While performing your PROACTIVE TapRooT® Root Cause Analysis, you observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. He lifts 30 pipes an hour 3 times a day from a rack waist high to a pallet placed on timbers floor level. This task used to be performed by two loaders before recent lay offs, so you go to the Root Cause category of Excessive Lifting and see these two questions in the Root Cause Tree Dictionary:
* Was the issue related to excessive lifting or force to move an object?
* Did the task require repetitive motion (lifting, twisting, bending, etc.) that lead to a musculoskeletal problem?
Since this is a Proactive Assessment there are no issues yet, so your are asking what is the worse issue that could occur by the lifting movements above? Now what does excessive mean? What would excessive lifting, twisting and bending be? We could bring in an external Ergonomic Expert… or we can use a simple calculation ourselves first?
NIOSH 1991 Lifting Calculator. Centers for Disease Control and Prevention (CDC), National Institute of Occupational Safety and Health (NIOSH), 208 KB ZIP*.
As you start doing these calculations, you should also see another Root Cause under Human Engineering start becoming very apparent: Arrangement / placement.
A question that comes to mind from the Root Cause Dictionary is:
* Did poor arrangement, placement, or situation of equipment, displays, or controls contribute to an issue?
So with these new found calculators and a better understanding of just a little bit of the Root Cause Tree Dictionary is this task a risk or not:
” You observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. This task used to be performed by two loaders before recent lay offs.”
The Associated Press reported that Chief Electrician’s Mate John G. Conyers suffered a severe electrical shock and was later pronounced dead at Sharp Coronado Hospital.
The AP reported that the Chief was conducting “routine work” when he was killed.
Normally, Chiefs are supervising, not performing, work. And there is nothing “routine” about working with electricity aboard a ship. Complacency (routine) with electricity on a ship is a deadly combination.
One of my early shipboard jobs in the Navy was being the Electrical Division Officer aboard USS Arkansas (a nuclear powered cruiser). One of the first “performance improvement” programs I ever attempted was to re-instill respect for electricity and get 100% compliance with our lock-out/tag-out program to isolate and check dead all sources of voltage during electrical maintenance work.
People who work with any hazard (for example, electricity), tend to become complacent over time. I’m not sure if this happened on the USS Ronald Reagan, but it certainly is a problem that every manager/supervisor who supervises people who work with a hazard has to confront head-on.
Also, supervisors can frequently be tempted to do work and even take shortcuts to get a job done. This takes them out of their roll to supervise a job and make sure it is done safely and puts them into a dangerous situation where no one is looking over their shoulder to make sure the job is done safely. Once again, I have no evidence that this happened aboard the USS Ronald Reagan, but I’ll be interested in what the eventual accident report has to say.
What can we learn from this fatality BEFORE the investigation is even completed?
First, TapRooT® Users would be getting a complete picture of WHAT happened before they started analyzing WHY it happened. As you can see from my background, there are several problems that I would automatically look for. But, TapRooT® requires the investigator to look at the evidence first before starting the root cause analysis. They have to have a good, complete, accurate, detailed SnapCharT® before they identify the accident’s Causal Factors and find each Causal Factor’s root causes.
Second, TapRooT® Users have a systematic root cause analysis technique, called the Root Cause Tree®, that helps them be sure to check for the many different potential root causes of a problem (Causal Factor). The tree helps guide them to areas they may not have thought of to investigate before. It helps the investigator get beyond blame to find real, fixable root causes that, when fixed, can prevent future accidents.
Third, once the root causes are identified, TapRooT® has a module called the Corrective Action Helper® that helps the investigator develop effective corrective actions. This helps the investigator and management develop corrective actions that might be “outside the box” as far as their experience with corrective actions is concerned.
If you are a TapRooT® User, you have already learned these lessons (but it is good to have them reinforced).
If you are NOT a TapRooT® User, get to a TapRooT® Course NOW! Investigating smaller accidents, incidents, and near misses, as well as using the TapRooT® techniques proactively, can help you avoid major accidents and keep your employees safe.
