The Associated Press came out with an article today about beefed up Inspections of Regional Airline Pilot Training. This increased activity is in REACTION to pilot errors listed following the New York Regional Jet Crash earlier this year. The good PROACTIVE note in this article was this comment, “Federal Aviation Administrator Randy Babbitt said in a statement they will also hold a meeting with the airline industry — both regional and major carriers — next week to seek better pilot training, cockpit discipline and other safety improvements.”
So what would you look at to determine the Training concerns:
1. “a series of critical errors by the captain and co-pilot preceded the crash of Continental Express Flight 3407 as it neared Buffalo Niagara International Airport on Feb. 12.”
2. “cockpit voice recorder showed the co-pilot describing her lack of experience flying in icy weather not long before the crash.” Did she miss training? Did the company decide not to train? Was she trained and testing needs improvement? Should there be continued training? Did practice and repetition need to be increased?
3. “captain may not have had hands-on training on a critical cockpit safety system. “Did he miss training? Did the company decide not to train? Was he trained and testing needs improvement? Should there be continued training? Was the task analyzed for this aircraft?
Then there was the Fatigue issue:
1. “co-pilot, Rebecca Shaw, lived near Seattle on the West coast with her parents and had commuted all-night to get to Newark Liberty International Airport in New Jersey on the East coast , where Flight 3407 originated”
2. “captain, Marvin Renslow, commuted to work from his home in Florida. It is not clear where either of them slept the night before the crash or how much sleep they received.”
3. “current rest rules “are less restrictive than truck drivers work under. Once you’ve been on duty for 13 hours, you are about 500 percent more likely to make an error, and once you’ve been on duty for 16 hours, you have the response rate of somebody who is legally drunk.”
Is the policy confusion or incomplete? Is the policy not strict enough? Does the communication of the Policy need improved? Is this a crew selection issue? A scheduling issue?
Now if you read the rest of the article linked below, you then have to ask about Oversight and Corrective Actions. There were “cracks” in the system? Don’t get me wrong, there are a lot of good aviation programs with good training….. maybe too many for the ratio of inspectors? What is the expectation of the controlling authority? How much is the push back from the private commercial sector when push comes to shove. After all, look at the discussion over the recent airbus accident and whether the pitot sensors needed to be replaced. According to reports, Air Bus highly “suggested” that they be replaced… and the air lines knowing that pitot sensor errors are only minor, instructed pilots to make sure they beefed their work around response for eradicate readings.
This is more than just a training issue. What questions do you have? Wonder where my questions come from? Come to one of our 5-day incident courses and walk through the early 1970 Florida aircraft crash.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training: http://www.taproot.com/courses.php#c1
Or even better, come to our Summit and Pre-Summit and talk with aviation industry experts trained in our process from Rotorcraft to Alaska Airlines. http://www.taproot.com/summit.php (more…)
Interesting; the second major event and repeated attention by OSHA. While the fines may not be much, shutting down the plant and paying all these medical bills must be quite costly at this point.
Excerpt:
“The second violation pertained to the employer’s investigation report following the ammonia leak in January 2008. The report said JBS did not adequately address … several factors that may have contributed to the accident.”
So they’ve had all these problems, OSHA told them that their report last year did not dig deep enough, and now they have had another major incident. Had they taken action the last time this event would not have happened.
I would love to know the final cost of these two major incidents and the fallout from all these inspections. I would bet it is enormous. And that does not consider public perception, which is hard to measure but very real and a bad public opinion about an organization can be very damaging to the business.
Do not fall into this trap. Send your investigators to advanced root cause analysis training so they can find ALL the REAL root causes and so they can correct them effectively, protect your employees, and save big $$$$$$.
If you would like to meet with Bill Sirois, COO of Circadian Technologies, stop by his booth at the Exhibit/Reception at the TapRooT® Summit. You can discuss the origins of this new way to manage fatigue and how fatigue may be affecting your workers.
Checking on the news in the town where my daughter lives I saw this article at www.kake.com, “Sno-Cone Mishap Leaves Sedgwick Co. Zoo Visitors Ill.” Turns out that the employees mistakingly used the dark colored degreaser instead of the dark colored blue sno-cone flavoring.
Here are the highlights from the article (see the link in read more to see the video):
Luckily, the bottle mix-up did not end up with any major injuries. Those involved did not ingest enough of the mixture to cause any harm. Still, they are not happy.
“They need to be more careful, especially serving food. Pay attention to what you’re grabbing because this could have turned out tragic,” the victim said.
The zoo says it will now stop serving blue sno-cones completely to make sure this kind of mix up never happens again.
Now do you think that the zoo officials have truly found the causal factors, identified the root causes, and found the failed safeguards? I am surprised they were not fined for having cleaners stored with food products.. that would be a failed safeguard and root cause of arrangement and placement… but everyone seemed to focus on the mistake made by the sno-cone machine attendants.
