The new web-based version of TapRooT® software utilizes a completely rewritten SnapCharT tool. As a result, there is a script that needs to run the first time you open the tool that adds your internal URL as a trusted site. However, on machines with Internet Explorer 8 installed, that action needs to be performed manually. We have an article that details how to do that and it can be found here
What do you do after an accident for those that are impacted by the accident? Linda will talk at the TapRooT® Summit about her medical sentinel event and how people involved need to be supported.
Here’s a video that will provide you some background about Linda and MITSS.
“HILTON HEAD ISLAND, S.C. – The kit-built single-engine plane was gliding quietly as it came down for an emergency landing on a beach. Pharmaceutical salesman Robert Gary Jones, listening to his iPod while jogging, likely never saw or heard it before the aircraft hit him from behind Monday evening and killed him.”
Should we ban headphones from public beaches or post a warning jog with headphones at your own risk?
Once you attend a TapRooT® course and learn how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? Questions like these are why so many course attendees plan to attend the TapRooT® Summit. The Summit is a place where TapRooT® users gather to discuss best practices, like innovative ideas for leading investigation teams. In 2010, Ken Reed will be teaching “Ideas for Leading Investigation Teams.” In this talk, he’ll discuss:
- Preparations required before an incident occurs
- The first steps when you receive that phone call
- How you actually use the TapRooT® tools during the course of a real-world investigation
Ken Reed is a Senior Associate at Sytem Improvements, and brings 21 years of US Navy nuclear operator and supervisor experience having served on numerous fast attack, ballistic missile, and research submarines. He is currently the Project Manager for the Equifactor® Equipment Troubleshooting module of the TapRooT® software, overseeing course and software updates and revisions. He holds a B.S. in Electronics Management from Southern Illinois University. He was born and raised in Watertown, NY, and currently resides in Knoxville, Tennessee.
Come to the Summit to learn advanced techniques like these and many more. Join us on the Riverwalk in San Antonio, Texas, October 27-29. (Learn more!)
Megan McArdle wrote an interesting article about the age statistics of the drivers involved in Toyota acceleration accidents. It seems older people (above 60 years old) are much more likely to be involved in an acceleration accident.
She then hypothesizes that this “age discrimination” means that these accidents are driver caused and not “Toyota caused.” Or at least that this is the reason that Toyota did not discover their problems sooner.
“Failure to test a cement casing at an oil well in the Timor Sea was a root cause of a blowout that caused Australia’s worst offshore oil spill, an inquiry has heard.“
It sure seems like there were many more “root causes” to me and that the analysis should have led to root causes that were much more in-depth. And it would be a big help if there was a SnapCharT® to help identify all of the Causal Factors.
We’ve scheduled two sessions at the October 2010 Summit where attendees will have the opportunity to learn valuable coaching skills:
1) Coach for Improved Corrective Action Development Implementation
Participants walk away with coaching skills and a coaching model that can be used in any work environment to support improving human performance in the workplace.
2) Coaching Skills to Sustain Behavior Change
Participants walk away with coaching skills and a coaching model that can be used in any work environment to support creating behavioral change in the workplace.
Both sessions will be taught by Jennifer Mounce. Jennifer is the founder of Coach Effect, Inc., a leadership coaching & organizational development boutique in San Francisco, California. With more than fifteen years of corporate experience in human resources and in coaching senior executives, Jennifer uses her expertise to partner with companies and increase their overall effectiveness by coaching, training, and consulting with mid– and senior level managers. Jennifer is a published author of two books and a professional speaker. Jennifer is a graduate of the Coach University Coach Training Program. Jennifer received her Bachelor’s in Speech Communication from University of Illinois and Master’s in Human Resource Management from Loyola University Chicago. She is a certified Senior Professional in Human Resources and is currently working toward her Professional Coach Certification.
Are you ready for the 2010 Summit? Learn more on our website!
