Coming to System Improvements, Inc. as a Six Sigma Black Belt with ” the good, the bad, and the ugly” of Six Sigma company implementations, I often get asked how does the TapRooT® root cause analysis system tie in with the above pictured improvement systems and tools? During recent WebEx’s and conference calls, System Improvements, Inc. clients are often concerned about the cost of replacing their current highly invested Six Sigma Programs with TapRooT®. Peculiar thing is that companies questioned the same thing about Kaizen, Lean, and Six Sigma implementations as discussed in an article by Terence T. Burton. For those with existing Six Sigma Programs you can rest; TapRooT® does not replace the above mentioned processes but instead compliments the gaps in root cause analysis (Define and Analyze) and corrective actions (Implementation) to ensure robust proactive and reactive solutions to multiple system problems. For more about six sigma and lean practices integration with TapRooT® sign up for the TapRooT® Summit.
Below are some hard learned lessons, I picked up along the way that should be useful to current process improvement practitioners.
1. There should be no improvement “system” distinction between lean, six sigma, or any other improvement tool or process. People argue needlessly for days. Think about the old schools of psychology, you were either for nurture or nature, or crazy like Freud. Now schools teach that people are effected in the womb by the environment (nurture) and the cells develop (nature) like good soup. Needs to be the right temp and right conditions at the right time and don’t shake the pot. When we are born we are predispositioned to behave certain ways… all the music lessons in the world will not give you a good ear for music. Then it is up to the environment to guide the person. Point is that you must integrate the tools in a process that suppliment or compliment weakness and strengths. See an example of combining a six sigma tool and TapRooT®.
2. “Experts” who implement lean without truly understanding the integrated supply chain, the business needs, and the market will work improvement projects that sub-optimize other projects. A bad thing.
3. Perceived easiness of certain root cause tools in company experts’ hands… i.e. engineers, mechanics, operators, QA…, are actually limiting the analysis. As experts we developed rules-of-thumb and already “know” what the problem is. Funny thing, our children must be ignorant because all they want to do is ask a lot of why and what questions. It is not until we become adults that we know everything. Link to root cause research
4. YOU (the project black belt) must personally convince the boss to change to make the boss commit to a project; if you can’t too bad….Wrong! Influencing without authority means find the person the boss listens to and convince that person the project is the right thing to do…. there are a number of ways to “plant the seeds” of change.
5. Toyota experts developed excellent tools to improve their company… wrong. They went out and looked, understood their process, and then developed tools to represent their improvement needs. The problem with this is that we go out and buy fancy tools, put garbage data in from a company process that we do not not fully understand and then blame six sigma for its failure. You must understand the process used to improve, understand the process you are trying to change, and use tools to complement these processes.
6. Another major problem of six sigma is keeping safety, hr, and training as the outsiders who don’t see the “hidden factory”. Why… because of the initial low Return of Investment. When has your six sigma program observed the core competencies (skills and tasks) needed to perform their job and do it successfully? Does annual training still cover key skill needs?
Last week I spent a couple of days working on the IEEE Root Cause Analysis Standard for Nuclear Power Plants. The picture about is four of the collaborators “relaxing” after a hard day of standard development.
Kay Gallogly (second from the right), founder of The 42 Group, will be describing the progress made so far at the TapRooT® Summit in Las Vegas (June 25-27). See: http://www.taproot.com/summit.php for more information about her talk and the rest of the Summit.
The map is produced by the US House of Representatives Committee on Education and Labor. It has about 10% of the total deaths that occurred in 2007.
Each pinpoint is interactive. Click on it to see a short story of the fatality.
Reviewing the map has to make you think of safety and all the things that can go wrong on a job. It should be employee safety training required reading!
Read this history of the TapRooT® Summit to understand why the TapRooT® Summit has developed into a highly rated, blockbuster event - our history of continuous improvement.
You will also understand why we decided to hold the TapRooT® Summit, what the Summit is, why you will want to attend to help your company turbo-charge performance.
Don’t confuse the TapRooT® Summit with the many excellent courses we sponsor each year. After all, what is the difference between a Summit and a course?
Although the Summit shares the TapRooT® name with the courses, the focus of the Summit is quite different. This quick Summit history lesson will show you the difference between the Summit and our great root cause analysis courses.
