One of the researchers on this study, Dr. Atul Gawande, was interviewed on National Public Radio this morning (link here). He went into even more detail and and provided further insight on this study. He discussed how complicated and intricate the medical profession has become, and therefore instituted the use of checklists in the operating room in 8 hospitals. He had some amazing (but not unexpected) findings:
“We get better results,” he says. “Massively better results.
“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”
Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.
How did the surgeons respond?
…when his team surveyed the doctors who used the checklist, “There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, ‘This is a waste of my time, I don’t think it makes any difference.’ And then we asked them, ‘If you were to have an operation, would you want the checklist?’ 94 percent wanted the checklist.”
Checklists are a way of life in many critical, complex industries. The airline, nuclear, and pharmaceutical industries all use checklists to some extent, but many in the medical community are still resistant. We have even seen a reluctance to perform a root cause analysis for sentinel events. Many people feel that, if they are using a checklist, they are perceived as not being an expert at their job. And yet, Dr. Gawande had some amazing statistics concerning the sheer volume of information presented to physicians:
– The average physician evaluates 250 primary diseases and conditions each year – These same patients have an additional 900 additional medical problems – The doctors prescribed over 300 different medications, 100 lab tests, and performed 40 different types of office procedures – In an ICU, the average patient requires 178 individual actions per day (administering drugs, suctioning lungs, etc) – Out of those 178 actions, 2 per day (~1%) were performed incorrectly
Sometimes, memory is just not enough. When a sentinel event occurs, perform a TapRooT® analysis. See how many times “no procedure” and “no standard turnover process” show up as root causes.
When can an accident teach us something about investigating accidents? When the accident helps us understand the human brain and it’s limitations.
A story in Wired Magazine titled: “Accept Defeat: The Neuroscience of Screwing Up” explains how scientists often disregard information that conflicts with their “hypothesis” and how this is caused by the way the human brain is wired. I recommend reading the article to better understand this phenomenon.
But how does this relate to accident investigation? Here’s the answer…
Root cause analysis systems based on the theory of cause-and-effect require the investigator to develop a hypothesis and then look for evidence to prove or disprove the hypothesis. The theory of cause-and-effect requires the investigator to already understand the cause-and-effect relationships they are looking for. Thus, they can only find cause-and-effect relationships that they already understand.
However their brain, according to the research in the article, automatically keeps them from seeing evidence counter to their hypothesis or outside their experience.
That is why cause-and-effect root cause analysis techniques frequently have widely different results when used by different individuals looking at similar evidence. Each individual sees the “evidence” the way they want to see it to support their theory of the accident’s cause.
TapRooT® is not built on this cause-and-effect theory. Instead, it is based on unfiltered review of the evidence leading the investigator to develop a detailed explanation of what happened before they start to analyze why it happened. The evidence isn’t collected to verify a hypothesis. Rather, it is collected to expand the investigator’s knowledge and understanding.
Also, instead of depending on the investigator’s knowledge of cause-and-effect, TapRooT® has built-in expert systems to help the investigator see causes that may be beyond their current knowledge of the cause-and-effect relationships of the incident being investigated. These built-in expert systems help the investigator side-step their brain’s built-in simplifying mechanisms and find causes that they might not have originally suspected (or even understood).
Of course, any investigator can stubbornly hold to preconceived notions, but TapRooT® doesn’t fall into the “scientist’s trap” that this article talks about. It naturally helps investigators go beyond their preconceived ideas and previous experience.
That’s an important lesson learned!
If you don’t care about the brain-science behind why TapRooT® works and other root cause analysis techniques fail, that’s OK! Don’t worry … You don’t have to be a neuroscientist to use TapRooT®. We’ll teach you how to use TapRooT® in a 2-Day, 3-Day, or 5-Day Course and then you can take advantage of the advanced science that is invisible to the user but is built into the TapRooT® System.
What?!? You haven’t learned TapRooT®? Then now is the right time to get to a course and experience how TapRooT® can help you find root causes that you previously would have overlooked and develop corrective actions that you and your management will agree are much more effective. Don’t wait! Sign up for a course at:
Here’s a link to an interesting article about research that indicates why texting while driving produces worse performance than talking or using a cell phone while driving. See:
There’s an interesting discussion from the pages on LinkedIn about politics and safety. I posted this perhaps controversial reply…
Interesting discussion.
