Here is a video with lessons learned about a fatal accident involving equipment (a scissor lift).
But there is an additional lesson that we can learn.
Every worksite should have a supervisor perform a quick Safeguard Analysis before people start work.
In this case, power lines were an obvious hazard (high voltage). And getting equipment with booms or lifts near them would cause the natural Safeguard (distance) to fail. If this Safeguard Analysis had been performed proactively, the worker could have been warned OR the actions (visually warnings and signage) could have been implemented to prevent the fatality.
Don’t wait for a fatality. Use TapRooT® to proactively prevent fatalities.
Would you like to learn to use TapRooT® to look for problems before accident, quality problems, and other failures happen? Then you should attend the upcoming TapRooT® for Audits Course on August 1-2 in San Antonio, Texas (just before the 2016 Global TapRooT® Summit on August 3-5). Register here:
Have you ever had a boss that you needed to fire?
A boss that is:
- hurting your company,
- damaging peoples’ careers, and
- miserable to work for.
I was making a list of the great leaders and mentors that I’ve had and that got me to think of the few really bad people that I’ve worked for.
Unfortunately, I couldn’t fire the bad ones.
In one case, I was in the military. In the military, you have no choice of who you work for. I know that movies make fragging (killing your boss) seem like an option in combat but I never considered that as an option. (Although, my Dad did during WWII. His wing commander was getting multiple pilots killed by bad calls. But he was lucky and didn’t have to choose between his commander and his fellow pilots. The Germans shot him down and the problem went away (although the bad boss survived).
In the second case, the boss was a miserable soul. His only thought was getting himself ahead – he wanted to be a VP. (Which he eventually accomplished.) Luckily, he “traded” me away (think baseball trades) for someone else to advance his agenda. It was great getting out from under his “leadership.”
I guess what really makes these two bad bosses seem even worse are the great leaders that I’ve worked for and known.
Therefore, here is my advice…
If you don’t have a great boss at a great company, fire your boss.
How do you do that?
Find a great boss at a great company that wants you. Get yourself traded.
The other possibility is to make YOU the boss by starting your own company. This has it’s own rewards and problems. (For example, you may not feel comfortable living without the safety net of a big corporation.)
Or you could just wait. (This might be a miserable existence waiting for someone to either fire, transfer, or promote your boss,)
But I’d suggest NOT waiting.
Life is too short to live with a miserable boss.
And for those living under a bad boss, here’s a song for you …
The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Quality Track. Come to the Summit and maximize improvement at your company!
Starring Chris Vallee. Produced by Benna Dortch.
Interested in the Investigation Track? Learn about it here!
Interested in the Asset Optimization Track? Learn about it here!
Interested in the Safety Track? Learn about it here!
The following is a video of a fatal accident. The vehicle drove around a tow truck sent to block the underpass and past a worker waiving his arms to stop her. She drove into water about 17 feet deep. DON’T watch the video if it will upset you. For others, hopefully you can use this to teach others to avoid standing water during flooding.
The explosion at the West Fertilizer Plant was thought to have been a tragic accident. However, the Associated Press has reported that the Alcohol, Tobacco, and Firearms, and Explosives Agency (ATF) has said that the fire that caused the explosion was “intentionally set.”
Here is a TV report link:
This is a TV report from 2007 …
Truthfully, we could make the same video today.
Why haven’t we made more progress to improve patient safety?
Each year we have a Track at the Global TapRooT® Summit about improving patient safety. If the good practices we present each year had been implemented across the country … we would be much better off.
Interested in learning best practices to improve patient safety? Sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas (August 1-5). See the complete schedule by CLICKING HERE. And see the Pre-Summit Courses at this link: http://www.taproot.com/taproot-summit/pre-summit-courses.
Then register for the summit at:
This video has a few four letter words so turn your sound off if you would be offended … but the footage is spectacular.
Certainly was an impressive way to arrive for the prom. But a bad day for the pilot!