HOW THE SUMMIT STARTED
I organized the first Summit in 1993 (to be held in 1994) because, after attending, and even helping organize, many conferences between 1983 and 1994, I saw a need for a conference with a focus on performance improvement, human factors, incident investigation, and the latest improvement technology. A conference that was NOT oriented toward research (although I appreciate good research). A meeting oriented toward practical applications that could be implemented at industrial facilities and in service organizations.
Wow! That’s a mouthful!
I also saw that there was MUCH to be gained by sharing information and ideas ACROSS INDUSTRY BOUNDARIES.
Thus this summit could not be held by one professional organization (with only a safety, quality, or equipment focus) or by a society oriented toward one industry (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …). And it had to be international — as most companies were expanding to worldwide operations.
This was a problem.
I had to start from scratch to organize, publicize, and pay for a meeting that needed to be held, but didn’t have an already established audience nor did I have a conference staff.
Some (Linda) said I was nuts!
But I knew it needed to be done. And nobody else was going to do it. So I become a conference organizer.
SUMMIT HISTORY
So in 1994 we held our first Summit in Gatlinburg, TN (with 33 participants).
It was a start. We learned a lot.
Feedback was very favorable.
And we decided to do it again.
1995 - Orlando - 72 participants.
At this Summit we started to figure out how to make the networking really special. That’s one of the things we’ve continued to improve as the Summit grows. Perhaps that’s why participants frequently remark about the valuable, new professional contacts and friends they make at the Summit.
(We went to Disney on Saturday after the Orlando Summit.)
1996 - Nashville - 85 participants.
Benchmarking became even a bigger part of the Summit.
Also, this was the first Summit with a session dedicated to medical errors at hospitals - an idea that was ahead of its time.
(We had a night at the Grand Ole Opry.)
1997 - San Antonio - 105 participants and growing strong.
Our first of many Texas Summits. We learned to make the networking even more enjoyable and how to get people together for a reception/party to continue networking in an informal environment.
(The Alamo in San Antonio)
After San Antonio in 1997, we decided to make the schedule about every 15 months to rotate the seasons. So our schedule would shift and occasionally “skip” a year. Thus Dallas was in the Fall of 1998, but we skipped 1999.)
1998 - Dallas - 119 participants.
We started having TapRooT® User present the results of their work in Success Stories. A great way to get best practice sharing started.
(We had a JR look-a-like. He didn’t look like the picture above. More like JR after a binge!)
2000 - Gatlinburg - 125 participants.
This was the start of the outstanding Keynote Speakers that wowed participants.
(Linda and Mark with our keynote speaker - a Shuttle Astronaut that discussed the first Shuttle disaster.)
2001 - Galveston - 133 participants.
Two days before the Summit, a Tropical Storm dropped 2 feet of rain! Lesson Learned: This is the last time we will schedule a Summit on the Gulf coast in late June!
This year we also started expanding the pre-Summit course selection. We’ve grown from 3 courses to choose from in 2001 to 11 to choose from in 2008.
(Band at the reception.)
2002 - Gatlinburg - 140 participants.
The networking and best practice sharing took a step up. And the reception was outstanding! Participants said it couldn’t get any better. But it did every year.
(Mark at opening talk.)
2003 - Dallas - 155 participants.
This was the Summit with the first TapRooT® Cup Golf Tournament - something that has become a fixture of Friday afternoon at the Summit and a part of the great networking that every Summit includes.
(Linda at dinner with participants on Thursday night.)
2005 - San Antonio - 169 participants.
Wow! What amazing Keynote Speakers, networking, and best practice sharing. The Summit that couldn’t get any better has hit a new high.
(Audience listening to the start of Scott Waddle’s talk. He was the CO of the submarine USS Greeneville when it collided with the Emime Maru (a Japanese fishing vessel). Most of the audience was in tears by the end of his talk - it was quite powerful.)
And golfing at the Quarry was also a high point.
2006 - Gatlinburg - 175 participants.
The best Summit so far. Each year we build upon the successes of the past and add new ideas to improve the best practice sharing and networking.
(Panel Discussion Debate)
This was also the Summit where we learned that smaller hotels promote better networking. People get lost in mega-complexes. Therefore, we try to hold Summits in nice, affordable, middle-sized hotels with convenient facilities.
2007 - San Antonio - 224 participants.
