Archive for the ‘Human Performance’ Category
Monday Accident and Lessons Learned: Fatality when Container Falls from Ship
Monday, August 30th, 2010
Safety Culture Components
Sunday, August 29th, 2010The Nuclear Regulatory Commission has developed 13 safety culture components that were updated and released earlier this year. They are:
- Decision-making
- Resources
- Work Control
- Work Practices
- Corrective action program
- Operating experience
- Self and independent assessments
- Environment for raising safety concerns
- Preventing, detecting, and mitigating perceptions of retaliation
- Accountability
- Continuous learning environment
- Organizational change management
- Safety policies
To read more about these safety culture components, see this NRC document:
Red Light Cameras – Helpful in Improving Safety or Just a Way to Raise Revenue?
Saturday, August 28th, 2010
Should Management Reward Investigators for Good Investigations?
Monday, August 23rd, 2010Here’s the results (as of 8/19/10) from my unscientific survey of TapRooT® Users:
Never Receive Rewards from Management for a Good Investigation: 76%
Get a Verbal “Atta-Boy/Girl” for Investigations: 20%
Get a Financial Reward for Investigations: 4%
Here’s the actual answers:
http://www.taproot.com/wordpress/2010/08/05/rewards/
I didn’t find these statistics surprising.
I also found it interesting that many of the investigators said that performing a good investigation and seeing people jobs get better (safer) was reward enough.
However, if managers want good investigations, shouldn’t they be rewarding what they want? Isn’t this basic management?
Therefore, one major improvement that management should consider for improving investigations is to start a systematic evaluation of investigations and rewards for good investigations.
What do you think? Is this a good idea?
Let me know by commenting here …
Plastic Surgeon Dies in Car Accident While Texting
Wednesday, August 18th, 2010
Loosing your life because you were making a Twitter post …
Here’s the story from CNN Entertainment/Peope:
http://www.cnn.com/2010/SHOWBIZ/celebrity.news.gossip/08/18/plastic.surgeon.texting.ppl/index.html
Best Practices in Behavior Change and Stopping Human Error
Tuesday, August 10th, 2010Come and learn best practices in Behavior Change and Stopping Human Error at the 2010 TapRooT® Summit. Sign up for this track and be part of these dynamic best practice sessions. (Read bios of the presenters on the Summit website):
Combining TapRooT® with INPO’s Error Prevention Tools to Improve Human Performance
Rob Fisher
and Ron Pryor will discuss how Alcoa Davenport Works improved performance by using TapRooT® tools to identify vulnerabilities, and known error reduction techniques to reduce the probability of events related to human errors.
Influencing Without Authority
Chris Vallee will be leading this interactive lecture and workshop. Ever heard these statements:
If only management would do the right thing!
The employees will not follow the rules unless being watched!
If the EHS/HSE department were not placed under XXXX in the Organization, I could get something done!
Management supports every corrective action after an incident happens.
Guess what? You have more control and influence than you realize:
1. Learn about influence Networks that make sense (it is not always about the job title).
2. Learn how to perform a Stakeholder Analysis (it is amazing how different this is from your actual company’s organizational chart).
3. Discuss live examples where it worked.
4. Decide what your next step is to influence without authority.
Practice Fixing Human Performance & Behavior Problems: An Interactive Exercise Session
Chris will also be leading this workshop … a time to put it all together. Here’s what attendees will work on:
1. Listing burning issues and discussing:
What’s been tried
What worked
What did not work
2. Based on what’s learned that week, you’ll identify what may be the gap between the issue AND solution.
Be prepared to dig deeper than the surface
Work with your industry AND outside industry peers
Work with the available* Behavior and Human Error presenters
(* some presenters are only present the day of their presentation)
Plan a follow up session
Coaching Skills to Sustain Behavior Change
Executive Coach Jennifer Mounce is returning to the Summit for the second year. Participants walk away from this session with coaching skills and a coaching model that can be used in any work environment to support creating behavioral change in the workplace.
Human Factors & Behavior Change Best Practices
Ralph Brickey will be presenting Ideas for Changing Behavior When Working Outside Western Culture. This session will explore issues of working with conflicting cultural thought when seeking to establish norms for investigations and implementing change in other cultures. Through a simple exercise participants will first examine a few of their own western “norms” and then apply these in a case study involving an investigation of a confined space incident that resulted in the deaths of two workers in an eastern culture.But that’s not all for this session, Tom Brower will also be presenting Practical Human Factors Lessons Learned.
Measuring Fatigue Using FACT
Rainer Gutkuhn from Circadian Technologies will be presenting this best practice session. There is now a global body of scientific evidence that shiftwork in the 24/7 workplace is a high risk occupational safety exposure, and that the development of Fatigue Risk Management Systems (FRMS) has emerged as the internationally accepted standard for managing the inherent costs, risks and liabilities of shiftwork. This session will review the new ANSI standard for FRMS in refining and petrochemical industries, as well how the other industries as diverse as Aviation, Railroads, Mining and Utilities are implementing Corporate FRMS systems as a continuous improvement process. It will also provide examples of fatigue management tools that can provide the analytics needed to ensure the success of programs for optimizing shiftworker health, safety and quality of life.
Using Mistake Proofing to Stop Human Error
Dr. John Grout will present how significant injuries are avoided and dollars are saved by companies around the world when they implement simple ideas that either eliminate the chance for a mistake to occur or make a mistake easy to detect. This concept (and the techniques that generate these simple fixes) is called Mistake-Proofing. It is also known as Poka-Yoke (pronounced POH-kah YOH-kay). This session will help you find practical, effective ways to remove the opportunities for error. What will you learn?
