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®!
While dumping the contents of a hydrovac unit, a swamper was killed when he was caught in the closing hydrovac tank door.
What Went Wrong?:
The truck operator and swamper were offloading the contents of the hydrovac truck at a designated area. The hydrovac truck tank had been elevated and the rear door was opened to allow the crew to clean out the tank.
Other relevant incident information:
Photograph of rear door configuration of a typical hydrovac truck. Note crush point.
The workers had cleaned the tank and had both stepped down from the rear tank access platforms (also known as beavertails).
The operator walked around to the drivers side of the truck to access the hydraulic control levers located directly behind the cab of the truck.
Unknown to the truck operator, the swamper had climbed back up onto the right, rear beavertail and became caught in the swing radius of the rear tank door as it was closing.
Corrective actions and Recommendations:
To prevent future incidents, the employer and the hydrovac truck supplier have worked together to implement a number of corrective actions.
Equipment Modifications (Engineering Controls)
The hydrovac truck supplier has altered the hydrovac truck involved in the incident including:
The bank of four control levers for the vacuum tank operation were changed;
Two control levers have been routed to other locations. The removal of these levers may allow for additional room between the remaining control levers to minimize an inadvertent activation due to their proximity; and
The control lever that operates the rear tank door was moved to the rear of the hydrovac tank, which allows the operator to maintain a clear line of sight of the door during opening and closing operations.
Flow restrictors have been installed on the hydraulic lines to the cylinder for the opening and closing of the rear tank door. This alteration slows down and controls the door’s rate of travel;
Hydraulic controls have been tagged with permanent markings to provide clearer identification of the function of the control; and,
Signs warning of the hazardous pinch point have been installed on both sides of the rear of the vacuum tank.
The supplier intends to make similar alterations to all new vacuum/hydrovac truck assemblies and all vacuum/hydrovac trucks, which are returned for service and recertification.
Revisions to Operating Procedures (Administrative Controls)
The employer has modified its hydrovac truck operating procedures to include:
An enhancement and ordering of the steps that will be followed for closing the tank door and lowering of the tank;
Added a requirement that the hydraulic rear door operator visually identifies any workers for whom the closing tank door may be a hazard, before the operator activates the controls; and
Added a provision for the engagement of the tank safety bar when the tank door is open. This provision would include a requirement that, when the tank is clean, the swamper should remove the bar while remaining in the operator’s line of sight and then instruct the truck operator to close the door.
The employer and hydrovac truck supplier involved in this incident believe that the actions summarized above are relevant to the manufacture, supply and associated procedures of similar equipment used at energy and construction work sites. They are urging other companies to reassess their operations in light of the measures identified above and identify if there is a need for similar preventive actions in their operations.
Source Contact:
This alert is being distributed via a partnership between the International Association of Oil and Gas Producers (http://www.ogp.org.uk/) and Enform (http://www.enform.ca/).
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.”
I have had some discussions concerning how you might use TapRooT® in criminal investigations. For example, how would TapRooT® work for a murder investigation? After all, TapRooT® is designed to be used to get to the root cause of why people make mistakes. When you have something like a murder, you are more into intentional acts. Where would you put this on the Root Cause Tree®? Some thoughts…
I would recommend looking under the Natural Disaster / Sabotage area. This is where intentional acts would be categorized. The investigation would then be turned over to a law enforcement-type investigation.
I’m not saying that TapRooT® is therefore not able to be used for any part of the investigation. The SnapCharT® is an ideal tool for evidence collection, and in fact, law enforcement agencies use a rudimentary form of charting for just that purpose.
You could also use Safeguards Analysis to help you figure out how you might have been able to detect, prevent, or mitigate the consequences of the criminal act.
Note that most crimes are not completely willful, and TapRooT® does a great job with that. Drunk driving, friendly fire, etc may be analyzed using TapRooT® with great results.
Some accidents are so historic that every accident investigator should know about them. The Challenger is one of those. It happened 24 years ago today. Dana Barclay, one of our TapRooT® Instructors with an Navy flight background, assisted with this massive investigation. Here is a link to the Report of the Presidential Commission:
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 Jeffery Hubbartt for his group. Watch and learn …
The Associated Press reports that Toyota is stopping production for at least a day at six assembly plants and is stopping sales of eight models until accelerator sticking problems are solved.
National Transportation Safety Board
Washington, DC 20594
January 26, 2010
The National Transportation Safety Board has launched a team of investigators to today’s Washington Metropolitan Area Transit Authority (WMATA) accident in Rockville, MD. At 1:45 am (EST) a hi-rail vehicle, in the work zone on the red line near Rockville Station, struck and killed two employees on the track.
NTSB rail investigator Stephen Klejst has been designated as the Investigator-in-charge and is accompanied by two investigators with expertise in operations and human performance.
“A new round of construction problems on U.S. Navy vessels built by Northrop Grumman Corp. have spawned yet another investigation into the nation’s largest Navy shipbuilder.