Participates were blown away by the Keynote Speakers and how well the Summit was organized. The Summit is a well-oiled networking/benchmarking/best practice sharing machine!
To hear what past participants have to say about the Summit, click on the videos at the bottom of the Summit home page:
So how has all this experience helped us create a Summit with unparalleled networking, benchmarking, and best practice sharing as well as exciting, motivating, practical Keynote Speakers?
First, we build upon the experience of each year to make each Summit better than the last. After each Summit we hold a lessons learned review. We review all the participant critiques. We discuss things that were a success and things that could be improved. And we come up with new ideas to try the next year. And we document ideas that worked that we want to continue. Since I have been involved in every Summit since 1994, I bring a wealth of history and experience to the planning process that helps each year get better.
Second, my full time job is looking for ways to improve performance and sharing that information about the new technology and ideas that I find. I learn things in the many TapRooT® Courses that I teach. I learn things at the half-dozen conferences I attend around the world (last year included conferences in Ireland, Italy, the USA, and England). I learn things from the TapRoot® Advisory Board Members (60 people) and TapRooT® Users around the world (tens of thousands of people). I learn things from the 26 TapRooT® Instructors - all highly qualified performance improvement experts - from around the world. Perhaps that why my e-mail box is overflowing.
Third, I use the information from all these sources to plan an event that will help people improve performance. I screen speakers and work with presenters to help develop content that is educational and useful. I use the knowledge I’ve gained three decades of studies in human factors, engineering, root cause analysis, performance improvement, equipment troubleshooting, and healthcare error management to put together a one-time-only meeting that focuses on solving problems by using proven, effective techniques and promotes the sharing of new ideas by hundreds of performance improvement professionals from around the world that participate in the Summit.
Finally, I turn the production over to my skilled, dedicated staff. Every year scores of people stop me at the Summit to compliment me on the professionalism, helpfulness, and friendliness of my experienced staff.
Thus the Summit is so amazing because of the input and hard work of hundreds of people and the experience and creativity of the staff at System Improvements.
Each Summit is a once-in-a-lifetime chance to learn the performance improvement secrets that - if applied - will carry your facility to a best-in-class status. And each year the Summit is better than the last. Don’t miss this performance improvement event!
Neil Roberts will be presenting “Advanced Behavioral Management: Developing a Modern Safety Culture” on the Safety and Risk Management and Human Error Reduction & Behavior Change Best Practices Tracks at the TapRooT® Summit on Thursday, June 26 at 9:15 a.m.
The session will have the following objectives:
1. To demonstrate the benefits and limitations of safety climate and safety culture surveys as a precursor to the introduction of a safety culture change programme.
2. To outline and demonstrate the benefits of a holistic and advanced approach that would encourage change in an organization’s safety culture. This would include reference to four key areas:
3. To demonstrate that habitualization of front line safety behaviors has its limitations, but if we are to make a systemic and long lasting difference to culture we need to identify and encourage a change of management based behaviors.
Although the title includes the word “advanced,” any attendee will benefit.
Neil’s background was originally in engineering (12 years). He became interested in Health and Safety when his father was seriously injured in a workplace accident in 1978. In 1991, his first involvement in occupational health and safety training occurred while employed at Water Training International. He ran intensive Deep Excavation courses and Confined Space courses at a purpose built facility in Derby (UK). He has been involved in occupational health and safety training for 18 years and joined Woodland Grange in the UK in 1995.
His current role is Senior Tutor at Woodland Grange and he delivers safety training courses at all levels (especially IOSH and NEBOSH courses). He is the Business Development Executive for Woodland Grange’s Modern Safety Culture programme. He has an involvement working with companies to develop their safety culture. Typical inputs would include safety climate surveys and interviews together with analysis of accidents and behavioral trends. Gap analysis recommendations are performed followed by the development of action plans, training workshops and programmes. He has been involved with many training events performed both in the (UK) and internationally.
Jose Gerard will be presenting: Como Evitar Accidentes de Trafico en Monterrey (How to Avoid Traffic Accidents in Monterrey) during the 2008 TapRooT® Summit Spanish Speaking Sessions planned for Friday, June 27.
Es una descripcion de las observaciones hechas durante muchos años de servicio en ambulancias y camiones de rescate urbano de los servicios medicos oficiales de emergencia en Monterrey y su area metropolitana, mientras tratamos de resolver los problemas que ya tiene la persona involucrada en un accidente de automovil.
