Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Buck Griffith for his group. Watch and learn …
This looks like they should have been applying Equifactor® before the accident to handle the equipment reliability problems they were having.
Also, see the lessons learned at the end of the “AccidentRussianHydroPlant.pdf” that is linked to above. Do you think they were based on a through root cause analysis?
Wouldn’t it have been nice to see a real TapRooT® Investigation of this accident…
Imagine a good, complete summer SnapCharT®. And root causes identified for each Causal Factor by using the Root Cause Tree®. And corrective actions developed using the Corrective Action Helper® Module and SMARTER.
How much knowledge is lost because we don’t effectively investigate problems?
Every accident Investigator should be familiar with certain classic accidents that provide lessons across all industries. The capsizing of the ship “herald of Free Enterprise” is one of those accidents. It happened on March 6, 1997.
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Steve Cavanaugh for his group. Watch and learn …
The Associated Press reported that Chief Electrician’s Mate John G. Conyers suffered a severe electrical shock and was later pronounced dead at Sharp Coronado Hospital.
The AP reported that the Chief was conducting “routine work” when he was killed.
Normally, Chiefs are supervising, not performing, work. And there is nothing “routine” about working with electricity aboard a ship. Complacency (routine) with electricity on a ship is a deadly combination.
One of my early shipboard jobs in the Navy was being the Electrical Division Officer aboard USS Arkansas (a nuclear powered cruiser). One of the first “performance improvement” programs I ever attempted was to re-instill respect for electricity and get 100% compliance with our lock-out/tag-out program to isolate and check dead all sources of voltage during electrical maintenance work.
People who work with any hazard (for example, electricity), tend to become complacent over time. I’m not sure if this happened on the USS Ronald Reagan, but it certainly is a problem that every manager/supervisor who supervises people who work with a hazard has to confront head-on.
Also, supervisors can frequently be tempted to do work and even take shortcuts to get a job done. This takes them out of their roll to supervise a job and make sure it is done safely and puts them into a dangerous situation where no one is looking over their shoulder to make sure the job is done safely. Once again, I have no evidence that this happened aboard the USS Ronald Reagan, but I’ll be interested in what the eventual accident report has to say.
What can we learn from this fatality BEFORE the investigation is even completed?
First, TapRooT® Users would be getting a complete picture of WHAT happened before they started analyzing WHY it happened. As you can see from my background, there are several problems that I would automatically look for. But, TapRooT® requires the investigator to look at the evidence first before starting the root cause analysis. They have to have a good, complete, accurate, detailed SnapCharT® before they identify the accident’s Causal Factors and find each Causal Factor’s root causes.
Second, TapRooT® Users have a systematic root cause analysis technique, called the Root Cause Tree®, that helps them be sure to check for the many different potential root causes of a problem (Causal Factor). The tree helps guide them to areas they may not have thought of to investigate before. It helps the investigator get beyond blame to find real, fixable root causes that, when fixed, can prevent future accidents.
Third, once the root causes are identified, TapRooT® has a module called the Corrective Action Helper® that helps the investigator develop effective corrective actions. This helps the investigator and management develop corrective actions that might be “outside the box” as far as their experience with corrective actions is concerned.
If you are a TapRooT® User, you have already learned these lessons (but it is good to have them reinforced).
If you are NOT a TapRooT® User, get to a TapRooT® Course NOW! Investigating smaller accidents, incidents, and near misses, as well as using the TapRooT® techniques proactively, can help you avoid major accidents and keep your employees safe.
For more TapRooT® information, including success stories from TapRooT® users, see:
The National Transportation Safety Board makes the following recommendations to the Federal Railroad Administration:
Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire- protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)
Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)
Here is a statement from Don Holmstrom, Investigations Supervisor, at the US CSB…
Good morning I am CSB Lead Investigator Don Holmstrom; thank you for coming to this CSB news conference. The Chemical Safety Board is an independent federal agency that investigates and reports to the public on the causes of major chemical accidents at industrial sites across the country. The CSB is headed by five board members appointed by the president and confirmed by the Senate. The CSB’s reports and safety recommendations to Congress, federal and state regulators, and industry are widely followed and applied throughout the United States. Our mission is to prevent disastrous accidents of the kind that occurred here less than three weeks ago.
The safety issues raised by this accident are not limited to Connecticut. These issues are larger than any particular company, facility, or individual. The U.S. has embarked an ambitious construction effort for new natural gas power plants. Thousands and thousands of workers across the country will be involved in constructing these plants. The safety of these workers and the nation’s energy independence are at stake as these gas-fired plants are built over the next 20 years.
