Root Cause Analysis Blog

For a cool video of a tank explosion, see:
Watch flames shoot from tank as it explodes
For the story at CNN’s web site see:

http://www.cnn.com/2007/US/04/28/tanker.fire.ap/index.html

I’ll try to get some materials posted this week and some attendee videos, pictures, …

I tried to think of my favorite session and to write a quick note, but there were too many. I’ll post a “comments section” tomorrow so that people can post comments to let everyone know what they thought.

Mark

Busy, Busy, Busy … and that’s just the start!

Wow! The speakers and sessions have been great and I haven’t had time to write about them.

Josh Davis, John Nance, and Dr. Beverly Chiodo have been excellent speakers with a message that hit home to all attendees. Many people attending the Summit shared how inspiring and useful the talks and sessions have been.

I’ll try to post some papers and tell you about the great speakers when I get more time. But the real lesson learned is that you need to attend the Summit if you want to gain the value of the knowledge of the speakers and the attendees.

Summit week is here.

Monday and Tuesday are Pre-Summit Course days. What do the courses look like? See the photos below…

Katherine busy coordinating registration and Summit planning.

Kevin teaching the Advanced Trending Techniques Course.

Trending class attendees working on an exercise.

Dana teaching the Interviewing and Evidence Gathering Course.

Linda and Brian teaching the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

Students listening intently.

Students talking on the break.

Joel teaching the Stopping Human Error Course.

Ed and Dan teaching the Getting the Most from Your TapRooT® Software Course.

Michele discussing the results of an exercise in the Innovation and Creative Solutions Course.

You’ve worked hard at conducting a detailed investigation, making sure you’ve gathered all the evidence you need, defining your causal factors, and conducting the root cause analysis. You used the Corrective Action Helper® to give you a hand developing good, solid, useful corrective actions. You’ve verified that they meet the SMARTER requirements, and now it is time to implement those fixes. This final step can go in two directions:

1. You present the corrective actions, and management is on board. You receive the resources you need, and you can be confident that the incident will not happen again.

2. You present your corrective actions, and management decides that they are not obligated to implement them. They dispute your findings, and nothing is fixed. The entire investigation was a waste. Resources dedicated to your investigation would have been better used figuring out what you will do when the incident occurs again (which it probably will).

These two scenarios arrived in my email from the Chemical Safety Board yesterday.

1. In the first report (link here), the CSB commends Kellogg, Brown, and Root (KBR) for exceeding the CSB’s recommendations for correcting an incident at one of their facilities last year. Corrective actions were developed and implemented, and this problem will not happen again.

2. In the second report (link here), the CSB’s investigation of another company’s incident had to be closed with their response as “unacceptable.” In this 2002 incident, a fire broke out, resulting in one hundred nearby residents evacuated, a local school closed, and significant environmental cleanup necessary due to firewater runoff. The facility was destroyed and never rebuilt. Here is a case where an enormous amount of resources was dedicated to the investigation, but the company decided to dispute the findings, with basically nothing being done to prevent another occurrence.

It can be frustrating when you conduct an investigation and have to fight for the resources to implement corrective actions. However, it is worth the struggle to prevent a recurrence of a serious incident.

The TapRooT® Summit is next week!!! Are you registered for the TapRooT® Golf Tournament?

Here are a list of Top 10 Caddy Comments:

#10 Golfer: “Think I’m going to drown myself in the lake.”

Caddy: “Think you can keep your head down that long?”

#9 Golfer: “I’d move heaven and earth to break 100 on this course.”

Caddy: “Try heaven, you’ve already moved most of the earth.”

#8 Golfer: “Do you think my game is improving?”

Caddy: “Yes sir, you miss the ball much closer now.”

#7 Golfer: “Do you think I can get there with a 5 iron?”

Caddy: “Eventually.”

#6 Golfer: “You’ve got to be the worst caddy in the world.”