What about the other sno-cone machines and food service areas, this may be a generic issue. Why was the issue not caught with proactive audits? If you want to reduce the possibility of this type of incident in the food industry come to our TapRooT® Summit in Nashville this October 5-6 (for the Pre-Summit) and October 7-9 (for the Summit). Found out about our proactive risk assessments and industry best practice tracks at this link: http://www.taproot.com/summit.php (more…)
If you like the article, you should think about attending the TapRooT® Summit and sitting in on Bill Sirois’ (COO of Circadian Technologies) talk titled:
“How Fatigue Impacts Human Error“
In fact, you might be interested in the whole Behavior Change and Stopping Human Error Track!
Operator error…..fire the guy….case closed. Or is it?
What is the real cause of the employee making a mistake? Apparently the authorities think training is one reason, but there may be others. When we look for someone to blame rather than investigating and solving the REAL problems, the accidents are bound to repeat; it may be 5 years from now, or it may be tomorrow, but it will happen.
If you want to do good investigations and eliminate the reasons for human performance problems (errors/mistakes), a good root cause analysis should be done using TapRooT®. Attend a course today - here is the schedule: http://www.taproot.com/courses.php
Mark Paradies has blogged about fatigue recently, and the Colgan crash has raised public awareness around the issue. It’s an important thing to consider, and most of us (me, for example) are not experts. Bill Sirois is, however, so make sure to attend his sessions at the 2009 TapRooT® Summit.
This week, the CEO’s from a number of regional airlines held their annual Regional Airline Association meeting in Salt Lake City. The Colgan Air commuter plane crash in Buffalo earlier this year was obviously a major focus. A lot of
attention has been brought to bear on both the fatigue and training level of the
cockpit crew. During the RAA meeting, the RAA president noted that industry personnel “have become too reliant on advanced technologies, and that they may need to focus more on human factors.” He further observed, “We need to consider the
psychological factors. Why do highly trained professionals fail to
follow their training and experience when faced with unusual
situations?” Check out the article here.
John Nance, an airline industry safety expert and a key-note speaker at our 2007 TapRooT® Summit, noted at the same meeting that it is “necessary to test all assumptions all the time. . .it’s time to ramp up.”
These are great observations. Accident investigations often seem to focus on just blaming the flight crew or mechanics. I’m sure that the Colgan Air pilot was trying to make the right decisions. The problem lies in finding a way to understand the rationale behind people’s decision-making. An effective root cause analysis system like TapRooT® will allow the investigators to focus on the real reasons that people make bad decisions.
The 2-Day TapRooT® Incident Investigation and Root Cause Analysis course will give you the basic tools you need to determine why people make the decisions they make. For even more comprehensive information on how to understand the psychology behind decision-making, and how to make our people want to make good decisions, attend a 5-Day TapRooT® Advanced Root Cause Team Leader Training course. Check out our course schedules here.
The first of the “15 Questions” on the TapRooT® Root Cause Tree® asks:
“Was a person excessively fatigued, impared,
upset, bored, distracted, or overwhelmed?”
Even though the questions in the Root Cause Tree® Dictionary help answer the question, assessing fatigue has always been difficult.
Now there is help.
About three years ago, I had a meeting with the management team at Circadian Technologies and helped convince them that they could take some complex, proprietary models that they used to assess fatigue and simplify them for use by company accident investigators.
They agreed to give it a try. After several years of R&D and testing, they now have a tool that usable and FREE.
What can it help you do? How about answering the following questions:
What is the probability that an individual was fatigued at the time of an incident/accident or operational deviation?
Was his/her fatigue the proximate cause of the incident/accident/operational deviation?
What was the source of excess fatigue risk (if any)?
At what level of the Fatigue Risk Management System did the fatigue risk originate?
What percent of my company’s incidents/accidents/operational deviations are caused by a fatigue impaired employee?
What is the cost of employee fatigue impairment at my company?
Answering these types of questions should be a high priority for any company with 24 hour operations, but especially for:
Hospitals
The transportation industry (aviation, maritime, trucking, mass-transit, rail, and bus)
Refineries
Nuclear plants
Oil platforms
Mines
Military operations
Pharmaceutical manufactureres
DOE sites
Really, any commercial or government facility with significant risk if a person makes an unexplained mistake.
But there’s more good news.
Bill Sirois, COO of Circadian Technologies, will be at the Summit to explain how to use FACTS and to help explain the effect of fatige on human performance.
To sign up for the Summit and Bill’s important sessions, see the Summit web site:
Here’s one more thing to think about. “Unexplained” human error costs industries billions of dollars a year. Many of these costs may be attributed to fatigued employees. Because employers don’t have a way to judge if employees are making mistakes because they are fatigued, they don’t take effective corrective actions to solve this problem.
By attending the Summit and learning about this new, free tool, you could potentially save your site millions of dollars when you can accurately identify fatigue as a cause of human error.