For more TapRooT® information, including success stories from TapRooT® users, see:
All too often we encounter managers who say: “If our people spent more time in bed getting their proper rest and less time watching TV, sitting in a bar, or allowing themselves to be compromised by family life and personal activities, then they wouldn’t be tired on the job!” (1).
Before managers jump to the conclusion that fatigue in the workplace is by-and-large a behavioral problem, it might be a good idea to review the research on daytime sleep. When you do, you’ll learn that there are certain times of day (11 a.m., for example) when it is difficult to obtain more than four hours of sleep, even if you’re exhausted and the conditions are perfect—dark, quiet, peaceful.
In this article we’ll review the science of daytime sleep and look at its implications for the way managers perceive employee fatigue and sleep management training.
What would your answers be for the Homework Questions below?
What is the answer when a TapRooT® instructor asks the class, “what are the three most frequent types of Corrective Actions?” Training shows up on every list! We then encourage students to look outside the box and even give industry accepted best practices in our Corrective Action Helper®.
STOP! Does this mean Training should not be a Corrective Action or a Root Cause? NO! It just means that you should understand the problem and behavior before you select Training as a “catch-all” or a “magic bullet”.
Understanding Training?
First off understand that Training has one initial goal: IMPROVE or SUSTAIN PERFORMANCE on a particular BEHAVIOR.
Second, Training is directed to the person doing a particular task. Regardless of the higher level regulatory requirements and internal company policy of how the training program should look or run… Training must be effective for the user.
Third, Training is not an independent function that can stand up on its own…..
A. Employee Hiring must be tied to core skills and task required of the employee.
B. Finance, Engineering, Quality Departments, and Safety must be tied to the Training and Hiring Group to ensure new processes and needs are incorporated and tie in the business case.
Finally, understand that there are four other Basic Cause Categories that will have an impact on what and who is trained:
A. Human Engineering (Level of Usability and Complexity of equipment and task)
B. Work Direction (Level of Qualifications and Supervision for and during the task)
C. Procedures (Quantity of steps performed during a task and risk of missing a step or performing the step incorrectly)
D. Communication (Focusing on person’s ability to understand AND apply the terminology)
Lastly, I asked about Training Effectiveness as it relates to metrics in the Homework Questions above. What might the Chart below depict as it relates to Training?
Often, I have seen this chart track two types of measures: Training Expenditures and Defect or Incident Expenditures…. usually there is a strong correlation between both charts once mapped out after the fact. What do your metrics show?
Many people have asked me to repost the talk that I gave at the 2008 TapRooT® Summit about TapRooT® and Safety Culture/Organizational Culture. So here it is in a pdf format…
From the “facts” in the story, on a dark, rainy night, a person crossed against the light and stepped in front of a car that was not speeding and had a green light. The driver’s lawyer says the driver was not texting at the time of the accident.
However, the Gwinnett police disagree and say that the outcome of the “accident” could have been different is the driver had not been texting. They say her use of the cell phone was a contributing factor and have charged Lori Reineke, the driver, with vehicular homicide.
(Police photo of Lori Reineke)
What do you think? Are we going too far in criminalizing accidents?
By the way, here’s the picture in case the footage above gets taken down again…
The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
This is the last turn and in the video, you can see him drop down from the curve and hit the inside wall, fly off his sled, go over the short wall. and hit a steel post head first.
The fixes to the “safe” course were to raise the wall all along the section where you can see it and to move the start line down the run to reduce speeds (which were higher than in any previous Olympic luge event.)
The Workers’ Compensation Board of British Columbia do a great job of sharing lessons learned after an investigation. Watch the video in this link to learn where Controls NI, Plant/Unit Differences, Arrangement/Placement, and Fatigue Root Causes come into the picture during a fatality investigation. Do you think this was the first time the wrong switch has been selected?
