Why do I ask this you may wonder? In today’s world “keyword’s” help internet users find what they need…. sometimes. However, many times “keyword” searches limit your field of opportunities, regardless of what the meaning or purpose of the word may represent. So continuing down this train of thought, would you consider losing a customer an incident?
Oxford’s definition of Incident:
An event or occurrence : several amusing incidents.
• a violent event, such as a fracas or assault : one person was stabbed in the incident.
• a hostile clash between forces of rival countries.
• ( incident of) a case or instance of something happening : a single incident of rudeness does not support a finding of contemptuous conduct.
• the occurrence of dangerous or exciting things : the winter passed without incident.
• a distinct piece of action in a play or a poem.
The TapRooT® definition of Incident:
• The reason the investigation is being conducted and defines the investigation scope
• The incident usually the most serious event that took place
So would losing a customer be a “serious event”? What if you had a customer complaint and still have a chance to keep from losing the customer? I don’t know about you, but I want to keep my customers. By defining the possible loss of a customer as a significant incident what should your next step be? Think TapRooT®, a root cause analysis system and training that helps solve problems both reactively and proactively. The next step is to find out where to learn about TapRooT®:
1. TapRooT® Summit
If you want to learn how others in numerous industries have applied TapRooT® to resolve customer and product issues in oil refining, oil drilling, bio and medical manufacturing, medical care, aviation (service and manufacturing), nuclear regulatory agencies, engineering companies, chemical manufacturing, governmental agencies…. and numerous others, the TapRooT® Summit in June may be your answer. Click on Summit on www.taproot.com to select a topic track that fits your business needs.
2. TapRooT® Public Courses
Meet other industries in a our public courses as you learn the way to perform a solid TapRooT® investigation for any type of incident. Click on Courses on www.taproot.com for a location near you.
3. TapRooT® Onsite Courses
Let us come to your company and train your employees, supervisors, and managers in house. Call us at 865.539.2139 for quotes.
If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.
It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?
A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.
My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.
Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.
In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.
As a TapRooT® root cause analysis instructor and a Six Sigma Black Belt for System Improvements, Inc., I ask the question in this article’s title to numerous safety leaders from multiple industries. What do you think the typical responses are before they attend a TapRooT® course…..
1. No Lost Time Injuries
2. No Fatalities
3. No Near Misses
What’s wrong with these answers? After all, to be best in class for safety you must report these types of numbers. What if I asked your company’s safety leader the following question… “what did you do wrong today to cause this person to get hurt?” This is basically the same question as above except now the safety leader has to answer that the safety department was not successful at the end of the day.
The point is that that the above answers are what are called “lagging metrics”. It’s too late to know what was done wrong or even what was done right! Think about it… when a a fatality occurs the investigation team must exert a lot of effort and time to understand what happened, why it happened, and how to prevent it from happening again. Prevention….. if only the team had understood the everyday problems and root causes that were present before the incident occurred in this area of the business.
Did you know that it takes less time to perform a TapRooT® audit in predetermined areas of company and hazard risk than it does do perform a post incident investigation? So the question to ask again is “how do I know I was successful today in safety?” Your answer could be, “based on a predetermined risk assessment, we lowered the high risk areas in fall protection from 70% to 60%!”
For for ideas about proactive TapRooT® audits, call us at System Improvements, Inc. at 865.539.2139 or even better, attend the TapRooT® Summit in June and see how other top industries are using our proactive audits. Below is a list of proactive opportunities. See you in June.
Lessons from recent travels . . . Differences between Europe and the US.
Regulators in Europe are convinced that pre-job hazard assessments (safety cases in the UK) are the key to improved safety. Workers wouldn’t be at risk and there would be no accidents if people would just review the job, spot all the hazards, implement effective techniques to remove or ameliorate the hazard, and then conduct the work.
The US regulatory view seems to be to regulate the highest hazard industries with rules to make people safe in the highest hazard jobs. Keeping people safe is the responsibility of the employer. If the employer fails, they are fined to encourage them to do better in the future (and as a warning to other employers). Some companies use pre-job hazard assessments, but a safety case isn’t required across every industry and job.
In the UK, many companies employ consultants to write the safety case. These people are trained and are an external set of eyes. Many (but not all) are experienced in the industries and jobs they are reviewing. They generally don’t use advanced root cause analysis as part of their assessment. They are not part of the workforce and it seems to me that they are viewed as outsiders. Their work isn’t appreciated much by the workers (who often see the restrictions they generate as unnecessary and a waste of time).
In Europe, when an accident happens, it is viewed as:
1) A failure of the pre-job hazard assessment/safety case process,
2) A failure of the hazard removal/amelioration techniques, or
3) A violation of the rules ordered by the pre-job hazard assessment/safety case.