This presentation includes Jose’s observations during his many years of service in ambulance and urban rescue trucks of the official emergency medical services in the metropolitan Monterrey area. Jose’s work includes resolution of problems encountered by persons involved in a car accidents.
A pesar de que la presentacion esta hecha para el area de Monterrey, las observaciones hechas aplican para casi cualquier ciudad en la que pueda pensar.
Jose’s observations apply to almost any other city you may think of (not just the Monterrey area).
David Davis is the Co-founder and Vice President of The Patient Safety Solutions Consulting Company Inc., specializing in healthcare solutions for Patient Safety & Risk Managers. He will be presenting in the Medical Error Reduction Best Practices Track at the 2008 TapRooT® Summit. David is presenting “Morbidity & Mortality Reviews (Hot Case Rounds)” and “Process for Running a Healthcare Root Cause Analysis.”
He is a Certified TapRooT® Instructor and the Southeast Region Quality Management and Accreditation Support Coordinator for Clinical Operations, Southeast Region Medical Command (SERMC) in Fort Gordon, Georgia. He worked for the U.S. Army: Winn Army Community Hospital in Fort Stewart Georgia as the Patient Safety/Risk Management Coordinator and was also the Patient Safety Program Manager for the U.S. Army: Dwight David Eisenhower Army Medical Center in Fort Gordon, Georgia. His experience also includes Chief/Perioperative Nursing, Infection Control Officer/Hospital Epidemiologist, Infection Control Nurse, Staff Development Officer/Senior Clinical Nurse, Head Nurse and Operating Room Nurse.
David was awarded Department of Defense 2006 Patient Safety Award for Most Innovative Solution to Address a National Patient Safety Goal and the Army Civilian Commendation Award for Excellence. He has been awarded many distinguished medals including Legion of Merit, Meritorious Service, Army Commendation, Army Achievement, Coast Guard Good Conduct, National Defense Service and Air Force Reserve.
Ken Bloch will be presenting “Using TapRooT® to Solve Complex Equipment Problems” at the 2008 TapRooT® Summit. This presentation is on the Equipment Reliability and Maintenance Best Practice Track and is scheduled for Thursday, June 25 at 2:40 p.m.
To solve a complex equipment problem you need to know what information to look for and where to find it. With over one hundred information sources in a typical production facility, this task is easier said than done. The session uses case histories to explain how TapRooT® is being used to isolate the evidence you need to solve complex equipment problems.
Heinz Bloch and Ken Bloch will be presenting “Examples of Extreme Equipment Failure Investigations” on the Equipment Reliability & Maintenance Best Practices Track at the 2008 TapRooT® Summit. This session with be held on Thursday, June 26 at 1:00 p.m.
A special failure category represents a combination of extremes (”Extreme Failures”). These failures have severe consequences, yet provide little (if any) physical evidence. You will examine several extreme failures to identify their similarities and shared anatomy. This understanding is being used to measure Extreme Failure Investigation effectiveness.
The TapRooT® Summit has 10 “Best Practice Tracks” focussed specific topics. One of those topics is:
Safety and Risk Management Best Practices
The purpose of this posting is to provide those interested in safety and risk management with a little better idea of the talks and discussion sessions they will experience if the attend the Safety & Risk Management Best Practices Track at the TapRooT® Summit.
Here is a list of sessions with a brief description of each session:
1. Hazard Recognition: The First Step in Safety & Risk Management - Peter Berkholz, Engineering Manager, Capability Resources
Peter will discuss practical strategies to identify hazards in the workplace and methods to get employees to spot and correct problems.
2. CHANGE
Dealing with Obstacles that Make Change Difficult - Hal Curry, Consultant, hal Curry & Associates
Managing the Risks Associated with Change - Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia
All safety improvement programs involve change. Hear these two talks that discuss change, obstacles to change, and risks associated with change.
Cameco Cigar Lake Mine Flood - Mark Wittrup, Cameco
Investigating Fatalities - Mario Chacon, Cal OSHA (invited)
Those interested in safety can learn a lot from the accidents of others. This session focusses on three different discussions about major accidents. First, Ken Turnbull will share how TapRooT® can be applied to public information about an accident to analyze it and learn lessons. Next, Mark Wittrup will present the results of a TapRooT® investigation of an expensive mine flooding accident. Then, Mario Chacon from Cal OSHA will share lessons from fatality investigations.
