Category: Performance Improvement

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

May 22nd, 2018 by

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Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Avoid Big Problems By Paying Attention to the Small Stuff

May 16th, 2018 by

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

Admiral Rickover’s 7 Rules

May 9th, 2018 by

Hyman Rickover 1955

Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

Are you using advanced root cause analysis to learn from past mistakes? Learn more about advanced root cause analysis by CLICKING HERE.

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

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But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

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 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

What is Senior Leadership’s Role in Root Cause Analysis

May 2nd, 2018 by

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Senior leadership wants root cause analysis to uncover the fixable root causes of significant accidents and precursor incidents AND to recommend effective fixes to stop repeat incidents.

But what does senior leadership need to do to make sure the happens? What is their role in effective root cause analysis? Here’s a quick list:

  • Best root cause system
  • Insist that it is used
  • Be involved in reviews
  • Insist on timely implementation of fixes
  • Check status of the implementation of fixes
  • Use trends to manage
  • Steer system to be more proactive

Let’s look at these in slightly more detail.

Best root cause system: Because so much is riding on the effective performance of a root cause system, leaders knows that second best systems aren’t good enough. They don’t want to bet their company’s future on someone asking why five times. That’s why they feel assured when their team uses advanced root cause analysis to find and fix the real root causes of problems. CLICK HERE to find out more about advanced root cause analysis.

Insist that it is used: One common theme in companies that get the most from their performance improvement programs is that senior leaders ASK for investigations. When they see a problem, they insist that the advanced root cause analysis process is used to get to the root causes and develop effective fixes. When middle management and employees see senior leadership asking for investigations and root cause analysis, they want to be involved to help the company improve.

Be involved in the reviews: When senior leaders ask for investigations, it’s only logical that they would want to review the outcome of the investigation they asked for. But it goes beyond being present. Senior management knows what to look for and how to make the review process a positive experience. People often get rewarded for good investigations. When the review process is a positive experience, people want to participate and have pride in their work.

Insist on timely implementation of fixes/Check status of the implementation of fixes: You might not believe this but I’ve seen many examples of companies where they performed root cause analysis, developed fixes, and then were very slow to implement them. So slow that the incident repeated itself, sometimes several times, before any fix was implemented. Good senior leadership insists on prompt implementation of fixes and makes sure they are kept up to date on the progress of implementation.

Use trends to manage: Good root cause analysis efforts produce statistics that can help leaders manage. That’s why senior leadership understands the use of advanced trending techniques and gets reports on the latest root cause trends.

Steer system to be more proactive: Would you rather wait for an accident or incident to find your next improvement opportunity? Or would you rather target and audit or assessment and have them apply advanced root cause analysis to develop effective improvements? The best senior leaders know the right answers to these questions.

That’s it! Senior leaders use proactive improvement and investigations of precursor incidents and major accidents (which rarely happen) to find where improvement needs to happen. They are involved with the system and use it to keep their company ahead of the competition. They are updated about the status of fixes and current trends. They reward those who make the system work.

Does that sound like your facility? Or do you have an improvement opportunity?

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

TapRooT® Around the World: Colombia

April 17th, 2018 by

Many thanks to Diana Munevar for this TapRooT® training photo from a refresher course at Occidental de Colombia, LLC in Colombia!

Put yourself in this picture. Advance your career and your development through TapRooT® training!

We are global to meet your needs. Register today for a TapRooT® Training course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.