We introduce these root causes in our TapRooT® Root Cause Analysis Courses, however seeing the impact of muscle memory and an almost reflex like movement in this fatality really adds strength to why these Root Causes are part of our analysis process. To help people get a better understanding of a person’s ability to feel, see, hear, smell, and move in his/her environment, I added hands on exercises in our Stopping Human Error course last year, which will be taught again in San Antonio this October at the Pre-Summit. For those students who took the course last year and asked for additional behavior changing techniques, this request was heard and will be added in this year.
So looking at the fatality above and after reviewing the video what could have been done when the two trucks were introduced to the workforce:
1. Inexpensive fix: Turn the toggle switches to match the movement of the container (↑ Up, ↓ Down, ← Out, → In); even with muscle memory from driving one truck or another, the person would get feedback when the switch did not move and the label would not need to be the only indicator.
2. Little more expensive fix: Put more space in between the switches which according to Fitt’s Law will improve speed and accuracy trade off.
Remember to use SMARTER, Corrective Action Helper®, and Root Cause Dictionary to help develop achievable and sustainable corrective actions.
In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.
The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists really helped avoid common errors and kept planes from crashing. Now, aviation checklists are a staple of the professional pilot.
I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals need to adopt the best practices that are the staple of high performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events. Especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.
That’s just one of the best practices that should be adopted immediately to improve performance in the complex environment of a modern hospital. Where can you learn more? Try a TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. Then attend the TapRooT® Summit in San Antonio (October 27-29) for more best practices to improve performance. You could be part of the movement to save thousands of lives every year by applying known best practices to improve healthcare quality and patient safety.
Part 2, as promised, is a discussion on our TapRooT® Users and Friends LinkedIn Group. This begins with a question asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.
“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”
My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.
Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don't put in don't dead head or run a pump dry. I've been doing this too long to expect that.]
That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.
Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.
Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.
ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!
First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!
At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.
The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.
First attack at the problem:
1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM
2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)
3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?
4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.
So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.
After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.
Posted 1 month ago | Delete comment
Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.
For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.
Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?
That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:
- Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
- Was he using the right tool? Did we provide him with the right tool?
- Was the right person performing this job?
- Was this job really required in the first place?
- Do supervisors ever watch their people do this particular job? Why not?
- Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
- Was the worker properly trained for this task?
- since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?
I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.
I also know that sometimes we think that people should already know these things. There are 2 possibilities:
1. The person really didn’t know (to cut away from himself)
- Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
- This is when my discussion above comes into play.
Hope this helps a little.
Posted 1 month ago | Reply Privately | Delete comment
Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.
I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.
My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.
Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.
So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.
The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.
Once again. Thanks guys. I appreciate the feedback.
Posted 1 month ago | Reply Privately | Delete comment
Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.
As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?
Steps of the process:
1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.
Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.
2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).
Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.
3. Shops have floating experts identified for employees who need a little help.
Problem: The new are training the new. The senior employees are too busy to.
So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .
Have senior employees attend training with new employees to help all do right.
Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.
According the the study/story, the rates where a ban has been passed mirror those of neighboring states with no law. Thus no decrease was seen by having a criminal penalty for hand held cell phone use.
Almost everyone agrees that drivers can be distracted by cell phone use so why didn’t this bans work? Here are some of my ideas…
1. Hand held cell phones is only one of many distractions.
2. Enforcement - people still use their phones.
3. People use phones in hands fee mode and are still distracted.
Have other ideas why this ban doesn’t improve accident statistics? Leave them here as a comment.
One more note …
I was over in the UK recently. They have all sorts of laws to make a driver pay attention. One of the big stories was a man who got a ticket for blowing his nose while he was stopped in traffic. The officer thought he was not “in full control of his vehicle.”
“WASHINGTON — Accident investigators uncovered such egregious behavior by train operators in the fatal 2008 accident near Los Angeles that they suggested Thursday that all railroads monitor crews with video surveillance.