Here is an example (not from the UK) that points to the issue …
An owner of a small (two truck) hauling firm was cleaning up debris (leftover wood, plywood, drywall, block, and other building materials) from a construction site. He had hired 3 Mexican-American workers to help. They spoke little English.
They were loading the materials (which he planned to “recycle”) onto a skid loader. The skid loader then transported them to the dump truck and lifted them up to the top edge of the trucks sides so they could unload and stack the various material in the back of the dump truck.
As the truck was filled up, the workers walked on the materials which were uneven. Eventually, the workers were above the level of the sides of the truck (about 8-10 feet in the air).
The owner got the last load to the truck and two of the workers were in the truck working to unload it. The owner turned off the skid loader and left for a bathroom break in a near-by (just 10 feet away) port-a-potty.
While he was gone, one of the workers fell from the truck and hit his head on the ground (a concrete surface). He later died from his injuries.
No other worker or the supervisor saw how the worker came to fall from the truck. The worker never regained consciousness. No one knows exactly why he fell.
An investigation by a federal safety organization found that the company (the “owner”) should:
1) Perform a pre-job risk assessment and identified and mitigated all hazards.
2) Provide safety training for all employees in the language that they understand (Spanish in this case).
3) Provide equipment that does not require workers to unload loads on elevated surfaces (in the back of a dump truck).
While I agree that items 1 and 3 would have prevented this particular accident, they would also probably eliminate this company from doing the work because:
a) They only have two dump trucks – no flatbeds or lowboys.
b) They didn’t have any other way to unload the materials into their trucks without damaging the materials (which they planned to reuse).
So, what they are asking the owner of two dump trucks to do is to perform a risk assessment and decide if the risk of someone falling off a truck is worth the benefit of being able to reuse the excess construction materials.
Not to “talk down” about everyday people, but this is probably someone with minimal education (high school education) and lots of work experience who has scrapped together enough money to buy a dump truck … and then another … and start doing work that is dirty, physical, and does not have high profit margins. He doesn’t have a “safety staff” and he doesn’t see loading a truck as a particularly hazardous assignment.
If he saw falling out of the truck as a hazard, he would probably have a mitigation strategy of telling the workers in English to “be careful.”
He is never going to pay for multilingual safety training on his profit margins. He can’t afford to rent special equipment to move excess construction materials.
So the question is:
Is loading a dump truck with excess construction materials by hand so hazardous that it never should be allowed?
If you say “Yes” … then you are the next example of “out of control” safety police.
The real problem is that we have a general tendency to be more risk adverse as time passes. Things that we did as kids are now “too hazardous” to be allowed.
I remember sitting on my grandpa’s lap & driving his car & driving the farm tractor when I was only 5 years old. When Brittany Spears did the same thing in her car, child protective authorities were called because it was seen as a form of child abuse.
Don’t get me wrong. I’m not in favor of killing employees/children. I’m not saying to ignore obvious safety hazards. I’m just pointing out the difficulty in providing a hazard-free workplace & not seeming like out of control safety police.
What do you think? Leave a comment here.
Also, consider joining theTapRooT® Root Cause Analysis Users and Friends Groupon LinkedIn for other interesting discussions that will help you use TapRooT® more effectively and improve your performance improvement efforts.
“A call from a flight attendant to the pilots of the Northwest Airlines plane that overshot Minneapolis catapulted the cockpit crew from complacency to confusion.
According to a statement signed by flight attendant Barbara Logan, she called the cockpit around 8:15 p.m. CDT to find out when they would be landing. She was told they would land around 12 Greenwich Mean Time. “I said I did not know the time — he said I was hosed and hung up.”
The lead flight attendant called to get gate information and was apparently also hung up on, according to Logan’s report. That flight attendant later got through to the cockpit.”
Years ago would the Flight Attendant have pushed so hard before CRM?
Now an example where CRM would helped in the death following a scheduled surgery. An everyday medical procedure ended up in an excessive delay of needed oxygen to the patient.
The article brought up a “new” test cheating incident by sailors on the nuclear aircraft carrier Harry S. Truman. It also mentioned a test cheating scandal revealed earlier this year aboard USS Dwight D. Eisenhower (another carrier) and the 2007 chemistry scandal aboard USS Hampton (a fast attack submarine).