4. Advanced Behavioral Management: Developing a Modern Safety Culture - Bob King, Director of HSE Training/Consulting, Woodland Grange, UK and Neil Roberts, Consultant, Woodland Grange, UK
Safety culture is a big topic in many industries (nuclear power, oil and refining, aviation, …). Instead of hearing the same perspectives that we have all heard, we decided to bring a fresh look at the topic from Woodland Grange in the UK. Bob King and Neil Roberts will share their experience and advice on developing and establishing a “modern” safety culture.
5. Panel Discussion: Is There a Tradeoff Between Process Safety and Industrial Safety - Panelists: Miles Kajioka (ConocoPhillips), Valarie Barnes (US NRC), Bob King (Woodland Grange), and Ken Turnbull (Consultant, previously with Texaco)
The explosion at the BP Texas City Refinery caused many to question their Process Safety Management programs. In a sworn deposition, the Process Safety Manager at BP Texas City implied that resources were diverted from process safety and used to improve industrial safety. The implication was that in any plant with limited budgets, any investment in industrial safety could be seen as taking resources away from process safety. The panel will provide their views on this “tradeoff” and discuss with participants things that can be done to make programs complimentary rather than competitive.
6. TapRooT® User Success Stories From Healthcare and Industry - Facilitators: Linda Unger and Barbara Phillips
Three TapRooT® Users (to be determined closer to the Summit) will share recent successes improving performance by applying the TapRooT® System. Learn from the best practices of others and apply their ideas to improve performance at your facility.
7. The Good, The Bad, and The Ugly: Rating Improvement Programs and Incident Investigations - Tom Brower, Consultant
Is your program Good, Bad, or Ugly. Rate it and see. Compare your program to others at the session. And learn techniques to rate your company’s incident investigations.
8. Senior Executive Involvement in Safety
Bringing Safety to the Corporate Board - Dave Prewitt, VP, FedEx
What the Corporate Board Needs to Know About Safety - Bob King & Darby Alan, Woodland Grange, UK
What does the Corporate Board need to know about safety? With new corporate manslaughter laws in countries around the world, perhaps more than they currently know. Part of the Chemical Safety Board’s investigation of the explosion at BP’s Texas City Refinery implied that senior management and the Corporate Board needed to know more about safety and the impact of budget decisions upon safety. because of these issues, we invited Dave Prewitt, VP at FedEX, and Bob King and Darby Alan of Woodland Grange in the UK to speak about getting senior management, and even the Corporate Board, involved and aware of safety.
9. Planning Your Improvements - Facilitated by TapRooT® Instructors
A session that allows time for you to develop your improvement plans, get them reviewed by an experienced TapRooT® Instructor, and then benchmark them with other Summit participants.
Beyond the Safety & Risk Management Best Practice Trach sessions, there are five interesting Keynote speakers:
Marcia Wieder, Nikki Stone, Lt Col Ralph Hayles, Carolyn Griffiths, and Ed Frederick. For more information about their talks, see:
So if you are interested in improving safety and managing risk, sign up for the TapRooT® Summit and register for the Safety & Risk Management Best Practices Track. See:
The China Association for Quality Promotion (CAQP) has recognized Otis Elevator Company as a leading service provider in China for its consistent national service model, standardized processes and best-in-class response time. Otis is a unit of United Technologies Corp and a Licensed TapRooT® User.
Otis was the only elevator company to receive the distinction and one of only 15 companies selected out of the 2,339 evaluated.
Otis Elevator Company is the world’s largest manufacturer and maintainer of people-moving products including elevators, escalators and moving walkways. With headquarters in Farmington, Connecticut, Otis employs 63,000 people, offers products and services in more than 200 countries and territories and maintains 1.6 million elevators and escalators worldwide. United Technologies Corp., based in Hartford, Connecticut, is a diversified company providing high technology products and services to the building and aerospace industries. United Technologies is a Licensed TapRooT® User worldwide.
Practical Solutions Group (PSG), one of our Australian TapRooT® Representatives, is looking for two new employees to teach and consult using TapRooT®. For more information, see:
Some call it a vision. Some call it a dream. But every improvement program needs a goal. Do you have a vision of what performance would look like if you could achieve the ideal state at your company? Achieving that vision is what Marcia Wieder, America’s Dream Coach, is all about. As the closing Keynote Speaker at the TapRooT® Summit, she will show you how to achieve your dreams and make your vision a reality.