The CSB has a team of ten here investigating at the Kleen Energy accident site. On behalf of all of us at the CSB, we extend our deepest condolences to the families of Ronald Crabb, Peter Chepulis, Raymond Dobratz, Kenneth Haskell, Christopher Walters and Roy Rushton. The goal of the CSB investigation is that terrible accidents like this will not happen again and that no families will suffer such tremendous losses in the future.
The CSB team arrived at the site on February 8th. Since that time, the CSB team has conducted a large number of interviews, reviewed documents, and closely examined the accident site on numerous occasions. We appreciate the outstanding cooperation from the workers at this facility, who despite living through such a horrible ordeal have provided valuable information to CSB investigators.
This accident occurred during a planned work activity to clean debris from natural gas pipes at the plant. To remove the debris, workers used natural gas at a high pressure of approximately 650 pounds per square inch. The high velocity of the natural gas flow was intended to remove any debris in the new piping. At pre-determined locations, this gas was vented to the atmosphere through open pipe ends which were located less than 20 feet off the ground. These vents were adjacent to the main power generation building and along the south wall. The open pipe ends are visible here in the photographs.
You can actually see the high-pressure gas venting out of one of these open pipe ends in this photograph taken a short time before the accident on February 7.
This cleaning practice is known within the natural gas power industry as a “gas blow.” Industry personnel have indicated to CSB investigators that gas blows are a common practice during the commissioning of new or modified gas pipes at their facilities.
CSB investigators have reviewed gas utility records for the morning of the accident. These records together with written pipe cleaning procedures and witness testimony confirm that the gas blows occurred intermittently over the course of the morning. At the same time that gas blows were underway, there were potential ignition sources present in the surrounding area, including inside the power plant building. There were many construction-related activities underway inside the building.
Determining the exact ignition source is not a major focus of our investigation at this point. In most industrial worksites, ignition sources are abundant and efforts at accident prevention focus first and foremost on avoiding or controlling the release of flammable gas or vapor.
Initial calculations by CSB investigators reveal that approximately 400,000 standard cubic feet of gas were released to the atmosphere near the building in the final ten minutes before the blast.
That is enough natural gas to fill the entire volume of a pro-basketball arena with an explosive natural gas-air mixture, from the floor to the ceiling.
This gas was released into a congested area next to the power block building. This congested area likely slowed the dispersion of the gas. The gas built up above the lower explosive limit of approximately 4% in air and was ignited by an undetermined ignition source.
In the days since the accident, companies and safety regulators from around the world have contacted the CSB asking about the circumstances of this devastating accident. Some companies, including a power plant here in the region, indicated that they themselves have been planning similar gas blows as part of commissioning pipes in the very near future.
A major focus of the CSB investigation is to determine what regulations, codes, and good practices might apply to these gas blows. To this point, no specific codes have been identified, but we are continuing our research.
In the meantime, we strongly caution natural gas power plants and other industries against the venting of high-pressure natural gas in or near work sites. This practice, although common, is inherently unsafe.
The CSB is investigating possible alternatives to this practice, including the use of air, steam, nitrogen, or water or the use of combustion devices to safely destroy the gas. Combustion devices like flares can safely burn up flammable gas or vapor, preventing the possibility of an explosion.
Recommending safer alternatives will be a primary focus of the CSB investigation as we move forward.
Just three days prior to this tragic accident, the Chemical Safety Board recommended changes to the National Fuel Gas Code to prevent disastrous explosions involving gas purging. We note with great appreciation that just yesterday, at a meeting in San Francisco, the NFPA panel responsible for the fuel gas code voted to move forward with the CSB’s recommendations to make purging practices safer at work sites across America. These provisions will apply at hundreds of thousands of facilities, once fully adopted.
The type of purging described in that code is different from the gas blows used in the power industry, and power plants remain exempt from the national fuel gas code. However, gas purging as defined in the code has certain similarities to gas blows, in that gas is applied at one end of a pipe and gas is intentionally vented at the other end to the atmosphere.
There is an underlying common theme among the tragic accidents at Kleen Energy, the ConAgra Slim Jim plant in North Carolina, the Ford River Rouge power plant in Michigan, the Hilton Hotel in San Diego, and many other purging-related accidents. Companies must ensure that flammable gases are not vented into close proximity with ignition sources and workers. That is a vital safety message from all these tragedies.
We encourage the gas power industry to closely study the very positive actions recommended by the NFPA and the American Gas Association committees yesterday. The CSB investigation will focus on determining what permanent changes in standards or practices are needed to prevent future accidents involving gas blows.
