Root Cause Analysis Blog

I’ve heard of cutting off the branch you are sitting on, but this is a little bit different.

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Why do articles about medical errors have an erie similarity?

The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

The Air Force Link reports that Col. Richard Haddan will chair an investigation board looking into a recent crash of a T-38 training jet. The crash killed Maj. Brad Funk and his student, 2nd Lt. Alec Littler.

No other information will be released prior to the completion of the board’s investigation.

Here’s a video of the crash that caused the investigation we previously reported on.

A subway accident is scary. On Sunday, the derailment of one wheel on two cars of a subway train required 449 passengers to be evacuated on a “rescue train.”

The accident caused Monday commuter service to be disrupted.

For more info, see the AP article at:

http://www.nj.com/news/index.ssf/2008/05/nycs_r_and_n_subway_lines_are.html

72 people have died after an accident in east China. The corrective action that has made headlines is the firing of officials. So far, eight have been fired. For a story with more information, see:

http://afp.google.com/article/ALeqM5gVmWAIUCA2mL6PlOR8ySRM3eHJmw

Is this effective corrective action?

Fatalities at sporting events are difficult to imagine. It seems we are past the point of gladiatorial combat where the spectacle of death was part of the show. But not every sport has heard about safety. For some interesting reading, see the following articles about a fatality during a practice run for a street luge race and an actual accident at a Formula 1 race.

Street Luge Article:

http://www.kansascity.com/115/story/596177.html

Formula 1 Accident Article:

http://www.telegraph.co.uk/sport/main.jhtml?xml=/sport/2008/04/28/umkova228.xml

The difference? Engineered Safeguards!

Your body is no match for a tree at 60 miles per hour.

But your body can survive a 150 miles an hour crash into a wall if it is properly protected.

As a TapRooT® root cause analysis instructor and a Six Sigma Black Belt for System Improvements, Inc., I ask the question in this article’s title to numerous safety leaders from multiple industries. What do you think the typical responses are before they attend a TapRooT® course…..

1. No Lost Time Injuries
2. No Fatalities
3. No Near Misses

What’s wrong with these answers? After all, to be best in class for safety you must report these types of numbers. What if I asked your company’s safety leader the following question… “what did you do wrong today to cause this person to get hurt?” This is basically the same question as above except now the safety leader has to answer that the safety department was not successful at the end of the day.

The point is that that the above answers are what are called “lagging metrics”. It’s too late to know what was done wrong or even what was done right! Think about it… when a a fatality occurs the investigation team must exert a lot of effort and time to understand what happened, why it happened, and how to prevent it from happening again. Prevention….. if only the team had understood the everyday problems and root causes that were present before the incident occurred in this area of the business.

Did you know that it takes less time to perform a TapRooT® audit in predetermined areas of company and hazard risk than it does do perform a post incident investigation? So the question to ask again is “how do I know I was successful today in safety?” Your answer could be, “based on a predetermined risk assessment, we lowered the high risk areas in fall protection from 70% to 60%!”

For for ideas about proactive TapRooT® audits, call us at System Improvements, Inc. at 865.539.2139 or even better, attend the TapRooT® Summit in June and see how other top industries are using our proactive audits. Below is a list of proactive opportunities. See you in June.

* Safety & Risk Management
* Human Error Reduction & Behavior Change
* Corrective Action Programs
* Proactive Improvement, Operational Excellence, and Lean/Six Sigma
* Medical Error Reduction
* Equipment Reliability & Maintenance
* Investigation & Root Cause Analysis
* Management & Measuring Performance
* Certified TapRooT® Instructor
* TapRooT® Software Techniques & Administration

For details, see:

http://afp.google.com/article/ALeqM5hMTIeesS8CXfofZqKjKYIk9hOWHA

For more info see the AP story on the CNN web site.

A press release from the CSB:

Washington, DC, April 30, 2008 - The U.S. Chemical Safety Board (CSB) announced that it will convene a public meeting on Tuesday, May 13, 2008, in Danvers, Massachusetts, to review  the final CSB investigation report on the causes of the November 2006 explosion at the CAI/Arnel ink and paint manufacturing plant.

The report examines company work practices, state and local licensing and permitting procedures, and state and national fire codes for the safe handling and processing of flammable liquids.

The meeting will begin at 6:30 p.m. at the Sheraton Ferncroft Hotel, North Shore Ballroom, located at 50 Ferncroft Road in Danvers.  The meeting is free and open to the public.  Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration.  The meeting is expected to conclude at approximately 9 p.m.