“A Navy inspector general report said investigators had substantiated that Graf assaulted subordinates (pushing one, grabbing another and once throwing wadded-up paper at another Sailor) and that she regularly verbally abused subordinates by publicly berating them, belittling them and using profane language.“
A Navy CO using profane language and berating crew members in public … sounds like the first ship I was on in 1980.
And, of course, assault should never be tolerated. But the female CO, Captain Holly Graf, (pictured above) pushed someone, grabbed someone, and throws a wadded up piece of paper at someone? This hardly seems like serious offenses. But perhaps it does show a lack of judgment. After all, the CO’s job on a ship is quite serious and there needs to be a certain amount of formality and separation maintained to maintain good order and discipline. Grabbing sailors (or officers) and throwing things at them isn’t setting a good example for your crew.
Then there is the drag racing.
I’ve seen two ships line up side by side to run a one mile race. We won! Our nuclear powered cruiser beat a gas turbine powered cruiser.
The AP story said this about the drag race:
“One sailor said that during the race, aimed at boosting morale, the McCain got ahead of the Cowpens and began drifting to the left into the path of the Cowpens. Though the report did not question that the race took place, it said the allegation of “hazarding a vessel” was unsubstantiated.”
One sailor said?
If every CO was relived because they swore, had sailors that didn’t like them, or even made occasional judgment failures (grabbed a sailor), we probably couldn’t keep our fleet at sea. But maybe there’s more to this story than what was printed in the Associated Press article?
I decided to look a little further and did a Google search on “Captain Holly Graf”.
WOW! What an eyeful! Lot’s more information was posted on-line about how bad Captain Graf was!
Of course you can’t believe everything you read on-line, but … read the comments at this blog:
After reading the material available, I would conclude that Captain Graf was an awful person to work for and a terrible leader. The Navy is lucky that no one was killed as a result of her leadership failings. (Having your crew be scared to talk to you is a great way to get a ship into deep trouble.)
But some of the charges seem silly. Guilty of having a Junior Officer play a Christmas Carol on the piano at a Christmas Party at the CO’s house? Or another charge that a Junior Officer walked the CO’s dog willingly? Come on.
But what about Navy leadership? How did she get to such a position of power? Why weren’t her poor leadership traits detected earlier?
Man or woman, I don’t care. Men and women can be great leaders. Or not.
Poor leaders at sea can have dreadful consequences. Our sailors deserve good leadership. Seems like the poor leadership qualities of Captan Holly Graf might indicate a generic problem with the way that leaders are developed and promoted inside the Navy. Certainly this isn’t the first “bad CO” that I’ve heard about. Perhaps a more in-depth analysis is required?
Plenty to dig into when analyzing the root causes (and generic causes) of a poorly led ship.
An article in Federal Computer Week says that a Congressional Panel has recommending expanding the DoD Office of Performance Management and Root Cause Analysis.
The office and the new Performance Assessment and Root Cause Analysis (PARCA) Czar, are the result of the Weapons System Acquisition Reform Act of 2009.
To find out more about the recommendations and the role of the new acquisitions PARCA Czar, see the article at:
Ed Skompski (VP hear at SI) had this story sent to him. Perhaps it’s even true…
During a private “fly-in” fishing excursion in the Alaskan wilderness, the chartered pilot and fishermen left a cooler and bait in the plane. And a bear smelled it. This is what he did to the plane…
The pilot used his radio and had another pilot bring him 2 new tires, 3 cases of duct tape, and a supply of sheet plastic. He patched the plane together and FLEW IT HOME!
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Buck Griffith for his group. Watch and learn …
While influenza outbreaks appear to be slowing, neither the WHO, nor CDC has declared an end to this pandemic. There are still some areas with widespread influenza activity.