The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Asset Optimization Track. Come to the Summit and maximize improvement at your company!
Starring Ken Reed. Produced by Benna Dortch.
Learn more about the Summit!
Interested in the Safety Track? Learn about it here!
Interested in the Investigator Track? Learn more about it here!
This is a great flashback. Remember when we were this young? It wasn’t all that long ago. And everything we said then is still true today – just even more so!
Don’t miss the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. See:
Improve your root cause analysis.
- Learn best practices
- Refresh your TapRooT® skills
- Be inspired!
- Get motivated!
That’s what the Global tapRooT® Summit is all about.
If you are in the Navy … it looks like this!
Notice how happy sailors look when they aren’t to blame! (Bet they don’t look that happy on the bridge.)
Just needs some duct tape for repairs!
The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Safety Track. Come to the Summit and maximize improvement at your company!
Starring Dave Janney. Produced by Benna Dortch.
LEARN MORE about the Summit, August 1-5, 2016, San Antonio, Texas.
Interested in Asset Optimization? Learn about that track here!
Interested in the Investigator Track? Learn more about that track here!
For the previous article, see:
The second of the “essential” elements for excellence described by Rickover is RESPONSIBILITY.
You probably think you know what this means. You probably think that this is something your company already emphasizes. But read on and you will discover that it may be a missing element of your process safety program, and one reason that your company is not achieving excellence.
In the Nuclear Navy, Admiral Rickover was totally responsible. He was in charge of the design, construction, operations, and maintenance of all the Navy’s nuclear reactors (prototypes, subs, and ships). This single point of responsibility was unique in the Navy and is unique in the civilian world.
And responsibility for safety was (and is) passed down the chain of command to each Commanding Officer, Engineer, Engineering Watch Officer, and Reactor Operator. If you see something unsafe, you are fully authorized and expected to act.
If a Reactor Operator saw some safety parameter go out of spec, s/he was fully authorized and expected to SCRAM (emergency shut down) the reactor. There was no asking permission or waiting for approval.
If a reactor accident (a meltdown) had occurred, Rickover would take full responsibility. And the rest of the chain of command would likewise take responsibility for their actions.
Do you remember the hearings in front of congress after the Deepwater Horizon accident? Each of the executives from BP, Transocean, and Halliburton pointed fingers at the other executives. None would take responsibility for the accident.
An Associated Press Story said:
“Executives of the three companies, all scheduled to testify before the Senate
Energy and Natural Resources Committee, are trying to shift responsibility for the
environmental crisis to each other, according to prepared testimony.”
The Washington Post had to say about the testimony:
“Three major oil industry executives agreed on one thing in a pair of
Senate hearings Tuesday: Someone else was to blame for the drilling rig accident
that triggered the massive oil spill in the Gulf of Mexico.”
Here is some coverage of the testimony that talks about “divided responsibility” …
Watch what it takes to get Tony Hayward to say he was the ultimately in command of safety at BP.
Without Rickover’s unique concept of total accountability/responsibility, people can sidestep responsibility. Without full accountability/responsibility, decisions to:
- cut budgets,
- reduce staffing,
- defer maintenance,
- opt for cheaper designs,
- or shortcut company requirements
are easy to make because no one person is responsible. As Philippe Paquet wrote:
“When everyone is responsible, no one is responsible.”
Therefore, as Rickover points out, you must have one person at the top clearly responsible for process safety or no one is responsible and you will NOT be able to achieve excellence.
That’s it for this week’s discussion of excellence. Next week’s topic is perhaps the most important concept in excellence and process safety … “Facing the Facts.”
Read Part 5: Normalization of Excellence – The Rickover Legacy – Facing the Facts
Here’s a short video that doesn’t share much. But nuclear plants are much safer today as a result of learning lessons from accidents and incidents.
Root cause analysis has helped nuclear plants perform at record levels of safety.