On the night of November 22, 2006, a CAI mixing tank containing flammable heptane and alcohol solvents overheated, releasing vapor that filled the building and then ignited at about 2:45 a.m.  The resulting explosion and fire destroyed the facility and created a blast wave that damaged or destroyed dozens of nearby homes and businesses in the Danversport neighborhood.  As CSB investigators noted at a May 2007 public meeting in Danvers, the building’s ventilation system was routinely turned off at night, contributing to the accumulation of the flammable vapor.

The meeting will include a detailed presentation by the CSB investigative team of the findings and conclusions from the agency’s investigation.  In preparing the final report, investigators examined the accident site; interviewed numerous company personnel, neighbors, and officials; conducted blast modeling and laboratory testing; and examined relevant federal, state, and local regulations and standards.

The investigation team will present new safety recommendations to prevent future accidents for consideration by the Board.

Following the presentation of the CSB report and recommendations, a panel of outside witnesses will describe changes in state and local oversight of chemical facilities that have been proposed or implemented since the explosion.  Officials from the state government and the Massachusetts fire services have been invited to testify, along with a community representative.

For more information, please contact Public Affairs Specialist Hillary J. Cohen at (202) 261-3601.

Runaway barges were rounded up after a collision with a bridge on the Mississippi River. For details, see:

http://www.natchezdemocrat.com/news/2008/apr/30/all-barges-recovered-cause-accident-investigated/

See:
http://www.aaib.dft.gov.uk/publications/formal_reports/5_2008_oo_tnd.cfm

Be careful! If your class doors are too clear, bad things can happen…

For more information see:

http://www.examiner.com/a-1363995~2_killed_in_explosion_at_coal_gasification_plant.html

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

For details, see:

http://www.chron.com/disp/story.mpl/world/5734833.html

Just a slight miscommunication …

The UK Rail Accident Investigation Branch (UK RAIB) has released a report on a collision between a train and a tractor near Limavady Junction, Northern Ireland, on August 2, 2007. The RAIB has made six recommendations. For the complete report see:

http://www.raib.gov.uk/cms_resources/070424_R102008_XL202.pdf

The UK Rail Accident Investigation Board has released two new reports.

The first is an investigation into the derailment of a tram at Pomona, Manchester on 17 January 2007. See:

http://www.raib.gov.uk/cms_resources/080424_R092008_Pomona.pdf

The second is an investigation into a runaway engineering wagon and its subsequent collision with a road-rail vehicle at Armathwaite, Cumbria, on 28 January 2007. See:

http://www.raib.gov.uk/cms_resources/070424_R082007_Armathwaite.pdf

An article in Advance for Nurses includes some interesting items:

Cost of a needle stick injury could = $1 million.

Fatigue, long hours, and shiftwork are a big cause of accidental needle sticks.

Best Safeguard … Go needleless.

The article is at:

http://nursing.advanceweb.com/Editorial/Search/AViewer.aspx?AN=NW_08apr14_n8p19.html&AD=04-14-2008

Needle Stick References:

http://nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles.aspx

The result of a private aircraft is often a lawsuit and damages.

After the 2002 crash of a Beech Baron, Teledyne Continental Motors was sued.

The result? A $4 million judgement.

This article:

http://www.aero-news.net/index.cfm?ContentBlockID=29f8d137-248f-4bae-8099-e053f42aa527

provides some details about the trial and evidence.

Here is what the NTSB had to say about the accident:

http://www.ntsb.gov/ntsb/brief2.asp?ev_id=20020108X00047&ntsbno=FTW02FA062&akey=1

What do you think about the evidence and verdict? Use the comment field to leave a note…

Here’s a news item from the UK:

Child killed while driving tractor

The father of a 12-year-old boy who was crushed to death by a tractor has been fined £1000 for letting his son drive the machinery while underage.

Sam Stanbridge was towing a roller on 25 March 2007 at the family farm at Kibworth Harcourt, Leicestershire, magistrates in Leicester heard on 28 February. There were no witnesses to the incident, but his mother found him unconscious while out riding. He had sustained a fatal injury to the head, having apparently been crushed by a two-and-a-half-tonne roller attached to the tractor he was driving. The tractor fell into a nearby canal. Sam was pronounced dead at Leicester Royal Infirmary.

