginia Tech, “Preventing Fatalities in the Construction Industry”. There are some interesting findings:

  • Dangerous Lunch Hour: construction site fatalities peak at noon, and are much lower on Fridays than Monday through Thursday
  • Small Contractors (less than 9 employees) are overrepresented in the statistics, with a fatality rate of 26 per 100,000 workers
  • Fully 1/3 of fatalities are from falls, and about 29% from Transportation incidents with e.g trucks or pickups
  • More experienced workers are not safer: fatalities start increasing after age 35 and keep growing so that 65 year olds are at the highest risk
  • Industrial projects are the most dangerous, followed by Residential and Heavy construction projects

The consequences of a fatality are devastating. There is a great human cost where families will have to deal with grief as well as financial issues. For the company there may be OSHA fines, law suits and criminal investigations. There really is no excuse for a builder not to have an active safety program, no matter how small the company.

Basic safety activities include providing and checking PPE and fall protection, correct use of scaffolding and ladders, on- going safety training, check- ins and audits. It is also a good idea to actively promote a safety culture, and to use a root cause analysis tool to investigate accidents and near misses, and prevent them from happening again.

The TapRooT® Root Cause Analysis methodology is a proven way of getting to the bottom of incidents, and come up with effective corrective actions. Focus is on human performance, and how workers can be separated from hazards like electricity, falls or moving equipment.

We can organize on- site training, or start by signing up for a public course. We offer the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as well as the introductory 2-Day TapRooT® Root Cause Analysis Training class.

Be proactive, do not let preventable accidents catch up with you… call us today!

#TapRooT_RCA #safety

Monday Motivation: Modify your dreams or magnify your skills!

June 5th, 2017 by

  You must either modify your dreams or magnify your skills. – Jim Rohn

“Dream big,”” they say.

“If you can dream it, you can become it,” they say.

It’s the season of high school and college graduations, and success clichés are in the air.  And, to be fair, there is a certain amount of vision that can be gleaned from inspirational quotes.  But there is more to reaching success in your career than simply having a dream.  Don’t settle and modify your dreams.  You can bridge the gap of where you are now to where you want to be by magnifying your skills.

We can help you do just that!

If you want to magnify your leadership skills, read the TapRooT® Root Cause Analysis Leadership Lessons book.

If you want to magnify your skills of conducting fast simple investigations, read the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book or attend our 2-day TapRooT® Root Cause Analysis Training.  We have made major strides in making TapRooT® easy to use. We even have a new five step process for doing a low-to-medium risk incident investigation.

If you want to magnify your skills of conducting major investigations, learn the whole TapRooT® process and tools for investigating high potential and high risk incidents by reading the TapRooT® Root Cause Analysis for Major Investigations book or attending our 5-day TapRooT® Advanced Root Cause Analysis Team Leader Training.  The book and course explain the entire 7-step TapRooT® System and all the TapRooT® Tools.

If you want to get ahead of accidents, incidents, and quality issues, then magnify your proactive/audit skills by reading the TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book.

Don’t settle for less than what you want to do with your career.  Magnify your skills!

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

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Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Root Cause Tip: “Enforcement Needs Improvement” – You Can’t Train Obedience/Compliance/Positive Behavior

May 26th, 2017 by

This is a quick clarification to stop a definite no-no in poorly developed corrective actions.

You find evidence during your root cause analysis to support the root cause “Enforcement NI” based on the following statements from your Root Cause Tree® Dictionary for a particular causal factor:

  • Was enforcement of the SPAC (Standards, Policies, Administrative Controls) seen as inconsistent by the employees?
  • Has failure to follow SPAC in the past gone uncorrected or unpunished?
  • Did management fail to provide positive incentives for people to follow the SPAC?
  • Was there a reward for NOT following the SPAC (for example: saving time, avoiding discomfort).
  • When supervisors or management noticed problems with worker behavior, did they fail to coach workers and thereby leave problems similar to this causal factor uncorrected?

But then if you create a corrective action to retrain, remind, and reemphasize the rules, directed at the employee or in rare occasions the immediate supervisor, your investigation started on track and jumped tracks at the end.

Now, I am okay with an alert going out to the field for critical to safety or operation issues as a key care about reminder, but that does not fix the issues identified with the evidence above. If you use Train/Re-Train as a corrective action, then you imply that the person must not have known how to perform the job in the first place. If that were the case, root causes under the Basic Cause Category of “Training” should have been selected.

Training covers the person’s knowledge, skills and abilities to perform a specific task safely and successfully. Training does not ensure sustainment of proper actions to perform the task; supervision acknowledgement, reward and discipline from supervision, senior leadership and peers ensure acceptance and sustainment for correct task behaviors.