May 2, 2018: Oklahoma City, Oklahoma, 2-Day TapRooT® Root Cause Analysis Training

May 7, 2018: Toronto, Canada, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

May 14, 2018: Cape Town, South Africa, 5-Day Advanced Root Cause Analysis Team Leader Training

May 24, 2018: Pittsburgh, Pennsylvania, 2-Day TapRooT® Root Cause Analysis Training

June 04, 2018: Gatlinburg, Tennessee, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

June 06, 2018: Aberdeen, Scotland, 2-Day TapRooT® Root Cause Analysis Training

June 11, 2018: Denver, Colorado, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

July 16, 2018: Auckland, New Zealand, 2-Day TapRooT® Root Cause Analysis Training

August 08, 2018: Sao Paulo, Brazil, 2-Day TapRooT® Root Cause Analysis Training

August 27, 2018: Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

September 26, 2018: Amsterdam, Netherlands, 2-Day TapRooT® Root Cause Analysis Training

October 14, 2018: Dubai, UAE, 5-Day Advanced Root Cause Analysis Team Leader Training

Scientific Method and Root Cause Analysis

April 4th, 2018 by

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I had someone tell me that the ONLY way to do root cause analysis was to use the scientific method. After all, this is the way that all real science is performed.

Being an engineer (rather than a scientist), I had a problem with this statement. After all, I had done or reviewed hundreds (maybe thousands?) of root cause analyses and I had never used the scientific method. Was I wrong? Is the scientific method really the only or best answer?

First, to answer this question, you have to define the scientific method. And that’s the first problem. Some say the scientific method was invented in the 17th century and was the reason that we progressed beyond the dark ages. Others claim that the terminology “scientific method” is a 20th-century invention. But, no matter when you think the scientific method was invented, there are a great variety of methods that call themselves “the scientific method.” (Google “scientific method” and see how many different models you can find. The one presented above is an example.)

So let’s just say the scientific method that the person was insisting was the ONLY way to perform a root cause analysis required the investigator to develop a hypothesis and then gather evidence to either prove or disprove the hypothesis. That’s commonly part of most methods that call themselves the scientific method.

What’s the problem with this hypothesis testing model? People don’t do it very well. There’s even a scientific term the problem that people have disproving their hypothesis. It’s called CONFIRMATION BIAS. You can Google the term and read for hours. But the short description of the problem is that when people develop a hypothesis that they believe in, they tend to gather evidence to prove what they believe and disregard evidence that is contrary to their hypothesis. This is a natural human tendency – think of it like breathing. You can tell someone not to breath, but they will breath anyway.

What did my friend say about this problem with the scientific method? That it could be overcome by teaching people that they had to disprove all other theories and also look for evidence to disproves their theory.

The second part of this answer is like telling people not to breath. But what about the first part of the solution? Could people develop competing theories and then disprove them to prove that there was only one way the accident could have occurred? Probably not.

The problem with developing all possible theories is that your knowledge is limited. And, of course, how long would it take if you did have unlimited knowledge to develop all possible theories and prove or disprove them?

The biggest problem that accident investigators face is limited knowledge.

We used to take a poll at the start of each root cause analysis class that we taught. We asked:

“How many of you have had any type of formal training
in human factors or why people make human errors?”

The answer was always less than 5%.

Then we asked:

“How many of you have been asked to investigate
incidents that included human errors?”

The answer was always close to 100%.

So how many of these investigators could hypothesize all the potential causes for a human error and how would they prove or disprove them?

That’s one simple reason why the scientific method is not the only way, or even a good way, to investigate incidents and accidents.

Need more persuading? Read these articles on the problems with the scientific method:

The End of Theory: The Data Deluge Makes The Scientific Method Obsolete

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

That’s just a small handful of the articles out there.

Let me assume that you didn’t read any of the articles. Therefore, I will provide one convincing example of what’s wrong with the scientific method.

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Supposedly he did this using the scientific method. And it worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Einstein was wrong!

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were wrong but that most everyone believed … what chance do you and I have to develop the right answer during our next incident investigation?

Now for the good news.

Being an engineer, I didn’t start with the scientific method when developing the TapRooT® Root Cause Analysis System. Instead, I took an engineering approach. But you don’t have to be an engineer (or a human factors expert) to use it to understand what caused an accident and what you can do to stop a future similar accident from happening.

Being an engineer, I had my fair share of classes in science. Physics, math, and chemistry are all part of an engineer’s basic training. But engineers learn to go beyond science to solve problems (and design things) using models that have limitations. A useful model can be properly applied by an engineer to design a building, an electrical transmission network, a smartphone, or a 747 without understanding the limitations of quantum mechanics.