A coroner’s inquest into his death concluded that Sam either slipped, tripped, or fell out of the cab; while getting in and out of the cab; or while already out of the cab. He had undertaken the same activity the day before the incident, and during the previous year, despite the law banning children under 13 years of age from driving or riding on agricultural machinery.

There was no evidence that the tractor had been driven recklessly, nor could any horseplay on Sam’s part be attributed to the cause of the incident.

In court, the boy’s father, Mark Stanbridge, pleaded guilty to breaching reg. 4 of the Prevention of Accidents to Children in Agriculture Regulations 1998, in that he allowed Sam to drive a tractor while carrying out agricultural work, which culminated in his death. He was fined £1000 and ordered to pay costs of £1500.

http://www.shponline.co.uk/article.asp?pagename=incourt&article_id=7308

How much punishment is enough?

Do you think the father needs to be fined £1000 to prevent future accidents?

Sometimes I wonder about courts and enforcement of regulations.

The Ontario Workplace Safety and Insurance Board created a set of fairly gruesome commercials that dramatically show the results of “accidents.” The message is that there are no accidents. Accidents are caused.

Here’s the video:

These are also available at the WSIB web site for download:

http://www.prevent-it.ca/index.php?q=see-it-tv-spots

The real question I have about these videos is the focus on blaming the worker, the supervisor, and management. We see the accident happen, but do we know what set the accident up?

To me, the video also shows the difficulties of finding and fixing the real root causes of an accident when our culture first looks to blame.

What do you think?

Press release from the NTSB:

Washington, D.C. - The National Transportation Safety Board today released preliminary aviation accident statistics for 2007.

“The U.S. aviation industry has produced an admirable safety record in recent years,” said NTSB Chairman Mark V. Rosenker. “However, we must not become complacent.  We must continue to take the lessons learned from our investigations and use them to create even safer skies for all aircraft operators and their passengers.”

The Safety Board’s aviation accident statistics show that in 2007, there were 24 nonfatal accidents involving Part 121 airlines (aircraft with 10 or more seats). One fatality occurred involving a nonscheduled Part 121 aircraft when a mechanic was fatally injured while working on a Boeing 737 in Tunica, Mississippi.

No fatalities occurred among Part 135 commuter operators (fewer than 10 seats).  However, on-demand (charters, air taxis, air tours and medical services when a patient is on board) Part 135 operations reported 43 fatalities (62 accidents, 14 fatal accidents), up from the 16 fatalities that occurred in 2006.

While the overall number of general aviation accidents rose from 1,518 in 2006 to 1,631 in 2007, the number of fatalities in 2007 was down from 703 to 491 (a 30 percent decrease), making it the lowest annual total in more than 40 years.

Foreign registered aircraft accounted for 11 accidents in the U.S. in 2007, with 3 fatalities from a single fatal accident.  Of the 14 accidents involving unregistered aircraft, 6 were fatal and resulted in 7 fatalities.

The 2007 statistical tables are found at:

http://www.ntsb.gov/aviation/Table1.htm

Stats for the past 10 years can be found at:

http://www.ntsb.gov/aviation/Stats.htm.

NTSB Media Contact:
Bridget Ann Serchak
(202) 314-6100
Bridget.serchak@ntsb.gov

The BBC reported that an accident in Scotland caused by a 30-ton digger falling off a truck while being moved and hitting car (killing a passenger) would have been prevented if the truck driver had been properly trained.

The story quotes Judge Lord Brailsford as saying:

“I express surprise and some concern at the absence of any requirement for compulsory training for drivers of heavy goods vehicles in relation to loading and securing of loads.”

“It seems to me that if such training had existed prior to July 5 in 2006 then there is at least the possibility that the accident which occurred might not have taken place.”

Training always seems like a potential solution after an accident with 20/20 hindsight. Without additional details of the sequence of events, the causal factors, and a thorough root cause analysis, the actual root causes may never be known.

A press release from the US Chemical Safety Board (CSB):

Apex, North Carolina, April 16, 2008 - In a case study report released today on the October 2006 hazardous waste fire at the Environmental Quality Company (EQ), the U.S. Chemical Safety Board (CSB) called for a new national fire code for hazardous waste facilities and for improving the information provided to community emergency planners about the chemicals those facilities store and handle.