In a controversial recommendation intended to draw a line in the sand against the rapid rise in accidents triggered by distractions from cellphones and other technology, the National Transportation Safety Board (NTSB) not only endorsed placing video cameras in train cabs, but said railroads should regularly monitor the videos to ensure that engineers follow safety rules.“
These recommendations by the NTSB will not only help improve the accountability for and the enforcement of SPAC (Standards, Policies, and Administrative Controls), they will also make future investigations much easier.
Have you thought about video/audio monitoring of key personnel and workspaces to provide increased accountability, better enforcement of SPAC, and better root cause analysis?
One of the researchers on this study, Dr. Atul Gawande, was interviewed on National Public Radio this morning (link here). He went into even more detail and and provided further insight on this study. He discussed how complicated and intricate the medical profession has become, and therefore instituted the use of checklists in the operating room in 8 hospitals. He had some amazing (but not unexpected) findings:
“We get better results,” he says. “Massively better results.
“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
How did the surgeons respond?
…when his team surveyed the doctors who used the checklist, “There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, ‘This is a waste of my time, I don’t think it makes any difference.’ And then we asked them, ‘If you were to have an operation, would you want the checklist?’ 94 percent wanted the checklist.”
Checklists are a way of life in many critical, complex industries. The airline, nuclear, and pharmaceutical industries all use checklists to some extent, but many in the medical community are still resistant. We have even seen a reluctance to perform a root cause analysis for sentinel events. Many people feel that, if they are using a checklist, they are perceived as not being an expert at their job. And yet, Dr. Gawande had some amazing statistics concerning the sheer volume of information presented to physicians:
- The average physician evaluates 250 primary diseases and conditions each year - These same patients have an additional 900 additional medical problems - The doctors prescribed over 300 different medications, 100 lab tests, and performed 40 different types of office procedures - In an ICU, the average patient requires 178 individual actions per day (administering drugs, suctioning lungs, etc) - Out of those 178 actions, 2 per day (~1%) were performed incorrectly
Sometimes, memory is just not enough. When a sentinel event occurs, perform a TapRooT® analysis. See how many times “no procedure” and “no standard turnover process” show up as root causes.
When can an accident teach us something about investigating accidents? When the accident helps us understand the human brain and it’s limitations.
A story in Wired Magazine titled: “Accept Defeat: The Neuroscience of Screwing Up” explains how scientists often disregard information that conflicts with their “hypothesis” and how this is caused by the way the human brain is wired. I recommend reading the article to better understand this phenomenon.
But how does this relate to accident investigation? Here’s the answer…
Root cause analysis systems based on the theory of cause-and-effect require the investigator to develop a hypothesis and then look for evidence to prove or disprove the hypothesis. The theory of cause-and-effect requires the investigator to already understand the cause-and-effect relationships they are looking for. Thus, they can only find cause-and-effect relationships that they already understand.
However their brain, according to the research in the article, automatically keeps them from seeing evidence counter to their hypothesis or outside their experience.
That is why cause-and-effect root cause analysis techniques frequently have widely different results when used by different individuals looking at similar evidence. Each individual sees the “evidence” the way they want to see it to support their theory of the accident’s cause.
TapRooT® is not built on this cause-and-effect theory. Instead, it is based on unfiltered review of the evidence leading the investigator to develop a detailed explanation of what happened before they start to analyze why it happened. The evidence isn’t collected to verify a hypothesis. Rather, it is collected to expand the investigator’s knowledge and understanding.
Also, instead of depending on the investigator’s knowledge of cause-and-effect, TapRooT® has built-in expert systems to help the investigator see causes that may be beyond their current knowledge of the cause-and-effect relationships of the incident being investigated. These built-in expert systems help the investigator side-step their brain’s built-in simplifying mechanisms and find causes that they might not have originally suspected (or even understood).
Of course, any investigator can stubbornly hold to preconceived notions, but TapRooT® doesn’t fall into the “scientist’s trap” that this article talks about. It naturally helps investigators go beyond their preconceived ideas and previous experience.