Thank you for attending this morning and we will be happy to answer questions from members of the media. Please state your name and affiliation with your questions.
The Mercury News reported that Cal-Osha fined the Department of Water Resources $140,000 after an accident caused by failing to replace an energy dispersion ring in a valve (the report said that they didn’t have time to replace the ring because of the upcoming season) and failure to inspect/maintain a steel wall for 40 years.
Does your facility have standards for maintenance and repairs?
What happens when a part related to safety isn’t available?
Who makes the decision what to do?
Has becoming “Lean” created spare parts shortages?
What old equipment needs safety inspections to make sure that wear or corrosion hasn’t made it unsafe?
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by William Missal for his group. Watch and learn …
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Ryan Cezair for his group. Watch and learn …
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?
More information on the sudden acceleration problems. The article starts with this paragraph:
“Complaints of deaths connected to sudden acceleration in Toyota vehicles have surged in recent weeks, with the alleged death toll reaching 34 since 2000, according to new consumer data gathered by the government.”
I thought that I would provide the guidance by breaking up the suggestions by the 7-Step TapRooT® Reactive Investigation Process that is detailed in Chapter 3 of the TapRooT® Book (Copyright 2009, used here by permission).
NOTE: If you don’t understand the terminology or reasons for the management actions below, it could be that you need more TapRooT® Training!
TapRooT® 7-Step Reactive Investigation Process
STEP 1
So let’s start with Step 1: Planning the Investigation - Getting Started.
Since we are just getting started, there is nothing for management to review. However, management does have several responsibilities.
a. Management needs to set criteria for what gets investigated. This should be documented in the site’s incident investigation procedure. Management should then make sure that all incidents are reported and investigated. Occasionally, management will identify an incident that doesn’t meet the criteria, but still, in their opinion, deserves a complete investigation and root cause analysis.
b. Management should make sure that their site is prepared for investigations. This includes having an investigation procedure, trained investigators, and investigation review process, and trained management. See the TapRooT® Book (Chapters 3 and 6 and Appendix A and C) for more information.
c. Management should ensure that evidence is preserved for the team.
d. Management should make sure they they have assigned an adequate investigative team to perform the investigation and that the team has all the resources and support that they need. Depending upon the seriousness of the investigation, the team may include independent facilitators or coaches to help the team and outside experts for technical guidance. Management should assign an independent (not from the organization involved in the incident) Team Leader for all but the most minor investigations. The Team Leader should be thoroughly trained (probably in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course).
e. Management should agree to an initial investigation scope (although the team should have the freedom to enlarge the scope based on the facts discovered during the investigation).
STEPS 2 & 3
Next, come Steps 2 & 3. I include these together because the main aspect that management will be reviewing is the team’s SnapCharT® with the incident’s Causal Factors. Management should make sure that:
a. The team has a detailed, logical SnapCharT® that is based on the evidence (facts) about the incident. Each Event and Condition should have a factual bases and not be an assumption (unless the reason for not verifying the assumption is adequately explained).
b. The evidence cannot support alternative scenarios.
c. All facts (not just those that supported this sequence of events) were considered.
d. Each Event includes the “Who did what” or “What did what” to clearly indicate the action that occurred.
e. ALL Causal factors have been identified (including those that were a “catch” for an error). May want to consider the using Safeguard Analysis to check the completeness of the Causal Factors.
f. The Causal Factors are the big picture causes of the incident and are not root causes. (They meet the definition of a Causal Factor and are at the “most general” end of the “So What?” chain.)
g. All Causal Factors have the associated information about them grouped together under the Causal Factor.
h. Only job positions (not people’s names) are used on the SnapCharT®.
i. Emphasis adjective are not used on the SnapCharT® (just state the facts - quantified when possible).
j. The Causal factors are repeatable and sufficient to cause the Incident.
STEPS 4 & 5
Next come Steps 4 & 5 - finding the incident root and generic causes. For these two steps, management should ensure that:
a. The team took each Causal Factor though the Root Cause Tree®.
b. Each root cause has evidence to support the finding and that the evidence provides a “Yes” answer to one of the questions in the Root Cause Tree® Dictionary.
c. The evidence is on the team’s SnapCharT®.
c. Management System root causes were considered.
d. The team checked for previous similar incidents and previous ineffective corrective actions.
e. Generic causes were considered for each root cause that was discovered.
f. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) was considered in analyzing the root causes’ generic causes.
g. There is evidence to support the finding of generic causes.