NOVEL H1N1
In an overview of flu activity during the 2009-10 flu season that started Aug 30, the US Centers for Disease Control and Prevention (CDC) said pediatric deaths from the pandemic virus are three times higher than the average for the past three seasons. Flu activity peaked on Oct 24, much earlier than the February peaks of the most recent flu seasons. The CDC pointed out that multiple waves were seen during the three most recent pandemics, emphasizing the importance of vaccination.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5902a3.htm?s_cid=mm5902a3_x
Though older people appear to have some immunity to the pandemic virus, the US Centers for Disease Control and Prevention learned of several outbreaks at nursing homes, detailing three inMorbidity and Mortality Weekly Report (MMWR). They occurred during the fall before the vaccine was widely available, and infections in healthcare workers were documented at two of the facilities. Infection control steps and antiviral prophylaxis seemed to slow flu spread.http://www.cdc.gov/mmwr/preview/mmwrhtml/mm5903a3.htm?s_cid=mm5903a3_x
During 2009, 73 laboratory-confirmed cases of human infection with highly pathogenic avian influenza A (H5N1) virus were reported to WHO from 5 countries. The 73 laboratory-confirmed cases of H5N1 virus infection were reported from Cambodia (1 case), China (7), Egypt (39), Indonesia (21) and Viet Nam (5); all of these countries reported human cases of H5N1 previously. Circulation of highly pathogenic H5N1 virus in poultry is considered to be endemic in these countries.
With almost double the number of human cases of H5N1 reported in 2009 compared with 2008, and with continuing circulation of the virus among certain poultry populations, it is clear that H5N1 remains a concern for both animal health and public health.http://www.who.int/wer/2010/wer8507.pdf
VACCINE
Given signs that the pandemic H1N1 virus will continue its dominance over other flu strains, the World Health Organization (WHO), CDC, FDA, etc. have recommended adding the pandemic strain as the H1N1 component of the seasonal flu vaccine for the Northern Hemisphere’s next flu season. Additionally, they have also changed the other influenza A strain, replacing the Brisbane H3N2 component with a Perth H3N2 strain. The influenza B component (changed last year) remains the same.The recommendation for next season’s vaccine:
· A/California/7/2009 (H1N1)-like virus
· A/Perth/16/2009 (H3N2)-like virus
· B/Brisbane/60/2008-like virus.
The Advisory Committee on Immunization Practices (ACIP) voted to expand the recommendation for annual influenza vaccination to include all people aged 6 months and older. The expanded recommendation is to take effect in the 2010 – 2011 influenza season. The new recommendation seeks to remove barriers to influenza immunization and signals the importance of preventing influenza across the entire population. The vote took place against a backdrop of incremental increases in the numbers and groups of people recommended for influenza vaccination in years past, and lessons learned from the world’s still ongoing first flu pandemic in 40 years.
In an effort to maintain the nation’s supply of drugs and other medical products in the event of a pandemic or other emergency, the US Food and Drug Administration (FDA) recently issued guidance to help pharmaceutical companies plan for high absenteeism rates. It focuses on “medically necessary products” such as antivirals and details what the FDA could do to help protect the supply. The guidance is also aimed at companies that make the raw materials and components used in the products.http://www.fda.gov/downloads/Drugs/GuidanceComplianceRegulatoryInformation/Guidances/UCM196497.pdf
College students living in dorms reduced their risk of influenza-like illness (ILI) at the peak of the flu season by wearing surgical masks a few hours a day and practicing good hand hygiene, say researchers from the University of Michigan. There have been many studies that point out the effectiveness of masks, hand hygiene & social distancing as very effective tools.http://www.cidrap.umn.edu/cidrap/content/influenza/general/news/jan2210masks.html
COMMENTARY
As the H1N1 pandemic vaccine becomes available in your area, I urge you to get it – for yourself, your family & your community. In the meantime, continue to practice good hygiene and social distancing.
“We should be careful to get out of an experience only the wisdom that is in it — and stop there — lest we be like the cat that sits down on a hot stove-lid. She will never sit down on a hot stove-lid again, and that is well; but also she will never sit down on a cold one any more.” - Mark Twain, author and humorist (1835-1910)
(Wisdom Quote is a new column published every Tuesday on the Root Cause Analysis Blog.)