Many in Europe don’t see root cause analysis as a particularly complex task. Their view is that all they need to do is discover which of the the three problems above is to blame, and then do a better job of hazard assessment/safety case, hazard removal/amelioration, and/or enforcing the rules next time . . . then the problems will go away.
In the US, since companies are blamed if something goes wrong and pre-job hazard assessment/safety case is not seen as a universal fix, companies are much more open to process improvement as a solution to problems and accidents. Because process improvement has a wide range of options to improve human and equipment performance, root cause analysis is seen as a more difficult and valuable process. US companies are more open to investing in advanced root cause analysis tools that can be applied across the enterprise to improve not only industrial, process, and public safety, but equipment reliability, product and service quality, process reliability, and environmental stewardship.
How could both cultures improve?
I know you won’t find it surprising that “Mr. TapRooT®” sees the application of advanced root cause analysis both BEFORE and AFTER work as a necessary part of effective improvement.
I think there is value in proactive pre-job assessments; they would be even more effective if advanced root cause analysis (TapRooT®) was applied proactively as part of the pre-job assessment/safety case by the employees (workers and supervisors) who would be trained to conduct the hazard assessment, develop the hazard reduction strategies, and even write the safety case (or at least help the consultant write it). This would create more effective pre-job assessment and better compliance with the resulting hazard mitigation rules and strategies and become a great way to improve safety both in the US and Europe.
Second, employers need to see accidents as more than failures of hazard assessment/safety case. They need to use advanced root cause analysis (TapRooT®) to understand the true causes of the accident and take effective steps to reduce the hazard by improving the process. This failure analysis technique - applying TapRooT®’s advanced root cause analysis tools - can then be applied across the enterprise to improve processes, safety, productivity, environmental stewardship, and profitability.
CNN posted an Associate Press article on their web site that explains FAA efforts to get accurate reports of controller errors that lead to violations of minimum separation requirements.
These efforts follow earlier disclosures (2005) of under-reporting by the same FAA region (Dallas).
What do you do to encourage reporting of near-misses at your facility? Are people afraid to report near-misses? Do they cover up mistakes? Do you need to improve your near-miss program to get even more near-misses reported?
The Summit is a great place to network and benchmark with industry leaders.
Attend the TapRooT® User Best Practices session and hear about industry leading programs to use root cause analysis to improve performance.
Attend the TapRooT® User Success Stories session and hear three TapRooT® Users describe the results of successful improvement programs.
Attend The Good, The Bad, and The Ugly: Rating Improvement Programs and & Incident Investigations session and participate in a evaluation/benchmarking session to evaluate your efforts and programs.
The Ontario Workplace Safety and Insurance Board created a set of fairly gruesome commercials that dramatically show the results of “accidents.” The message is that there are no accidents. Accidents are caused.
Here’s the video:
These are also available at the WSIB web site for download:
The real question I have about these videos is the focus on blaming the worker, the supervisor, and management. We see the accident happen, but do we know what set the accident up?
To me, the video also shows the difficulties of finding and fixing the real root causes of an accident when our culture first looks to blame.
Pictures below are from a test of the new light rail line being put in service by the Charlotte Area Transit System. CATS is a TapRooT® User and two of their safety professionals are on The TapRooT® Advisory Board.
The video above shows the BC Ferry Spirit of British Columbia exiting the narrow Active Pass.
On March 17, 2008, the same ferry had a near-miss when they came within 180 meters of a Seaspan ferry that carried trucks. This passing distance was legal but violated BC Ferry policy that does not allow passing of vessels in the narrow south pass entrance.
The reason given for the near-miss was that the BC Ferry miscalculated the speed of the other vessel and arrived at the narrow passage before the other vessel had cleared the entrance to the pass. According to press reports, the vessels were in communication and had planned to pass each other outside the entrance to the pass.
The Captain that was fired was a long time BC Ferry employee who had retired and was brought back to work on a contract basis as a relief captain.
Questions from this “near-miss:”
1. Is this how to handle a near-miss?
2. All agree that a mistake was made, but does the Captain deserve to be fired?
3. What are the root causes of this near-miss?
4. What role did the vessel from Seaspan play? Did it have a similar rule? Or did Seaspan allow passing in the Active Pass entrance?
5. Is the BC Ferry system safer after firing an experienced Captain?
6. Have the root causes of this near-miss been fixed?
This certainly is an interesting maritime near-miss and there may be valuable lessons learned. The problem is that the press statements from BC Ferry and the press reports don’t seem to include much useful information for learning lessons.
If you have any more information about this near-miss and it’s causes or know where to find reports that detail the root causes, leave us a message here.
Washington, D.C. - The National Transportation Safety Board today released preliminary aviation accident statistics for 2007.