Also, being an engineer I found that the best college course I ever had that helped me understand accidents wasn’t an engineering course. It was a course on basic human factors. A course that very few engineers take.

By combining the knowledge of high reliability systems that I gained in the Nuclear Navy with my knowledge of engineering and human factors, I developed a model that could be used by people without engineering and human factors training to understand what happened during an incident, how it happened, why it happened, and how it could be prevented from happening again. We have been refining this model (the TapRooT® System) for about thirty years – making it better and more usable – using the feedback from tens of thousands of users around the world. We have seen it applied in a wide variety of industries to effectively solve equipment and human performance issues to improve safety, quality, production, and equipment reliability. These are real world tests with real world success (see the Success Stories at this link).

So, the next time someone tells you that the ONLY way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there is a better way to do it today.

If you don’t know how to use the TapRooT® System to solve problems, perhaps you should attend one of our courses. There is a basic 2-Day Course and an advanced 5-Day Course. See the schedule for public courses HERE. Or CONTACT US about having a course at your site.

Effective Listening Skills Inventory for Investigative Interviews

March 29th, 2018 by

Do you ever interrupt someone because you fear “losing” what you want to say? Do you become momentarily engrossed in your thoughts, then return to reality to find someone awaiting your answer to a question you didn’t hear? Most of us are at fault for interrupting or being distracted from time to time. Particularly, though, in an interview environment where focus is key, distractions or interruptions can be detrimental to the interview.

Watch, listen, learn from this week’s conversation between Barb Carr and Benna Dortch:

Effective Listening Skills Inventory For Investigation Interviews from TapRooT® Root Cause Analysis on Vimeo.

Now, learn how to inventory your listening skills. Internalizing suggestions can recalibrate your thought and communication processes. Your work and your communication style will reflect the changes you’ve made.

Feel free to comment or ask questions on Facebook. We will respond!

Bring your lunch next Wednesday and join TapRooT®’s Facebook Live session. You’ll pick up valuable, workplace-relevant takeaways from an in-depth discussion between TapRooT® professionals. We’ll be delighted to have your company.

Here’s the scoop for tuning in next week:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, April 4, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Thank you for joining us!

Who Invented Operational Excellence?

March 28th, 2018 by

Who Invented Operational Excellence?

Admiral Hyman G. Rickover

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As a Navy Nuclear Power trained officer, I experienced the rigors of achieving operational excellence first hand.

Rickover explained that there were a series of principles that helped the Nuclear Navy achieve excellence but the top three were:

  1. Total Responsibility
  2. Technical Competence
  3. Facing the Facts

Read about these three principles in a series of articles that I wrote:

http://www.taproot.com/archives/54027

 Rickover lived out this quote:

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He fought against the lax standards that the Navy practiced and implemented a system of excellence to run the Navy’s nuclear reactors.

You might think that he would be praised and lauded by the Navy for his success. Instead, he had to fight every inch of the way to steer a course true to his principles. And the oldest Admiral ever was fired by the youngest Secretary of the Navy ever. Sometimes that’s how Washington politics works.

Want to read more about Rickover’s life and how he developed his concepts of operational/process excellence? Read his semi-official biography (written by the official Nuclear Navy historian Francis Duncan) Rickover – The Struggle for Excellence. (Picture of the book at the top of the page.)

Construction’s Fatal Four – A Better Approach to Prevention

March 26th, 2018 by

In 2016, 21% of fatal injuries in the private sector were in the Construction industry as classified by the Department of Labor. That was 991 people killed in this industry (almost 3 people every day). Among these were the following types of fatality:

Falls – 384 (38.7%)
Struck by Object – 93 (9.4%)
Electrocutions – 82 (8.3%)
Caught-in/between – 72 (7.3%)

Imagine that. Eliminating just these 4 categories of fatalities would have saved over 630 workers in 2016.