· Why we make mistakes
· Basic concepts of mistake-proofing
· Where mistake-proofing works well and where it does not
· Where mistake proofing fits in your quality or safety toolbox
· How to create poka-yokes that solve quality or safety problems
Lesson Learned About Human Factors & Generic Causes from Recent Airline Incidents
Brian Crawford and Ken Turnbull will present this session about recent airline incidents and lessons learned.
AND DON’T FORGET our 2010 Keynote speakers.
ANOTHER OPTION for learning how to stop human error is our special 2-day course held just prior to the Summit (October 25-26):
Stopping Human Error Pre-Summit Course
REGISTER for the 2010 TapRooT® Summit!
Can You Demonstrate a Strong Safety Culture?
Thursday, August 5th, 2010“Safety Culture” has been a topic of increasing interest since the term was first used in the report on the Chernobyl accident.
In 2004, the Institute of Nuclear Power Operations (INPO) published “Principles for a Strong Nuclear Safety Culture.” It outlines INPO’s expectations for utilities to maintain a strong, positive safety culture. See the document here:
Outside the nuclear industry, safety culture has also been a topic of interest.
The Baker Panel report on the BP Texas City explosion was critical of the BP safety culture. See the document below:
From the INPO report, the principles for a strong nuclear safety culture are:
1. Everyone is personally responsible for nuclear safety.
2. Leaders demonstrate commitment to safety.
3. Trust permeates the organization.
4. Decision-making reflects safety first.
5. Nuclear technology is recognized as special and unique.
6. A questioning attitude is cultivated.
7. Organizational learning is embraced.
8. Nuclear safety undergoes constant examination.
These are similar to the Nuclear Regulatory Commissions work on nuclear safety culture, a sample of which is contained in this document:
Organizational learning (which includes root cause analysis) is my favorite safety culture topic. Here’s a quote from the above NRC document:
“The organization maintains a continuous learning environment in which opportunities to improve safety and security are sought out and implemented. For example, individuals are encouraged to develop and maintain current their professional and technical knowledge, skills, and abilities and to remain knowledgeable of industry standards and innovative practices. Personnel seek out and implement opportunities to improve safety and security performance.”
I added the bold to the text. And let me highligft it even more…
How do YOU demonstrate a good safety culture? For organizational learning, how do YOU:
- Maintain your skills?
- Remain knowledgeable of industry standards?
- Learn new innovative practices?
And do you do this ONLY in your industry or do you look for learning across industries to find best practices?
Let me suggest a way to do all of this:
Those who have attended the Summit and one of the pre-Summit special courses know that it’s a great place to maintain and advance your skills, network across industries, and learn best practices from around the world.
Therefore attending the Summit is a great way to show that you are supporting a strong safety culture.
Don’t contribute to a bad safety culture … Sign up for the Summit today. Register here:
REWARDS
Thursday, August 5th, 2010When was the last time you were rewarded for a good investigation?
This question is NOT a comment about how good or bad your investigations are.
This question is about how frequently or infrequently management rewards investigators.
Leave your answer here.
Some of you (maybe most) may have never had a special reward for doing an investigation. Let me know about that too …
Friday Joke: The “House” Method for Analyzing Human Error
Friday, July 30th, 2010Watch and learn…
Want to better understand human error? Consider taking this course prior to the TapRooT® Summit:
http://www.taproot.com/courses.php?d=5
Medical device problems hurt 70,000+ kids annually
Monday, July 26th, 2010..”About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.”
..”Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.”
..”The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.”
…”Malfunction and misuse are among possible reasons”
I read the article and then asked “AND”? There is so much more information that needs to be collected and compared.
… “is there damage with this equipment for children and adults?”
… “is there a difference between different manufacturers for the same types of equipment?”
…”what allowed 70,000 incidents to occur without having the root causes listed already?” …. yes I know there are patient and company privacy issues but that is not a good excuse!
So what would your next steps be? (more…)
Monday Accident & Lessons Learned: Run Over by Equipment Video
Monday, July 5th, 2010Saudi Food and Drug Authority take the Lead in Investigating Medical Device Failures
Tuesday, June 29th, 2010
The newly developed SFDA (Saudi Food and Drug Authority) located in Riyadh, Saudi Arabia, has taken the lead in medical oversight of conformity; not only by creating a Medical Devices Sector, but also by ensuring that their Medical Device team has a thorough understanding of human error and equipment failure and has the best tool to investigate it with, TapRooT® Root Cause Analysis.
Here are few pictures taken during the onsite 2-Day TapRooT® Incident Investigation and Root Cause Analysis, 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis, Stopping Human Error, and 1-Day Evidence Gathering Courses held in June.
If you look closely you can see that they are using the new individual software… (another user test to make sure it is ready to go out to all users)
Character Driven Success!
Tuesday, June 15th, 2010
Dr. Beverly Chiodo has been invited to speak about Character at the 2010 TapRooT® Summit!
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.”
This is Dr. Chiodo’s fourth year to appear at the Summit. 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 “Improvement Program” track? Check out our track schedules on our Summit Schedules page: http://www.taproot.com/summit.php?t=schedule
CSB News Release: CSB Releases New Hot Work Safety Video Emphasizing Effective Hazard Evaluations and Gas Monitoring Procedures around Storage Tanks
Wednesday, June 9th, 2010
CSB Releases New Hot Work Safety Video Emphasizing Effective Hazard Evaluations
and Gas Monitoring Procedures Around Storage Tanks
Washington, DC, June 7, 2010 – The U.S. Chemical Safety Board (CSB) today released a 14-minute safety video warning of the hazards of welding and other hot work activities in and around storage tanks containing flammable materials.
