Category: Investigations

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

January 29th, 2018 by

Screen Shot 2018 01 27 at 2 48 07 PM

On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

January 27th, 2018 by

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

NewImage

CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

January 17th, 2018 by

NewImage

Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.

NewImage

Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

Equipment Troubleshooting in the Future

January 5th, 2018 by

Equipment Troubleshooting in the Future
By Natalie Tabler and Ken Reed

If you haven’t read the article by Udo Gollub on the Fourth Industrial Revolution, take some time to open this link. This article can actually be found at many links on the internet, so attribution is not 100% certain, but Mr. Gollub appears to be the probable author.

The article is interesting. It discusses a viewpoint that, in the current stage of our technological development, disruptive technologies are able to very quickly change our everyday technological expectations into “yesterday’s news.” What we consider normal today can be quickly overtaken and supplanted by new technology and paradigms. While this is an interesting viewpoint, one of the things I don’t see discussed is one of the most common problems with automating our society: equipment failure. If our world will largely depend on software controlling machinery, then we need to take a long hard look at avoiding failure not only in the manufacturing process, but also in the software development process.

The industrial revolution that brought us from an agricultural society to an industrial one also brought numerous problems along with the benefits. Changing how the work is done (computerization vs. manual labor) does not change human nature. The rush to be first to come out with a product (whether it be new software or a physical product) will remain inherent in the business equation, and with it the danger of not adequately testing, or overly optimistic expectations of benefit and refusal to admit weaknesses.

If we are talking about gaming software – no big deal. So, getting to the next level of The Legend of Zelda – Breath of the Wind had some glitches; that can be changed with the next update. But what if we are talking about self-driving cars or medical diagnostic equipment? With no human interaction with the machine (or software running it) the results could be catastrophic. And what about companies tempted to cut some corners in order to bolster profits (remember the Ford Pinto, Takata airbags, and the thousands of other recalls that cost lives)? Even ethical companies can produce defective products because of lack of knowledge or foresight. Imagine if there were little or no controls in production or end use.

Additionally, as the systems get more complex, the probability of unexpected or unrecognized error modes will also increase at a rapid rate. The Air France Flight 447 crash is a great example of this.

So what can be done to minimize these errors that will undoubtedly occur? There are really 2 options:

1. Preventative, proactive analysis safety and equipment failure prevention training will be essential as these new technologies evolve. This must also be extended to software development, since it will be the driving force in new technologies production. If you wonder how much failure prevention training is being used in this industry, just count the number of updates your computer and phone software sends out each year. And yes, failure prevention should include vigilance on security breaches. A firm understanding of human error, especially in the software and equipment design phase, is essential to understanding why an error might be introduced, and what systems we will need in place to catch or mitigate the consequences of these errors.  This obviously requires effective root cause analysis early in the process.

2. The second option is to fully analyze the results of any errors after they crop up. Since failures are harder to detect as stated in #1, it becomes even more critical that, when an error does cause a problem, we dig deep enough to fix the root cause of the failure. It will not be enough to say, “Yes, that line of code caused this issue. Corrective action: Update the line of code.” We must look more deeply into how we allowed the errant line of code to exist, and then do a rigorous generic cause analysis to see of we have this same issue elsewhere in our system.

With the potential for rapidly-evolving hardware and software systems causing errors, it will be incumbent on companies to have rigorous, effective failure analysis to prevent or minimize the effects of these errors.

Want to learn more about equipment troubleshooting? Attend our Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis training February 26 and 27, 2018 in Knoxville, Tennessee and plan to stay for the 2018 Global TapRooT® Summit, February 28 to March 2, 2018.

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

December 21st, 2017 by

ATL

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

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

Hack of safety system causes plant shutdown …

December 18th, 2017 by

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

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

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

December 14th, 2017 by

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

 

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

NewImage

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

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

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

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

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

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

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

One last comment.

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

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

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

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

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

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

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

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

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

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

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

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

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

For more information, here are some previous blog articles:

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

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Fake News or Real?

December 6th, 2017 by

FakeNews

That’s the headline. Here is the link:

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

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

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

Not Near-Misses … They Are Precursors

December 5th, 2017 by

I had an epiphany today.

Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?

I think part of the problem may be the terminology.

Near-miss just doesn’t sound very serious. After all … it was a miss.