Northrop, already under fire for widespread yet unrelated welding problems that surfaced two years ago at its Newport News shipyard, now faces quality issues at its Gulf Coast yards in Avondale, La., and Pascagoula, Miss., the Navy said Thursday.
All Gulf Coast vessels built by the company over the last several years are under investigation for a host of problems, including improper welds and defective engines and lube-oil systems, the Navy said.“
Other bad press for Northrop Grumman Shipyards include:
Sounds like they need better root cause analysis and better corrective actions! Maybe it’s time they took a TapRooT® Course?
Poor quality over an extended period of time is an indicator that your problem reporting and corrective action programs aren’t working. Applying the same old corrective actions of blame, counseling employees, more training, and making procedures longer doesn’t solve quality issues. People stuck in the blame game need a systematic investigation process that finds the true root causes of problems and the solutions.
TapRooT® does that with proprietary, copyrighted systems and training, and patented software that comes with a money back guarantee. Nobody else stands behind their system like we do. And that’s just one of the reasons that industry leaders choose TapRooT®.
If you are interested in thorough investigation of quality problems with effective corrective actions, consider sending some of your quality professionals to a 5-Day TapRooT® Advanced Team Leader Training public course. See:
Washington, DC, January 25, 2010 – The U.S. Chemical Safety Board (CSB) today voted to initiate an investigation of recent accidents at the DuPont chemical complex in Belle, West Virginia, following a release of highly toxic phosgene on Saturday that fatally injured a veteran operator.
DuPont officials told the CSB that a braided steel hose connected to a one-ton capacity phosgene tank suddenly ruptured, releasing phosgene into the air. An operator who was exposed to the chemical was transported to the hospital, where he died the following day.
The phosgene release followed two other accidents at the same plant this week, including an ongoing release of chloromethane from the plant’s Hexazinone unit, which went undetected for several days, and a release of sulfur dioxide from a spent sulfuric acid unit. The plant announced over the weekend that it would be shutting down a number of process units immediately for safety checks.
Speaking for the three-member board, Member William E. Wright said: “The Board is concerned by these releases, which had tragic consequences, and will proceed with an investigation to understand why these unfortunate events occurred.” Mr. Wright cautioned that the new case would likely delay efforts to complete other investigations that are being conducted by same investigative team, including those at the Bayer CropScience facility in Institute, West Virginia, and an Ohio environmental services company. Including DuPont, the CSB has 17 open investigations, the largest number in its 11-year history.
In voting to approve the investigation, the Board noted that the CSB was aware of six other releases from the plant since December 2006. The DuPont Belle complex is a large facility that is regulated under the EPA Risk Management Program and the OSHA Process Safety Management standard because of the volume and hazards of the materials it handles and the potential risk to workers and the community.
CSB investigator Johnnie Banks will lead the four-member team which is expected at the site on Tuesday.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz, (202) 261-7613, cell (202) 441-6074, or Public Affairs Specialist Hillary Cohen, (202) 261-3601, cell (202) 446-8094.
NTSB ASSISTS U.S. COAST GUARD INVESTIGATION INTO TANKER COLLISION AND OIL SPILL NEAR PORT ARTHUR, TEXAS
*************************************************
The National Transportation Safety Board has launched a go-team to participate with the U.S. Coast Guard (USCG) in its investigation of Saturday’s collision involving the tank vessel EAGLE OTOME and the tug DIXIE VENGEANCE near Port
Arthur, Texas, in accordance with the Memorandum of Understanding between the two federal agencies.
Marine investigator Rob Jones is leading the NTSB team and is accompanied by specialists in engineering and hazardous materials.
Media inquiries about the status of the investigation should be directed to the USCG Joint Information Center for Port Arthur at 409-812-0261.
If you had the unexpected worst case accident at your plant, would you be ready to complete a root cause analysis that would stand up to regulatory and press scrutiny in just 60 days?
“And within 60 days, the company must provide a corrective action plan, hazard and operability study, and a ‘root cause analysis’ of what triggered the disaster. The company could face fines of $500 a day or more if the information isn’t submitted on time, according to an agreed order among NDK, the Boone County state’s attorney’s office and the Illinois attorney general’s office.“
Let’s hope NDK Crystals has some experienced root cause analysts ready to go with advanced root cause analysis techniques ready to apply and maybe a Corrective Action Helper® Module in their patented software. Because on the day you sign the consent order with the EPA, it’s too late to start looking for a TapRooT® Class for your investigators.
“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?
The RAIB is carrying out an investigation into a fatal accident that occurred at Moreton-on-Lugg level crossing, Herefordshire, on the railway between Shrewsbury and Hereford, on 16 January 2010. For more info, see the UK RAIB web site at:
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 Dan Evans for his group. Watch and learn …
“A fire aboard an Apache Corp. oil and natural gas platform in the Gulf of Mexico left one contract worker dead and halted production at the facility. …”
See the accident report at:
