Here’s some pictures taken during an exercise during a recent class we held for Rio Tinto in Brazil (Ken Turnbull and Boris Resnic were the instructors) …
In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.
The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists really helped avoid common errors and kept planes from crashing. Now, aviation checklists are a staple of the professional pilot.
I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals need to adopt the best practices that are the staple of high performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events. Especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.
That’s just one of the best practices that should be adopted immediately to improve performance in the complex environment of a modern hospital. Where can you learn more? Try a TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. Then attend the TapRooT® Summit in San Antonio (October 27-29) for more best practices to improve performance. You could be part of the movement to save thousands of lives every year by applying known best practices to improve healthcare quality and patient safety.
The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce.
Dan Daamon will be presenting Advanced Ideas for Corrective Actions: Using Risk to Rank Corrective Actions at the 2010 TapRooT® Summit, October 27-29 in San Antonio, Texas. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization.
Daniel Daamen has a diploma in Civil Engineering Technology, a degree in business administration, and holds a Masters of Business Administration from the University of Windsor (Ontario, Canada). Mr. Daamen currently is the Manager of Field EHS, for Union Gas Ltd, a Spectra Energy Company. Within this capacity he focuses on the strategic execution of EHS policies and best practices throughout the various districts within Ontario, Canada. Prior to joining Union Gas in 2007, Mr. Daamen was employed with the Blue Water Bridge Authority, a Canadian federal crown corporation, for 10 years. He was responsible for maintaining critical infrastructure and assets which included the Canadian portions of two international bridges. A major focus in this role was creating and implementing strategy related to infrastructure maintenance systems and developing and implementing EHS polices and procedures.
Learn more about our best practice presenters on our website!
The economy stinks! Jobs are scarce and the jobs that are available, people scramble to fill them. Unemployment, according to many “experts,” is the highest since the late 1970’s and many people have simply stopped looking. While jobs are scarce, advice for job searchers is abundant. With the abundance of this information, there always seems to be as much confusion about what advice to accept and what to ignore.
Kara Greene of Career Counselors Consortium and executive coach Barbara Frankel and this writer (guest columnist, Captain George Burk), offer a few tips that can help job seekers stand out from the competition, avoid some of the major pitfalls and, hopefully, get the job.
The tips are useful for any type of organizations—public, private and non-profit.
The bold quotes are some interview gaffes by job candidates. I didn’t make them up.
Hard to imagine anyone could be so dumb and have so little common sense and personal decorum. The examples, based on a survey of 3,061 U.S. hiring managers and human resources professionals by Harris Interactive found the top 10 most outrageous mistakes.
Myth #1. Ask questions at the end of the interview. There’s an element of truth in this bit of advice. Be prepared to ask questions that relate to the job. The myth is that you must wait until the interview’s over or it’s your turn to speak.
The interview is a two-way street. You want them to hire you and you want to make sure it’s the type of organization where you want to work. When you wait for the interviewer to ask you if you have any questions, “it becomes an interrogation instead of conversation,” says Greene.
“Candidate answered cell phone and asked interviewer to leave her own office because it was a private conversation.”
Approach the interview as a sales call. The product you’re selling is you and you’re selling yourself to the employer. “You can’t be passive in a sales call or you aren’t going to sell your product,” Greene says.
For example, Frankel says, if the interview says, “Tell me about yourself,” you should first respond to that question and then complete the response with your own question, like, “Please tell me more about the position.” The interview should be a dialogue, not a one-way discussion.
“Candidate told the interviewee he wouldn’t be able to stay with the job long because he thought he might get an inheritance if his uncle died—and his uncle ‘wasn’t looking too good.’”
Myth #2. It’s okay to have flaws. That’s life and reality. Almost every interviewer will ask you to name at least one flaw. Often, job seekers are told to avoid the question completely by providing a “good flaw.” An example of a “good flaw” is “I’m too committed to my work.” Generally, this kind of response serves to hurt you more than it helps. “Every competent recruiter can see right through that,” Greene says of faux flaws.
“Candidate asked the interviewer for a ride home after the interview.”