Caddy: “I don’t think so sir. That would be too much of a

coincidence.”

#5 Golfer: “Please stop checking your watch all the time.

It’s too much of a distraction.”

Caddy: “It’s not a watch - it’s a compass.”

#4 Golfer: “How do you like my game?”

Caddy: “Very good sir, but personally, I prefer golf.”

#3 Golfer: “Do you think it’s a sin to play on Sunday?”

Caddy: “The way you play, sir, it’s a sin on any day.”

#2 Golfer: “This is the worst course I’ve ever played on.”

Caddy: “This isn’t the golf course. We left that an hour ago.”

. . And the #1 best caddy comment:

Golfer: “That can’t be my ball, it’s too old.”

Caddy: “It’s been a long time since we teed off, sir.”

TIS Insurance Services Inc is currently looking for a Loss Control Representative in the Knoxville, Tennessee area. The position requires providing technical direction to clients on safety and health issues, conducting construction jobsite audits, as well as conducting safety and health training.

The candidate should have at least five years experience in the construction health and safety field with some commercial insurance background. Being an authorized OSHA 500 trainer is a definite plus but is not required.

Salary will be based on qualifications and experience. A comprehensive benefit package is also available.
Please send, fax or email resume with references to:

John Jeffries
TIS Insurance Services Inc
1900 Winston Road, Suite 100
Knoxville, TN 37919
Fax: (865) 470-3907
jjeffries@tisins.com

Here it is … The super computer pairings for the TapRooT® Cup Golf Tournament!

See the information below the pairings for complete tournament details…

Team 1
Cart A: Ken Turnbull    Andrew Sides
Cart B: Jeff Cooper        Phil Dortch

Team 2
Cart A: Brian Locker            Tom Bartzis
Cart B: John MacCormick    Gordon Mason

Team 3
Cart A: Michele Lindsay    Darren Marvin
Cart B: Keith Recsky            Richard Despres

Team 4
Cart A: Hal Curry        Tracy Moy
Cart B: Gerald Hipp    Michael Gibilterra

Team 5
Cart A: Mark Olson    David Doyle
Cart B: Sam Tittel        Dan Phillippe

Team 6
Cart A: Ken Scott            Steve McCrillis
Cart B: Marcia Harmon  Paul Krytusa

Team 7
Cart A: Ken Reed            Robert Bush
Cart B: Patrick Lackey    Joe Muehlbauer

Team 8
Cart A: Dan Verlinde    Mike Rodriguez
Cart B: Lloyd Maher      Ron Pryor

Team 9
Cart A: Linda Unger            Dana Smith
Cart B: Jade Washmon      Tara Kulin

Team 10
Cart A: Mark Paradies    Chuck Selman
Cart B: Joel McAlister      Shay Underwood

Team 11
Cart A: Ed Skompski          Steve Dobbs
Cart B: Daniel Stevenson    Reynard Burgess

Team 12
Cart A:  Kevin McManus    Jimmy Owen
Cart B:  Buck Griffith            Catherine Griffith

Tee 1 was given to Ken Turnbull as the team captain of last year’s championship team.

Tee 2 was given to Brian Locker for being team captain of the winning team for the prior two years.

Now for administrative details:

1. Contact your Team Captain to plan your transportation (let him/her know if you have a car available).

2. Lunch, greens fees, a bucket of balls for the driving range, a hat, and a sleeve of balls are included in your tournament fee.

3. Rental clubs are available by reservation (those of you who have reserved clubs already are listed below). You can still rent clubs by e-mailing Katrina before 4/21. Rental fees are payable when you pick up your clubs.

4. The lunch buffet starts at 12:15.

5. The shotgun start is at 1:30. Your Team Number is your starting tee selection.

RULES: This will be a scramble format.