Thus, if you think you might have fatigued employees (and anyone in the industries I’ve listed above SHOULD be thinking of this possibility), you should get signed up for the Summit now and make sure that you attend Bill’s session (Wednesday in the third breakout from 2:40-3:55 and Thursday in the sixth breakout from 2-2:20).
We don’t know much from reading this story, but we do know this much:
*He was a very experienced employee *Shutting down the operation for 24 hours is a significant disruption *This did not have to happen
If something like this could happen to someone so experienced, it could happen to anyone. It is management’s job to make sure the system does all possible to stop human error and prevent accidents. This is done through best practices and application of knowledge. The kind of knowledge and best practices that can be leveraged proactively through TapRooT®.
Attend a course today and make sure something like this never happens at your worksite.
A swamper was walking behind the pole truck in the “danger zone” and tripped as the truck was backing up with the load. The worker was fatally injured when the vehicle drove over him.
NOTE: This alert was submitted to Enform following a recent fatality; however this is not an isolated incident. Five similar fatalities have been identified in the oil and gas industry over the past two years. These are summarized on page three of this alert.
June 2008 - A drilling rig was being moved to a rack site. On the second day of the job, with approximately a dozen loads left to transport off the site, a pole truck driver and his swamper were relocating a grated landing across the lease. A 4-leg sling was secured to each corner of the landing and it was raised off the ground with the pole truck winch. The load was not secured to the truck and tag lines were not used to control the suspended load. The driver proceeded to move the landing in reverse at a walking speed. At some point in the move, the swamper entered into the danger zone at the back of the truck to stabilize and guide the suspended load. Halfway across the lease, the swamper stumbled, lost his balance and fell down directly in the path of the rear wheels of the pole truck. Neither the driver nor the swamper were able to react quickly enough to avoid having the rear passenger side tires drive over the swamper’s legs and mid torso.
What Went Wrong?:
Causal Analysis:
Standards (Worker compliance with documented safe work rules and acceptable industry practices):There are a number of causes relating to a culture in this industry sector that tolerates risk taking in the danger zone while trucks and/or loads are moving. The specific root causes are in the areas of; compliance with rules and industry practices; communication & worker understanding of the company’s standards; accepting accountability to be intolerant of at-risk behaviour, and auditing and evaluating the company’s operations for compliance to expected safe work practices.
Work Direction (Worker responsibility & task preparation):There are multiple layers of supervision onsite during a rig move. Each task, even if it is apparently a low-risk task, must have a task leader to assume preparation, review and coordination responsibilities to accomplish the work safely.
Corrective actions and Recommendations:
We Can Prevent Similar Incidents
Working to Accepted Industry Practices:
Narrow suspended loads moved by a pole truck must be secured to the truck or controlled by the use of tag lines outside of the danger zone.
Workers will not be present in the danger zone when the truck is moving.
Drivers will stop their truck when their swamper, who is participating in the task, is not completely visible.
Understanding and Working to the Company’s Standards:
Establish a proactive culture that adheres to and supports safe work rules & expectations through:
improved communication
improved understanding of worker accountability for safety of themselves and coworkers,
intolerance for silent acceptance of deviation from safe work practices,
the application of a job specific worker observation program to stop and correct at-risk behaviours and positively recognize safe work behaviours.
Supervisory Responsibilities:
Establish a clear understanding that every task has a designated (competent) leader who is responsible to prepare and accomplish the task safely.
Use pre-task planning “walk-throughs” throughout the work day to calibrate the work team to the agreed upon approach that will be taken to conduct specific tasks.
Other Recent Contact with Mobile Equipment Fatalities:
January 2007 A 47-year old worker, employed as a plant operator, was assisting a truck driver hook up a trailer. He was run over by the tractor unit. Based on Alberta WHS Fatality Report: WHS-PUB_FR-2007-01-20 Link: http://employment.alberta.ca/documents/WHS/WHS-PUB_FR-2007-01-20.pdf
March 2007 A 31-year old worker, employed as a medic, was guiding a truck driver who was reversing a tank truck with an attached pup when the worker was pinned between the pup and another piece of equipment. Based on Alberta WHS Fatality Report: WHS-PUB_FR-2007-03-11Link: http://employment.alberta.ca/documents/WHS/WHS-PUB_FR-2007-03-11.pdf
November 2007 A 43-year old worker, employed as a truck driver, was in the process of helping load an empty 400 lb oil storage tank onto a flat bed truck and got pinned between the tank and the truck. Based on Workplace Incident Fatalities Investigated in 2007 by Alberta Workplace Health and Safety (Page 5) Link: http://employment.alberta.ca/documents/WHS/WHS-PUB_wpfatal_2007.pdf
January 2008 A 38-year old worker was fatally injured when he became pinned against an oilfield tank by the pressure truck he was operating. The truck was accidently put into gear by the worker who was immediately outside the truck. The truck moved forward and pinned the worker against the tank. Based on Workplace Incident Fatalities Investigated in 2008 by Alberta Workplace Health and Safety (Page 2) Link: http://employment.alberta.ca/documents/WHS/WHS-PUB_wpfatal_2008.pdf
August 2008 A 20 year-old worker was run over by a truck while he was helping a fellow employee to back up the truck. Based on Workplace Incident Fatalities Accepted by the Workers Compensation Board in 2008 (Page 5) Link:http://employment.alberta.ca/documents/WHS/WHS-PUB_wpfatal_wcb_2008.pdf
Source Contact:
This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).