The fire occurred on the night of October 5, 2006, at the EQ hazardous waste transfer facility on Investment Boulevard in Apex, a suburb of Raleigh, North Carolina.  The facility was not staffed or monitored after hours, and no EQ employees were present at the time of the fire.  Emergency responders did not have access to specific information on the hazardous chemicals stored at the site and ordered the precautionary evacuation of thousands of Apex residents.  The evacuation order remained in place for two days, until the fire had subsided.

The CSB also today released a new 16-minute CSB safety video, entitled ‘Emergency in Apex - Hazardous Waste Fire and Community Evacuation,’ available on free DVDs and on the agency’s video website, Safetyvideos.gov.

The CSB investigation found that a small fire originated in the facility’s oxidizer storage bay, one of six storage bays where different wastes were consolidated, stored, and prepared for transfer off-site to treatment and disposal facilities.  Within the oxidizer bay were a number of chemical oxygen generators, which had earlier been removed from aircraft during routine maintenance at a facility in Mobile, Alabama.  However, they had not been safely activated and discharged before entering the waste stream.  Solid chlorine-based pool chemicals were stacked on top of the box containing still functional oxygen generators.

Apex firefighters initially responded to a 911 emergency call from a resident driving past the facility, who reported observing a haze with a ’strong chlorine smell.’  When firefighters arrived, they discovered what was still a small ’sofa-size’ fire.  But that fire spread quickly, most likely as the aircraft oxygen generators discharged and accelerated the blaze.

‘The only fire control equipment on-site consisted of portable, manually operated fire extinguishers,’ said CSB Supervisory Investigator Rob Hall, P.E., who led the investigation.  ‘The facility lacked fire walls and automatic fire suppression systems.  As a result, the fire spread quickly into other bays where flammables, corrosives, laboratory wastes, paints, and pesticides were stored.’  The bays were separated by six-inch-high curbs only designed to contain liquid spills.

The facility was destroyed in the ensuing fire and explosions, which sent fireballs hundreds of feet into the air.  About 30 people, including one firefighter and 12 police officers, required medical evaluation at local hospitals for respiratory distress and other symptoms that occurred as a plume from the fire drifted across the area.

Hazardous waste facilities like EQ’s are regulated under the federal Resource Conservation and Recovery Act (RCRA).  The investigation noted that RCRA regulations developed by the Environmental Protection Agency (EPA) require facilities to have ‘fire control equipment’ but do not specify what equipment and systems should be in place.  In addition, there is no national fire code to define good fire protection practices for hazardous waste facilities.

The CSB investigation identified 22 other hazardous waste fires, explosions, and releases that have occurred at U.S. hazardous waste facilities in past five years.  More than a third had adverse community impacts, such as evacuations, orders to shelter, and transportation disruptions.

Federal RCRA regulations require operators to ‘familiarize’ local responders in advance concerning facility hazards, but do not describe what specific information must be shared about stored chemicals, or define the frequency of communications.  Similarly, EPA regulations under the 1986 Emergency Planning and Community Right-to-Know Act do not require facilities to share information about hazardous wastes with local agencies, since those wastes are generally exempt from Occupational Safety and Health Administration (OSHA) rules requiring preparation of material safety data sheets (MSDSs).

In fact, the investigation found that EQ had had limited contact with the Apex Fire Department prior to the October 2006 fire.

‘Specific, accurate, up-to-date information on chemical hazards is essential to emergency response planning,’ said CSB Board Member William Wark, who accompanied the investigative team to Apex in October 2006.  ‘Communities have a fundamental right to know about stored hazardous chemicals that may affect their health and well-being.  For first responders, having prompt access to such information is a matter of basic life safety.’

The CSB report recommended the EPA require that permitted hazardous waste facilities periodically provide specific, written information to state and local response officials on the type, approximate quantities, and location of hazardous materials.

The Board called on the Environmental Technology Council, a trade association representing about 80% of the U.S. hazardous waste industry, to develop standardized guidance on waste handling and storage to prevent releases and fires.  The CSB also recommended that the Council petition the National Fire Protection Association (NFPA) - an organization that authors national fire codes - to develop a specific fire protection standard for the hazardous waste industry.  The new standard should address fire prevention, detection, control, and suppression.  Similar NFPA standards already exist for other industries, such as wastewater treatment.

Earlier, in June 2007, the CSB issued a safety advisory and urgent recommendations designed to ensure that chemical oxygen generators are safely activated and discharged prior to transportation and disposal.  The advisory cited findings of the National Transportation Safety Board (NTSB) following the 1996 ValuJet crash in Florida, which was caused when generators activated and ignited in the plane’s cargo bay.