Recruiters conduct interviews all day, every day. They’ve seen it all and have an innate ability to see through candidates who try to dodge questions.
For those who may consider themselves nearly perfect and “flaw-free,” earth to candidate…everyone has weaknesses. But, according to Frankel, supply your interviewer with one genuine flaw, explain how you are working to correct it, and then move to a new question.
“Candidate smelled his armpit on the way to the interview room.”
Myth #3.Identify all of your strengths and skills to the employer. Certainly, you want the interviewer to know why you are a valuable candidate, but a literal “laundry list” of your skills and abilities won’t win you any points. What you will be asked in an interview is what can go wrong in certain scenarios and how you would respond.
“You don’t want to list a litany of strengths,” Frankel said.
Often, some of the more typical responses are, “‘I’m a good communicator,’ ‘I have excellent interpersonal skills,’ ‘I am responsible,’” Greene says. “You have to give accomplishments. I need to know what did you accomplish when using these skills.”
“Candidate said she could not provide a writing example because all of her writing had been for CIA and it was ‘classified.’”
Green recommended doing a little “spade work” before the interview so you can be better prepared to answer this question. She tells clients to find out as much as possible about the potential job role and the organization. “What makes an interview powerful is to give an example related to their particular needs or challenges that you have demonstrated in the past.”
Generally, provide three strengths, with examples. You will get much further with a handful of real strengths than an unconvincing list of traits.
“Candidate told the interviewer he was fired for beating up his last boss.”
Myth #4.Let the employer know your salary expectations. Salary is one of the most difficult questions to answer in an interview. The fact is you don’t have to answer when asked about your desire salary.
“When an applicant was offered food before the interview, he declined saying he didn’t want to line his stomach with grease before going out drinking.”
According to the book, Acing the Interview: How to Ask and Answer the Questions that Will GetYou The Job, a good answer would be “I want to earn a salary that is commensurate with the contributions I can make. I am confident I can make substantial contributions at your firm. What does your firm plan to pay for this position?”
Greene suggests a response similar to: “I prefer to discuss the compensation package after you’ve decided that I’m the best candidate and we can sit down and negotiate the package.”
“A candidate for an accounting position said she was a “people person” not a “numbers person.”
Myth #5.The employer determines if you get the job. Yes, the employer is obviously the one who offers you the position, but interviewees have more control in the hiring process than they realize. According to Greene and Frankel, candidates have a larger say in the final hiring decision than they believe.
“Candidate flushed the toilet while talking to the interviewer during a phone interview.”
Greene says, “They should call the interviewer or hiring manger and say: ‘I’d really like to be part of the company.’ It can’t hurt, it can only help you.”
Send a “Thank you“ note to the interviewer and follow-up periodically. Once a month until the position is filled is a good rule of thumb, twice a month at most. You want to show your continued interest but, at the same time, you don’t want to come off as a pest.
An email thank you from a web site or directly from you is fine. But, when you know the interviewer’s (hosts) work or home address, a written note with postage and mailing it shows a personal touch and that took the time to write to them. It adds an extra touch. Most of your “competitors” don’t follow-up with any type of a “Thank you.” They choose to take way of least resistance and effort…and wonder.
Remember: there are three types of people: Those who watch what happened; those who wonder what happened; and those who make things happen.
“Candidate took out her hair brush and combed her hair.”
Acing the interview encourages candidates to conclude the interviews with one question: “Based on your interview, do you have any concerns about my ability to do the job?” If the answer is yes, ask the interviewer to be explicit. “Deal forthrightly with each concern.”
Some other blunders and other detrimental mistakes candidates made during an interview: dressing inappropriately was the biggest mistake a candidate could make.
Talking negatively about a current or former employer was second and appearing disinterested was third.
Other mistakes included appearing or sounding arrogant, not providing specific answers and not asking good questions.
“If a candidate is overly negative, plays the blame game, is easily frazzled or doesn’t come prepared it usually ends up a red flag for employers,” said Careerbuilder.com spokeswoman Rosemary Haefner.
“We have met the enemy and he is us.” ~ POGO, cartoon character
I opened a Fortune Cookie this week that was with our meal.
“You will live the life that makes all others not envious, but proud of you.”
I can only hope and pray it is so!
====================
Authored by: Captain George Burk, USAF (Ret), Plane crash and burn survivor (excerpts from Karen Noonan, TradePub.com). Captain Burk is a motivational speaker, author and writer, and we are pleased to announce that he will be a speaker at the 2010 TapRooT® Summit in San Antonio, Texas October 27-29, 2010. For more information about Captain Burk contact him at:
One of the best things about a TapRooT® course is the final exercise where students get to demonstrate what they learned by completing an investigation and presenting to management (the rest of the class). Here are some pictures from students working on their projects:
We completed the course just before the blizzard arrived. It was really something to see; Michele (the other instructor) and I were very lucky to get out before the airport was shut down for two days with several feet of snow and high winds. See a video of the blizzard HERE.
The patient who was getting an MRI had a knife strapped to his leg (guess he wanted to be ready for anything during the MRI). The story then says…
“The knife got sucked out of its sheath and cut the patient in the abdomen, requiring stitches. Before he was taken to the MRI, the patient was screened for objects that would be attracted to the magnet. He reportedly ’stated that his pockets were empty.‘”
Part 2, as promised from a discussion on our TapRooT® Users and Friends LinkedIn Group, this is a question on LinkedIn asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.
“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”
My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.
Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don't put in don't dead head or run a pump dry. I've been doing this too long to expect that.]
That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.
Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.
Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.
ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!
First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!
At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.
The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.
First attack at the problem:
1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM
2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)
3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?
4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.
So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.
After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.
Posted 1 month ago | Delete comment
Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.
For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.
Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?
That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:
- Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
- Was he using the right tool? Did we provide him with the right tool?
- Was the right person performing this job?
- Was this job really required in the first place?
- Do supervisors ever watch their people do this particular job? Why not?
- Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
- Was the worker properly trained for this task?
- since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?
I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.
I also know that sometimes we think that people should already know these things. There are 2 possibilities:
1. The person really didn’t know (to cut away from himself)
- Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
- This is when my discussion above comes into play.
Hope this helps a little.
Posted 1 month ago | Reply Privately | Delete comment
Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.
I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.
My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.
Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.
So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.
The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.
Once again. Thanks guys. I appreciate the feedback.
Posted 1 month ago | Reply Privately | Delete comment
Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.
As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?
Steps of the process:
1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.
Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.
2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).
Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.
3. Shops have floating experts identified for employees who need a little help.
Problem: The new are training the new. The senior employees are too busy to.
So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .
Have senior employees attend training with new employees to help all do right.
Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.
We are just finishing a Spanish 5-Day course in Bogotá. Looks like they are having a great time improving performance. Looks like a great meal, too! Great job by Marco Flores, the instructor in the first picture. Diana Munévar (in the third picture) from T&PS Certified Training partnered with us to set up the course.
It makes some good points that we’ve had in Chapter 6 of the TapRooT® Book since 2008.
If you are looking for ways to keep your improvement program progressing (especially if you are using TapRooT®), consider attending the TapRooT® Summit on October 27-29 in San Antonio. You get great, fresh ideas to make your program better and to keep people involved. For details, see:
Issue: Employees did not receive their pay stubs on pay day.
·Why? Because the printing system failed the day before pay day.
·Why? Because the system could not recover from a hardware fault.
·Why? Because the system uses outdated hardware that has no automatic redundant backup.
·Why? Because the system hasn’t been replaced as it hasn’t been identified as a high enough priority to allocate budget to its replacement in the current economic climate.
·Why? Because the organization does not have an enterprise planning methodology that weighs the risks of current operational systems failing versus the criticality of these systems and the impact of such a failure.
We have scheduled a public root cause analysis training course for Spanish speaking professionals in Monterrey, Mexico.
Monterrey is the third largest city in Mexico. Monterrey visitors can enjoy a rich nightlife, cultural activities, and exciting sporting events. Many of the local people enjoy locally brewed beer while watching fútbol on a weekly basis. Visitors can also enjoy machaca con huevo, a traditional Monterrey dish. We are taking registration for:
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis - March 1 - 3
Some popular tourist destinations in Monterrey are:
The Museum of Mexican History is an informative and interesting collection of Mexican history. The museum offers free guided tours during regular hours as well as self-guided tours of the many exhibits. Tuesday and Fridays are free admission to the museum and there are frequently concerts for museum guests. El Museo de Mexicana Historia is an enjoyable place for people of all different interests to visit.
Futbol is an important part of the culture in Monterrey. There are two teams that call Monterrey home and much of Monterrey entertainment revolves around the schedules of the games. The Rayados and the Tigres both play in Monterrey.
“El Templo de la Purísima, es el símbolo de la piedad cristiana de Monterrey. La Basílica y Parroquia La Purísima Concepción de Monterrey, es parte de la Arquidiócesis de Monterrey y en su organización Diocesana corresponde al Decanato I de Catedral y a la primera Zona de Pastoral” (http://lapurisimamonterrey.org/index.php).
The church of the Immaculate was built in the 1940s and was the first religious building with modern architecture in Mexico. The design was very controversial at the time it was being built, but is not a well-known landmark in Monterrey. Visitors can attend Roman Catholic masses twice a day each day of the week.
The Outdoors
“Are you the outdoors type? The mountains surrounding Monterrey offer recreation options available nowhere else in Mexico! Go rock climbing or hiking. Explore caves few humans have ever visited. Take a mountain bike down some of the most extreme slopes anywhere!” (Source: http://www.allaboutmonterrey.com/)
Are you looking for a Spanish speaking root cause analysis course, or do you have an associate who would be interested in performance improvement, problem-solving and corrective action programs taught in Spanish?
And it talks about the safety and budget issues at WMATA.
I guess that putting the bus driver in jail after the accident last year (or was it two years ago?) didn’t stop the accidents at WMATA.
The blog writer at the Baltimore Sun pins his hopes on the NTSB. But in my book, only management can really change safety after they fully understand the root causes of the problems.
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 Stephen Wagner for his group. Watch and learn …
I am up in St. John’s this week teaching the two-day course with Michelle Lindsay. Here are some pictures:
If you missed us this time, we will be back in June. Or you can join us somewhere else; we teach courses all over the world. To register, see the course schedule HERE.
An AP story published in the Houston Chronicle says that Transportation Secretary Ray LaHood said that Toyota was:
“…dragging its feet on safety concerns over its gas pedals, suggesting the automaker was ‘a little safety deaf’ to mounting evidence of problems.”
He also said that:
“… federal safety officials had to ‘wake them up’ to the seriousness of the safety issues that eventually led Toyota to recall millions of cars such as its Camry and Corolla. That included a visit to Toyota’s offices in Japan to persuade them to take action.“
The article also said:
“… the government was considering civil penalties for Toyota over its handling of the recalls…”
This kind of press couldn’t come at a worse time as Toyota struggles with this quality/safety issue and the bad press that it has generated.
How much damage to your reputation can a quality/safety issue do? Toyota is finding out the hard way.
CAPTAIN’S INAPPROPRIATE ACTIONS LED TO
CRASH OF FLIGHT 3407 IN CLARENCE CENTER,
NEW YORK, NTSB SAYS
********************************************
The National Transportation Safety Board determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.
In a report adopted today in a public Board meeting in
Washington, additional flight crew failures were noted as causal to the accident.
On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport.
The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post-crash fire. The flight was a 14 Code of Federal Regulations (CFR)Part 121 scheduled passenger flight from Newark, New Jersey. Night visual meteorological conditions prevailed at the time of the accident.
The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column.
However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall.
Contributing to the cause of the accident were the
Crew members’ failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures.
Other contributing factors were the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots.
At today’s meeting, the Board announced that two issues that had been encountered in the Colgan Air investigation would be studied at greater length in proceedings later this year.
The Board will hold a public forum this Spring exploring pilot and air traffic control high standards.
This accident was one in a series of incidents investigated by the Board in recent years - including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance, and the Northwest Airlines incident last year where the airliner overflew its destination airport in Minneapolis because the pilots were distracted by non-flying activities - that have involved air transportation professionals deviating from expected levels of performance.