Entitled “Dangers of Hot Work,” the video presents key lessons from the CSB’s hot work safety bulletin, released on March 4, 2010, in Wausau, Wisconsin, near the Packaging Corporation of America (PCA) facility where three workers were killed in July 2008 during a hot work-related explosion.
Hot work is defined as burning, welding, or similar spark-producing operations that can ignite fires or explosions. Since the release of the CSB hot work safety bulletin last March, there have been at least an additional eleven hot work accidents resulting in five fatalities and 14 hospitalizations. Included in these events is the explosion and fire at the Navajo Refining Company that killed two workers and injured two others in Artesia, New Mexico, where a crew of insulators was reportedly working on a crude oil storage tank.
The video uses 3-D computer animations to depict three hot work accidents at Partridge-Raleigh, an oil production site in Central Mississippi; the Bethune Waste Water Treatment Plant in Daytona Beach, Florida; and the Motiva Enterprises Refinery in Delaware City, Delaware.
The video also features an interview with John Capanna, who suffered burns over ninety percent of his body following a hot work accident while he performed maintenance activities at a refinery in New Jersey in 1979.
Mr. Capanna warns: “Don’t think that something this tragic couldn’t happen to you or somebody you love. This could happen to anybody.”
Also featured in the video is Casey Jones, the wife of crane operator Clyde Jones, who was fatally burned at the Bethune Waste Water Treatment Plant in January 2006.
Mrs. Jones says, “As a wife, I just assumed that he had a normal, everyday 7:00 to 3:30, Monday through Friday job, safe as my job. I would have never dreamed in a million years he would have been killed in an explosion.”
Hot work accidents occur throughout many industries in the U.S., including food processing, pulp and paper manufacturing, oil production, fuel storage, and waste treatment. CSB Investigations Supervisor Donald Holmstrom states in the video, “We typically hear about hot work accidents weekly. It has become one of the most significant types of incidents the CSB investigates, in terms of deaths, in terms of frequency.”
Emphasizing key lessons from the safety bulletin, Chairman Bresland states, “Hazard assessments and combustible gas detectors should be routinely used to identify and monitor for flammable atmospheres before and during hot work. Effective gas monitoring will save lives.”
The video is available for viewing and downloading on the CSB’s website as well as the agency’s YouTube channel. Free DVD’s can be requested by completing the online request from www.csb.gov.
The CSB investigation of the explosion at Packaging Corporation of America remains ongoing; a final report with formal safety recommendations is expected later this year.
For more information, contact the Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074; Sandy Gilmour, 202-261-7614, cell 202-251-5496, or Hillary Cohen, 202-267-3601, cell 202-446-8094.
Article Tries to Justify Fatigued Doctors
Thursday, June 3rd, 2010
A TapRooT® User passed along an article about doctor fatigue. His comment? The medical industry really needs TapRooT®.
Here’s the article:
http://www.usatoday.com/news/opinion/forum/2010-06-02-column02_ST1_N.htm
The article tries to justify fatigued doctors by showing some problems that reduced work hours might create.
Instead of applying techniques to fix these new problems, they imply that fatigued (error prone) doctors may be the only answer.
For example, they quoted an article written by two Vanderbelt surgeons that claimed that more than 80 hour work weeks were required to allow surgical trainees to learn techniques, dexterity, and stamina required in their profession.
Perhaps the surgeons should have been looking for more effective ways for students to learn and develop the skills they need since long hours is not the only way to learn (and adequate sleep is needed to embed even muscle memory – like that needed for basketball or surgery.
I’ve worked 80 hour weeks under high stress. I’ve done 24, 36, and even 72 hour workdays. I can tell you that you don’t want a doctor near the end of a 36 hour shift (or even at 4 AM if they came in to work the previous day at lunch.
Don’t buy the argument that fatigued doctors are just a fact of life. Every problem mentioned has solutions. Fatigued doctors ARE NOT the solution. They are one of the problems that keep people from getting quality care.
Monday Accident & Lessons Learned: Accident Video from the National Marine Safety Association
Monday, May 31st, 2010Monday Accident & Lesson Learned: Either You Are Leading the Solution or You Are Part of the Problem
Monday, May 24th, 2010I learned the lesson I am sharing in this article while investigating an oil platform fire back in the mid-90’s. But the recent congressional testimony of executives from BP, Transocean, and Halliburton brought the lesson back to mind.
These lessons are NOT just for people in the petroleum industry. They apply to all industries where a major accident could cause loss of life, damage to the company’s reputation (ie, Toyota’s accelerator problems), or a major financial loss.
After a major accident, there are NO clean hands. There is blame enough for everyone. If you are in the chain of command of the organization that had the accident, you WILL be seen as PART OF THE PROBLEM.
It’s not my fault … YOU are to blame!
Finger pointing is counter productive. Managers may be able to point out others that share the blame, but they won’t be able to get rid of their share of the blame.
This is true even for the “blessed” level of the corporation. CEOs, Presidents, and Senior Vice Presidents can usually avoid blame for lesser mistakes. But when a major accident – multiple lives lost, extensive environmental damage, and/or a big hit to the company’s reputation and finances – occurs, even the corporate elite can’t escape the blame from the press and politicians.