One of the most interesting parts of the article was at the end of the article. It said:
“Colgary and another retired nuclear-trained officer who asked not to be named said the “nukes” are generally good people who aren’t working against the system but can sometimes be pushed too hard by it.
“We try to find the root cause of problems instead of treating symptoms of the problem,” Colgary said. “Typically it comes down to personalities. You can get overwhelmed sometimes with maintenance, preparing for getting underway, preparing for deployment. And oh, by the way, you have to balance your life at home.”
That doesn’t excuse a lack of integrity in the nuclear Navy’s zero-defect mentality.
“You have to trust every watchstander on the ship,” Colgary said. “God help you if you’re in a time of war and these things are amplified even more.”
Colgary said the exam proctor who stopped the cheaters should be commended. “It would be just as easy for that proctor to turn his back and let it go,” he said.
For the eight sailors who were kicked off Truman, their Navy careers might already be over. McMichael said sailors who are stripped of their nuclear NECs essentially lose their rating. They must then try to transfer to another rating, if there is room for them. If the alternative ratings are fully manned, the sailor may have no place to go and be administratively separated from the Navy.
Getting caught cheating also made them significantly poorer very quickly. Nukes are eligible for retention bonuses up to $125,000, depending on their rates and qualifications.”
“We try to find the root causes of problems instead of treating the symptoms…” and “…typically it comes down to personalities.” You must be kidding!??
Let’s start looking for root causes other than “bad sailors” (personalities). What is the operating tempo? How short staffed (undermanned?) are these crews? How much more are they trying to do with less? How long can this “war footing” go on with too little budget and too few ships?
Even a good horse can be run into the ground if you push it long enough (“…’nukes’ are generally good people…”).
I can’t help but think there is more to the root causes of recent Nuclear Navy problems than just some bad young sailors (and, yes, some bad COs, Officers, and Chiefs).
Click on the link for some interesting reading at his blog.
One other thing to consider is TEACHING people why using a checklist is important in some situations by providing a hands on exercise (the Communication Exercise) that we include in out 2-Day and 5-Day TapRooT® Root Cause Analysis Courses.
And if anyone has Eric Cropp’s contact information, please have him contact me about speaking at the Summit. Telling others about his mistake is a part of his sentence and I think his experience would be enlightening to those that investigate accidents.
(Ex-pharmacists Eric Cropp as he enters
a no contest plea to involuntary manslaughter.)
Because instead of looking at each collision as an isolated failure of the Commanding Officer (or members of the crew), perhaps these accidents/incidents in the Submarine fleet that include – running into a sea mountain, colliding with and sinking a Japanese fishing vessel, gun-decking chemistry logs, and hitting another Navy ship – are part of a pattern of problems that indicate deeper issues.
After all, does the CO, Commander Ryan Brookhart – pictured above, look like a bad person?
“Over several months” prior to the incident, hundreds of watchstanders were tested in their ability to understand how to analyze the movement of surface contacts. The exams yielded results of 10 percent to 15 percent passing grades among enlisted watchstanders and 60 percent of officers.
“Given the attention I have personally placed on submerged contact management in briefing the waterfronts, this is unacceptable,” McAneny wrote in the message obtained by Navy Times.
Doesn’t this seem to indicate a problem far beyond a bad CO?
I haven’t finished reading the Navy JAG Manual Investigation Report, but the articles that refer to it are in full “blame” mode. They protect those higher in the chain of command by making this a story about one bad CO with some bad watch standers who broke well established rules. They were bad people. They listened to iPods! Fire the CO, discipline some sailors, and warn everyone else not to be bad like they were, and the problem goes away.
When I’m finished reading the 100+ page report (see attachment here):
Until then, history tells me that we haven’t found the real root causes of this accident. And without REAL, advanced root cause analysis, they never will.
Bad behavior between doctors and nurses in hospitals can cost patients their lives. So about a year ago, the Joint Commission required hospitals to create a “zero-tolerance” policy for intimidating and disruptive behavior.
Recently, the American Medical News published an article that indicates that the requirement for a policy might not be working.
After reading the article you might ask yourself the question:
“Can a policy stop bad behavior?“
And what does “zero-tolerance” mean? Any bad behavior should get a nurse fired or a doctor’s privileges suspended?
