If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.
It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?
A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.
My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.
Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.
In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.
If you think that some root causes were missed, what is your evidence?
Here’s a tip.
Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.
What Causal Factors led to this fatality?
Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.
One final question…
How do you assess the thoroughness of investigations at your facility?
For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).
The Ontario Workplace Safety and Insurance Board created a set of fairly gruesome commercials that dramatically show the results of “accidents.” The message is that there are no accidents. Accidents are caused.
Here’s the video:
These are also available at the WSIB web site for download:
The real question I have about these videos is the focus on blaming the worker, the supervisor, and management. We see the accident happen, but do we know what set the accident up?
To me, the video also shows the difficulties of finding and fixing the real root causes of an accident when our culture first looks to blame.
The government is considering moving the Plum Island Animal Disease Center from an Island off the coast of New York, to a facility on the mainland of the United States.
Previous unintentional releases of live foot-and-mouth disease have been contained to the island because of the distance from the mainland.
The government argues that the release happened long ago (1978) and that modern safety rules, policies, and procedures make it safe to move the facility to one of these potential locations:
San Antonio, TX
Manhattan, KS
Athens, GA
Butner, NC
Flora, MS
House Energy and Commerce Committee is considering the administration’s plans to move the facility. The new site could be selected later this year, and the lab would open by 2014.
Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.
There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.
First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:
Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See: http://www.iprr.org/manuals/ntsbaviationman.pdf
Many countries have their equivalent of the NTSB. A list of national aviation investigation boards with links to their web sites can be found at:
I previously wrote a blog entry about the wrong kidney being removed from a cancer patient.
Yesterday, I read an AP article with the following quotes:
“Twenty-four wrong-site surgeries were reported to the Minnesota Department of Health between October 2006 and October 2007. Two were at Methodist, but Carlson said they were relatively minor compared with last week’s error: a needle biopsy on the wrong lung, and a diagnostic exam of the wrong bronchial tube.”
“Kathleen Harder, a University of Minnesota researcher, said medical errors of this magnitude are rare but do happen.”
“Medical errors” certainly are NOT rare. The question is: “How rare are high consequence medical errors?”
The answer is: “No one knows.”
Why?
Because their is no national law that requires the reporting of high consequence medical errors to a central reporting agency.
Thus all statistics are a guess.
On top of that, to avoid liability errors may disguised as normal deaths. I read a sad story about a family being told that “every possible had been done” to save the life of their grandmother. They chose not to have an autopsy performed. Later, they found out that she had been administered large doses of blood thinner that may have contributed to, or caused, a fatal hemorrhage in her brain. The death would have been a natural death in the statistics. It would have gone unreported. Yet, the family now believes it was a covered up medical error that was detected by a nurse (a family member) reviewing the medical records.
I’m not a person that favors large government regulatory initiatives. And I’ve seen many government programs go astray. But unless the healthcare industry can come together to establish effective reporting and improvement programs, a large government lead regulatory initiative will surely be the eventual result.
If you are interested in efforts to reduce medical errors, you should participate in the TapRooT® Summit in Las Vegas on June 25-27. There is a Best Practice Track dedicated to medical error reduction. And you can network with experts inside the medical field and from a large variety of other industries. The cross industry networking may be the only hope for accelerated improvement in the healthcare industry. After all, as Sam Levenson quipped:
“You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.“
If you are in the medical industry leading an improvement effort, don’t miss this once a year chance to learn from others.
Investing in advanced root cause analysis is a winning proposition.
For example, a Peoria nursing home had a chance to find the root causes of previous fall incidents and develop a plan to improve performance. Instead, a Peoria Journal-Star article quotes a Illinois Department of Public Health report as concluding that:
“This policy does not address investigation, tracking or monitoring of accident/incidents or how this data will be analyzed to identify trends and patterns to perform root-cause analysis in order to develop and implement corrective actions to address the falls occurring in the facility.”
The result? More falls and a $40,000 fine from the state.
That’s just one of many fines from the state that can be attributed to a failure to investigate problems and develop effective fixes to correct the problems’ root causes. Another was fined $22,500 and a third was fined $1,908.
Besides the fines, these nursing homes could have avoid injuries to their patients if they had addressed the root causes of quality of care issues.
Nursing homes are usually on a tight budget. but failing to invest in advanced root cause analysis and corrective actions is a fool’s bargain. Don’t be “Penny wise and Pound foolish.” Find out how TapRooT® Training can help your staff and get some signed up for one of our courses.
The results of thousands of “lost” bags are called a “Luggage Mountain.”
They have had to fly jumbo jets loaded with just bags across the ocean to try to unite travelers with their luggage.
And news outlets say the problem could get WORSE!
The cost of this “incident” is more than just the immediate costs to the airlines and travelers. Some say it has caused damage to the whole British reputation.
What is the “cause?” Everyone has an opinion. Most are looking for someone to blame.
But instead of looking for someone to blame, they should try advanced root cause analysis.
TapRooT® has been applied by many major airlines. Alaska Airlines even used it to analyze delayed flights and improve on-time departure statistics.
Perhaps British Air should try TapRooT® to stop the baggage meltdown and improve customer service?
And next time they should use root cause analysis as a PROACTIVE tool to improve performance BEFORE they open a new terminal and thus avoid a major quality of service incident.
Some call it a vision. Some call it a dream. But every improvement program needs a goal. Do you have a vision of what performance would look like if you could achieve the ideal state at your company? Achieving that vision is what Marcia Wieder, America’s Dream Coach, is all about. As the closing Keynote Speaker at the TapRooT® Summit, she will show you how to achieve your dreams and make your vision a reality.
To hear a little of the type of advice America’s Dream Coach will provide at:
Here’s an interesting CBS News video on sleep, fatigue, and human performance:
One of our speakers at the TapRooT® Summit is Bill Sirois of Circadian Technologies. Bill will be speaking about fatigue and human performance. He will also share a scientific way to evaluate fatigue in an accident investigation (called FACT). For more Summit info, see:
I take pride in my time served in the Nuclear Navy and the two ships I served aboard (USS ARKANSAS and USS LONG BEACH). It’s difficult to write about failings in leadership in the Nuclear Navy. But I wrote about it before (blog article 1, 2, 3) and predicted the outcome. By looking at the failings that occurred aboard USS HAMPTON, we may be able to understand how hard achieving operational excellence is in the demanding world of submarine operations and how people can fall short of demanding expectations.
It started out just fine. Commander Mike Portland (right) takes command of the USS HAMPTON, SSN-767.
His command ended in scandal as a ORSE Board discovered that reactor chemistry logs had been gun-decked (faked). This led to a Judge Advocate’s General Manual investigation and a Commodore’s Mast that uncovered many minor and some major “integrity violations.”
The Navy Times reported on the failures in various articles, including the most recent article:
To my eye, the trail of “evidence” reminds me of a witch hunt where one of the accused is caught in a minor indiscretion and then must offer up others who they think may be more or equally guilty. Some of the most guilty are likely to name many others to provide the appearance that “everybody was doing it.” Even in the Nuclear Navy, anyone may have a slight indiscretion. A chief may have heard a rumor he didn’t report. An officer may backdate a form that was completed, but that he forgot to sign at the time. An Officer may use an old exam to prepare for an upcoming exam, and then, when he’s not sure if this practice (studying from old exams) is allowed, lie about it when he sees everyone getting disciplined (end of career) for a variety of “integrity violations.”
Let those who have never sinned throw the first stone.
But the indiscretions aboard the USS HAMPTON were more than petty indiscretions. Reactor chemistry logs were faked for an extended period of time. And the disciplinary report - that claimed that reactor safety was never compromised - didn’t seem to explain the root causes of this failure.
Rear Adm. Joseph Walsh, Pacific Submarine Force Commander, wrote in his endorsement of the report. “The specific deficiencies identified during this investigation resulted in no unsafe operations or maintenance of reactor or propulsion plant systems and no loss of radioactive material.”
First, if reactor samples were never taken … this IS unsafe reactor operations. One of the Safeguards to maintain reactor safety - sampling - was compromised. The later samples verified was that the reactor was not damaged. These later samples did not restore the “safety” that was compromised by the previous lack of samples.
If anyone thinks differently, then let’s QUIT taking samples while operating at sea (since not taking samples does not compromise reactor safety) and just take a sample when the ship gets back to port. This would save a lot of work.
Reactor safety can only be assured by following the rules and taking the samples that are designed to catch failures BEFORE major damage can occur. If you don’t take the samples, reactor safety is unknown - this is a compromise. Taking later samples doesn’t restore the integrity of those who falsified the records or restore reactor safety. It just confirms the fact that other, redundant safety factors worked even though the samples were skipped.
The Nuclear Navy’s uncompromising enforcement of the rules is one of the things that sets it apart from other organizations that accept shortcuts. Word games in statements for the press meant to reassure the public do little. These types of statements seem like a cover-up for performance that is clearly substandard.
Now for the corrective actions. Much is “redacted” from the report (names are crossed out). But this much we do know:
The Commanding Officer, Mike Portland, was “detached for cause” (fired).
Why? The endorsement by Rear Adm. Joseph Walsh says:
“Commander Portland set unachievable standards for his crew, was intolerant of failure, and publicly berated personnel.”
For those who have served in the Nuclear Navy, leaders with these attributes are not rare. It sounds like my first CO. Or maybe Admiral Rickover. I’d guess (from my limited experience) that about 50% of senior Nuclear Navy leaders use this style. However, it also says:
“He failed to exercise oversight of personnel and processes … “
Oversight is a keystone of the Nuclear Navy. Was he really absent from “back aft?” Was he isolated from the crew? Is this a “Cain Mutiny” situation on a nuclear submarine?
It continues to say:
“… failed to train his leadership team to effectively manage issues under their cognizance.”
That is especially worrisome. Shouldn’t the crew be trained to manage issues BEFORE they join the ship? Shouldn’t his XO and Department Heads coach the Junior Officers and train them? Does the CO need to train everyone or should he make sure that everything is working and make adjustments as needed?
However, the CO wasn’t the only one punished.
The Engineering Officer was fired.
Two officers were “de-nuked” (the end of their career - but let’s make them serve out their time in some obscure job in a bad place).
Two sailors were stripped of their naval enlisted classification codes (de-nuked).
Several junior sailors, including ELTs, were “masted” (disciplined) or referred for additional review by their current commands (because they had already left the ship).
Note that at least two officers chose to “take the 5th” when it was their turn to participate in the witch hunt.
Let’s take one more look at the CO’s job.
What if everything wasn’t working when he took over in the shipyard? With a demanding shipyard schedule followed by pre-deployemnt work-ups and deployment operational commitments, when was the CO and crew suppose to get the time to train in leadership and managing things under their cognizance if they didn’t already have those skills when they reported to the ship? Then add in a surprise deployment.
Could a good CO turn around a poor crew without much help in a demanding environment? Maybe.
What about an average CO? Maybe not.
What about a screemer who was doing all he could just to keep his head above water (oops - not required on a sub)? Very unlikely.
So the report seems to imply that:
1. The CO didn’t do his job.
2. The Officers didn’t do their job.
3. The Chiefs didn’t do their job.
4. The sailors didn’t do their job.
According to the Navy statement, THIS HAS NOTHING TO DO WITH THE REST OF THE SUBMARINE FORCE.
It was just one bad boat.
It doesn’t indicate a reactor safety issue.
The failures of the crew aboard USS HAMPTON are isolated incidents.
The punishment of the CO and crew addressed the root causes of these leadership failures by getting rid of a few bad apples.
But the Navy Times article goes on to say:
The Submarine Forces commander, Vice Adm. Jay Donnelly, questioned whether the integrity violations had gone beyond Hampton, and last fall ordered “Deep Dive” teams to the fleet to look more closely at morale and retention woes.
Experienced submariners say they believe the investigations revealed a broader practice of questionable reports and shady practices across the force. One called the Hampton situation “a failure of the worst kind.”
So is this just an isolated incident? Has the submarine force been pushed beyond their limits? Have the strong traditions that Admiral Rickover established been broken? Can trying to do too much with too little for too long eventually result in a cultural meltdown? Will the Nuclear Navy follow the pattern at BP and eventually have their own “Texas City” style incident?
Perhaps the “Deep Dive” teams know. Without more information, we could only guess.
Is there a lesson that can be learned here? I think so.
(Bow of fishing trawler before sinking
after being hit by the Japanese Self-Defense
Forces Aegis destroyer, Atago)
The investigation into the cause of the crash of a 30+ foot fishing trawler with a Japanese destroyer is still underway, but the first corrective action - firing the Chief of Japan’s Navy, Admiral Eiji Yoshikawa (photo below) - has already been completed.
Blame is an interesting concept. But is it effective in improving performance?
In the US, the first fired are usually the last people to touch whatever it was that caused the problem. In this case, those “held responsible” would usually be the Commanding Officer of the ship, the Officer of the Deck, and perhaps a lookout.
In Japan, discipline seems to start at the top (or near it) and work it’s way down.
Will either form of discipline improve performance?
Not if the root causes of the accidents aren’t uncovered and corrected by a thorough accident investigation.
(Not everything is excitement in the Nuclear Nayy - Shutdown RO at S1W)
I can still remember when I first heard about the accident at Three Mile Island. I was on a bus heading out to S1W (a Nuclear Navy Prototype Reactor in the desert in Idaho). I was partly snoozing and the bus driver had a transistor radio playing. The music was interrupted for breaking news. The commercial nuclear power reactor at Three Mile Island was having some sort of problem - perhaps a meltdown! The on-the-scene reporter was interviewing a farmer near the plant. He said his cows weren’t acting right and that morning he could “…taste the radiation…”.
Ed Frederick, Keynote Speaker at the TapRooT® Summit, was a member of the Control Room crew at the onset of the Three Mile Island Unit 2 accident on March 28, 1979. The decisions made, and actions taken by Mr. Frederick and the rest of the crew on that morning resulted in a partial meltdown of the reactor core. The accident is the only General Emergency and evacuation associated with nuclear power in the United States. The accident at TMI was the subject of intense public interest and is still remember each year in television news.
But the accident at TMI happened back in 1979. What could we possibly learn that’s new from such an old accident?
(Picture of Three Mile island)
Look at the various “facts” that are available at various places on the internet:
The causes for the accident at TMI and the experiences related by someone who was “investigated” after the accident are just as applicable today as they were back in 1979. And they are applicable across industries around the world. That’s why I’ve been asking Ed to speak at the Summit for years - the lessons are important for everyone who is interested in investigations and performance improvement to learn. And this year Ed will share his inside view of the accident and the aftermath.
Ed will also conduct a Best Practices Session that allows investigators to practice their skills by drawing and revising a SnapCharT® based on what they “know” and answers from the person involved - Ed Frederick.
For more information on the rest of the sessions and Keynote Speakers at the Summit and to register, see:
Agricultural/food accidents aren’t all that uncommon. In this case an auger claimed a life. When I was in college, a friend lost his leg in an auger accident. He was trapped for hours in a remote field before anyone found him and he almost died.
Could agricultural companies apply advanced root cause analysis to improve performance and reduce deaths and injuries? You bet. Some already have.
CNN reports that the FAA has required air carriers to install improved black boxes to collect more flight data and longer periods of voice communication. The requirement call for the devices to be installed by March 7, 2012.
The requirement comes 9 years after it was requested by the National Transportation Safety Board.
The FAA did not require cockpit cameras as requested by the NTSB. The FAA said the cameras were not justified by a cost/benefit analysis.
IF YOU ARE NOT in the aviation industry, why do you care?
You should think about automatic data recording for your facility (in case of an accident).
Things to think about include:
Recording radio communications.
Videos in the control room.
Data recording.
Security camera recordings.
Security access data (swipe card data to see who went where).
Don’t wait until it is too late! Think through your data recording requirements before an accident occurs.
Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.
There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.
First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:
Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See:
For those that aren’t aware, I am the Summit Chair and with the help of the TapRooT® Advisory Board, the Track Chairs, the staff at System Improvement, and previous year Summit participants (that a lot of help!), I plan the TapRooT® Summit.
I also hand pick the courses that are offered prior to the Summit - this year on June 23-24. I pick these courses based on the experience I have with performance improvement programs around the world. My goal is to put together a world-class selection of courses that will help people solve their toughest problems.
Each year I bring back some old favorites and some brand new courses.
The old favorites are based on previous attendance and feedback.
The new courses are based on requests from participants and problems that I observe in my extensive travels.
This year there are three new courses:
1. Hazard Recognition Best Practices
2. Engineering Equipment Reliability Techniques
3. TapRooT® and FMEA for Healthcare Root Cause Analysis
There are also, eight returning veterans:
1. Advanced Trending Techniques (10th year)
2. Innovation & Creative Solutions (2nd year)
3. Stopping Human Error (5th year)
4. Risk Management Best Practices (5th year)
5. Interviewing and Evidence Collection (3rd year)
6. Getting the Most from Your TapRooT® Software (2nd year)
Winning an Olympic Gold Medal sets you apart. You are the best on the planet at your event.
But Nikki Stone’s story goes beyond being the best. She showed exceptional dedication & persistence to come back from a career-ending injury (that prevented her from standing, much less skiing).
Why is Nikki a TapRooT® Summit Keynote Speaker? Because people leading performance improvement initiatives need to overcome obstacles that seem insurmountable.
After being inspired by Nikki’s determination and courage, these obstacles won’t seem so large. You can achieve success!
Don’t miss Nikki’s Keynote address. And talk to Nikki one-on-one at the Summit reception.
To see an interview with Nikki, click on the YouTube video below:
A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.
Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.
What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).
Software written internally by HSBC caused an intermittent failure (don’t you hate those) of Mastercard’s Maestro system last weekend. This caused thousands of HSBC’s customers to be unable to make purchases or withdraw cash.
The bank is now conducting a “major incident review” that should be completed by Friday. The review will look at the problems with the software and why recovery took so long (four hours after the offending software was removed).
How is a root cause analysis of a software failure different than the root cause analysis of a equipment failure or a human error that causes an explosion or plant shutdown? Really, there isn’t a difference in the tools to use. The only difference is the technology involved.
I found this out back in the 90’s when working with Gerald Starling at BellSouth. He used TapRooT® to investigate telecommunications incidents (network reliability, 911 outages, etc.). These were often software issues. And using TapRooT®, he found fixable root causes that improved performance.
The technology (network reliability) was very different than the types of investigations I had perviously performed. Even though I am an electrical engineer, the terminology of network reliability was completely foreign to me. Yet the reasons for human errors and system failures were in the Root Cause Tree® (part of the TapRooT® System).
The reason for this is that the causes of unreliable human performance (mistakes - human errors) are the same no matter what type of technology the human is involved with. Therefore, the ways to achieve reliable human performance are a basic part of the analysis that TapRooT® helps an investigator perform.
For those that investigate accidents and incidents, Lt Col Ralph Hayles story is immensely interesting.
Involved in a “friendly fire” accident at the start of Gulf War I, Lt Col Hayles was singled out for blame, discipline, and public vilification.
His “accident” was similar to many others. A combination of mistakes and equipment failures that led to a fatal result. And like many others, the last person to touch it (in this case the trigger) is blamed for all of the consequences.