STEPS 6 & 7
The final management jobs in Steps 6 & 7 are to ensure that sufficient corrective actions are adopted and implemented to prevent recurrence of this incident and, if applicable, similar incidents. Therefore, management should ensure that:
a. Each root cause/generic cause has a corrective action.
b. The corrective action is SMARTER.
c. The investigation team considered the recommendations in the Corrective Action Helper® (check their recommendations against the Corrective Action Helper®).
d. For a significant incident’s root causes, Type 1-4 corrective actions are used (see below). Preference should be given to removing the hazard if possible, next removing the target, and then guarding the target.
(From the TapRooT® Book. Copyright 2008. Used by Permission.)
e. Any corrective action that includes a “re” should be questioned. (For example: retrain, remind, and re-emphasize.) “Re” corrective actions are just repeating actions that didn’t work in the past. Why do we expect them to work now? Also, note that if the corrective action is counseling an employee to remind them about rules or procedures, this is “re” corrective action and should not be used alone, but must be combined with other behavior change techniques.
f. Reject any corrective action that includes these words - Ensure, Assure, Insure, Make Sure - unless the team can explain how they will make sure that the change occurs (and this additional information should be included in the corrective action to make it specific).
g. Corrective actions that are studies be carefully evaluated to see why the study has to be delayed and can’t be completed before the investigation is concluded. (Examples of studies are: Investigate, Evaluate, Consider, Analyze.)
h. Any corrective actions that require behavior to change have considered what factors are causing current behavior and how these will be removed and what rewards/incentives and punishment will be clearly linked to the desired behavior to make it occur.
i. Training is not used as punishment or to embarrass an employee.
j. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) were considered in developing corrective actions and are documented on the SnapCharT®.
k. The people responsible for implementing the corrective actions and the people impacted by the corrective actions agree that the corrective action will be effective.
l. Corrective action will be sufficient to eliminate significant risk or if additional Safeguards or process redesign need to be considered because the risk is so significant.
m. Corrective actions are assigned to the appropriate individual/organization for implementation.
n. The organization responsible for corrective actions has adequate resources to implement the corrective action by the assigned due date.
o. The corrective actions are tracked, and if significant enough, verified, and validated. Management should periodically be updated on corrective action status, especially overdue corrective actions.
p. Significant corrective actions are periodically checked (audited) to ensure their continued effectiveness.
q. Significant corrective actions that may impact other facilities are shared within a corporation.
r. Names of employees are not used in the report.
s. Emphasis adjective are not used in the report (just state the facts).
t. Pictures are used effectively to help explain what happened in the report and presentation.
u. Rewards are given for good investigations.
v. Evidence and reports are retained to meet any legal requirements.
Not every one of these “management must” items must be performed by a manager for each investigation. Management can set up systems , review teams, or review boards to help ensure the quality of investigations.
- - - -
Now for your comments … What do you think? Additions? Deletions? Modifications?
And how is your site doing to make sure the TapRooT® Process is being used correctly, efficiently, and effectively?
By the way, many of the points above originally were shared as best practices at the TapRooT® Summit. If you would like to keep up with the latest TapRooT® best practices, attend the 2010 TapRooT® Summit in San Antonio on October 27-29.
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.)
I can’t tell you how shocked I was to read that tag line. A fatality investigation that only took one day? You have got to be kidding.
It only took officials one day to learn that there was no “fault” on their part in the accident.
First of all, I do understand this is a dangerous sport and the participants understand the dangers. However, that does not mean there cannot or should not be measures to make it is as safe as possible. Interestingly, they are going to make some changes now, after someone was killed.
Even if guaranteeing that someone going that speed is difficult (but I think possible) to keep on the course if they lose control, how difficult is it to make sure there are no hazards for them to hit? Or putting some padding on things? A steel pole you are sure to hit if you fly off the track does not seem safe to me. And what about the concerns that were raised?
Seems a little bias, expediency, or ignorance is in play here. Just my opinion.
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.
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Renauld Washington for his group. Watch and learn …
“Authorities launched a criminal investigation Monday into the cause of an explosion that killed five people at a power plant under construction, saying they couldn’t rule out negligence.“
“‘If everything went right, we wouldn’t all be here right now,’ Middletown Mayor Sebastian Giuliano said. ‘There’s a point where negligence raises to the level of criminal conduct, and that’s what we’re investigating.‘”
For the complete story, see this Houston Chronicle link:
Interestingly, The Chemical Safety Board investigators were turned away because this was a “criminal investigation.”
If you thought the only place where accidents can become “criminal” was in the UK where they have a Corporate Manslaughter Law, I guess you are mistaken. If you would like to find out more about “criminal” investigations of accidents, you might want to attend the new pre-Summit Course that is being provided by our UK TapRooT® Instructors. They are both retired detectives with extensive criminal investigation experience, including the criminal investigation of industrial accidents.