That’s why the minor amount of finger pointing by executives at the BP / Transocean / Halliburton hearings only seems to make people more upset. They wanted these executives to accept their responsibility for things that have obviously gone wrong.
BP should have lead the way by taking responsibility for the accident. BP should have admitted that their performance was unacceptable. And BP should have then shown that they were ready to lead the way – for the whole industry – when developing solutions to keep this kind of accident from happening ever again anywhere else.
Instead of the statement made by BP’s President (which you can watch on the CSPAN videos posted previously on this blog), they should have said something like the following:
Statement I proposed for Lamar McKay, President of BP Americas…
“Chairman Bingaman, ranking member Murkowski, and members of the committee, representatives of the press, and people of American and around the world, I come here today with a heavy and contrite heart for the accident that I have allowed on my watch.
First, let me apologize to the families and loved ones of the 11 workers who were killed in the initial explosion on the Deepwater Horizon. Their loss is tragic and unacceptable and I pledge here that I will do everything in my power to discover the root causes of the fatal blast so that we can learn from it and ensure that it never happens again.
Second, I would like to apologize to the people impacted by the subsequent release of oil from our well. We at BP are responsible for the environmental damage. BP will pay all valid claims without regard to any liability caps. We will do this because we feel it is our responsibility to compensate those who have been harmed.
The extent of this spill is larger than anything we thought possible. The fact that it happened means that our preparations and measures to prevent the accident were insufficient. We should have been better prepared for the unimaginable. We are currently bringing all the resources we can to bear on stopping the spill and mitigating the damage of the oil that is being released.
Furthermore, we pledge to take the lessons we have learned in the spill response and continue to research ways that we can be even more prepared if something of this nature happens again. Our goal is to find the root causes of the spill and prevent it. But we should never again be caught unprepared if the unthinkable happens.
At BP, we believe there will be a need for a reasonably priced source of oil for decades to come. We pledge our best efforts to finding and recovering this oil without loss of life or unacceptable environmental damage. By allowing the current accident to occur, we have failed our shareholders, employees, and the American people. For this we are sorry and we hope to be able to prove to you that we can changed course so that we won’t fail again.
As for plans to prevent future accidents, we have put together a team of experts in deepwater oil exploration and root cause analysis to find the causes of this failure. They will be given complete access to all records and personnel to determine what went wrong, how it went wrong, and why it went wrong. The goal of this investigation is not to point fingers and attribute blame. Rather, the goal is to find out how we can improve our performance so that an accident like this one NEVER happens again. Not at BP. Not at any other exploration site around the world.
It is too early to tell exactly what caused the explosion that killed 11 people and started this environmental accident, but I can say that the fact that it happened means that things went wrong. Somewhere down the well, barriers that we thought were sufficient to prevent the blowout failed. Also, the blowout preventer didn’t prevent a blowout. And our planned emergency response efforts were insufficient to deal with the size and scope of the spill that we now face. I am sure that all of these problems could have been prevented if we had foreseen the outcome. Unfortunately, we didn’t. That is a fact that we wish we could change but we can’t.
What we can do is to understand why bad decisions were made so that we can avoid bad decisions in the future. We want to know any mistakes that were made in sealing the well. If industry practices were followed, why they failed. If industry practices were not followed, why that occurred. If we should have preceded differently, we need to find out what went wrong and how we can do to do it right next time. We need to understand why the blowout preventer didn’t function as intended. We also need to understand what we need to do to be better prepared for a large spill.
What I can pledge to you is that BP wants to redeem our reputation. We pledge to become the safest, most environmentally benign oil producer in the world. We pledge to lead efforts to develop safer methods for deepwater drilling and to share the practices across our industry. We will work with our contractors and suppliers to establish much more reliable blowout preventers. We will lead an industry effort to establish an emergency preparedness and response capability up to the challenge of a spill of this size even though we plan to never have anything like this happen ever again.
After my fellow industry colleges have had the chance to share their thoughts about the accident, I would be happy to answer questions about our efforts to discover and eliminate the root causes of this accident and our current efforts to stop the spill and mitigate the environmental damage done.
So to close, thank you for this forum that we can start to express our sincere regret for our past performance and explain how we can start to redeem ourselves with efforts to lead progress in understanding and improving the safety and environmental performance of our company.“
At this point, Mr. McKay would have to really have a plan. BP would have to really be performing a thorough, accurate, critical root cause analysis using advanced root cause analysis tools that aren’t looking to place blame. Tools that have advanced human performance, organizational performance, and equipment performance evaluation methods. They would have to really be committed to leading the industry and taking actions to change the culture that has lead to a string of accidents across BP’s business units.
Maybe that is too much to ask. BP management may not be capable of this critical analysis – admitting that they were wrong and need to change BP’s culture.
Also, some of you might think that MARK IS CRAZY. No executive would take this kind of responsibility. Think of future lawsuits. Think of the corporate liability.
But I believe that the company is already guilty by the fact that an “unthinkable” accident has happened. Only if this was a terrorist act or a case of sabotage, could BP escape blame. Since there is no evidence of this, BP will be found to have made mistakes that contributed to the accident. You can count on that.
So my conclusion is that defensive management … management that points fingers at others … management that rejects or doubts their responsibility … can’t successfully lead the change efforts that are needed to improve performance and prevent future accidents of this magnitude.
Eventually these defensive managers WILL lose their jobs because they can’t change something they are defending.
In other words, management all up and down the line – from BP’s CEO to BP’s Company Man on the rig, must recognize their responsibility and their need to lead change or the Management System root causes (which there will be in an accident of this magnitude) will not be fixed.