This article underscores the fact that any initiative, no matter how good the concept, must be properly implemented, appropriate follow-up must be done, and politics must not be part of the equation. It’s not easy to do that in big organizations or when multiple entities are involved.
The basic premise of ASAP is to find problems and fix them before something bad happens, and this is done through voluntary reporting with limited amnesty. It is a good thought process and should work (in a perfect world). I’m not surprised to hear that the follow-up has been lacking, but this can be acted on and improved. What there is not much mention of is the political angle - unions play a big role in this and for this reason the process is fraught with difficulty. Understanding that the unions are trying to protect their membership, I’ve seen firsthand how they stall the process (for years in fact), and this is unfortunate. Hopefully the IG’s report will be the impetus for improvement, not the dismantling of what promises to be a good thing. Let’s not throw the baby out with the bathwater.
Aviation is very safe as industries go; I worked in the industry for 27 years and now travel as a customer most weeks. It’s not perfect, and is very unforgiving, however. We can all improve no matter which rung of the quality ladder we are currently standing on. Hopefully the airlines, the FAA, and the unions can do a better job of working together and improve aviation safety for all of us.
The New York Times reports that after an accident that killed 25 people and injured 130 more, the Metrolink Board of Directors has voted to authorize $975,000 to install hidden video cameras on Metrolink commuter trains.
Last year train engineer Robert Sanchez ran a “red light” and hit an oncoming Union Pacific freight train. He was “texting” when he should have been driving the train.
Now Metrolink wants better forensic evidence to perform better investigations of accidents, incidents, and near-misses. The new cameras are a step in that direction.
What do you do to make incident investigation evidence collection and interviewing better? Have you thought about this important piece of an accident/incident investigation?
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Also, if you are interested in improving your incident investigations, consider attending the Investigation and Root Cause Analysis Track at the TapRooT® Summit in Nashville on October 7-9.
What will you learn?
First, you will see three accident presentations that will help you learn best practices from the presenters (including how to investigate multiple accidents to learn generic lessons).
Second, hear two best practice investigations from TapRooT® Users. Dennis Ward, from the Alaska Medallion Foundation, will share his experience using TapRooT® to find common causes of aviation accidents. Next, Ron Pryor of Alcoa will explain how TapRooT® was used in a Kaizen project to improve product quality.
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
3 rules for improving investigation questions,
who to get someone to share more information, and
how to confirm understanding.
Fourth, learn if your investigation system is “The Good, The Bad, or The Ugly” and what you can do to improve it.
Fifth, attend the one-and-only session where TapRooT® Users share their best ideas … the TapRooT® User Best Practice Sharing Forum. You will participate in a session that is always rated as one of the most helpful to TapRooT® Users who are looking for innovative ways to make investigations more efficient and effective.
Sixth, learn how to use new, free on-line software to evaluate if fatigue was a cause of a human error. Bill Sirois, COO of Circadian Technologies will share this important, innovative software.
Seventh, learn new ideas for defining Causal Factors from Ken Turnbull, an experienced investigator and TapRooT® Instructor.
Eighth, Steve Hawkins, a very experience fatality investigator who is the Assistant Director of Tennessee OSHA, share the lessons he has learned in many investigation.
You will find that these sessions aren’t boring and dry. Instead, they are packed with ideas that you can use to make your investigations more effective and more efficient.
But these sessions are NOT the whole Summit.
There are five Keynote Talks that will provide even more information and motivation.
There are other Tracks that you can pick from to make your own custom Summit experience.
There are networking and social events to make the Summit fun and to help you add to your list of industry contacts.
Want more info? see this list of “frequently asked questions” …
So, if performing world-class accident/incident investigations to prevent future accidents is business critical to your company, I look forward to seeing you there!
CNN reported on causes of the crash of the Colgan Air flight in Buffalo, NY. The NTSB is investigating the crash that killed 50 people and many details of the investigation were discussed at a public meeting.
One controversial aspect of their discussions was that fatigue may have been a cause because of off-the-job sleep patterns of the two pilots. Read about it here:
My experience is that fatigue is often “under-investigated.” That’s one of the reasons that I scheduled Bill Sirois from Circadian Technologies give two talks about fatigue at the TapRooT® Summit.
The first talk is in the Investigation and Root Cause Analysis Track and is titled:
“How To Prove That Fatigue Was the Cause of an Incident.”
It will cover some new software that is available to investigators to prove that fatigue was a factor in poor human performance.