For more information, in Apex contact Dr. Daniel Horowitz at (202) 441-6074.  In Washington, DC, contact Mr. Sandy Gilmour at (202) 261-7614 / (202) 251-5496 or Ms. Hillary Cohen at (202) 261-3601 / (202) 446-8094.

The Irish Times reports that an accident that injured two people at an air show in Ireland was the result of “mindless curiosity.”

Read the story and see if you think this answer qualifies as a root cause.

I know shooting birds at jets is a topic of Jeff Foxworthy’s jokes, but somethime performance improvement includes engineering for expected hazards.

This video shows the testing of bird impacts on jet engines. Dead birds were used, but some of the slow motion videos are still pretty gruesome.

The video isn’t an accident. It is a 1993 United Airlines safety video for the ground operations personnel. But accidents of this type have happened.

What lesson can you learn from this video? Think about how are you training your employees to recognize hazards in the workplace. Before they can report and avoid hazards, they need to be able to recognize them.

One of the pre-Summit courses (June 23-24 in Las Vegas) is the:

HAZARD RECOGNITION BEST PRACTICES TRAINING

Peter Burkholz, one or our TapRooT® Instructors from Australia with 25 years of industrial and mining experience, will teach tried and true methods of hazard recognition including at risk or safe behavior, legislation implications, and hazard identification and rectification. The course includes a site visit to a Caterpillar site for practical application of the theories learned.

To register, see:

http://taproot.com/courses.php?d=19

A press release from the UK Rail Accident Investigation Board:

The RAIB is carrying out an investigation into a derailment of a Docklands Light Railway train near Deptford Bridge station on 4 April 2008.

At 05:27 hrs on 4 April the 05:19 hrs service from Lewisham had just left Deptford Bridge station, and was traveling towards Greenwich, when it struck an object on the track and was derailed by the second axle of the first bogie. The front of the train came to a rest 88 meters after hitting the object. There were no injuries to the 59 persons on board the train and all were evacuated safely back to Deptford Bridge station.

The train, which was the first train of the day from Lewisham, was under automatic operation. The object on the track was found to be a steel drilling template that had been in use during engineering activities the previous night.

The RAIB’s investigation into the derailment is independent of any investigations by the safety authority.

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website:

http://www.raib.gov.uk

- - -

The Chief Inspector for the UK RAIB is Carolyn Griffiths. She is one of the Keynote Speakers at the TapRooT® Summit being Held on June 25-27 in Las Vegas, Nevada. For more information about the Summit and for registration, see:

http://www.taproot.com/summit.php

The RAIB is carrying out an investigation into an accident when a road coach moved as a shuttle train departed from the UK terminal on 4 April 2008.
At 17:08 hrs a tourist shuttle train was departing from the UK terminal when a road coach moved backwards relative to the shuttle train, trapping the coach’s driver against the internal fire barrier door.  Another passenger activated the emergency alarm to alert the train crew.  As the train stopped the coach moved forward releasing the coach driver.  The coach driver received injuries that required him to be admitted to hospital for treatment.

The RAIB’s investigation into the incident is proceeding independently of any parallel investigations by the safety authority, but the RAIB will share technical evidence as appropriate, subject to legal exclusions such as the identity and statements of witnesses.

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website:

http://www.raib.gov.uk

A debate taking place in the agricultural community and on Capital Hill is really about the strength of Safeguards.

A story in the Houston Chronicle explains the debate.

The government is considering moving the Plum Island Animal Disease Center from an Island off the coast of New York, to a facility on the mainland of the United States.

Previous unintentional releases of live foot-and-mouth disease have been contained to the island because of the distance from the mainland.

The government argues that the release happened long ago (1978) and that modern safety rules, policies, and procedures make it safe to move the facility to one of these potential locations:

San Antonio, TX
Manhattan, KS
Athens, GA
Butner, NC
Flora, MS

House Energy and Commerce Committee is considering the administration’s plans to move the facility. The new site could be selected later this year, and the lab would open by 2014.

Spaceflight Now says that $150 million will be paid by an insurance company after a DISH Network satellite failed to reach its required orbit. The failure was caused by a rocket shutting down prematurely.

The article also said that a Russian Board is looking into the failure of the Proton’s Breeze M upper stage engine and is “close to determining the failure’s root cause.”