Thus my conclusion …
YOU ARE EITHER LEADING THE SOLUTION …
OR YOU ARE PART OF THE PROBLEM.
Of course, after a major accident it is customary that managers will lose their jobs. The first target are those managers on the rig that made decisions the night of the accident. Next, the next level of management up the chain at BP and Transocean. But more senior management should also be worried. The complete management chain – from the Refinery Business Unit Manager to the CEO – eventually resigned or were let go after the BP Texas City explosion.
I believe the ONLY way that managers in this predicament can save their job is to claim their responsibility and then be seen as STRIDENTLY LEADING the change needed to prevent future accidents.
Now for your ideas and comments …
IS MARK CRAZY?
Should management not only admit errors but actually claim their share of the blame?
Can leading positive change save a corporate manager’s job?
Is pointing fingers and shifting blame a better survival strategy?
Is sincerely apologizing and accepting blame too dangerous?
What do you think?
Leave a comment here.
Lots of Comments on “Does Choice of a Root Cause Analysis Tool Increase or Decrease Blame?”
Thursday, May 20th, 2010
We have had plenty of time for comments and I posted my idea yesterday … So here is a link to the blog post and comments so that you can catch up with the debate:
The Hazards of Incentive Programs for Injury Reporting
Thursday, May 13th, 2010
Dr. David Michaels, Assistant Secretary of Labor for OSHA, held an on-line discussion about incentive programs. You can listen to his discussion here. He discussed the fact that many safety incentive programs do not enforce the correct behaviors. His example was a pizza party at the end of the week for any division which has no reported injuries. This is a pretty common type of incentive program. He was specifically targeting injury prevention, but it could be expanded to included production bonuses, etc. Let’s examine this a little closer.
First of all, does this pizza party encourage safer behavior during the week? People are not normally trying to hurt themselves, and so probably already have some level of attention to their own personal safety. I doubt that an extra slice of pizza on Friday will make any appreciable difference in my safety consciousness on Tuesday. Therefore, there is no new incentive toward safer behavior due solely to the offer of the pizza.
So what are we really encouraging with these types of programs? Non-reporting! There are numerous ways that this is actually manifested. There can be overt threats from co-workers to not report an injury. There are more subtle feelings of letting down their co-workers that make people automatically want to hide injuries. A boss whose semi-annual evaluation is determined (in part) by his department’s injury rate may either overtly or subtly “recommend” non-reporting.
OSHA appears to be struggling with this issue, and at least seems to recognize that these can be problems. We discuss Soon, Certain, Positive rewards when trying to change peoples’ behaviors, and these guidelines can be used when developing your own SMARTER corrective actions.
I’d like your thoughts on what programs you’ve seen that actually work. For example, a program that rewards employees for identifying potentially hazardous situations is a much more proactive method of lowering injury rates and raising safety awareness and compliance.
What else have you seen that encourages safe work practices? What Soon, Certain, Positive incentives have you seen that enforce safe behaviors?
Monday Accident & Lessons Learned: Two Near-Misses Back-to-Back – Was Anything Learned?
Monday, May 10th, 2010Watch the video. Do you think anything was learned?
I know, this video teaches us how good the “train avoidance training” was that we gave the worker. Now all we have to do is teach the rest of the employees how to leap out of the way at the last second!
Interesting Article on Shiftwork – The Paper Schedule and the Real Schedule
Wednesday, April 21st, 2010See:
The article explains how overtime and training days can cause shiftwork problems and fatigue.
Aviation Human Factors & SMS Wings Seminar…. what a great conference!
Tuesday, April 13th, 2010I had the opportunity to attend a conference with three of my passions: Aviation, Human Factors, and TapRooT®. Even better, it was held in the Frontiers of Flight Museum in Love Field, Dallas, Texas. I posted just a few of my favorite aircraft.
It was nice to see that many of our clients from Jazz, American Airlines, FAA, NASA and Southwest Airlines were also present.
Plus a special appreciation to meeting Dr. Besco who worked with Dr. Chambers (a friend and professor who passed away). Both of these Experts were Frontiers in Human Factors.
The F-16, my First Aircraft as a fuel Systems Mechanic…. at least the aircraft kept its shape : )
Admiral Byrd and the Ryan PT
The Lan FN 2100 and Vintage Bell Helicopter
Piper PA
And this one is…….
Air Force Blames “Pilot Error” for Predator Drone Crash in Afganistan
Tuesday, March 30th, 2010The US Taxpayers lost $3.8 million dollars when a Predator Drone crashed during a mission in Afghanistan.
What’s the root cause? Pilot error due to a loss of situational awareness due to channelized attention.
In other words, they were human.
For the article about the report, see:
http://www.af.mil/news/story.asp?id=123197262
If anyone finds a link to the original report on-line, please post it as a comment.
An Organization’s Code Boosts Ethical Behavior
Monday, March 29th, 2010Personal and professional conduct codes may seem basic when it comes to leaders demonstrating and encouraging ethical behavior. I’ve worked for leaders who mirrored the types of ethical behavior they wanted their staff to emulate, both on and off duty.
I’ve also worked for and witnessed leaders and specific staff who thought ethics were for everyone else; a one-time thing to be used only when it was professionally convenient or made them appear and sound ethical. The ‘leaders’ or specific staff espoused and “preached” ethics but when they thought no one was looking or no one would find out, their true colors shone loud and clear. They always appeared out front to verbally reinforce specific ethical standards written in manuals, orders and memos. But when it came time to demonstrate those behaviors, often at organization and personal sponsored events, these individuals came up short. Through their words and actions, they often violated the specific ethical rules they ‘championed’ and were expected to follow themselves. The rules were meant for others, not themselves. This was especially true after they received a promotion.