The course is new and information about it hasn’t been posted on the Summit site yet, so watch for future announcements for more information.
And it talks about the safety and budget issues at WMATA.
I guess that putting the bus driver in jail after the accident last year (or was it two years ago?) didn’t stop the accidents at WMATA.
The blog writer at the Baltimore Sun pins his hopes on the NTSB. But in my book, only management can really change safety after they fully understand the root causes of the problems.
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Stephen Wagner for his group. Watch and learn …
An AP story published in the Houston Chronicle says that Transportation Secretary Ray LaHood said that Toyota was:
“…dragging its feet on safety concerns over its gas pedals, suggesting the automaker was ‘a little safety deaf’ to mounting evidence of problems.”
He also said that:
“… federal safety officials had to ‘wake them up’ to the seriousness of the safety issues that eventually led Toyota to recall millions of cars such as its Camry and Corolla. That included a visit to Toyota’s offices in Japan to persuade them to take action.“
The article also said:
“… the government was considering civil penalties for Toyota over its handling of the recalls…”
This kind of press couldn’t come at a worse time as Toyota struggles with this quality/safety issue and the bad press that it has generated.
How much damage to your reputation can a quality/safety issue do? Toyota is finding out the hard way.
CAPTAIN’S INAPPROPRIATE ACTIONS LED TO
CRASH OF FLIGHT 3407 IN CLARENCE CENTER,
NEW YORK, NTSB SAYS
********************************************
The National Transportation Safety Board determined that the captain of Colgan Air flight 3407 inappropriately responded to the activation of the stick shaker, which led to an aerodynamic stall from which the airplane did not recover.
In a report adopted today in a public Board meeting in
Washington, additional flight crew failures were noted as causal to the accident.
On February 12, 2009, a Colgan Air, Inc., Bombardier DHC-8-400, N200WQ, operating as Continental Connection flight 3407, was on an instrument approach to Buffalo-Niagara International Airport, Buffalo, New York, when it crashed into a residence in Clarence Center, New York, about 5 nautical miles northeast of the airport.
The 2 pilots, 2 flight attendants, and 45 passengers aboard the airplane were killed, one person on the ground was killed, and the airplane was destroyed by impact forces and a post-crash fire. The flight was a 14 Code of Federal Regulations (CFR)Part 121 scheduled passenger flight from Newark, New Jersey. Night visual meteorological conditions prevailed at the time of the accident.
The report states that, when the stick shaker activated to warn the flight crew of an impending aerodynamic stall, the captain should have responded correctly to the situation by pushing forward on the control column.
However, the captain inappropriately pulled aft on the control column and placed the airplane into an accelerated aerodynamic stall.
Contributing to the cause of the accident were the
Crew members’ failure to recognize the position of the low-speed cue on their flight displays, which indicated that the stick shaker was about to activate, and their failure to adhere to sterile cockpit procedures.
Other contributing factors were the captain’s failure to effectively manage the flight and Colgan Air’s inadequate procedures for airspeed selection and management during approaches in icing conditions.
As a result of this accident investigation, the Safety Board issued recommendations to the Federal Aviation Administration (FAA) regarding strategies to prevent flight crew monitoring failures, pilot professionalism, fatigue, remedial training, pilot records, stall training, and airspeed selection procedures. Additional recommendations address FAA’s oversight and use of safety alerts for operators to transmit safety-critical information, flight operational quality assurance (FOQA) programs, use of personal portable electronic devices on the flight deck, and weather information provided to pilots.
At today’s meeting, the Board announced that two issues that had been encountered in the Colgan Air investigation would be studied at greater length in proceedings later this year.
The Board will hold a public forum this Spring exploring pilot and air traffic control high standards.
This accident was one in a series of incidents investigated by the Board in recent years - including a mid-air collision over the Hudson River that raised questions of air traffic control vigilance, and the Northwest Airlines incident last year where the airliner overflew its destination airport in Minneapolis because the pilots were distracted by non-flying activities - that have involved air transportation professionals deviating from expected levels of performance.
In addition, this Fall the Board will hold a public forum on code sharing, the practice of airlines marketing their services to the public while using other companies to actually perform the transportation. For example, this accident occurred on a Continental Connection flight, although the transportation was provided by Colgan Air.
A summary of the findings of the Board’s report are available on the NTSB’s website at:
They question Toyota’s management, organization, and cost cutting efforts.
Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.
The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”
The story also said:
“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“
Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!
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The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