Now, I’m not naive enough to think we can suddenly eliminate an entire category of injury or fatality in the U.S. However, I am ABSOLUTELY CERTAIN that, at each of our companies, we can take a close look at these types of issues and make a serious reduction in these rates. Simply telling our workers to “Be careful out there!” or “Follow the procedures and policies we give you” just won’t cut it.

NOTE: In the following discussion, when I’m talking about our workers and teammates, I am talking about ALL of us! We ALL violate policies and procedures every day. Don’t believe me? Take a look at the speedometer on your car on the way home from work tonight and honestly tell me you followed the speed limit all the way home.

As an example, take a look at your last few incident investigations. When there is an incident, one of the questions always asked is, “Did you know that you weren’t supposed to do that?” The answer is almost always, “Yes.” Yet, our teammates did it anyway.

Unfortunately, too many companies stop here. “Worker knew he should not have put his hand into a pinch point. Corrective action, Counseled the employee on the importance of following policy and remaining clear of pinch points.” What a completely useless corrective action! I’m pretty sure that the worker who just lost the end of his finger knows he should not have put his hand into that pinch point. Telling him to pay attention and be more careful next time will probably NOT be very effective.

If we really want to get a handle on these types of injuries, we must adopt a more structured, scientific strategy. I’d propose the following as a simple start:

1. Get out there and look! Almost every accident investigation finds that this has happened before, or that the workers often make this same mistake. If that is true, we should be getting out there and finding these daily mistakes.

2. To correct these mistakes, you must do a solid root cause analysis. Just yelling at our employees will probably not be effective. Remember, they are not bad people; they are just people. This is what people do. They try to do the best job they can, in the most efficient manner, and try to meet management’s expectations. We need to understand what, at the human performance level, allowed these great employees to do things wrong. THAT is what a good root cause analysis can do for you.

3. As in #2, when something bad DOES happen, you must do a solid RCA on those incidents, too. If your corrective actions are always:

  • Write a new policy or procedure
  • Discipline the employee
  • Conduct even MORE training

then your RCA methodology is not digging deep enough.

There is really no reason that we can’t get these types of injuries and fatalities under control. Start by doing a good root cause analysis to understand what really happened, and recognize and acknowledge why your team made mistakes. Only then can we apply effective corrective actions to eliminate those root causes. Let’s work together to keep our team safe.

Root Cause Analysis Audit Idea

March 22nd, 2018 by

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In the past couple of years has your company had a major accident?

If they did, did you check to see if there were previous smaller incidents that should have been learned from and if the corrective actions should have prevented the major accident?

I don’t think I have ever seen a major accident that didn’t have precursors that could have been learned from to improve performance. The failure to learn and improve is a problem that needs a solution.

In the TapRooT® root cause analysis of a major accident, the failure to fix pervious precursor incidents should get you to the root cause of “corrective action NI” if you failed to implement effective corrective actions from the previous investigations.

If this idea seems like a new idea at your facility, here is something that you might try. Go back to your last major accident. Review your database to look for similar precursor incidents. If there aren’t any, you have identified a problem. You aren’t getting good reporting of minor incidents with potential serious consequences.

If you find previous incidents, it’s time for an audit. Review the investigations to determine why the previous corrective actions weren’t effective. This should produce improvements to your root cause analysis processes, training, reviews, …

Don’t wait for the next big accident to improve your processes. You have all the data that you need to start improvements today!

Are you a Proficient TapRooT® Investigator?

March 19th, 2018 by

 

 

 

 

 

 

 

I teach a lot of TapRooT® courses all over the world, to many different industries and departments.  I often get the same questions from students during these courses.  One of the common questions is, “How do I maintain my proficiency as a TapRooT® investigator?”

This is a terrific question, and one that you should think carefully on.  To get a good answer, let’s look at a different example.:

Let’s say you’ve been tasked with putting together an Excel spreadsheet for your boss.  It doesn’t have to be anything too fancy, but she did ask that you include pivot tables in order to easily sort the data in multiple ways.  You decide to do a quick on-line course on Excel to brush up on the newest techniques, and you put together a great spreadsheet.