The second talk is in the Behavior Change & Stopping Human Error Track and is titled:
“How Fatigue Impacts Human Error.”
This talk will cover the impact that fatigue has on human performance and human error.
If you want to prevent dangerous human errors and be able to tell if fatigue is causing accidents at your facility, you need to hear these two talks.
So let me understand; latent industry conditions decades old and NOW the politicians want to be involved? Why do I anticipate the hearings will be blame oriented and political? Why do these public servants not take action BEFORE something bad happens?
Investigations and politics are not good companions. I’d say let the NTSB do their job, the last thing we need is grandstanding for public consumption. If the politicians really want to do something useful for the industry how about they support and fund the modernization of the air traffic control system? This would improve safety, the economy, and the environment at the same time. Just my opinion.
Rarely does something like this make the national news, but it happens more than you might think. Why? Doctors and Nurses are human, and they make mistakes the same ways and for the same reasons as machinists, factory workers, forklift drivers, pilots, you, and me. The question is, does the organization have the management systems and best practices in place to stop or minimize human error? Does the organization apply the knowledge they have effectively or do they seek outside knowledge to help them?
I’ve asked these questions for a reason; because human performance, best practices, and using knowledge are what the TapRooT® system is all about. Humans only work within the system we (management) provide and we owe it to them to develop and implement a system that works and to fix problems when we find them (or they find us!)
It was part of the cause of the following accidents:
Challenger
Columbia
BP Texas City Refinery Explosion
Davis-Besse Reactor Vessel Hole (near-miss)
Chernobyl
Many think that establishing an appropriate corporate culture is the most essential cornerstone of maintaining a high performance organization.
What are you doing to understand, maintain, and improve the culture at your company?
Safety, quality, and equipment reliability improvement at your site might be impossible to improve without understanding and changing your corporate culture.
If you are interested in improving your understanding of culture and what you can do to change the culture at your company, there are some “must attend” sessions at the TapRooT® Summit (Nashville - October 7-9). Here’s the list…
First, attend the “Becoming the Best” session in the Safety Track. Dennis Osmer, who helped make a major change in corporate culture at Ciba Vision, will present “Pursuit of World Class EH&S.” Hear the lessons he learned that saved millions of dollars while improving injury and illness statistics.
In the same session, Brian Dolin will discuss “Systematic Safety and Process Safety Improvement.” Again, Brian brings tons of practical industry experience to efforts to improve safety that are dependent upon the culture of the organization. These first two talks will get your mind started on a journey to improved culture at your facility.
For the second breakout session, you need to choose between two informative talks. In the Safety Track you can hear Clare Solomon from the UK explain “Communicating Your Safety Message Effectively.” Her innovative and practical ways to get the message out are critical to any culture change program.
Or for this second breakout you may choose to hear Brian Locker’s talk: “Leadership for Doing Things Right.” Brian will discuss the differences he has observed first hand between organizations that excel and organizations that have major accidents. This is definitely a culture issue.
In the third breakout session, there is an opportunity to explore an issue that is a symptom at many sites with a troubled culture - people don’t report problems. You’ll jump over to the Safety Management Track and Kevin McManus, an expert in establishing business systems, will present: “8 Reasons People Don’t Report Problems and 8 Solutions to Improve Employee Involvement.” This talk really highlights effective, practical ways to get people involved in reporting problems (so they can be solved). This be a major improvement to a corporation’s culture.
The next talk that will really catch your interest is from Keynote Speaker Mike Kelley. He has practical experience establishing an amazing corporate culture as VP at TODCO. His Keynote talk, “Establishing a Culture that Promotes Super-Performance,” will share his vision for senior management in setting a high performance corporate culture. You will leave his talk more motivated and enthused to make culture change happen.
He will follow up the Keynote presentation with a breakout session (the fourth) in the Safety Track titled: “The Keys to Successful Safety Culture Change.” In this session he will get into the “how to” details of culture change. Mike speaks from real experience and you will appreciate his practical advice that he has used to successfully change culture in a high hazard industry (oil drilling).
In the fifth breakout session, you’ll transfer over to the Behavior Change Track to learn from Dr. Beverly Chiodo. Beverly is a management professor at Texas State University where she has won every teaching award they have. She brings her excellent presentation skills to her presentation: “Character Driven Success.” Understanding character is essential to establishing a positive, high performance culture. And nobody does a better job of explaining character than Dr. Chiodo. (PS: if you think a discussion of culture and character is boring, please note that Dr. Chiodo has received the highest ratings on this very session from past Summit attendees who say she is “awesome!”)
Next, in the sixth breakout session, Dr. Chiodo continues her discussion of character and culture with a talk titled “Changing Behavior by Praising the 49 Character Traits.” This is a practical talk about ways to apply Character Driven Success in the workplace. It is a real culture change tool.
In the seventh breakout session, we head “Down Under” to learn some culture change secrets from the Aussies who are presenting “Safety Improvement Ideas from Down Under” in the Safety Track. Greg Allan’s talk, “Measuring Safety Performance & Improving Safety Culture” is great advice for those who want to measure culture improvement.
The Thursday afternoon Keynote address from Dave Prewitt and Mark Paradies : “Systematic Management of Improvement.” Managers use systematic methods to obtain financial results. Mark and Dave will discuss ways that safety can be improved using systematic methods/tools.
Friday morning, John Miller, a personal accountability expert, will present “Personal Accountability.” Accountability is a critical element of culture and John’s inspiring talk will get you motivated to take accountability for improvement.
Next, in the eighth keynote session, John will get into the specifics of personal accountability in his presentation: “Practical Lessons for Applying Personal Accountability.”
The final breakout session is time to develop your culture improvement plan. You’ll have a little over an hour to develop your plan and have it reviewed by an experienced TapRooT® Instructor.
Wow! That’s a culture improvement extravaganza. If “culture” is important to your company, this custom program at the Summit is a must attend improvement event.
But wait, as they say on TV, “There’s more!”
Before the Summit there is a Pre-Summit Course (October 5-6) - Improving Your Organization’s Safety Culture.This course was developed by one of our Australian TapRooT® affiliates. For more info, see:
The final investigation reports are likely months away, so we should not jump to any conclusions. However, there are many things to consider here; manufacturer recommended training, company training processes, company oversight, FAA oversight, and fatigue. It’s easy to point the finger at the pilot but there looks to be a lot more to this one. It will be interesting to see what the final report reveals.
Living in Knoxville, I fly commuter airplanes all the time, and I feel safe. However, I also worked in the airline industry for 27 years and understand what these small carriers are up against. Financial pressure from the majors, trouble recruiting, and in many cases, less evolved management systems than the major carriers. As an aside, I worked for a company that ground handled Colgan back in the day some 28 years ago. They’ve been around a long time and that speaks to their ability to remain focused in an industry that has seen many come and go. Hopefully, Colgan, the FAA, and the NTSB can work together to make sure this never happens again.
I flew Colgan late last year and we aborted our takeoff in Houston due to engine problems. Not fun but I’m glad the pilot aborted!
If you want to ensure good management systems and training are in place, you should use TapRooT® proactively. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, we spend most of the morning on day 4 talking about proactive measures. We cover best practices throughout the rest of the course as well. Why not join us for the next course? Here is the schedule:
There is an interesting comment at the end of the article about the police investigating themselves. That brings up an interesting question; when should you require an independent review? Does your company have a policy in this regard?
There are several reasons you should hire someone outside of your organization; when you are having trouble finding the root causes yourself or don’t have trained investigators, when you just need that “second set of eyes,” or when you expect litigation or legal action. If you have not considered these things before, I would encourage you to incorporate criteria into your investigation policy.
System Improvements has experienced investigators located throughout the world who are trained in performing investigations using TapRooT® to find root causes and fix problems.
If you are interested in our help with the facilitation of your investigation(s), contact us at 865-539-2139 or info@taproot.com
The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report has an interesting statistic.On average, 52% of hospital staff surveyed did not report any medical errors in their hospital over a 12-month period. The statistic is based on data from nearly 200,000 hospital staff from 622 hospitals nationwide.
Can an employee really go a year without making any mistakes? Very doubtful. Even with outstanding human performance on an well designed action, a person will make a mistake one in 10,000 tries. More normal performance is one error in 1000 tries.
So what do these stats mean? That errors are largely under-reported.
Before you criticize the medical industry, look at your facility’s statistics. How many error reports did you have last year. How many employees do you have. I’d bet that more than 50% of your employees never report a single error.
Have you ever thought about the costs associated with these unreported, uncorrected errors? It many be more than you think. The problem with under-reporting is that cheap opportunities to improve performance (near-misses) are being missed. Only big errors (to obvious not to be reported) are acted upon. So you have to think not only of the cost of the small errors, but of the cost of the big problems that could have been prevented.
Would you like to improve your near-miss reporting? Then there’s a session by Kevin McManus at the TapRooT® Summit that you need to attend:
“8 Reasons Why People Don’t Report Problems &
8 Solutions to Improve Employee Involvement”
Learn why people don’t report problems and practical things that you can do to improve your error reporting program to make it world-class.
And if you would like to learn how to analyze and prevent human errors, attend theStopping Human Error Coursebefore the TapRooT® Summit on October 5-6. This course is being completely redesigned for 2009 (more about this in later posts) but we know that you will learn practical ways to make major improvements in human performance at your facility. I’ll send you the latest details if you e-mail me by clicking on the “Contact Us” button at the top of the page.
We don’t have much information about this yet; however, it sounds like the passengers are very lucky. I worked in the airline industry for 27 years and can tell you that tailstrikes are not that uncommon - but it sounds like this one barely made it off the ground. There is likely more to this story than the typical tailstrike. Hopefully the investigators will get to the bottom of it.
Maybe when he gets out of prison he should appear on “Indonesian Idol” and try to start a new career. But seriously….