“Wise leaders generally have wise counselors.”
Diogenes, philosopher
But recent studies indicate Ethical Codes are more than basic—they have a huge impact.
Here are a few tips to help make them work:
Write the Code(s). Lisa Shu, a recent graduate student at Harvard University and two professors found that simply putting a code of conduct in place cut cheating in half. But Shu and co-authors Francesca Gino, an assistant professor at North Carolina, and Max Bazerman, a professor at Harvard Business School, discovered that there’s an even stronger impact when people sign the code. They become owners of it. Taking that step virtually eliminated unethical conduct.
“People underestimate the impact of these codes,” Shu said. “But it’s a nudge in the right direction.”
Customize it. Many organizations use a kind of boilerplate code of ethics. Don’t use only a consultant. Get the organization’s key staff and employees involved in the development and implementation of the code. Consultants don’t have to live with and by the code they help develop. The leadership and employees do! This is one important way to get leadership and employees to “Commit and enroll.”
For example, Johnson and Johnson’s Code of Ethics, their “Credo” lists shareholders last.
John and Johnson believe if it does all else right, shareholders will gain, too. The Credo matches the belief s of the firm’s people.
Ethical behavior should become more defined, with more accountability, not less, the higher you rise in the organization. This is especially true in politics at the national, state and local levels.
“I believe every right implies a responsibility, every opportunity an obligation, every possession a duty.”
John D. Rockefeller, Jr., oil executive
Set the tone. Shu’s research found that more people cheated when no one kept tabs on them and held them accountable. On the surface, that may see quite obvious. However, people often define ethics and integrity as doing the right thing even if no one is watching. “Environmental cues matter a lot,” Shu said. “It’s shocking how much of our morality does depend on our environment.”
Reinforce it. The people who cheated remembered only one part of the code of conduct, Shu’s study found. The honest ones remembered five parts of the code. That could be a memory issue or perhaps the cheaters way to try and justify their actions. Find the means and methods to reinforce the code of ethics at every opportunity at staff meetings, training sessions and through the organizations electronic mail and newsletters. Case studies are an effective tool to reinforce the code.
“The greatest conflicts are not between two people, but between one person and himself.”
Garth Brooks, singer
Live with and by the code. Walk the talk. Think it, live it; breathe it. Make it one of your personal core values. It must be seamless, (really) transparent and sequential. Personal, then professional. Inside out, NOT outside in.
“Abraham Lincoln did not go to Gettysburg having commissioned a poll to find out what would sell in Gettysburg. There were no people with percentages for him, cautioning him about this group or that, what they found in exit polls a year earlier.”
Robert Coles, author
It’s far worse and more destructive to put a code of conduct in place and ignore it than to not have one at all. Absent a code, employees may believe the ethical dilemma wasn’t completely thought through. Ignoring the code shows it just didn’t matter to those at the top of the organization. That type of attitude breeds even more cynicism among the employees.
Train your staff. Train up and down and across the organization. Not just once or to “fill the square” of some governmental or hierarchal requirement. Make ethics training and the Code of Conduct a part of the organizations quarterly, semi-annul and annual training processes. That demonstrates that the organization’s serious about ethics and the code. But…training aside, there’s nothing better or more effective than mirroring the behavior you want! Train all levels of staff and the senior levels, too. Lead by example.
Follow-up. After the code is in place and the initial training is completed, the real work has just started. Organizations must put in place various methods like whistle-blower hotlines (don’t shoot the messenger), to help uncover any errors or wrongdoing. Organizations must have specific enforcement plans in place and be willing and capable of taking whatever preventive measures that may be required. Accountability is key!
See it through. When leaders find any number of emotionally convenient and comfortable reasons (excuses) to stop reminding their staff (and family) of the importance of acting in an ethical manner with integrity and honor, the staff (and family) may soon forget of its importance. The results are the staff (and family member) may resort to cheating and/or cutting corners on their behavior. They may revert to the behavior of least resistance and most familiar and comfortable.
“Ninety-nine percent of failures come from people who have the habit of making excuses.”
George Washington Carver, botanist
Always presume (never assume) the best. When you develop and write the code of conduct, write it with the expectation, mind-set and core belief that people are basically honest and want to do the right thing and take the proper action. Don’t write a list of don’ts, Shu says.
A personal observation. Recently, my wife and I attended our 13 year-old nephews 7th grade flag football game. One of the rules is the quarterback must throw the football within four seconds. If he doesn’t, it’s a loss of a play. Each team has 10 plays per possession. There’s one referee per game. A father on our nephew’s school team watched as the referee continued to give the opponent’s team’s quarterback up to 10 seconds to throw the ball. An obviously violation of the spirit and intent of the rule and gave the opponents an unfair advantage.
After the first quarter, the father approached the referee to question him about the apparent rules violation. What the referee did was a surprise, even to me. He didn’t call time-out and take a few seconds to listen to the parent’s concern. What the referee did was throw the yellow flag at the feet of the parent—a penalty against our nephew’s team—and began to scream at the parent. My wife and I were seated about 30 yards away and we could hear the referee’s loud and inappropriate words and watch his obnoxious behavior. Other parents heard it and sadly, so did the young 13 year-old players.
There was a part of me that was surprised and a part of me that wasn’t. As a former high school and college athlete and parent, I’ve seen this type of behavior from parents, referees and individual players most of my life. From this recent example, there’s no doubt in my mind the referee felt he was being challenged. His ego, authority and position were, in his mind, at risk. Given his physical stature, attitude and overall disposition, my concept of the “frustrated jock syndrome” was alive and well. After the game, I suggested to my wife that the parent should report the referee’s unethical behavior and actions to school officials. ‘Adults’ like this shouldn’t be refereeing or coaching at any level! I know I wouldn’t have stood there and taken his verbal abuse.
Parents and officials need to let the kids play. It’s NOT brain surgery and life and death. (Though in some cases you’d think it was.) Ethics, integrity, honor and character start at home. Parents need to stop living vicariously through their child’s athletic endeavors. ‘We won, the kids lost.’ Teach them to play hard, give no quarter, expect none in return, play fair and leave it all on the field or court. And model the behavior!
And yes, our nephew’s team lost. But he really won! Our nephew’s a winner!
“The important thing is to learn a lesson every time you lose.”
John McEnroe, tennis champion
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This article was reprinted with permission from Captain George Burk, USAF (Ret), Speaker, trainer, author & writer. Captain Burk is a plane crash & burn survivor. He will be speaking about how to achieve quality in life and work at the 2010 TapRooT® Summit. Visit his website at: www.georgeburk.com.
Monday Accident & Lessons Learned: Should You Discipline BEFORE an Investigation is Complete?
Monday, March 29th, 2010The New York Times reported that a crane tipped and hit a building in New York City.
According to the story. Christopher Cosban, the top level crane operator at the site, left the site for the day without lowering the 250 ft boom as far as it could go.
The investigators said that his mistake – not lowering the boom – contributed to the accident. (But might not have been the “sole” cause.)
What action did they take? City officials suspended his license.
Now for the question …
Should we discipline people before we complete an investigation?
In this case the article seemed pretty clear that lowering the boom when not at the worksite was a requirement. But I’ve seen many cranes left for the weekend with the booms still up. Actually, I can’t think of too many places in NYC where you could lover a 250 ft boom and leave it down for the weekend (think of streets and businesses blocked for two days).
So maybe they should have completed their investigation before they blamed the operator.
Is this a lesson we can learn? Let me know what you think.
Monday Accident & Lessons Learned: Flying to the Scene of the Crash
Monday, March 22nd, 2010Some airports are more forgiving than others. They have longer runways, better approaches, and less challenging weather conditions.
The video below is from London City Airport, a more challenging approach, especially when there is a stiff crosswind.
(.mp4 format video – click to play)
This wasn’t an accident but one could say it was a near-miss (look how close the tail came to hitting the runway and how close the plane came to flipping).
When faced with a challenging approach, pilots must make a last minute decision – land or go around and try again. If they decide wrong, the mistake can be called “Flying to the scene of the crash” because they should have judged that they didn’t meet the criteria to land and then quickly decided to add power, pull up, and go around.
What helps the pilots make the right decision? Training/experience, instrumentation (good human factors), and the company culture (do the pilots get ribbed if they have to go around?).
Now let’s think about your company.
Most readers aren’t at airlines. But do your employees have to make decisions about production vs. safety under pressure? What do you do to help them make the right decisions?
This can be an interesting lesson learned.
Statistical Analysis of Toyota “Acceleration” Accidents
Tuesday, March 16th, 2010Megan McArdle wrote an interesting article about the age statistics of the drivers involved in Toyota acceleration accidents. It seems older people (above 60 years old) are much more likely to be involved in an acceleration accident.
She then hypothesizes that this “age discrimination” means that these accidents are driver caused and not “Toyota caused.” Or at least that this is the reason that Toyota did not discover their problems sooner.
Interesting article. See:
http://www.businessinsider.com/a-deep-dive-into-toyota-sudden-acceleration-accident-stats-2010-3
Navy CO of USS Cowpens Loses Job After “Drag Racing” Incident – A Lesson in Bad Leadership?
Sunday, March 14th, 2010The Navy must have changed a lot since I was in it.
Here’s a quote from an Associated Press article printed in Military.com:
“A Navy inspector general report said investigators had substantiated that Graf assaulted subordinates (pushing one, grabbing another and once throwing wadded-up paper at another Sailor) and that she regularly verbally abused subordinates by publicly berating them, belittling them and using profane language.“
A Navy CO using profane language and berating crew members in public … sounds like the first ship I was on in 1980.
And, of course, assault should never be tolerated. But the female CO, Captain Holly Graf, (pictured above) pushed someone, grabbed someone, and throws a wadded up piece of paper at someone? This hardly seems like serious offenses. But perhaps it does show a lack of judgment. After all, the CO’s job on a ship is quite serious and there needs to be a certain amount of formality and separation maintained to maintain good order and discipline. Grabbing sailors (or officers) and throwing things at them isn’t setting a good example for your crew.
Then there is the drag racing.
I’ve seen two ships line up side by side to run a one mile race. We won! Our nuclear powered cruiser beat a gas turbine powered cruiser.
The AP story said this about the drag race:
“One sailor said that during the race, aimed at boosting morale, the McCain got ahead of the Cowpens and began drifting to the left into the path of the Cowpens. Though the report did not question that the race took place, it said the allegation of “hazarding a vessel” was unsubstantiated.”
One sailor said?
If every CO was relieved because they swore, had sailors that didn’t like them, or even made occasional judgment failures (grabbed a sailor), we probably couldn’t keep our fleet at sea. But maybe there’s more to this story than what was printed in the Associated Press article?
I decided to look a little further and did a Google search on “Captain Holly Graf”.
WOW! What an eyeful! Lot’s more information was posted on-line about how bad Captain Graf was!
Of course you can’t believe everything you read on-line, but … read the comments at this blog:
http://www.susankatzkeating.com/2010/01/captain-holly-graf-plows-down-whale.html
Then a picture of the “drag race” at this blog site:
http://www.militarycorruption.com/hollygraf5.htm
(Can’t tell if it is photoshopped or not.)
And a legal review of the charges against Captain Holly Graf:
http://admiraltymaritimelaw.blogspot.com/2010/03/navy-inspector-generals-report-on-holly.html
After reading the material available, I would conclude that Captain Graf was an awful person to work for and a terrible leader. The Navy is lucky that no one was killed as a result of her leadership failings. (Having your crew be scared to talk to you is a great way to get a ship into deep trouble.)
But some of the charges seem silly. Guilty of having a Junior Officer play a Christmas Carol on the piano at a Christmas Party at the CO’s house? Or another charge that a Junior Officer walked the CO’s dog willingly? Come on.
But what about Navy leadership? How did she get to such a position of power? Why weren’t her poor leadership traits detected earlier?
Man or woman, I don’t care. Men and women can be great leaders. Or not.
Poor leaders at sea can have dreadful consequences. Our sailors deserve good leadership. Seems like the poor leadership qualities of Captan Holly Graf might indicate a generic problem with the way that leaders are developed and promoted inside the Navy. Certainly this isn’t the first “bad CO” that I’ve heard about. Perhaps a more in-depth analysis is required?
Plenty to dig into when analyzing the root causes (and generic causes) of a poorly led ship.
Root Cause Analysis Tip: What does excessive lifting mean and is there an easier way to calculate it?
Wednesday, March 3rd, 2010While 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 you are asking what is the worst 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 can we use a simple calculation ourselves first?
A simple calculator: http://www2.worksafebc.com/calculator/llc/liftlower/Default.htm
A little more technical: http://www.osha.gov/SLTC/etools/electricalcontractors/additionalreferences.html
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.”
Post your response!
Monday Accident & Lessons Learned: Chief Dies After Electrical “Accident” on the Aircraft Carrier USS Ronald Reagan
Monday, March 1st, 2010The 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:
http://www.taproot.com/about.php
And for more information about TapRooT® Courses, see:
Is Employee Fatigue a Behavioral Problem? What’s the Science Say …
Friday, February 26th, 2010All 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.
(Read article on Circadian 24/7 Workplace Solutions’ website. Excerpt of article reprinted with permission. Bill Sirois, COO of Circadian Technologies, will present “Measuring Fatigue Using FACT” at the 2010 TapRooT® Summit, October 27-29 in San Antonio, Texas.)
Root Cause Analysis Tip: “Training”… the most misunderstand and misapplied Root Cause of them all!
Wednesday, February 24th, 2010What 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.
Here is a recent article where we discussed “common sense’s” role in Training: Root Cause Analysis Tip: Part 2: Behind Closed Doors with A Common Sense Discussion
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?
Mark’s Talk on TapRooT® & Safety Culture
Sunday, February 21st, 2010Many 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…
Atlanta Suburb Makes Accident Criminal – Your Thoughts?
Tuesday, February 16th, 2010Here’s the Atlanta Journal-Constitution article:
http://www.ajc.com/news/gwinnett/gwinnett-first-vehicular-homicide-298753.html
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?
Here’s the Un-Cut ABC Footage of the Fatal Luge Accident
Sunday, February 14th, 2010Although the video isn’t bloody, don’t play it unless you are thinking about sources of information for an investigation of this accident.
Note: They took down the ABC footage, and all other sources I could find, but this ABC footage has a couple of pictures…
Watching the video does make one think … shouldn’t there have been more Safeguards in place?
90 miles per hour and fixed steel objects just a few feet way.
It seems the only Safeguard was the “goodness” of the luge driver.
What do you think??? Was this “safe enough”?
See a previous blog post by Dave Janney here:
http://www.taproot.com/wordpress/2010/02/13/probe-completed-in-luge-accident/
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.)
Root Cause Analysis Tip: Understanding Human Engineering Investigations after a Fatality
Thursday, February 11th, 2010
See the Video of the Incident Investigation here: http://www2.worksafebc.com/media/fss/garbageTruck/slideshow.htm
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.
Monday Accident & Lessons Learned: Hospitals Adopt a Best Practice from 1935
Monday, February 8th, 2010In 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.
Root Cause Analysis Tip: Part 2: Behind Closed Doors with A Common Sense Discussion
Thursday, February 4th, 2010Part 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.
Thanks All,
Jason
Now the rest of the discussion from the TapRooT® Users and Friends LinkedIn Group
Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor
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.
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Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor
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.
Posted 1 month ago | Delete comment
Does Passing a Law Increase Safety? Not This Time.
Sunday, January 31st, 2010Several states passed laws prohibiting the use of hand-held cell phones. Did these laws work? (Reduce accidents?)
No, according to a study by the Highway Loss Data Institute reported on by Top News.
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.”
Next, making sneezing illegal while driving…
Root Cause Analysis Tip: Where Do You Need to Install Cameras and Microphones to Improve Your Investigations?
Friday, January 22nd, 2010“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?
Maybe now is the time to suggest it…