“The U.S. aviation industry has produced an admirable safety record in recent years,” said NTSB Chairman Mark V. Rosenker. “However, we must not become complacent. We must continue to take the lessons learned from our investigations and use them to create even safer skies for all aircraft operators and their passengers.”
The Safety Board’s aviation accident statistics show that in 2007, there were 24 nonfatal accidents involving Part 121 airlines (aircraft with 10 or more seats). One fatality occurred involving a nonscheduled Part 121 aircraft when a mechanic was fatally injured while working on a Boeing 737 in Tunica, Mississippi.
No fatalities occurred among Part 135 commuter operators (fewer than 10 seats). However, on-demand (charters, air taxis, air tours and medical services when a patient is on board) Part 135 operations reported 43 fatalities (62 accidents, 14 fatal accidents), up from the 16 fatalities that occurred in 2006.
While the overall number of general aviation accidents rose from 1,518 in 2006 to 1,631 in 2007, the number of fatalities in 2007 was down from 703 to 491 (a 30 percent decrease), making it the lowest annual total in more than 40 years.
Foreign registered aircraft accounted for 11 accidents in the U.S. in 2007, with 3 fatalities from a single fatal accident. Of the 14 accidents involving unregistered aircraft, 6 were fatal and resulted in 7 fatalities.
We’ve all heard about the cancelled flights at American, Southwest, and others. And then there are the Congressional hearings with FAA whistleblowers explaining how the FAA and airlines are too close. You would think our air transport system was on the verge of disaster - planes falling from the sky.
Investing in advanced root cause analysis is a winning proposition.
For example, a Peoria nursing home had a chance to find the root causes of previous fall incidents and develop a plan to improve performance. Instead, a Peoria Journal-Star article quotes a Illinois Department of Public Health report as concluding that:
“This policy does not address investigation, tracking or monitoring of accident/incidents or how this data will be analyzed to identify trends and patterns to perform root-cause analysis in order to develop and implement corrective actions to address the falls occurring in the facility.”
The result? More falls and a $40,000 fine from the state.
That’s just one of many fines from the state that can be attributed to a failure to investigate problems and develop effective fixes to correct the problems’ root causes. Another was fined $22,500 and a third was fined $1,908.
Besides the fines, these nursing homes could have avoid injuries to their patients if they had addressed the root causes of quality of care issues.
Nursing homes are usually on a tight budget. but failing to invest in advanced root cause analysis and corrective actions is a fool’s bargain. Don’t be “Penny wise and Pound foolish.” Find out how TapRooT® Training can help your staff and get some signed up for one of our courses.
The results of thousands of “lost” bags are called a “Luggage Mountain.”
They have had to fly jumbo jets loaded with just bags across the ocean to try to unite travelers with their luggage.
And news outlets say the problem could get WORSE!
The cost of this “incident” is more than just the immediate costs to the airlines and travelers. Some say it has caused damage to the whole British reputation.
What is the “cause?” Everyone has an opinion. Most are looking for someone to blame.
But instead of looking for someone to blame, they should try advanced root cause analysis.
TapRooT® has been applied by many major airlines. Alaska Airlines even used it to analyze delayed flights and improve on-time departure statistics.
Perhaps British Air should try TapRooT® to stop the baggage meltdown and improve customer service?
And next time they should use root cause analysis as a PROACTIVE tool to improve performance BEFORE they open a new terminal and thus avoid a major quality of service incident.
Coming to System Improvements, Inc. as a Six Sigma Black Belt with ” the good, the bad, and the ugly” of Six Sigma company implementations, I often get asked how does the TapRooT® root cause analysis system tie in with the above pictured improvement systems and tools? During recent WebEx’s and conference calls, System Improvements, Inc. clients are often concerned about the cost of replacing their current highly invested Six Sigma Programs with TapRooT®. Peculiar thing is that companies questioned the same thing about Kaizen, Lean, and Six Sigma implementations as discussed in an article by Terence T. Burton. For those with existing Six Sigma Programs you can rest; TapRooT® does not replace the above mentioned processes but instead compliments the gaps in root cause analysis (Define and Analyze) and corrective actions (Implementation) to ensure robust proactive and reactive solutions to multiple system problems. For more about six sigma and lean practices integration with TapRooT® sign up for the TapRooT® Summit.
Below are some hard learned lessons, I picked up along the way that should be useful to current process improvement practitioners.
