Root Cause Analysis Blog

 

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

Posted: August 18th, 2017 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

Friday Joke

Posted: August 18th, 2017 in Jokes

Technically Speaking – Help Desk Humor

Posted: August 17th, 2017 in Software, Technical Support, Technically Speaking

Are you stuck trying to find the right questions to ask to determine the Root Cause or what lead up the incident? Let the TapRooT® method and software help you with these questions by using optional techniques. To learn about these optional techniques and the TapRooT® method check into attending a course near you by clicking HERE.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

Posted: August 16th, 2017 in Accidents, Current Events, TapRooT, Video

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

Posted: August 16th, 2017 in Current Events, Pictures, Quality, TapRooT

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

ACE – How do you find the root causes?

Posted: August 16th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Ace clipart four aces playing cards 0071 1002 1001 1624 SMU

First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Can Regulators Use TapRooT® Investigation Tools?

Posted: August 15th, 2017 in Investigations, Performance Improvement

Regulator Inspection Investigation

I had a question recently from one of our friends who works as a regulator in his country. He was wondering about the advantages of using TapRooT® as a regulator as opposed to an industry user. I think this is a great question.  We often think about doing incident investigations for ourselves, but how do you help those you oversee as a regulating body?

As a government agency, you have great potential to affect the safety and health of both your employees and those you oversee.

  • Just attending the TapRooT® training will give your staff the basic understanding of true, human-performance based root causes.  It gives your team a new perspective on why people make poor decisions, and just as importantly, why people make good decisions.  This understanding will guide your thinking as to why problems occur.   Once this perspective is clear, your team will no longer be tempted to just blame the individual for problems.  They will think more deeply about the organizational issues that are causing people to make bad decisions.
  • The training will give you the tools to perform accurate, consistent investigations.  You can have confidence in knowing that your team has discovered not one or 2 issues, but all the problems that led to an incident.
  • Your investigations and investigation report reviews using TapRooT® will be based on human performance expertise, helping to eliminate your team’s biases.  EVERYONE has biases, and using TapRooT® helps keep you focused on the true reasons people make mistakes.
  • You will also have the tools to be able to more accurately assess the adequacy of the investigations and corrective actions that are submitted to you by those you oversee.  You can see where they are doing good investigations, and where they probably need to improve.  The corrective actions that are suggested by those you oversee are often poorly written and do not address the real reasons for the incident.  The TapRooT® training will ensure you are seeing effective corrective actions.
  • If your agency conducts trending of the their results, you’ll be able to produce consistent, trendable data from your investigations.  If you ensure your industry constituents are also using TapRooT®, the data you receive from them will also allow for more accurate trending results.
  • Finally, you can use the TapRooT® tools learned during the course to perform proactive audits of your industry partners.  When you perform onsite inspections, you can ensure you are looking for the right problems, and assigning effective corrective actions for the problems encountered.  Instead of just looking for the same problems, the tools allow you to look deeper at the processes you are inspecting to find and correct potential issues before they become incidents.

TapRooT® gives you confidence that the results of your investigations, and those of those you oversee, result in fixable root causes and effective corrective actions.

Monday Accident and Lesson Learned: Unsecured Load Falls Onto Worker

Posted: August 14th, 2017 in Accidents

Just a couple of days ago at Pacific Northwest National Laboratory in Washington, a worker backed into a cart that had a large, heavy cylinder loaded on it. He soon figured out the cylinder was not secured properly as it tipped over slightly hitting the workers back. Luckily he walked away unharmed, but large, heavy objects should be secured well to avoid any major injuries. Another lesson learned is to always check your surrounding well before you begin working.

 

(Resource: https://opexshare.doe.gov/lesson.cfm/2017/8/9/14769/Unsecured-Load-Falls-onto-Staff-Member-from-Wheeled-Cart)

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

Posted: August 11th, 2017 in Accidents, Current Events, Investigations, Pictures

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

Friday Joke

Posted: August 11th, 2017 in Jokes

Technically Speaking – Exporting SnapCaps into Powerpoint

Posted: August 10th, 2017 in Software, Technical Support, Technically Speaking, Video Depot

Ever wanted to take just a portion of a SnapCharT® and put it into a Powerpoint presentation? Watch as the TapRooT® Tech Guy discuss the process in our new TapRooT® VI release.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, it doesn’t mean it has to be complicated!

Enter a Caption for a Chance to Win!

Posted: August 10th, 2017 in Contest

Create the most clever caption and you could be the winner!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by September 2.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter.

Our staff will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on September 2.

Get creative and have fun!

via GIPHY

How Far Away is Death?

Posted: August 10th, 2017 in How Far Away Is Death?

Lumberjacks

How to Be a Great Root Cause Facilitator (Part 2)

Posted: August 9th, 2017 in Video, Video Depot

In the second part of this series, Benna Dortch, Ken Reed and Mark Paradies, Creator of TapRooT®, discuss more important and valuable traits of a great root cause facilitator. If you want some best practice tips to help you improve your investigations and just be better at your job, watch this series.

 

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

Posted: August 8th, 2017 in Accidents, Current Events, Investigations, Pictures, Video

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

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