Now, if your boss asked you to produce another spreadsheet 8 months from now, what would happen?  You’d probably remember that you can use pivot tables, but you’ve probably forgotten exactly how it works.  You’ll most likely have to relearn the technique again, looking back over your last one, or maybe hitting YouTube as a refresher.  It would have been nice if you had worked on a few spreadsheets in the meantime to maintain the skills you learned from your first Excel course.  And what happens if Microsoft comes out with a new version of Excel?

Performing TapRooT® investigations are very similar.  The techniques are not difficult; they can be used by pretty much anyone, once they’ve been trained.  However, you have to practice these skills to get good at them and maintain your proficiency.  When you leave your TapRooT® course, you are ready to conduct your first investigation, and those techniques are still fresh.  If you wait 8 months before you actually use TapRooT®, you’ll probably need to refresh your skills.

In order to remain proficient, we recommend the following:

  • Obviously, you need to attend an initial TapRooT® training session.  We would not recommend trying to learn a technique by reading a book.  You need practice and guidance to properly use any advanced technique.
  • After your class, we recommend you IMMEDIATELY go perform an investigation, probably within the next 2 weeks or so.  You need to quickly use TapRooT® in your own work environment.  You need to practice it in your own conference room, know where your materials will be kept, know who you’re going to contact, etc.  Get the techniques ingrained into your normal office routine right away.
  • We then recommend that you use TapRooT® at least every month.  That doesn’t necessarily mean that you must perform a full incident investigation monthly, but maybe just use a few of the techniques.  For example, you could perform an audit and run those results though the Root Cause Tree®.  Anything to keep proficient using the techniques.
  • Refresher training is also a wonderful idea.  We would recommend attending a refresher course every 2 years to make sure you are up to speed on the latest software and techniques.  If you’ve attended a 2-Day TapRooT® course, maybe a 5-Day Advanced Team Leader Course would be a good choice.
  • Finally, attending the Annual Global TapRooT® Summit is a great way to keep up to speed on your TapRooT® techniques.  You can attend a specialized Pre-Summit course (Advanced Trending Techniques, or Equifactor® Equipment Troubleshooting, or maybe an Evidence Collection course), and then attend a Summit track of your choosing.

There is no magic here.  The saying, “Use it, or Lose it” definitely applies!

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

March 14th, 2018 by

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

Hire a Professional

March 12th, 2018 by

root cause analysis, RCA, investigation

I know every company is trying to do the best they can with the resources that are available. We ask a lot of our employees and managers, trying to be as efficient as we can.

However, sometimes we need to recognize when we need additional expertise to solve a particular problem. Or, alternatively, we need to ensure that our people have the tools they need to properly perform their job functions.  Companies do this for many job descriptions:

  • Oil analyst
  • Design engineer
  • Nurse
  • Aircraft Mechanic

I don’t think we would ask our Safety Manager to repair a jet engine.  THAT would be silly!

However, for some reason, many companies think that it is OK to ask their aircraft mechanics to perform a root cause analysis without giving them any additional training.  “Looks like we had a problem with that 737 yesterday.  Joe, go investigate that and let me know what you find.”  Why would we expect Joe, who is an excellent mechanic, to be able to perform a professional root cause analysis without being properly trained?  Would we send our Safety Manager out to repair a jet engine?

It might be tempting to assume that performing an RCA is “easy,” and therefore does not require professional training.  This is somewhat true.  It is easy to perform bad RCA’s without professional training.  While performing effective  investigations does not require years of training, there is a certain minimum competency you should expect from your team, and it is not fair to them to throw them into a situation which they are not trained to handle.

Ensure you are giving your team the support they need by giving them the training required to perform excellent investigations.  A 2-Day TapRooT® Essential Techniques Course is probably all your people will need to perform investigations with terrific results.

 

What does bad root cause analysis cost?