In a scramble all participants tee off and then you select the best ball. All participants then hit from that point. This continues until someone sinks a putt. The score is the number of best ball strokes. For example if you all teed off, then everyone chipped (and someone hit the green), and then someone sunk their first putt, the score would be a 3 for that hole. The Team Captain (in bold) will be responsible for keeping the score and for selecting the best ball if the team can’t agree on whose ball is best.

There will also be awards for 1) a closest to the hole (two holes) and 2) the longest drive (on two holes).

For those who would like a course preview and directions, here’s the course’s web site:

http://www.republicgolfclub.net/

Men will use the normal Men’s tees and Women can use the Women’s tees.

I would suggest that teams plot their strategy at the Summit reception on Wednesday night.

Looking forward to seeing you at the Summit!

Mark
(more…)

An ES&H representative is needed for at least 25 weeks near Las Vegas. Will pay per diem.

A bachelor’s degree plus a minimum of 5 yrs related safety and health and industrial hygiene experience is required. Board certification by an accredited ES&H organization is preferred. A comprehensive understanding of OSHA regulations, ACGIH, ANSI, NIOSH, CDC and the ability to promote and implement a comprehensive industrial hygiene program is also required.

Email resume to cfoy@tfeinc.net

A report in the Occupational Health and Safety eNewsletter for this week had a great article on nail gun injuries (article). I have used a nail gun to shingle my Dad’s house, and it had an interlock that prevented me from pulling the trigger until the foot of the gun was pushed against the roof. I’ve seen those guns where the professionals just pull the trigger and bounce the gun against the roof, but I assumed that these guns were not available to the regular consumer.

Apparently, I was wrong, and so were the nearly 15,000 people in 2005 who were injured by nail guns. When I Googled for a picture of a nail gun injury, I had so many to choose from that it took a few minutes to work through them. Not a good sign.

How do you fix equipment problems like this? First, you must recognize the hazard. This means you need to be informed about what hazards are associated with the equipment. A nail gun may seem obvious (NAILS!!!), but what about the air discharge ports shooting dirt into your eyes? What about damaged airlines pressurized to 150 psi? And where do you use this thing? On a ladder? On the roof? Are you now off-balance using this thing?

Once you recognize the hazards, you must now figure out what safeguards are available. The trigger interlock is a prime example. Sure, you might look cool bouncing that nail gun across the roof, but it isn’t quite as cool when it bounces across your foot. And considering the number of times a consumer uses a piece of equipment like this, how much time is really saved over the life of the nail gun? A couple of hours? Balance this “time savings” against the risks involved, and I hope the answer is clear.

The nail gun is only an example. Take a hard look at the risks you are taking with equipment, both at home and at work. Are you clearing jams in the machine while it is running because “it will only take a minute” and “we’ve always done it that way”? Maybe we should figure out why the machine is jamming in the first place (probably not designed to jam!).

Risk versus time savings. It’s always a gamble, and the increased risk rarely works out in your favor.

Logan Gresham - 7 lbs 9 ozs - 52 cm

Malcolm Gresham, one of our TapRooT® Instructors in Australia, is a proud father again (his 4th child).

The Summit starts next Wednesday. I’m really excited about the great sessions, the people who I’ll meet, and being in San Antonio during Fiesta week. But I have a problem…

There are too many great sessions to attend.

I can’t get to them all.

There are 8 breakouts, each with multiple session to select from. For example, in Breakout 1 on Wednesday, I am presenting, “What’s New and Improved in TapRooT®“. But I would also like to attend:

Good to Great Corrective Action Programs

and

How Minor Mechanical Failures Lead to Major Accidents

In Breakout 2, I’m one of three presenters and a moderator in the “Panel Discussion: Comparison of Root Cause Analysis Techniques“. Burt there are three other sessions that I would like to attend.

Breakout 3: I don’t have to present but there are two sessions I really want to attend.

Breakout 4: Two sessions I really want to attend.

Breakout 5: Three sessions I really want to attend.

Breakout 6: Three sessions I really want to attend.

Breakout 7: Five sessions I really want to attend.