To hear a little of the type of advice America’s Dream Coach will provide at:
Here’s an interesting CBS News video on sleep, fatigue, and human performance:
One of our speakers at the TapRooT® Summit is Bill Sirois of Circadian Technologies. Bill will be speaking about fatigue and human performance. He will also share a scientific way to evaluate fatigue in an accident investigation (called FACT). For more Summit info, see:
I take pride in my time served in the Nuclear Navy and the two ships I served aboard (USS ARKANSAS and USS LONG BEACH). It’s difficult to write about failings in leadership in the Nuclear Navy. But I wrote about it before (blog article 1, 2, 3) and predicted the outcome. By looking at the failings that occurred aboard USS HAMPTON, we may be able to understand how hard achieving operational excellence is in the demanding world of submarine operations and how people can fall short of demanding expectations.
It started out just fine. Commander Mike Portland (right) takes command of the USS HAMPTON, SSN-767.
His command ended in scandal as a ORSE Board discovered that reactor chemistry logs had been gun-decked (faked). This led to a Judge Advocate’s General Manual investigation and a Commodore’s Mast that uncovered many minor and some major “integrity violations.”
The Navy Times reported on the failures in various articles, including the most recent article:
To my eye, the trail of “evidence” reminds me of a witch hunt where one of the accused is caught in a minor indiscretion and then must offer up others who they think may be more or equally guilty. Some of the most guilty are likely to name many others to provide the appearance that “everybody was doing it.” Even in the Nuclear Navy, anyone may have a slight indiscretion. A chief may have heard a rumor he didn’t report. An officer may backdate a form that was completed, but that he forgot to sign at the time. An Officer may use an old exam to prepare for an upcoming exam, and then, when he’s not sure if this practice (studying from old exams) is allowed, lie about it when he sees everyone getting disciplined (end of career) for a variety of “integrity violations.”
Let those who have never sinned throw the first stone.
But the indiscretions aboard the USS HAMPTON were more than petty indiscretions. Reactor chemistry logs were faked for an extended period of time. And the disciplinary report - that claimed that reactor safety was never compromised - didn’t seem to explain the root causes of this failure.
Rear Adm. Joseph Walsh, Pacific Submarine Force Commander, wrote in his endorsement of the report. “The specific deficiencies identified during this investigation resulted in no unsafe operations or maintenance of reactor or propulsion plant systems and no loss of radioactive material.”
First, if reactor samples were never taken … this IS unsafe reactor operations. One of the Safeguards to maintain reactor safety - sampling - was compromised. The later samples verified was that the reactor was not damaged. These later samples did not restore the “safety” that was compromised by the previous lack of samples.
If anyone thinks differently, then let’s QUIT taking samples while operating at sea (since not taking samples does not compromise reactor safety) and just take a sample when the ship gets back to port. This would save a lot of work.
Reactor safety can only be assured by following the rules and taking the samples that are designed to catch failures BEFORE major damage can occur. If you don’t take the samples, reactor safety is unknown - this is a compromise. Taking later samples doesn’t restore the integrity of those who falsified the records or restore reactor safety. It just confirms the fact that other, redundant safety factors worked even though the samples were skipped.
The Nuclear Navy’s uncompromising enforcement of the rules is one of the things that sets it apart from other organizations that accept shortcuts. Word games in statements for the press meant to reassure the public do little. These types of statements seem like a cover-up for performance that is clearly substandard.
Now for the corrective actions. Much is “redacted” from the report (names are crossed out). But this much we do know:
The Commanding Officer, Mike Portland, was “detached for cause” (fired).
Why? The endorsement by Rear Adm. Joseph Walsh says:
“Commander Portland set unachievable standards for his crew, was intolerant of failure, and publicly berated personnel.”
For those who have served in the Nuclear Navy, leaders with these attributes are not rare. It sounds like my first CO. Or maybe Admiral Rickover. I’d guess (from my limited experience) that about 50% of senior Nuclear Navy leaders use this style. However, it also says:
“He failed to exercise oversight of personnel and processes … “
Oversight is a keystone of the Nuclear Navy. Was he really absent from “back aft?” Was he isolated from the crew? Is this a “Cain Mutiny” situation on a nuclear submarine?