March 7th, 2018 by

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Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

Highlights from the 2018 Global TapRooT® Summit

March 5th, 2018 by

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Coming up with a highlight reel from the 2018 Global TapRooT® Summit is almost impossible. I always think that the Summit just can’t get any better and then we outdo ourselves planning the next one. Here are some highlights followed by the top six items attendees shared that they needed to do better at their facilities.

First, a video to share the experience…

By the way, the next Global TapRooT® Summit is scheduled for March 11-15, 2019, in Houston (Montgomery, TX) at the La Torretta Lake Resort & Spa (picture below).

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Now for my impressions of the highlights …

First, the Keynote Speakers were outstanding.

We started with Dr. Carol Gunn who gave an inspiring talk about medical errors and how to encourage error reporting and effective investigations. Carol is a TapRooT® User and medical doctor … she knows what she is talking about.

Next, we had an UNBELIEVABLE talk by Boaz Rauchwerger who told us all to take a positive approach to improvement.

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The final keynote on Wednesday was Inky Johnson. How can I explain how he inspired us? There was a long line of people who just came up to thank Inky and get their picture taken with him. If you don’t know Inky’s story. watch it below for motivation to accomplish more in life.

 

After Inky’s keynote, Carl Dixon entertained us at the Summit Reception. Here I am singing Proud Mary with him…

 

On Thursday, I was the opening keynote and concluded with a TapRooT® Implementation Gap Analysis. People shared where they needed to improve their TapRooT® implementation. What were the top 6 items they needed to do better?

  1. Use advanced root cause analysis (TapRooT®) for both reactive and proactive investigations.
  2. Use an investigation rewards program more effectively.
  3. Guide their improvement programs through management’s use of performance measures and advanced trending techniques.
  4. Proactive improvement that drives improvement success (tie with 5).
  5. Develop a leadership succession plan.
  6. Communicate improvement accomplishments successfully.

These items will help us plan sessions for next year’s Summit.

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Vincent Phipps closed out the day with his discussion of the four personality types and how to use them to communicate more effectively.

On Friday we started with the session that helped attendees develop plans to fill their program gaps (started with the gap analysis performed on Thursday).

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Then, I (Mark Paradies) interviewed Mike Williams about his experiences when the Deepwater Horizon experienced a blowout, explosion(s), and fire. Wow! What an experience. People were sitting on the edge of their seats as Mike answered my questions and all the questions from the Summit participants. We actually ran over the finish time by 15 minutes as people asked interesting questions. The lessons learned from this one session about emergency response, investigations, and safety were … UNBELIEVABLE! I learned several things about the accident that I didn’t know from the various reports (CSB, Presidential Commission, BP, or Coast Guard) that added to my understanding of the Causal Factors and root causes. There was also an important lesson for investigators about empathy and PTSD after a major accident.

And that’s just a summary of the Keynote Speakers impact. There were also some great Best Practice Sharing sessions and speakers. My favorite was the TapRooT® Users Share Best Practices Session (soon, you will be seeing videos from this session to share some of the best practices).

Here are what some TapRooT® Users had to say about their 2018 Global TapRooT® Summit experience…

 

What a Summit! Hope to see you in Houston in 2019!

Nuclear Plant Fined $145,000 for “Gun-Decked Logs”

February 21st, 2018 by

When I was in the Navy, people called it “gun-decking the logs.”

In the Navy this means that you falsify your record keeping … usually by just copying the numbers from the previous hour (maybe with slight changes) without making the rounds and taking the actual measurements. And if you were caught, you were probably going to Captain’s Mast (disciplinary hearing).

The term “gun-decking” has something to do with the “false” gun deck that was built into British sailing ships of war to make them look like they had more guns. Sometimes midshipmen would falsify their navigation training calculations by using dead reckoning to calculate their position rather than using the Sun and the stars. This might have been called “gun-decking” because the gun deck is where they turned their homework over to the ships navigator to be reviewed.