Breakout 8: I’m presenting “Lean Root Cause Analysis” but there is another session I really want to attend.

I really need one of those Harry Potter movie spells so that I can be in two places at one time.

The only solution I can think of for next year is to not schedule so many excellent sessions - but that seems like the wrong idea.

So, I will have to pick the best of the best - just like everyone else attending - and be happy with the sessions that I can attend.

If you would like to look at the schedule and see the topics being covered, go to:

http://www.taproot.com/summit.php?sched=1

And if you get so excited about the topics that are scheduled in the 10 breakout tracks that you decide to attend, then register today and get your travel set, because the Summit is next week and you don’t have much time to think about which sessions are the best for you to attend.

Click on the PDF below to see the slides for the Summit opening session.

TFE Inc would like to hire a trainer, with specific experience in teaching Hoisting & Rigging, Aerial Lifts, Forklifts, Overhead Crane Operations, etc. Submit your resume to cfoy@tfeinc.net as soon as possible.

I was looking on-line for video footage of the BP Texas City Explosion and I ran across the BP Texas City Explosion web site site up by Brent Coon, an attorney handling one of the lawsuits filed against BP.

What an eye opener!

If you work in safety or management of a highly hazardous facility, review this site in detail. Read the depositions. Watch the videos. Think of how you could answer the questions if something was to go wrong at your site.

Especially watch these three videos of deposition:

Kathleen Lucas - Operations Manager at BP Texas City

Joe Barnes – Head of HSSE at BP Texas City

Bill Ralph – Head of Process Safety at BP Texas City
Are you adequately trained to perform your job? How much training in process safety and root cause analysis do you need? Could your qualifications stand up to a deposition?

One way to continuously improve your root cause analysis investigations is to grade each investigation (just like you were in school). But how do you grade an investigation? Here are eight ideas for grading a root cause analysis from the nuclear industry:

Root Cause Analysis Grading Sheet.doc
RCAInvScoresheet.doc
RCA Score Card.xls
RCA grading sheet.doc
ExpectationActionsChecklists.doc
Cause Analysis Quality Index.xls
CARB Checklist.doc
CACG Action Review Check Sheet.doc

The TapRooT® Summit is just around the corner! Are you registered? In honor of the TapRooT® Golf Tournament (we still have room for you to play!), we present the Gospel according to St. Titlelist:



1. Eighteen holes of match play will teach you more about your foe than 18 years of dealing with him across a desk or on the battle field.

Grantland Rice, (psychoanalyst to George Patton and Bernard Montgomery)

2. Golf appeals to the idiot in us and the child. Just how childlike golf players become is proven by their frequent inability to count past five.

John Updike

3. It is almost impossible to remember how tragic a place the world is when one is playing golf.

Robert Lynd

4. If profanity had any influence on the flight of the ball, the game of golf would be played far better than it is.

Horace G. Hutchinson

5. They say golf is like life, but don’t believe them. Golf is more complicated than that.

Gardner Dickinson

6. If a lot of people gripped a knife and fork as poorly as they do a golf club, they’d starve to death.

Sam Snead

7. Golf is a day spent in a round of strenuous idleness.

William Wordsworth

8. If you drink, don’t drive. Don’t even putt.

Dean Martin

9. If you are going to throw a club, it is important to throw it ahead of you, down the fairway, so you don’t have to waste energy going back to pick it up.