Ralph Brickey will be sharing “Ideas for Changing Behavior When Working Outside Western Culture” at the 2010 Summit in San Antonio, Texas (October 27-29, 2010).
This session will explore issues of working with conflicting cultural thought when seeking to establish norms for investigations and implementing change in other cultures. Through a simple exercise participants will first examine a few of their own western “norms” and then apply these in a case study involving an investigation of a confined space incident that resulted in the deaths of two workers in an eastern culture.
Ralph Brickey’s experience in facilitating individuals and teams through transformational change has given him an appreciation for the potential for sustainable high performance within every organization. His work with exceptional leaders at all levels has confirmed the importance of developing the spirit of leaders to enable them to inspire organizations to achieve results. Ralph works with organizations to prepare and empower facilitators and culture change leaders to effectively impact the attainment of a thriving high performance culture.
Ralph has ten years experience facilitating insight-based learning experiences and working with teams to enhance effectiveness and performance. He has facilitated numerous root cause analysis learning experiences with many corporate clients throughout the United States and Canada. He has a special interest in improving cultures to impact safety in organizations. As program manager for Tennessee Valley Authority’s STAR 7 culture-shaping program, Ralph coached both internal facilitators and executives on their leadership skills. His successful experience with executives, first line leaders, and union members has given him unique insights into thriving cultures and the ability to move comfortably from sector to sector when working with organizations.
Ralph holds a Doctor of Education in Collaborative Learning from the University of Tennessee. His research interests are dialogue and reflective practice. Ralph is curious about almost everything and interested in the rest. He is beginning to research the impact of culture on safety within high risk organizations. He has represented the University of Tennessee in facilitating two seminars on Action Research in Thailand.
Ralph lives in Kingston, Tennessee with his wife Janice. Ralph enjoys traveling and exploring out of the way places. He is very interested in amateur archaeology and has visited the Angkor Wat complex in Cambodia, Authyia in Thailand, the Khyber Pass in Pakistan/Afghanistan, and most of the major pyramids and sites in Mexico and Central America. He enjoys playing with his three young grandsons and introducing them to bicycles, motorcycles, jeeps, caves, cliffs and kayaks, just a few of his many and varied interests. He frequently rides long distance bicycle tours both solo and with groups. His longest ride was a 3,000 mile Pacific to the Atlantic coast ride in 27 days.
“As an explorer, I am excited about partnering with organizations to explore and appreciate together what I believe is the unlimited potential for growth and excellence of performance in both individuals and teams to create healthy high performance safety cultures.”
I wanted to take just a moment and share with you some some upcoming events:
I will be giving a talk “Advanced Root Cause Analysis in Investigations and Audits” at the International Conference in Mining Safety and Security in Lima, Peru on March 25.
Mark, Mhorvan, and Alan will be exhibiting at the IOSH Conference in Glasgow, Scotland on March 24-25.
Chris will be exhibiting at the Aviation Human Factors Conference on March 31-April 1.
Linda, Mhorvan, and Alan will be exhibiting at the UK Safety and Health Expo in Birmingham, England on May 11-13.
Chris and I will be exhibiting at the ASQ World Conference on Quality and Improvement in St. Louis on May 23-25.
Mark, Linda, Ken, and I will be exhibiting at the VPPPA Conference in Orlando on August 23-27.
I will be presenting “Making the Business Case for Safety” and “Safeguards; Raising the Bar on your Worksite Analysis Programs” at VPPPA, exact dates to be determined.
This looks like they should have been applying Equifactor® before the accident to handle the equipment reliability problems they were having.
Also, see the lessons learned at the end of the “AccidentRussianHydroPlant.pdf” that is linked to above. Do you think they were based on a through root cause analysis?