In addition, this Fall the Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. For example, this accident occurred on a Continental Connection flight, although the transportation was provided by Colgan Air.
A summary of the findings of the Board’s report are available on the NTSB’s website at:
So I looked into my bathroom at the hotel, and I think, hey, a little small, but OK…
Then I looked a little closer, and noticed something doesn’t look quite right…
Hmm, THIS could be interesting!
I’ve seen accident investigations (not using TapRooT®, of course!) that point to the worker as needing to be more careful. “Inattention to detail” is the root cause. “Worker did not keep eyes on path.” It’s easy to come up with these poor “root causes.” What we really need to do is find out why the worker was “clumsy.” There’s a good chance that there was a poorly-designed piece of equipment, walkway, or room arrangement that made it very difficult to do a job correctly. I’ll try to avoid hurting myself in this room. I’ll “be more careful.”
Here a link to the interview that Charlie Rose did with Jeffery Skiles, the co-pilot of flight 1549. Jeffery will be speaking on Friday at the TapRooT® Summit so please plan to stay for his session.
They question Toyota’s management, organization, and cost cutting efforts.
Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.
The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”
The story also said:
“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“
Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!
While dumping the contents of a hydrovac unit, a swamper was killed when he was caught in the closing hydrovac tank door.
What Went Wrong?:
The truck operator and swamper were offloading the contents of the hydrovac truck at a designated area. The hydrovac truck tank had been elevated and the rear door was opened to allow the crew to clean out the tank.
Other relevant incident information:
Photograph of rear door configuration of a typical hydrovac truck. Note crush point.
The workers had cleaned the tank and had both stepped down from the rear tank access platforms (also known as beavertails).
The operator walked around to the drivers side of the truck to access the hydraulic control levers located directly behind the cab of the truck.
Unknown to the truck operator, the swamper had climbed back up onto the right, rear beavertail and became caught in the swing radius of the rear tank door as it was closing.
Corrective actions and Recommendations:
To prevent future incidents, the employer and the hydrovac truck supplier have worked together to implement a number of corrective actions.
Equipment Modifications (Engineering Controls)
The hydrovac truck supplier has altered the hydrovac truck involved in the incident including:
The bank of four control levers for the vacuum tank operation were changed;
Two control levers have been routed to other locations. The removal of these levers may allow for additional room between the remaining control levers to minimize an inadvertent activation due to their proximity; and
The control lever that operates the rear tank door was moved to the rear of the hydrovac tank, which allows the operator to maintain a clear line of sight of the door during opening and closing operations.
Flow restrictors have been installed on the hydraulic lines to the cylinder for the opening and closing of the rear tank door. This alteration slows down and controls the door’s rate of travel;
Hydraulic controls have been tagged with permanent markings to provide clearer identification of the function of the control; and,
Signs warning of the hazardous pinch point have been installed on both sides of the rear of the vacuum tank.
The supplier intends to make similar alterations to all new vacuum/hydrovac truck assemblies and all vacuum/hydrovac trucks, which are returned for service and recertification.
Revisions to Operating Procedures (Administrative Controls)
The employer has modified its hydrovac truck operating procedures to include:
An enhancement and ordering of the steps that will be followed for closing the tank door and lowering of the tank;
Added a requirement that the hydraulic rear door operator visually identifies any workers for whom the closing tank door may be a hazard, before the operator activates the controls; and
Added a provision for the engagement of the tank safety bar when the tank door is open. This provision would include a requirement that, when the tank is clean, the swamper should remove the bar while remaining in the operator’s line of sight and then instruct the truck operator to close the door.
The employer and hydrovac truck supplier involved in this incident believe that the actions summarized above are relevant to the manufacture, supply and associated procedures of similar equipment used at energy and construction work sites. They are urging other companies to reassess their operations in light of the measures identified above and identify if there is a need for similar preventive actions in their operations.
Source Contact:
This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).
The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce.
We completed the course just before the blizzard arrived. It was really something to see; Michele (the other instructor) and I were very lucky to get out before the airport was shut down for two days with several feet of snow and high winds. See a video of the blizzard 