The Aviation Safety Network provides preliminary reports on aviation accidents around the world. Here is an example from April 9th:

http://aviation-safety.net/database/record.php?id=20080409-0

The FBI concluded that the crash of Senator Joe Lieberman’s web site WAS NOT a dirty trick from the opposing camp (Ned Lamont).

According to the FBI the data logging indicates a simple overload of the site combined with a misconfiguration of the server by the administrator. The FBI concludes that:

“The system administrator misinterpreted the root cause…”

For the complete story see The New York Times article:

http://cityroom.blogs.nytimes.com/2008/04/09/fbi-lieberman-2006-crashed-its-own-site/

On 1/6/05 a Norfolk Southern train derailed and ruptured a car carrying chlorine. The poisonous cloud spread throughout the small town of Graniteville. Nine people died, 250 were injured, and 5,400 people were evacuated.

The derailment occurred next door to the Avondale Mills, a textile manufacturer. Avondale Mills sued Norfolk Southern for $420 million in equipment damages.

It took over three years but on April 8th, after a four week trial, the parties settled the lawsuit for an undisclosed sum. 

Preventing an accident is surely less expensive than the legal wrangling that occurs after a major accident.

On April 4, Brent Coon, lawyer for several plaintiffs after the BP Texas City Refinery explosion, finally got his chance to depose Lord Browne, former CEO of BP.

A Houston Chronicle article says that during the telephone interview, Browne acknowledged that he had ordered deep budget cuts and that these would generally affect refinery maintenance. The articles says that he denied knowing that there were numerous complaints about how the cuts were impacting BP’s refineries.

This ends years of fighting over Coon’s plans for a deposition of the BP CEO.

Dromoland Castle

The RTE News reports that two men were injured when using a gas burner to seal a window at the Dromoland Castle in Ireland. The burner exploded, critically burning one of the workers and burning the other.

A link to those that were injured, the occupation, or the location, always makes an accident more personal. I’ve stayed at the castle in one of my trips to Ireland. It was very nice. If I stay there again, I’ll think of the accident.

A forklift accident at a refinery in the UK left a work with head and rib injuries. For more info see:

http://www.dailyecho.co.uk/news/latest/display.var.2173681.0.worker_is_injured_in_refinery_accident.php

Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.

There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.

First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:

http://www.icao.int/icao/en/dgca/Annex13attE_en.pdf

Or you can purchase it on-line at:

http://icaodsu.openface.ca/documentItemView.ch2?ID=6594

The International Civil Aviation Organization - Air Navigation Bureau also has a Accident Invesigation & Prevention web page at:

http://www.icao.int/icao/en/anb/aig/

Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See:
http://www.iprr.org/manuals/ntsbaviationman.pdf

Many countries have their equivalent of the NTSB. A list of national aviation investigation boards with links to their web sites can be found at:

http://aviation-safety.net/investigation/aaibs.php

These links should keep you busy and lead to many other sites with more information on aviation accident investigation.

Today, The Wall Street Journal reported that the baggage mess at Heathrow Airpo’s Terminal 5 will cost British Airways $32 Million Dollars. These costs are the result of cancelled flights (lost revenue), the cost of forwarding bags, and the cost of putting up stranded passengers at hotels. The costs do not include the damage to the airline’s reputation.

What does this mean to people performing root cause analysis?

If testing, audits, and proactive root cause analysis had been used prior to the opening of this terminal, these costs could have been avoided.

Also, the industry (or at least British Airways) didn’t learn from the root causes of the fiasco at the new Denver airport (not so many years ago). If the root causes of that failure were analyzed and shared, lessons could have been learned that might have prevented this “baggage meltdown.”

The largest healthcare insurer in Ohio has announce that it will start implementing the Medicare rules and refuse to pay for treatment due to a medical error or a hospital acquired infection.

For more informations, see:

http://www.cleveland.com/medical/plaindealer/index.ssf?/base/news/1207211620124580.xml&coll=2

For ideas to stop medical errors, attend the Medical Error Reduction Track at the TapRooT® Summit in Las Vegas on June 25-27.

With Hearings on Capital Hill about the FAA and Aviation Safety, I thought I’d reprint some aviation accident photos to remind us where we’ve come from and how much progress has been made.

Power lines sometimes provide their own fireworks show.

I previously wrote a blog entry about the wrong kidney being removed from a cancer patient.

Yesterday, I read an AP article with the followin