Here’s a list of the “bad behaviors” that were reported in the American College of Physician Executives 2009 Doctor-Nurse Behavior Survey and the percentage of respondents that had observed that type of behavior in the last year in their organization …
Degrading comments and insults … 84.5%
Yelling … 73.3%
Cursing … 49.4%
Inappropriate joking … 45.5%
Refusing to work with a colleague … 38.4%
Refusing to speak to a colleague … 34.3%
Trying to get someone unjustly disciplined … 32.3%
Throwing objects … 18.9%
Trying to get someone unjustly fired … 18.6%
Spreading malicious rumors … 17.1%
Sexual harassment … 13.4%
Physical assault … 2.8%
Other … 10%
Could we really have a zero-tolerance policy for yelling? For inappropriate joking?
Who would decide what inappropriate is and then enforce it across all hospitals?
I’m not saying that any bad behavior including yelling and telling inappropriate jokes is a good thing. I just don’t know if “zero-tolerance” is the way to change behavior…
The crew had just finished an intense operational phase of its deployment and “everybody let down their guard” for what was actually one of the most challenging phases, crossing the strait at periscope depth, he said.
“There was a great deal of complacency involved in the crew,” he said. “They had been at sea for 63 days operating in areas with high contact density.”
He also noted that more or better technology would not have helped the situation, as the sub knew the New Orleans and another ship were nearby.
“There were a whole host of watchstanders that failed to recognize the sensor data that was presented to them,” he said.
Lessons learned are already being integrated into submariner training, he added.
US Navy Lessons Learned: 1. If you are the CO … Don’t run into another ship! 2. If you are the Chief of the Boat … Ditto! 3. Advanced technology can’t prevent collisions. 4. Firing people CAN prevent collisions. 5. Don’t be complacent. 6. Don’t let down your guard (no matter how tired you get).
For those not in the US Navy …
Interesting that fatigue was not mentioned as a potential cause. Seems like you might replace the word “complacent” with the word “fatigued” and this incident would make a whole lot more sense.
Of course, officers and sailors in the US Navy never get fatigued no matter how little sleep they get.
There’s been a lot of talk lately about drivers of cars and trains texting, but this is the first I’ve seen about pilots using a computer while flying.
Do you think any other pilots will admit what they are doing in the cockpit in the future if a problem happens? My guess is they will ask for an attorney and take the fifth!
Also, since pilots use computers in the cockpit (for example, they program computerized autopilots), what computer use is acceptable and what isn’t? When is a computer distracting and when is it OK?
Yes, I understand this computer use violated company rules. But did it break a federal law?
Taking away someone’s livelihood seems fairly severe – especially when they have probably already learned their lessons.
Will this discipline be a deterrent to other pilots using laptops or just a deterrent to pilots being honest during an investigation of a problem?
interesting questions … What do you think. Leave a comment below.
I’m in a session on Success Stories from TapRooT® Users that have applied advanced root cause analysis techniques. Theresa Guay from Irving Oil gave an excellent talk about their use a TapRooT® to make pretty dramatic improvements in safety.
Right now, Ron Pryor is providing a very interesting talk on a kaizen project to improve environmental performance. He’s showing the Iowa’s largest SnapCharT®.
Wish you could be hear to hear the really useful lessons learned.
(Picture of Ron presenting and Iowa’s largest SnapCharT®. Boy … Ron sure is moving fast!)
This new course if designed to provide practical ways to solve common causes of human error and help people better understand human capabilities and limitations.
Read the article on the IOSH web site and you’ll find that MISTAKES (human errors) administering oxygen to patients in UK hospitals is what actually killed nine in five years.
“I’m sure my guys wouldn’t check a petroleum storage tank gas-free with a lit welding torch…” See this link
“I’m sure my guys wouldn’t purge a natural gas line into an enclosed space inside the building…” See this link
People make poor decisions all the time. In hindsight, it sometimes looks like these people “just weren’t thinking.” However, the opposite is usually true. Poor decisions are usually made after some type of internal risk analysis, often with many variables considered:
- I’ve never had a problem with this before - This will only take a minute - It’s not really that dangerous - I’m more careful than the normal person
This thought process may only take 3 seconds, but it does occur. What we need to do is figure out what made this decision OK in the minds of the people performing the evolution.