Tommy Bolt

10. Man blames fate for all other accidents, but feels personally responsible when he makes a hole-in-one.

Bishop Sheen

11. I don’t say my golf game is bad, but if I grew tomatoes they’d come up sliced.

Arnold Palmer

12. My handicap? Woods and irons.

Chris Codiroli

13. The ardent golfer would play Mount Everest if someone would put a flag stick on top.

Pete Dye

14. I’m hitting the woods just great; but having a terrible time getting out of them!

Buddy Hackett

15. The only time my prayers are never answered is playing golf.

Billy Graham

16. If you think it’s hard to meet new people, try picking up the wrong golf ball.

Jack Lemmon

17. It’s good sportsmanship to refrain from picking up lost golf balls, particulary if they haven’t stopped rolling.

Mark Twain

18. Don’t play too much golf. Two rounds a day are plenty.

Harry Vardon

19. Golf and sex are the only things you can enjoy without being good at either of them.

Jimmy DeMaret

20. May thy ball lie in green pastures, and not in still waters.

Ben Hogan

21. If I hit it right, it’s a slice. If I hit it left, it’s a hook. If I hit it straight, it’s a miracle.

All Us Hackers

22. The difference between golf and government is that in golf you can’t improve your lie.

George Deukmejian.

And Finally. .

23. Golf is a game invented by the same people who think music comes out of a bagpipe.

Lee Trevino

Attendance Record Will Be Set - Will You Be There?

I knew the topics and activities and location (San Antonio) made this Summit special. But you never know if others agree until they sign up. Our past record for attendance was 178 people in Gatlinburg in 2006. But we already have over 200 people registered for this year’s Summit and the number is still growing!

So if you are interested in learning the latest best practices in the following 10 tracks:

• Human Error Reduction & Behavior Change Best Practices
• Safety & Risk Management Best Practices
• Corrective Action Program Best Practices
• Lean, Process, & Quality Improvement Best Practices
• Medical Error Reduction Best Practices
• Equipment Reliability & Maintenance Best Practices
• Investigation & Root Cause Analysis Best Practices
• Proactive Improvement Best Practices
• Certified TapRooT® Instructor Best Practices
• TapRooT® Software Techniques & Administrator Best Practices

See the web site and register.

And don’t forget that in addition to the 5 great keynote speakers:

• Olympian, Josh Davis
• Performance Improvement Expert and Author, John Nance
• Award Winning Educator and Consultant, Beverly Chiodo
• Safety Consultant and Speaker, Richard Hawk
• NJ Supreme Court Justice and Fox News Senior Judicial Analyst, Judge Andrew Napolitano

There are smaller sessions where attendees can network and share best practices.

And before the Summit there are 8 different courses that will help you improve performance.


If you would like to read what past attendees said about their experience … click here.

If you would rather watch what they have to say (a video) … click here.

The Summit is less than two weeks away so register today and make your travel plans!

After reading the final Chemical Safety Board report on the BP Texas City Refinery explosion, it is obvious that there were almost too many problems to count. Management problems, a non-existent safety culture, procedural non-compliance… the list goes on and on. Take a look at everything we teach and emphasize during a 5-Day course, and none of that was done.

Just trying to get your arms around the problems is tough. I decided to take a subset of the problems and take a look at only the issues related to instrumentation and equipment malfunction. Even this had an enormous amount of data involved, and trying to perform an accurate, comprehensive root cause analysis with the information presented in the report is not possible. However, it is obvious that equipment problems made up a large number of causal factors in this accident.

This incident is an extreme example of allowing your equipment failures to run your facility or business. Many of the actions taken by operators, supervisors, and the management team were dictated by the operational state of the equipment and instrumentation. Procedures were changed on the fly because the entire process did not work as it was initially designed. Actions were taken by operators and supervisors based on faulty indications. Some actions were not taken at all because some indications were never present. Work orders were not generated for known problems, and known problems were accepted as normal.

Many of the equipment problems were actually minor in nature. Fixing some of them would have been easy, but many reasons were given for allowing them to exist:
Not enough money
Not enough time (schedule pressure)
People were too busy
Work-arounds were already in place
Work order system was ineffective

Yet, none of these were that difficult to fix. They were allowed to happen, with full knowledge of the issues at all levels, from the operators up through senior management.

At the TapRooT® Summit later this month (information here), I will be giving a presentation on how “Minor Mechanical Failures Lead to Major Accidents.” A good portion of this discussion will pull examples from the BP refinery explosion. Come join in the discussion, and see how easy it is to get yourself into these types of situations. Even better, see how easy it can be to keep yourself out of these situations.