That’s an important lesson learned!
If you don’t care about the brain-science behind why TapRooT® works and other root cause analysis techniques fail, that’s OK! Don’t worry … You don’t have to be a neuroscientist to use TapRooT®. We’ll teach you how to use TapRooT® in a 2-Day, 3-Day, or 5-Day Course and then you can take advantage of the advanced science that is invisible to the user but is built into the TapRooT® System.
What?!? You haven’t learned TapRooT®? Then now is the right time to get to a course and experience how TapRooT® can help you find root causes that you previously would have overlooked and develop corrective actions that you and your management will agree are much more effective. Don’t wait! Sign up for a course at:
Here’s a link to an interesting article about research that indicates why texting while driving produces worse performance than talking or using a cell phone while driving. See:
There’s an interesting discussion from the pages on LinkedIn about politics and safety. I posted this perhaps controversial reply…
Interesting discussion.
Here is an example (not from the UK) that points to the issue …
An owner of a small (two truck) hauling firm was cleaning up debris (leftover wood, plywood, drywall, block, and other building materials) from a construction site. He had hired 3 Mexican-American workers to help. They spoke little English.
They were loading the materials (which he planned to “recycle”) onto a skid loader. The skid loader then transported them to the dump truck and lifted them up to the top edge of the trucks sides so they could unload and stack the various material in the back of the dump truck.
As the truck was filled up, the workers walked on the materials which were uneven. Eventually, the workers were above the level of the sides of the truck (about 8-10 feet in the air).
The owner got the last load to the truck and two of the workers were in the truck working to unload it. The owner turned off the skid loader and left for a bathroom break in a near-by (just 10 feet away) port-a-potty.
While he was gone, one of the workers fell from the truck and hit his head on the ground (a concrete surface). He later died from his injuries.
No other worker or the supervisor saw how the worker came to fall from the truck. The worker never regained consciousness. No one knows exactly why he fell.
An investigation by a federal safety organization found that the company (the “owner”) should:
1) Perform a pre-job risk assessment and identified and mitigated all hazards.
2) Provide safety training for all employees in the language that they understand (Spanish in this case).
3) Provide equipment that does not require workers to unload loads on elevated surfaces (in the back of a dump truck).
While I agree that items 1 and 3 would have prevented this particular accident, they would also probably eliminate this company from doing the work because:
a) They only have two dump trucks - no flatbeds or lowboys.
b) They didn’t have any other way to unload the materials into their trucks without damaging the materials (which they planned to reuse).
So, what they are asking the owner of two dump trucks to do is to perform a risk assessment and decide if the risk of someone falling off a truck is worth the benefit of being able to reuse the excess construction materials.
Not to “talk down” about everyday people, but this is probably someone with minimal education (high school education) and lots of work experience who has scrapped together enough money to buy a dump truck … and then another … and start doing work that is dirty, physical, and does not have high profit margins. He doesn’t have a “safety staff” and he doesn’t see loading a truck as a particularly hazardous assignment.
If he saw falling out of the truck as a hazard, he would probably have a mitigation strategy of telling the workers in English to “be careful.”
He is never going to pay for multilingual safety training on his profit margins. He can’t afford to rent special equipment to move excess construction materials.
So the question is:
Is loading a dump truck with excess construction materials by hand so hazardous that it never should be allowed?
If you say “Yes” … then you are the next example of “out of control” safety police.
The real problem is that we have a general tendency to be more risk adverse as time passes. Things that we did as kids are now “too hazardous” to be allowed.
I remember sitting on my grandpa’s lap & driving his car & driving the farm tractor when I was only 5 years old. When Brittany Spears did the same thing in her car, child protective authorities were called because it was seen as a form of child abuse.
Don’t get me wrong. I’m not in favor of killing employees/children. I’m not saying to ignore obvious safety hazards. I’m just pointing out the difficulty in providing a hazard-free workplace & not seeming like out of control safety police.
What do you think? Leave a comment here.
Also, consider joining theTapRooT® Root Cause Analysis Users and Friends Groupon LinkedIn for other interesting discussions that will help you use TapRooT® more effectively and improve your performance improvement efforts.
“A call from a flight attendant to the pilots of the Northwest Airlines plane that overshot Minneapolis catapulted the cockpit crew from complacency to confusion.
According to a statement signed by flight attendant Barbara Logan, she called the cockpit around 8:15 p.m. CDT to find out when they would be landing. She was told they would land around 12 Greenwich Mean Time. “I said I did not know the time — he said I was hosed and hung up.”
The lead flight attendant called to get gate information and was apparently also hung up on, according to Logan’s report. That flight attendant later got through to the cockpit.”
Years ago would the Flight Attendant have pushed so hard before CRM?
Now an example where CRM would helped in the death following a scheduled surgery. An everyday medical procedure ended up in an excessive delay of needed oxygen to the patient.
The article brought up a “new” test cheating incident by sailors on the nuclear aircraft carrier Harry S. Truman. It also mentioned a test cheating scandal revealed earlier this year aboard USS Dwight D. Eisenhower (another carrier) and the 2007 chemistry scandal aboard USS Hampton (a fast attack submarine).
One of the most interesting parts of the article was at the end of the article. It said:
“Colgary and another retired nuclear-trained officer who asked not to be named said the “nukes” are generally good people who aren’t working against the system but can sometimes be pushed too hard by it.
“We try to find the root cause of problems instead of treating symptoms of the problem,” Colgary said. “Typically it comes down to personalities. You can get overwhelmed sometimes with maintenance, preparing for getting underway, preparing for deployment. And oh, by the way, you have to balance your life at home.”
That doesn’t excuse a lack of integrity in the nuclear Navy’s zero-defect mentality.
“You have to trust every watchstander on the ship,” Colgary said. “God help you if you’re in a time of war and these things are amplified even more.”
Colgary said the exam proctor who stopped the cheaters should be commended. “It would be just as easy for that proctor to turn his back and let it go,” he said.
For the eight sailors who were kicked off Truman, their Navy careers might already be over. McMichael said sailors who are stripped of their nuclear NECs essentially lose their rating. They must then try to transfer to another rating, if there is room for them. If the alternative ratings are fully manned, the sailor may have no place to go and be administratively separated from the Navy.
Getting caught cheating also made them significantly poorer very quickly. Nukes are eligible for retention bonuses up to $125,000, depending on their rates and qualifications.”
“We try to find the root causes of problems instead of treating the symptoms…” and “…typically it comes down to personalities.” You must be kidding!??
Let’s start looking for root causes other than “bad sailors” (personalities). What is the operating tempo? How short staffed (undermanned?) are these crews? How much more are they trying to do with less? How long can this “war footing” go on with too little budget and too few ships?
Even a good horse can be run into the ground if you push it long enough (”…’nukes’ are generally good people…”).
I can’t help but think there is more to the root causes of recent Nuclear Navy problems than just some bad young sailors (and, yes, some bad COs, Officers, and Chiefs).
Click on the link for some interesting reading at his blog.
One other thing to consider is TEACHING people why using a checklist is important in some situations by providing a hands on exercise (the Communication Exercise) that we include in out 2-Day and 5-Day TapRooT® Root Cause Analysis Courses.
And if anyone has Eric Cropp’s contact information, please have him contact me about speaking at the Summit. Telling others about his mistake is a part of his sentence and I think his experience would be enlightening to those that investigate accidents.
(Ex-pharmacists Eric Cropp as he enters
a no contest plea to involuntary manslaughter.)
Because instead of looking at each collision as an isolated failure of the Commanding Officer (or members of the crew), perhaps these accidents/incidents in the Submarine fleet that include - running into a sea mountain, colliding with and sinking a Japanese fishing vessel, gun-decking chemistry logs, and hitting another Navy ship - are part of a pattern of problems that indicate deeper issues.
After all, does the CO, Commander Ryan Brookhart - pictured above, look like a bad person?
“Over several months” prior to the incident, hundreds of watchstanders were tested in their ability to understand how to analyze the movement of surface contacts. The exams yielded results of 10 percent to 15 percent passing grades among enlisted watchstanders and 60 percent of officers.
“Given the attention I have personally placed on submerged contact management in briefing the waterfronts, this is unacceptable,” McAneny wrote in the message obtained by Navy Times.
Doesn’t this seem to indicate a problem far beyond a bad CO?
I haven’t finished reading the Navy JAG Manual Investigation Report, but the articles that refer to it are in full “blame” mode. They protect those higher in the chain of command by making this a story about one bad CO with some bad watch standers who broke well established rules. They were bad people. They listened to iPods! Fire the CO, discipline some sailors, and warn everyone else not to be bad like they were, and the problem goes away.
When I’m finished reading the 100+ page report (see attachment here):
Until then, history tells me that we haven’t found the real root causes of this accident. And without REAL, advanced root cause analysis, they never will.
Bad behavior between doctors and nurses in hospitals can cost patients their lives. So about a year ago, the Joint Commission required hospitals to create a “zero-tolerance” policy for intimidating and disruptive behavior.
Recently, the American Medical News published an article that indicates that the requirement for a policy might not be working.
After reading the article you might ask yourself the question:
“Can a policy stop bad behavior?“
And what does “zero-tolerance” mean? Any bad behavior should get a nurse fired or a doctor’s privileges suspended?
Here’s a list of the “bad behaviors” that were reported in the American College of Physician Executives 2009 Doctor-Nurse Behavior Survey and the percentage of respondents that had observed that type of behavior in the last year in their organization …
Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%
Could we really have a zero-tolerance policy for yelling? For inappropriate joking?
Who would decide what inappropriate is and then enforce it across all hospitals?
I’m not saying that any bad behavior including yelling and telling inappropriate jokes is a good thing. I just don’t know if “zero-tolerance” is the way to change behavior…
The crew had just finished an intense operational phase of its deployment and “everybody let down their guard” for what was actually one of the most challenging phases, crossing the strait at periscope depth, he said.
“There was a great deal of complacency involved in the crew,” he said. “They had been at sea for 63 days operating in areas with high contact density.”
He also noted that more or better technology would not have helped the situation, as the sub knew the New Orleans and another ship were nearby.
“There were a whole host of watchstanders that failed to recognize the sensor data that was presented to them,” he said.
Lessons learned are already being integrated into submariner training, he added.
US Navy Lessons Learned: 1. If you are the CO … Don’t run into another ship! 2. If you are the Chief of the Boat … Ditto! 3. Advanced technology can’t prevent collisions. 4. Firing people CAN prevent collisions. 5. Don’t be complacent. 6. Don’t let down your guard (no matter how tired you get).
For those not in the US Navy …
Interesting that fatigue was not mentioned as a potential cause. Seems like you might replace the word “complacent” with the word “fatigued” and this incident would make a whole lot more sense.
Of course, officers and sailors in the US Navy never get fatigued no matter how little sleep they get.
There’s been a lot of talk lately about drivers of cars and trains texting, but this is the first I’ve seen about pilots using a computer while flying.
Do you think any other pilots will admit what they are doing in the cockpit in the future if a problem happens? My guess is they will ask for an attorney and take the fifth!
Also, since pilots use computers in the cockpit (for example, they program computerized autopilots), what computer use is acceptable and what isn’t? When is a computer distracting and when is it OK?
Yes, I understand this computer use violated company rules. But did it break a federal law?
Taking away someone’s livelihood seems fairly severe - especially when they have probably already learned their lessons.
Will this discipline be a deterrent to other pilots using laptops or just a deterrent to pilots being honest during an investigation of a problem?
interesting questions … What do you think. Leave a comment below.
The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