Don’t forget, it is just as easy for supervision to ignore unsafe behavior as it is for an employee to deviate from a task (assuming the task was doable in the first place). Reward and discipline applies to changing supervision’s behavior as well.

Something else to evaluate. If the root cause of Enforcement NI shows up frequently, make sure that you are not closing the door prematurely on the Root Cause Tree® Dictionary Near Root Causes of:

  • Oversight/Employee Relations (Audits should be catching this and the company culture should be evaluated).
  • Corrective Actions (If you tried to fix this issue before, why did it fail?).

Remember, you can’t train obedience/compliance/positive behavior. Finally, if you get stuck on developing a corrective active for Enforcement NI or any of our root causes, stop and read your Corrective Action Helper®.  

Learn more by attending one of our upcoming TapRooT® Courses or just call 865.539.2139 and ask a question if you get stuck after being trained.

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Are You Writing the Same Corrective Actions?

April 17th, 2017 by

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

Why Does TapRooT® Exist?

March 28th, 2017 by

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

http://www.taproot.com/archives/category/success-stories

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.

As Bart Simpson says:

“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”

Blame is so common that people take it for granted.

Somebody makes a mistake and what do we do? Discipline them.

If they are a contractor, we fire them. No questions asked.

And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.

Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?

But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.

Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution. 

How do you stop blame and get people to cooperate with investigations? Here are two best practices.

A. Start Small …

If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous. 

Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.

B. Use a SnapCharT® to facilitate your investigation and report to management.

We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.

Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame. 

What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:

TapRooT® Training

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2. FIRST ASK WHAT NOT WHY

Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.

Why?

Because they should have started by asking what before they asked why.

Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem. 

How do you get people to ask what instead of why?

Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.

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3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE

Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.

What happens when an investigator starts an investigation by jumping to conclusions?

They ignore evidence that is counter to their hypothesis. This problem is called a:

Confirmation Bias

It has been proven in many scientific studies.

But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.

What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?

Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.

How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.

THAT’S IT…

The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.

If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.

If your organization faces:

  • Quality Issues
  • Safety Incidents
  • Repeat Equipment Failures
  • Sentinel Events
  • Environmental Incidents
  • Cost Overruns
  • Missed Schedules
  • Plant Downtime

You need to be apply the best root cause analysis system: TapRooT®.

Learn more at: 

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

And find the dates and locations for our public TapRooT® Training at:

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

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The 7 Secrets of Root Cause Analysis – Video

December 12th, 2016 by

Hello everyone,

Here is a video that discusses some root cause tips, common problems with root cause analysis, and how TapRooT® can help. I hope you enjoy!

Like what you see? Why not join us at the next course? You can see the schedule and enroll HERE

Monday Accident & Lessons Learned: Overspeed at Fletton Junction

September 19th, 2016 by

This incident notice is from the UK Rail Investigation Branch about an overspeed incident at Fletton Junction, Peterborough on 11 September 2015.

At around 17:11 hrs on 11 September 2015, the 14:25 hrs Virgin Trains East Coast passenger train service from Newcastle to London King’s Cross passed through Fletton Junction, near Peterborough at 51 mph (82 km/h) around twice the permitted speed of 25 mph (40 km/h). This caused the carriages to lurch sideways resulting in minor injuries to three members of staff and one passenger.

It is likely that the train driver had forgotten about the presence of the speed restriction because he was distracted and fatigued due to issues related to his family. Lineside signs and in-cab warnings may have contributed to him not responding appropriately as he approached the speed restriction and engineering controls did not prevent the overspeeding. Neither Virgin Trains East Coast, nor the driver, had realised that family-related distraction and fatigue were likely to be affecting the safety of his driving. Virgin Trains East Coast route risk assessment had not recognised the overspeeding risks particular to Fletton Junction and Network Rail had not identified that a speed limit sign at the start of the speed restriction was smaller than required by its standards.

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The incident could have had more serious consequences if the train had derailed or overturned. The risk of this was present because the track layout was designed for a maximum speed of 27 mph (43 km/h).
As a consequence of this investigation, RAIB has made five recommendations. Two addressed to Virgin Trains East Coast relate to enhancing the management of safety critical staff with problems related to their home life, and considering such issues during the investigation of unsafe events.

A recommendation addressed to Virgin Trains East Coast and an associated recommendation addressed to Network Rail relate to assessing and mitigating risks at speed restrictions.

A further recommendation to Network Rail relates to replacement of operational signage when this is non-compliant with relevant standards.

RAIB report also includes learning points relating to managing personal problems that could affect the safety performance of drivers. A further learning point, arising because of a delay in reporting the incident, stresses the importance of drivers promptly reporting incidents which could have caused track damage. A final learning point encourages a full understanding of the effectiveness of safety mitigation provided by infrastructure and signalling equipment.

For more information see:

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