The interesting point in this article to me is the comment around the bonuses paid for saving fuel. I worked in the airline industry for 27 years and can tell you that saving fuel is a good thing; however, how many times do we reward people for doing things quickly and ultimately cutting corners? On the opposite side of the spectrum, do we punish them for not doing things fast enough thereby encouraging them to ignore requirements to get the job done? I don’t know if this in fact had anything to do with this accident as it seems there may be some politics involved but I thought it was worth bringing up this point.
In this case, their oversight failed to identify problems, their troubleshooting resulted in wasted efforts trying to fix a problem, an unapproved tool was used, and finally, the emergency response lacked (duties not delegated, in TapRooT® terms, Crew Teamwork NI).
Defense in Depth (Multiple Safeguards) failed and led to the accident.
What is the common thread in all these failures? Human Error.
If you want to learn how to investigate human performance problems, proactively monitor performance and put best practices in place to avoid these types of problems, attend a TapRooT® course. The schedule and course enrollment link is here:
Not a lot of information here; however, let me ask a simple question - do you have a good process for severe weather and the impacts to your operation?
The video below should remind us all that some worksites are more hazardous than others.
(click tp play - .wmv format)
The amazing part is that those nearest the hazards sometimes become complacent. After all, they live with the hazard day after day.
What does this have to do with root cause analysis?
First, you can apply root cause analysis proactively BEFORE any accident happens.
Two ideas that could have worked in this case are Safeguards Analysis and Equifactor®.
Safeguards Analysis
Before an accident happens, you can review any process and identify the Hazards, the Targets, and the Safeguards.
In this case, the energy being absorbed by the cable is one Hazard.
Someone reviewing this process could ask: “If the arresting system fails, what are the Safeguards to the energy in the cable?
This might identify potential Safeguards that need to be implemented to:
1) Reduce the number of targets.
2) Protect people who need to be nearby.
When I see all the people just standing around unprotected, I think this is an example where many targets (people who really didn’t need to be there) could be removed.
One other note. What was the Safeguard that worked for the “Yellow Shirt” that jumped the cable twice? His human performance (alertness) probably saved his legs. But one might ask, should we rely on this? Or should there be better Safeguards?
Equifactor®
Also, a reliability professional might use Equifactor® proactively to analyze potential failures in the arresting gear system to reduce the likelihood of failure. This would reduce the likelihood that the hazard (the energy in the cable) would be released.
Learn More
To learn more about Safeguards Analysis and Equifactor® and other TapRooT® root cause analysis techniques that can be applied proactively to stop accidents before they happen, attend a TapRooT® Course.
While the airline involved is very embarrassed, the family members said their deceased family member hated flying and had a great sense of humor. He must be laughing right now.
The question is how many packages get shipped incorrectly and that is considered acceptable… is it now?
Dr. Beverly Chiodo has been invited to speak at the 2009 TapRooT® Summit. The only problem we had with her returning last year (for the second year) is that many attendees who sat in her presentation the first year decided to attend again, and the room was packed to overflowing! She was a top-rated speaker both years, and we are delighted she can join us again.
Dr. Chiodo is a professor in the Department of Management at Texas State University. Dr. Jerry Supple, former President of Texas State, said she has won every teaching award the university offers, and she’s been recognized for her teaching effectiveness at the state and national levels as well. In 1996, she was featured as “Hero of the Day” by CBS national TV program — This Morning. In 1997, Beverly was named “The Best Business Professor in the Nation” by the National Business Education Association. She has published widely in her field and is a frequent presenter at seminars and conferences.
Beverly earned her BBA degree from Baylor University, her MBA from Texas Tech, and her Ph.D. from Texas A&M. She is known by her students as the “Doctor of Encouragement.” Beverly says that her teaching philosophy can be summed up in the proverb which says, “A wise teacher makes learning a joy.”
Don’t miss the chance to hear these talks — as busy as she is, this may be the last chance you have to hear her at the Summit!
Here is some information about Dr. Chiodo’s sessions:
Character Driven Success
You will learn to:
* Motivate people to respond nobly to life’s challenges.
* Express specific ways others have benefited your life and the life of your organization.
* Discover the secret of “going the second mile.”
* Create an environment which builds rapport and team spirit.
The purpose of this session is to broaden your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
Changing Behavior by Praising the 49 Character Traits
The purpose of Dr. Chiodo’s presentation is to enlarge your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
As you participate, laugh, and refine your ability to speak and write, you will learn to influence and motivate others. Your life will be changed as Dr. Chiodo teaches you how to empower others.
Have you looked at the other world-class speakers on the “Behavior Change & Stopping Human Error” track? Check out our track schedules on our Summit Schedules page: http://www.taproot.com/summit.php?t=schedule
If one of the altimeters fail, like it did on the Turkish Airlines Flight 1951, then the automatic throttles will slow the plane down. (Like it did on that flight dropping them from 2000 ft into a muddy field.)