Wouldn’t it have been nice to see a real TapRooT® Investigation of this accident…
Imagine a good, complete summer SnapCharT®. And root causes identified for each Causal Factor by using the Root Cause Tree®. And corrective actions developed using the Corrective Action Helper® Module and SMARTER.
How much knowledge is lost because we don’t effectively investigate problems?
We discussed the use of checklists in the medical industry in a previous blog entry. Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University. He was selected in 2008 as Time Magazine’s Top 100 Most Influential People. He had a great discussion on the use of checklists in medical industry, specifically hospitals. He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists. He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed. Quite a statement! Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development. What do you think? With so much research indicating the benefits of checklists, why have they not yet come into widespread use?
There are two basic formats of a resume. Since an employer will spend less than 30 seconds forming an initial impression of a resume, it’s important to know which format is best for you. The two formats are chronological and functional.
A chronological resume lists each previously held position in order by date with the most recent position listed at the top of the resume. A chronological resume is best for a person who has:
a focused career path
no significant gaps in employment
a steady advancement in his or her career path
Sometimes people decide to change careers or take time out from a career to raise a family or retrain. A functional resume is a better fit for that type of person. A functional resume emphasizes specific experience and is not listed in date order. The experience, training or volunteer work the person has that qualifies him for the position he/she is applying for would appear at the top, even though it is not the most recent. A functional resume is best for a person who has:
just graduated from college
little or no work experience
large gaps in employment
worked in a variety of fields
Remember, the point of a resume is not to get a job, but to get an interview. Your experience and training should be listed in a way that will catch an employers interest long enough to call you for more information. The format you choose could very well determine whether you get the interview!
“Best Practices for Implementing TapRooT® into an Existing Incident Management System” is just one idea that will be discussed October 27-29 at the 2010 TapRooT® Summit in San Antonio, Texas.
At this TapRooT® Summit session, Patrick Fortune will be speaking on the “exhilaration and tribulations” of incorporating TapRooT® into an existing Incident Management System. Expect to take away some Best Practices and even some learnings from Patrick’s mistakes, giving you the freedom not to repeat them yourself! Patrick describes his focus as a mix of “speaking truth to power, no matter what the consequences” and “let’s work the problem people.”
Patrick began his industrial career in the Operations department of a “state of the art” pulp mill. Midstride in his career, he moved into the Oil & Gas industry with EnCana Corporation. He progressed through a variety of Operations positions in Heavy Oil, Sour Gas and Power Generation with EnCana. Patrick was then enticed to join the “dark side” as a Safety Coordinator with EnCana’s EH&S division, where he has been for 5 years. Last year Patrick successfully challenged the Canadian Registered Safety Professional Designation (CRSP). He also has a liberal arts degree in Biblical Studies, and a 2nd Class Power Engineer Certificate of Competency.
Patrick has been the “go to guy” for the integration of TapRooT® into the existing Crisis Response and Incident Management Systems, within EnCana’s Canadian Division. He is a certified In House Trainer for TapRooT® and has been involved with numerous serious incident investigations across two provinces in Canada. Patrick has also served as on scene liaison with Police and anti terrorist task forces, during the investigation of several domestic terrorist attacks against EnCana.
On a personal note Patrick has enjoyed a wide variety of activities including hiking, snowboarding, hang gliding, flying small aircraft and sailplanes, rock climbing, motorcycling, martial arts, drama, and now has his eye on powered paragliding (and a bigger bike … ). When questioned about the dichotomy between “safety guy” and his love of higher risk activities he will respond with “risk management, it’s all about risk management.” His marvelous (& patient) wife of 25 years will roll her eyes at that statement, given that their two teenagers are unfortunately now using similar rebuttals …
Come to the Summit in October and meet Patrick for a fresh set of ideas about investigations! Learn more about the Summit on our FAQs page.
Every accident Investigator should be familiar with certain classic accidents that provide lessons across all industries. The capsizing of the ship “herald of Free Enterprise” is one of those accidents. It happened on March 6, 1997.
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