But what if we called these incidents PRECURSORS.

A precursor tells you that something IS going to happen unless you change.

If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.

You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.

One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.

Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.

Just a thought…

Join us LIVE on Facebook, Wednesday, December 6 at Noon Eastern

December 2nd, 2017 by

 

Click image to go to our Facebook page.

Noon Eastern

11:00 a.m. Central

10:00 a.m. Mountain

9:00 a.m. Pacific

December 6: Join Mark Paradies as he discusses the Human Factors Best Practice Track at the 2018 Global TapRooT® Summit!

Put your root cause analysis data to use

November 20th, 2017 by

 

“Just as the introduction of electricity shifted the world’s industrialized economies into higher gear a century ago, digital technologies are fueling economic activity today. This time, however, the transformation is unfolding exponentially faster.” from Digital America: A Tale of the Haves and Have Mores, McKinsey & Company

We live in an age of information, data is collected in evermore places and shared between people and machines in the IoT. Data collection and analysis is becoming easier and easier, with apps, new devices and software.

Still, in the construction industry 30% to 60% of contractors surveyed in the recent Construction Technology Report use manual processes or spreadsheets to manage takeoff, estimating, subcontractor prequalification, bids and data collection. Fewer than half of contractors responding to the survey use mobile apps for daily reporting, worker time entry, managing safety, or tracking job performance.

When it comes to investigating issues and doing root cause analysis, the TapRooT® approach yields effective and consistent results across different industries. For several years software has been available to support teams with their investigations. Now in it’s 6th version, the TapRooT® software offers the highest productivity. Charting incidents is easy, powerful tools assist with identifying Causal Factors and Root Causes, as well as with writing Corrective Actions.

New and improved graphing tools makes it easy to plot data, and trends can be better captured, over time. Watch this short video, or read more here. Stay tuned for updates about a future smart phone App.

#taproot_RCA

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

November 20th, 2017 by

NewImage

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

Here is the press release from the NTSB:

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

11/14/2017

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

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

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

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

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

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

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

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

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

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

 

Monday 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.

NewImage
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.

NewImage

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.

NewImage

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.

NewImage

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.

NewImage

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.

Join us LIVE on Facebook, Wednesday, November 8 at Noon Eastern

November 6th, 2017 by

Click image to go to our Facebook page.

Here is our upcoming November schedule (all live segments will be held on Wednesdays, 12 p.m. Eastern time):

November 8: We have exciting news to share about our Keynote Speakers! Join Mark Paradies & Benna Dortch.
November 15: Learn about our Safety Best Practice Track at the Global TapRooT® Summit with Dave Janney & Benna Dortch.
November 22: Bring all your questions about getting your TapRooT® Team trained! Ken Reed & Benna Dortch have answers!
November 29: Thinking about signing up for our Investigator Best Practices Track? Per Ohstrom & Benna Dortch will share the details!

See you soon!

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.

Screen Shot 2017 11 01 at 4 40 39 PMUSNAVYCOLLISIONS.pdf

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.

Interviewing & Evidence Collection Tip: Are you Ready for the Unexpected?

November 2nd, 2017 by

 

No one wants an accident to happen but it’s important to be ready. Here are four things to get into place so you will be:

1. Formal investigation policy. Do you have a policy that sets out the reporting process, goals of investigation and the systematic process an investigator will use to complete the investigation? Has it been updated within the past year?

2. Emergency response. Is your response plan written down? Do you have trained responders who can administer care and who will mitigate additional damages after an accident? Has the list of first responders been evaluated within the past year (people come and go and new people may need to be trained).

3. Accident investigation training. Do all employees know how to report accidents and near-misses? Are all of your investigators trained in the systematic process of investigation set out in your investigation policy?

4. Accident investigation kit. Do you have tools and equipment that aids your investigators gathered together in a grab-and-go kit? This varies from facility to facility, industry to industry. It may be as simple as forms (such as a form to record initial observations of the witnesses) and a disposable camera.

Join me and Reb Brickey on February 26 and 27, 2018 in Knoxville, Tennessee for our TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about this topic.

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.

NewImage

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?

NewImage

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.

NewImage

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.