Summit Golf

The Summit Tournament is almost here (Friday - April 27th).

Will a new team step up to win the coveted TapRooT® Summit Cup or will Ken Turnbull’s Team return to dominate the tournament?

Part of the TapRooT® Summit in San Antonio is meeting new people and having fun. Spend an afternoon in the Texas sunshine:

• at a great course (Republic Golf Club - rated #1 in San Antonio!)
• in a “scramble” (best ball) tournament
• making friends with your teammates
• contributing to your team’s success!

The tournament is a scramble format. Each team member takes their turn and then the team plays from the best shot. Each team turn is a “stroke”. That means that even beginners can contribute to the team effort by having a lucky shot or a good putt. And the competition for the trophy is intense. And you can win individual trophies on particular holes:

  • Longest drive
  • Closest to the pin

Spots in the tournament are limited so sign up for the Summit and register for the tournament today! For more info see the Golf Tournament link.

Students - interested in an internship at CSB? See:

http://www.csb.gov/career_opportunities/CSB-002-07.pdf

We’ve all heard stories about people being injured doing root cause analysis. The most famous that I can remember was the investigator who lost his fingers when he demonstrated how someone else had lost their fingers. But I’ve never heard of a safety engineer being killed getting ready for safety training. Read the article below and see what you can learn.

http://phoenix.swarthmore.edu/2007-03-22/news/17058

Chevron Corporation, one of the world’s leading energy companies, employs over 47,000 people in 180 countries. In the UK they refine, market and supply energy products to the world, as part of the Texaco brand.

Their growth has created an opening for the following position at their refinery in Pembroke, West Wales.

Asset Maintenance Co-ordinator - Analysers (Ref 5165)

This position, reporting to the Planning & Shared Services Leader, is part of the Maintenance team responsible for ensuring the integrity and reliability of analyser systems across the Refinery.

Responsibilities include

* Defining and updating the maintenance policies, PM programme and records system for analyser systems to meet business objectives and comply with legislation and company standards.

* Providing day to day support and expertise to the Term Maintenance Contractor Analyser Team and the initial analysis of equipment failures. Also supplying recommendations and changes in design and/or planned maintenance activities to improve the long term reliability of the equipment.

* Establish and lead processes that continually improve the reliability of analyser systems by targeting bad actors and investigating equipment failures using Root Cause Failure Analysis tools as ‘Five-Y’s’, TapRooT, etc.

For the rest of the job announcement see:

http://icwales.icnetwork.co.uk/1400icjobs/hotjobs/tm_jobid=14001&method=display_ad&objectid=14462380&siteid=50082-name_page.html

Take a look

Hello everybody, welcome to another edition of Tech Support Thursday.

Today we’re going to talk about Windows Vista and it’s compatibility with the TapRooT System Software. Ready for the answer? It’s just inside….

(more…)

I thought I’d post a quick note to introduce Barbara.

Although she’s been at SI for almost a year, readers may not know that she coordinates the publishing of the monthly TapRooT® Friends/Experts e-Newsletter and makes entries on this blog.

In her spare time, she is also my executive assistant and keeps me efficient.

If you are attending the TapRooT® Summit, you can meet her in person. She will be coordinating the Advisory Board Meeting for me.

What is the root cause of all the knowledge and fun that these people are having?

The answer?

The TapRooT® Summit!

Come experience all that you can learn and the fun that you can have doing it!

Don’t wait!

The Summit is being held on April 23-28, 2007, in San Antonio, Texas. Sign up today.

Click here for the:

Schedule

San Antonio info

Registration

A few of our Friends/Experts e-Newsletter subscribers are receiving our e-mails poorly (including those who use Eudora, Lotus Notes, OE/Macintosh, and Outlook ‘97). By “poorly,” I mean that they receive the e-Newsletter garbled, and other times the internal links in our Newsletter do not work.