- What made this poor decision acceptable to the worker? - Did management condone these decisions in the past? - What safeguards are, or should be, in place to prevent this decision from being implemented? - What do we have in place to help our workers make the right decisions?
Performing a root cause analysis using TapRooT® will help you understand why we do these “dumb” things, and put in place solid corrective actions to prevent the problem from happening again.
Yes…Yes…Yes! Always list a Root Cause if it affects the Causal Factor (Investigation) or Significant Issue (Audit) no matter what the final Corrective Action. If it is not documented then it is not a problem..right?
For instance, the Root Cause Noisy under Communications must be marked if it lead to why an individual could not hear the message and Human Engineering must be marked if hearing protection was required because of the loud machines operating. Management may not have any plans to replace the monster thunder machines so Noisy must be mitigated.
Executive VP for Shell debates “complexity” of PPE with others in the industry at the Aberdeen Offshore Europe Exhibition and Conference. For an article about the discussion, see:
What could be worse than such an incident? Getting someone injured during the response! Take a look at this other picture and see if anything here makes you nervous….
New NTSB Chairwoman Deborah Hersman’s first act after being ceremonially sworn into her job (she started the job officially on July 28) was to sign a new policy banning calling or texting while driving for all NTSB employees (including herself).
She said: “Consider it a sterile cockpit rule… .”
Is your auto a “sterile cockpit” or do you allow distractions while driving?
How much distraction do you allow?
Did you take our poll about “illegal” distractions?
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wrote it in the first paragraph.
The toll of this inadequate leadership is staggering – about 50,000 deaths per year. (Taking the estimate of deaths in the US from the Institute of Medicine report and multiplying it by 50%).
Another way to think about this is that perhaps 1/2 of the 5708 registered hospitals in the US have inadequate leadership. That’s 2604 hospitals that need to improve their leadership and probably should be concentrating on learning advanced root cause analysis and performance improvement best practices.
We’ve always sent information about the Eliminating Healthcare Sentinel Events Best Practice Track and TapRooT® Training to risk management, patient safety, and quality improvement professionals at hospitals. Maybe we should be sending the information to hospital administrator to reach the top of the leadership pyramid?
If you think your administrators need to know more about root cause analysis and preventing sentinel events, pass our newsletters along. Or sign them up to get our newsletters monthly at:
Also, pass along information about the Eliminating Healthcare Sentinel Events Best Practice Track at the TapRooT® Summit. They will be amazed at what they learn. See the schedule by clicking on the appropriate button on the left at:
It’s called the “Bottleneck” Theory, because you have limited attentional resources…..yah the report is on my desk, stupid phone always rings when I’m busy, what’s for dinner tonight… oh, like I was saying we have limited attentional resources. The more attention required to focus on a task, the more the other passive actions have to wait or just happen with just a little attention to keep it going.
Here are some of the report findings…. keep in mind that this study was performed on Guinea Pigs (college students)….who may not represent you who or me because WE always get our work done on time and never cram anymore!
The researchers studied 262 college undergraduates, dividing them into high and low multitasking groups and comparing such things as memory, ability to switch from one task to another and being able to focus on a task.
“found multitaskers are more easily distracted and less able to ignore irrelevant information than people who do less multitasking.”
“The huge finding is, the more media people use the worse they are at using any media.”
“The high media multi-taskers couldn’t ignore the blue rectangles. “They couldn’t ignore stuff that doesn’t matter. They love stuff that doesn’t matter,” he said.”
“High multitaskers just love more and more information. Their greatest thrill is to get more,” he said. On the other hand, “exploiters like to think about the information they already have.”
Now the really good part…. for those of us who usually only get to learn new things when we make a mistake and have to figure out what we messed up, You get another chance to learn about Multi-Tasking, Fatigue, our Senses, Procedures that a rocket scientists could never follow (mandated to be followed by the average worker), ways to improve Situational Awareness, and way to measure that you made a difference in Stopping Human Error.
