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:
“CERN has been working since late last year to repair the damage caused by a faulty electrical joint. The breakdown occurred nine days after the spectacular start up of the $10 billion machine last Sept. 10 when beams of subatomic particles were sent around the accelerator in opposite directions.”
“He (spokesman James Gillies) said the biggest cause of the “bad accident” last year was ‘probably due to human error caused by rushing the project.’”
“‘But I view it as a temporary black eye. We’ll get it up and running,’ Kaku said.”
“CERN expects repairs and additional safety systems to cost about 40 million Swiss francs ($37 million) over the course of several years, covered by the 20-nation organization’s budget.”
If human error could cost your company millions. maybe it’s time to invest in a little training that will help you stop human error. See the course at this link:
It seems the driver was fatigued and had an accident. Prosecutors tried to convince the judge that the fatigue was the direct cause of the accident and that the management knew that the drivers didn’t have proper sleep, but used them anyway.
The driver received a four year jail term for the accident. But management was acquitted. Why? The judge was not convinced by the expert testimony that fatigue was a cause of the accident.
At this year’s Summit, there is a session about proving that fatigue is the cause of an accident. It will teach a technique to analyze fatigue using available data. This “simplified” technique isn’t qualified for use as evidence in court. But the more robust technique that it is based on is. Perhaps if this more robust technique had been presented to the judge, he would have been convinced that managers were guilty.
If your company does business in the UK, are you prepared for accidents in light of the Corporate Manslaughter Act?
Our UK instructors teach a course to prepare your managers for their new responsibilities and risks under the Corporate Manslaughter Act. They are experienced detectives and can share with your management the challenges they will face and the preparation they need to take to be ready if a fatal accident occurs,
Contact us by using the link below for more information:
They are “leaning” away from human error. “It was just a freak thing that happened.”
I would be willing to bet human error was in fact involved. Possibly they are implying that the two individuals involved did not err, which I would understand; however, if the equipment failed do you think human error may have been involved?
Normally when equipment fails, it is because HUMANS do no operate or maintain the equipment properly, which means what? Human error.
If you are interested in equipment failure, please sign up for our FREE equipment newsletter. See this blog entry for more details.
If you are interested in learning more about human error, attend our Stopping Human Error course on October 5-6. We would also invite you to stay the following three days for the TapRooT® Summit. You can attend the Behavior Change and Stopping Human Error Track, the Equipment Reliability and Maintenance Track, or you can mix it up and attend sessions from both tracks (or the other 10 tracks!) We have something for everyone, so please join us.
By the way, I can’t let you go without making one more comment about the window washer article; the comment about Massachusetts not enforcing OSHA laws is totally misleading. MA falls under Federal OSHA jurisdiction, while some states have state plans which require adherence to the federal guidelines at least, with some guidelines being stricter (CA/OR/UT/KY for example). Most states fall under the federal plan just like Massachusetts.
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