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What happened at the Nuke Plant? A Nuclear Regulatory Commission inspector found that 13 operators had gun-decked their logs. Here’s a quote from the article describing the incident:

“An NRC investigation, completed August 2017, found that on multiple occasions during the three-month period, at least 13 system operators failed to complete their rounds as required by plant procedures, but entered data into an electronic log indicating they had completed equipment status checks and area inspections,” the NRC said in a statement.”

What was the corrective action? The article says:

“The plant operator has already undertaken several corrective actions, the NRC said, including training for employees, changes in the inspection procedures and disciplinary measures for some staff.”

Hmmm … training, procedures, and discipline. That’s the standard three corrective actions. (“Round up the usual suspects!”) Even problems that seem to be HR issues can benefit from advanced root cause analysis. Is this a Standards, Policy, and Administrative Controls Not Used issue? Is there a root cause under that Near Root Cause that needs to be fixed (for example, Enforcement Needs Improvement)? Or is discipline the right answer? It would be interesting to know all the facts.

Want to learn to apply advanced root cause analysis to solve these kinds of problems? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the upcoming public courses by CLICKING HERE. Or CLICK HERE to contact us about having a course at your site.

What is the Fastest Way to Get Fired After an Accident?

February 7th, 2018 by

If you work at a blame-oriented company, the answer to the question above is easy. Just admit that you were the last person to touch whatever went wrong that caused the accident.

Or, if you are in the Navy, all you have to do is to be the CO of a ship that has a collision at sea.

A slower way to get fired is to be the Plant Manager or Division Manager who doesn’t have good answers when he or she is asked by the corporate VP, “What are you going to do to prevent a repeat accident in the future?” Actually, they probably don’t fire someone this high in the organization. Rather, they transfer them to a staff job where they are never heard from again.

What is the best way to avoid being fired? Don’t have the accident in the first place! Instead, have a proactive improvement program that identifies problems, finds their root causes, and effectively fixes them before an accident happens.

Want to learn more about using TapRooT® in a proactive improvement program? Attend Dave Janney’s pre-Summit course: TapRooT® for Audits.

What’s covered in the course?

DAY ONE

  • TapRooT® Process Introduction and Initial Audit
  • SnapCharT® and Exercise
  • Significant Issues and Exercise
  • Root Cause Tree® and Exercise
  • Generic Causes
  • Corrective Actions and Exercise

DAY TWO

  • The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
  • Audit Programs, Trend and Process Root Cause Analysis
  • TapRooT® Software Introduction
  • Frequently Asked Questions about TapRooT®
  • Final Audit Observation Exercise

Don’t miss this course coming up quickly on February 27-27 in Knoxville, TN. Register by CLICKING HERE.

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Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Where Do You Get Ideas To Improve Root Cause Analysis?

January 31st, 2018 by

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Mark Ed 2

 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

L M Astronaut

Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

Linda1988

Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

Bestpractice

People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

4 Signs You Need to Improve Your Investigations

January 29th, 2018 by

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.

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FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.

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SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

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You can download the matrix that Jack uses here: http://www.taproot.com/content/wp-content/uploads/2015/04/RateRootCauseAnalysis11414.xlsx.

Don’t be satisfied. Continually improve your root cause analysis!

Interesting Article in “Stars & Strips” About Navy Court-Martials for COs Involved in Collisions

January 22nd, 2018 by

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The article starts with:

The Navy’s decision to pursue charges of negligent homicide against the former commanders of the USS Fitzgerald and USS John McCain has little precedent, according to a Navy scholar who has extensively scrutinized cases of command failure.”

See the whole article at:

https://www.stripes.com/news/navy/few-navy-commanders-face-court-martial-for-operational-failures-1.507226

The article implies that blame and shame is the normal process for COs whose ships are involved in accidents.

Isn’t it time for the US Navy to learn real advanced root cause analysis that can teach them to find and fix the causes of problems at cause collisions at sea?

Safety Fines Double in One Year in UK

January 18th, 2018 by

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

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

January 17th, 2018 by

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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.

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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.

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