Behind Door Number One: Our 2-Day Pre-summit Course Stopping Human Error with hands on exercises and Solutions. This course has been completely revolutionized for 2009 but the reasons to attend it are still the same… http://www.taproot.com/summit.php?t=pre-summit#humanerror
Behind Door Number Two: Our Behavior Change & Stopping Human Error Track During the 3-Day Summit
One course in particular Practical Tools to Stop Worker Error has just been added; introduces reason for human performance tools and INPO’s 8 fundamental human performance tools which should be used for every job. These include: Situational Awareness tools of Task Preview, Job Site Review, Questioning Attitude, and Stop When Unsure, Compliance tools of Self-Checking and Procedure Use/Adherence and Communication tools of Three-way Communication and the Phonetic Alphabet…. and we will also show how Critical Human Action Profile (CHAP) and Change Analysis can help you decide when these tools were not used when should have been and where Human Engineering changes should have been the long-term answer.
“Denise Nichols, the vice president of the National Gulf War Resource Center, says the VA is blaming a coding error for the mistake.”
Where would this event be placed for investigation… the Quality Group? …… the Risk Group? Would it get a thorough Root Cause Analysis? Where would you start… with the Coding problem? … when the notifications were sent out? When the problem was caught?
The answer is all of the above! Problem is that often quality issues will not get the level of attention as would a Sentinel Event. Problem is Quality and Patient Safety are part of the same system, no matter what the title on the door.
“The cause was being investigated, the authorities said, but it appeared that both mechanical failure and human error played some role in the collapse.” _______________
I don’t know if it’s true that his harness was not properly secured, but the other two workers survived. That is what harnesses are for.
I blogged about some window washers a couple of weeks ago who were stranded when their platform gave way. See this entry for information on equipment/mechanical failure.
We don’t have all the facts yet but what I can say for sure is neither of these incidents had to happen.
“O’Toole, an Australian in charge of PNG’s governmental Air Crash Investigation unit, told AAP in April last year that authorities had failed to properly investigate 19 air crashes since 2000 in which 16 people, including three Australians and three New Zealanders, died.”
“Lack of funds and facilities are blamed for the failure of PNG’s Civil Aviation Authority and Department of Transport to fully examine those plane and helicopter crashes, despite legislation in 2004 establishing an Air Accident Commission.”
“The situation is endangering lives. How can recommendations be made if there are no insights in why planes have gone down?”
——————————-
Wow. No insight into why, i.e. no root cause analysis. That comes as no surprise since these problems have reoccurred.
Obviously this is a very challenging operating environment and therefore should have even more controls in place to prevent such incidents.
If the inspector’s comments are accurate, this is very troubling. I hope the authorities get some structure built around their investigations so they can start preventing these.
Saying you are going to do root cause analysis is just the first step; you then have to make sure your investigators have the knowledge, training, and system to perform investigations that really find the problems and prevent them from re-occurring. TapRooT® can help; why not attend one of our upcoming courses? You can see the schedule HERE.
Are you interested in learning more about human error? We have a new course, Stopping Human Error, which will be offered on October 5-6 in Nashville, TN. For more information and to enroll, click HERE.
You can also stay for three more days and attend the Behavior Change and Stopping Human Error Track at the 2009 TapRooT® Summit. For more information and the schedule of best practice talks for the track, click HERE.
We hope to see you there, because to err is human.
Take a quick test and see how you do. Once done, ask yourself:
…which tasks require what sense or senses in your company?
…what would happen if you were fooled by your sense during a critical step?
…during your process observations or task audits are sense critical tasks identified?
…if it is vital to be able to smell a chemical if it leaks and you have a cold, then what?
To learn more about the senses and stopping human error, join Mark Paradies and I during the Pre-Summit in Nashville this October. First, you have to register for the Stopping Human Error Course:http://www.taproot.com/summit.php?t=pre-summit#humanerror
Airlines, hospitals, utilities, trucking companies, barge companies, refineries, nuclear plants, the military, railroads, or any 24 hour operation has a constant problem that haunts their workers: FATIGUE.
Here’s an article about pilot fatigue in the Houston Chronicle:
If fatigue is a possible cause of accidents at your company, perhaps you should attend the TapRooT® Summit and find out more about investigating fatigue related incidents and how to fight fatigue related problems.
Bill Sirois, COO of Circadian Technologies, will present two talks about fatigue. They are:
“How Fatigue Impacts Human error”
and
“How to Prove that Fatigue Was the Cause of an Incident.”
For the complete Summit schedule for all 12 Summit Best Practice Tracks, click on the appropriate buttons at:
That’s only one of the great talks you will hear in the Investigation and Root Cause Analysis Best Practices Track at the TapRooT® Summit. For more information about all the tracks, see:
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