It continues to say:
“… failed to train his leadership team to effectively manage issues under their cognizance.”
That is especially worrisome. Shouldn’t the crew be trained to manage issues BEFORE they join the ship? Shouldn’t his XO and Department Heads coach the Junior Officers and train them? Does the CO need to train everyone or should he make sure that everything is working and make adjustments as needed?
However, the CO wasn’t the only one punished.
The Engineering Officer was fired.
Two officers were “de-nuked” (the end of their career - but let’s make them serve out their time in some obscure job in a bad place).
Two sailors were stripped of their naval enlisted classification codes (de-nuked).
Several junior sailors, including ELTs, were “masted” (disciplined) or referred for additional review by their current commands (because they had already left the ship).
Note that at least two officers chose to “take the 5th” when it was their turn to participate in the witch hunt.
Let’s take one more look at the CO’s job.
What if everything wasn’t working when he took over in the shipyard? With a demanding shipyard schedule followed by pre-deployemnt work-ups and deployment operational commitments, when was the CO and crew suppose to get the time to train in leadership and managing things under their cognizance if they didn’t already have those skills when they reported to the ship? Then add in a surprise deployment.
Could a good CO turn around a poor crew without much help in a demanding environment? Maybe.
What about an average CO? Maybe not.
What about a screemer who was doing all he could just to keep his head above water (oops - not required on a sub)? Very unlikely.
So the report seems to imply that:
1. The CO didn’t do his job.
2. The Officers didn’t do their job.
3. The Chiefs didn’t do their job.
4. The sailors didn’t do their job.
According to the Navy statement, THIS HAS NOTHING TO DO WITH THE REST OF THE SUBMARINE FORCE.
It was just one bad boat.
It doesn’t indicate a reactor safety issue.
The failures of the crew aboard USS HAMPTON are isolated incidents.
The punishment of the CO and crew addressed the root causes of these leadership failures by getting rid of a few bad apples.
But the Navy Times article goes on to say:
The Submarine Forces commander, Vice Adm. Jay Donnelly, questioned whether the integrity violations had gone beyond Hampton, and last fall ordered “Deep Dive” teams to the fleet to look more closely at morale and retention woes.
Experienced submariners say they believe the investigations revealed a broader practice of questionable reports and shady practices across the force. One called the Hampton situation “a failure of the worst kind.”
So is this just an isolated incident? Has the submarine force been pushed beyond their limits? Have the strong traditions that Admiral Rickover established been broken? Can trying to do too much with too little for too long eventually result in a cultural meltdown? Will the Nuclear Navy follow the pattern at BP and eventually have their own “Texas City” style incident?
Perhaps the “Deep Dive” teams know. Without more information, we could only guess.
Is there a lesson that can be learned here? I think so.
John Richter, the EHS EnCana Corporation Team Lead in Wyoming, invited his contract operators to two back to back 2-Day TapRooT® Incident Investigation and Root Cause Analysis courses this week in Rock Springs, Wyoming. We had a good turn out with operators and EHS leads attending, some even on their days off. For those not familiar with Rock Springs, last Friday there was new snow on the ground and only one day to test drive the 2009 snowmobiles.
Mark Olson, a System Improvements Inc. Instructor, leads the class in understanding how to group problems during an investigation.
The class and Chris Vallee, a System Improvements Inc. Senior Associate, listen attentively to John Richter on what EnCana Corporation would like to see from them after attending this class.
This group takes a picture of their SnapCharT® for documentation…. not a bad idea.
(Bow of fishing trawler before sinking
after being hit by the Japanese Self-Defense
Forces Aegis destroyer, Atago)
The investigation into the cause of the crash of a 30+ foot fishing trawler with a Japanese destroyer is still underway, but the first corrective action - firing the Chief of Japan’s Navy, Admiral Eiji Yoshikawa (photo below) - has already been completed.
Blame is an interesting concept. But is it effective in improving performance?
In the US, the first fired are usually the last people to touch whatever it was that caused the problem. In this case, those “held responsible” would usually be the Commanding Officer of the ship, the Officer of the Deck, and perhaps a lookout.
In Japan, discipline seems to start at the top (or near it) and work it’s way down.
Will either form of discipline improve performance?
Not if the root causes of the accidents aren’t uncovered and corrected by a thorough accident investigation.