Our e-Newsletter service (Constant Contact) formats, transmits and displays our e-Newsletter so that it is received well by the e-mail services that follow certain Internet standards — since the largest majority of e-mail services follow those standards in their design. We also keep our design as plain text as possible since so many subscribers have trouble with graphics. Unfortunately, even though we carefully test every link before we distribute the e-Newsletter through Constant Contact, since we have such a large subscriber base who use so many different e-mail services, some of our subscribers are not receiving the newsletter in good format.

If you are having trouble receiving the e-Newsletter in the right format, and have an alternate e-mail address (free web based mail like Yahoo® or Hotmail® receive our e-Newsletter well), please e-mail me, Barbara, your new address at info@taproot.com. Your alternate e-mail address may follow the Internet standards you need to receive the e-Newsletter in the right format.

Also, if you thought you were subscribed to our e-Newsletter but are not receiving it, it may be because of your SPAM filter. If that is the case, again, please contact me so I can help you resolve the issue.

We appreciate you as a subscriber! Don’t let your SPAM software or e-mail provider keep you from getting the latest topics in root cause analysis and incident investigation delivered right to your inbox!

Barbara Phillips

The TapRooT® Summit will be held in San Antonio April 25-28 and it’s not too late to register!

Bring your family and not only enjoy Fiesta Week, (San Antonio’s annual celebration) but also these great attractions:

Sea World (1-800-700-7786)

San Antonio Museum of Art (210-978-8100)

IMAX Theater River Center (next to the Alamo) (210-247-4629)

Six Flags Fiesta Texas (210-697-5050)

Schlitterbahn Waterpark Resort

San Antonio Zoo (210-734-7184)

The Alamo (For San Antonio Group Tours, call 210-212-5395)

Caverns of Sonora ((325) 387-3105, Exit 392 off of I-10)

Retama Park ((210) 651-7000, Live Horse Racing)

Texas Ski Ranch ((830) 627-2843, Action Sports Complex)

For more information, visit:

Fearn’s Traveler Info Guide.

And sign up to learn Best Practices beyond our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Team Leader Course and 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training! Learn more at our Summit Website.

Interesting article on brian research and distraction. See:

http://dsc.discovery.com/news/2007/03/29/attention_hea.html?category=health&guid=20070329151500

The research shows that you can’t “will” yourself not to be distracted. Willful attention and distraction are controlled by two different parts of the brain and distraction occurs even when you are trying to concentrate. Also, some people are naturally more easily distracted than others.

Here’s a quote from an article in the Gardian Unlimited in the UK:

- - -

Officials from Railtrack, the precursor to Network Rail, were warned at least five years before the collision that a set of signals was badly laid out and so difficult for drivers to interpret that a serious incident was likely to happen, the hearing was told.

The signals had been misinterpreted by drivers at least seven times in the previous five years, and had been the subject of internal inquiries.

The Paddington disaster, which was likened in court to a “senseless and unnecessary terrorist attack”, would never have happened had it not been for a string of safety blunders.

Failures spanned several years and flowed from “the culture at the top” of the company, the court heard.

Passing sentence, Mr Justice Bean said Railtrack had admitted that its failure to carry out “adequate root cause analysis” of signals passed at danger (Spads) had been “systemic and unacceptable”.

Quoting from his judgment, he added: “It was due, as counsel to the [Lord Cullen] inquiry submitted, to a combination of incompetent management and inadequate process, the latter consisting in the absence of a process at a higher level for identifying whether those who were responsible for convening such committees were or were not doing so.

- - -

What can you learn? That root cause analysis is essential for safety of your passengers and employees in the transportation business. If your company has responsibility for the safety of your customers, you had better throughly investigate safety errors and near-misses (close-calls).

To read the complete article, see:

http://business.guardian.co.uk/story/0,,2046717,00.html