“Boeing recommends operators inform flight crews of the above investigation details and the (Dutch Safety Board) interim report when it is released. In addition, crews should be reminded to carefully monitor primary flight instruments,”
Be careful? Is that enough?
How many other automatic features do they need to “be careful” about?
Is this adequate corrective actions?
Do they need a better engineering fix?
Is “be careful” just a temporary interim corrective action?
So now that you’ve read the article, I have a question - which is cheaper; paying fines/failure costs and spending time dealing with problems or preventing them from happening? The answer should be obvious but some companies do in fact elect to consider these problems as the cost of doing business. For those who understand that preventing problems is good business, remember, this is NOT the time to cut back on problem solving. The struggling economy is the BEST time to improve your business and attack the competition - if you don’t, they will in fact attack you. Please don’t let this happen.
Here are some ways you can avoid being in the news and improve your business:
*Attend a two, three, or five day TapRooT® course. Bring your safety, environmental, reliability, process, and quality teams with you. Here is the schedule: http://www.taproot.com/courses.php
*Attend the TapRooT® Summit in Nashville on October 7-9. Meet people from your industry and other industries and share best practices. Select a best practices track and attend the topics that meet your needs; everything from human performance, to improving quality, to risk management, we have it. Hopefully you will attend my session, “Making a Business Case for Improvement” where we will explore the business side of things and talk about ways to sell your safety/quality efforts to management and show your value to the organization. We also have great keynote speakers, a disco party, and a golf outing. Sign up today, here is the information: http://www.taproot.com/summit.php
*Since you are coming to the Summit, come two days early and attend a Pre-Summit course. Here are the sessions you have to choose from:
Safety Culture Improvements 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Advanced Trending Techniques TapRooT® Advanced Techniques Interviewing & Evidence Collection Stopping Human Error Innovation & Creative Solutions Risk Management Best Practices Hazard Recognition Best Practices Getting the Most from Your TapRooT® Software TapRooT® and FMEA for Healthcare Root Cause Analysis
If you like the article, you should think about attending the 
Bill Sirois, COO of Circadian Technologies, will be at the Summit to explain how to use FACTS and to help explain the effect of fatige on human performance.
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
There are other 
First, attend the “Becoming the Best” session in the Safety Track. Dennis Osmer, who helped make a major change in corporate culture at Ciba Vision, will present “Pursuit of World Class EH&S.” Hear the lessons he learned that saved millions of dollars while improving injury and illness statistics.
In the same session, Brian Dolin will discuss “Systematic Safety and Process Safety Improvement.” Again, Brian brings tons of practical industry experience to efforts to improve safety that are dependent upon the culture of the organization. These first two talks will get your mind started on a journey to improved culture at your facility.
For the second breakout session, you need to choose between two informative talks. In the Safety Track you can hear Clare Solomon from the UK explain “Communicating Your Safety Message Effectively.” Her innovative and practical ways to get the message out are critical to any culture change program.
Or for this second breakout you may choose to hear Brian Locker’s talk: “Leadership for Doing Things Right.” Brian will discuss the differences he has observed first hand between organizations that excel and organizations that have major accidents. This is definitely a culture issue.
In the third breakout session, there is an opportunity to explore an issue that is a symptom at many sites with a troubled culture - people don’t report problems. You’ll jump over to the Safety Management Track and Kevin McManus, an expert in establishing business systems, will present: “8 Reasons People Don’t Report Problems and 8 Solutions to Improve Employee Involvement.” This talk really highlights effective, practical ways to get people involved in reporting problems (so they can be solved). This be a major improvement to a corporation’s culture.
The next talk that will really catch your interest is from Keynote Speaker Mike Kelley. He has practical experience establishing an amazing corporate culture as VP at TODCO. His Keynote talk, “Establishing a Culture that Promotes Super-Performance,” will share his vision for senior management in setting a high performance corporate culture. You will leave his talk more motivated and enthused to make culture change happen.
In the fifth breakout session, you’ll transfer over to the Behavior Change Track to learn from Dr. Beverly Chiodo. Beverly is a management professor at Texas State University where she has won every teaching award they have. She brings her excellent presentation skills to her presentation: “Character Driven Success.” Understanding character is essential to establishing a positive, high performance culture. And nobody does a better job of explaining character than Dr. Chiodo. (PS: if you think a discussion of culture and character is boring, please note that Dr. Chiodo has received the highest ratings on this very session from past Summit attendees who say she is “awesome!”)
In the seventh breakout session, we head “Down Under” to learn some culture change secrets from the Aussies who are presenting “Safety Improvement Ideas from Down Under” in the Safety Track. Greg Allan’s talk, “Measuring Safety Performance & Improving Safety Culture” is great advice for those who want to measure culture improvement.
Friday morning, John Miller, a personal accountability expert, will present “Personal Accountability.” Accountability is a critical element of culture and John’s inspiring talk will get you motivated to take accountability for improvement.