Monday Accidents & Lessons Learned: Cardiac and Vascular Patient Pathways

October 30th, 2017 by

The Healthcare Safety Investigation Branch (HSIB) was notified by an ambulance service of an incident that occurred in April 2017 relating to safety issues arising from the care of a patient with type A aortic dissection. The notification raised specific concerns relating to cardiac and vascular patient pathways and more generally the transfer of seriously ill patients between hospitals. Click here to read the Interim Bulletin.

How Far Away is Death?

October 26th, 2017 by

A worker fell four stories from a building under construction and lived to tell the tale. Click here to read the story on “The Queensland Times.”

Interviewing & Evidence Collection Tip: How to Handle an Inconsistent Statement

October 26th, 2017 by

 

 

long-25529_1280

Not every inconsistent statement is meant to deceive.

 

A new investigator may believe that if an interviewee is telling the truth, he will be consistent in his recollection of an event every single time. However, not every inconsistent statement made by an interviewee is made to intentionally deceive.

In fact, most interviewees want to be helpful. Further, an inconsistent statement may be as accurate or even more accurate than consistent claims. That is, an account repeated three times with perfect consistency may be more of a red flag to dig deeper.

The two most important things to think about when evaluating inconsistencies are the passage of time between the incident and its recollection, and the significance of the event to the interviewee. Passage of time makes memory a bit foggy, and items stored in memory that become foggy the quickest are things that we don’t deem significant, like what we ate for lunch last Wednesday. That being said, we still have to be on the lookout for possible fallacies and know how to test them.

There are four ways to decrease the possibility of innocent inconsistent statements during the interviewing process.

  1. Encourage the interviewee to report events that come to mind that are not related or are trivial. In this way, you discourage an interviewee trying to please you by forcing the pieces to fit. They do not know about all the evidence that has been collected, and may believe that something is not related when it truly is.
  2. Tell the interviewee, explicitly, not to try to make-up anything he or she is unsure of simply to prove an answer. If they don’t know, simply request they say, “I don’t know.” This will help them relax.
  3. Do not give feedback after any statement like “good” or “right.” This will only encourage the interviewee to give more statements that you think are “good” or “right”– and may even influence them to believe that some things occurred that really didn’t.
  4. Ask the interviewee to tell the story of what happened from finish to start instead of start to finish. If the interviewee is intentionally trying to cover something up, he or she will have a hard time remembering the same order to the story he or she recited the first time because the interviewee will have a greater cognitive load to bear telling the story in reverse order.

We have plans to go over many more details on how to conduct a good interview at the 2018 Global TapRooT® Summit. Join us for TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills February 26 and 27. Learn more.

TapRooT® Road Trip!

October 25th, 2017 by

Travel is one of the most rewarding things you can do in life but it gets expensive and hard to fit in the schedule sometimes. Why not take an opportunity to increase your skills and travel to a new destination? Just don’t hole up in your hotel room eating, working and watching TV after you get there. Get out and see a little of what our featured cities have to offer. Click the image below to learn about our upcoming host cities.

 

Click image to view featured courses.

 

Root Cause Tip Warning: Do not define the impact level of your incident too low or too high

October 19th, 2017 by

 

When defining the Incident during a TapRooT® Root Cause Analysis and its impact to the business (the scope of your investigation), I often hear this statement…

“If we focus on the delay of correcting the problem, then less importance will be placed on what caused the problem.”

Take the scenario of a fire pump failing to turn on during a fire response test. The team originally wanted to focus on the pump failure only. Not a bad idea however, the pump could not be repaired for 2 weeks because of a spare part shortage. I pushed the team to raise the scope and impact of the investigation to Automatic Fire Suppression System out of service for 14 days.

Now this elevation of the incident does not lessen the focus on the pump failure, it does the opposite. A system down for 2 weeks elevates the focus on the pump failure because of impact and also allows the team to analyze why we did not have access to spare pump in a timely manner.

A caution also must be mentioned in that elevating the impact of an incident too high can cause a regulating agency to get involved or/and additional resources to be spent when not required.

Which problem is worse? Elevating a problem too high or not high enough? Your thoughts?

Interviewing & Evidence Collection Tip: Get More Out of Interviews

October 5th, 2017 by

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

In March of 1994, two of our investigators were sent to the TapRooT 5-day Incident Investigator Team…

Fluor Fernald, Inc.

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 …

Contact Us