1. There should be no improvement “system” distinction between lean, six sigma, or any other improvement tool or process. People argue needlessly for days. Think about the old schools of psychology, you were either for nurture or nature, or crazy like Freud. Now schools teach that people are effected in the womb by the environment (nurture) and the cells develop (nature) like good soup. Needs to be the right temp and right conditions at the right time and don’t shake the pot. When we are born we are predispositioned to behave certain ways… all the music lessons in the world will not give you a good ear for music. Then it is up to the environment to guide the person. Point is that you must integrate the tools in a process that suppliment or compliment weakness and strengths. See an example of combining a six sigma tool and TapRooT®.
2. “Experts” who implement lean without truly understanding the integrated supply chain, the business needs, and the market will work improvement projects that sub-optimize other projects. A bad thing.
3. Perceived easiness of certain root cause tools in company experts’ hands… i.e. engineers, mechanics, operators, QA…, are actually limiting the analysis. As experts we developed rules-of-thumb and already “know” what the problem is. Funny thing, our children must be ignorant because all they want to do is ask a lot of why and what questions. It is not until we become adults that we know everything. Link to root cause research
4. YOU (the project black belt) must personally convince the boss to change to make the boss commit to a project; if you can’t too bad….Wrong! Influencing without authority means find the person the boss listens to and convince that person the project is the right thing to do…. there are a number of ways to “plant the seeds” of change.
5. Toyota experts developed excellent tools to improve their company… wrong. They went out and looked, understood their process, and then developed tools to represent their improvement needs. The problem with this is that we go out and buy fancy tools, put garbage data in from a company process that we do not not fully understand and then blame six sigma for its failure. You must understand the process used to improve, understand the process you are trying to change, and use tools to complement these processes.
6. Another major problem of six sigma is keeping safety, hr, and training as the outsiders who don’t see the “hidden factory”. Why… because of the initial low Return of Investment. When has your six sigma program observed the core competencies (skills and tasks) needed to perform their job and do it successfully? Does annual training still cover key skill needs?
The TapRooT® Summit has 10 “Best Practice Tracks” focussed specific topics. One of those topics is:
Safety and Risk Management Best Practices
The purpose of this posting is to provide those interested in safety and risk management with a little better idea of the talks and discussion sessions they will experience if the attend the Safety & Risk Management Best Practices Track at the TapRooT® Summit.
Here is a list of sessions with a brief description of each session:
1. Hazard Recognition: The First Step in Safety & Risk Management - Peter Berkholz, Engineering Manager, Capability Resources
Peter will discuss practical strategies to identify hazards in the workplace and methods to get employees to spot and correct problems.
2. CHANGE
Dealing with Obstacles that Make Change Difficult - Hal Curry, Consultant, hal Curry & Associates
Managing the Risks Associated with Change - Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia
All safety improvement programs involve change. Hear these two talks that discuss change, obstacles to change, and risks associated with change.
Cameco Cigar Lake Mine Flood - Mark Wittrup, Cameco
Investigating Fatalities - Mario Chacon, Cal OSHA (invited)
Those interested in safety can learn a lot from the accidents of others. This session focusses on three different discussions about major accidents. First, Ken Turnbull will share how TapRooT® can be applied to public information about an accident to analyze it and learn lessons. Next, Mark Wittrup will present the results of a TapRooT® investigation of an expensive mine flooding accident. Then, Mario Chacon from Cal OSHA will share lessons from fatality investigations.
4. Advanced Behavioral Management: Developing a Modern Safety Culture - Bob King, Director of HSE Training/Consulting, Woodland Grange, UK and Neil Roberts, Consultant, Woodland Grange, UK
Safety culture is a big topic in many industries (nuclear power, oil and refining, aviation, …). Instead of hearing the same perspectives that we have all heard, we decided to bring a fresh look at the topic from Woodland Grange in the UK. Bob King and Neil Roberts will share their experience and advice on developing and establishing a “modern” safety culture.
5. Panel Discussion: Is There a Tradeoff Between Process Safety and Industrial Safety - Panelists: Miles Kajioka (ConocoPhillips), Valarie Barnes (US NRC), Bob King (Woodland Grange), and Ken Turnbull (Consultant, previously with Texaco)
The explosion at the BP Texas City Refinery caused many to question their Process Safety Management programs. In a sworn deposition, the Process Safety Manager at BP Texas City implied that resources were diverted from process safety and used to improve industrial safety. The implication was that in any plant with limited budgets, any investment in industrial safety could be seen as taking resources away from process safety. The panel will provide their views on this “tradeoff” and discuss with participants things that can be done to make programs complimentary rather than competitive.
6. TapRooT® User Success Stories From Healthcare and Industry - Facilitators: Linda Unger and Barbara Phillips
Three TapRooT® Users (to be determined closer to the Summit) will share recent successes improving performance by applying the TapRooT® System. Learn from the best practices of others and apply their ideas to improve performance at your facility.
7. The Good, The Bad, and The Ugly: Rating Improvement Programs and Incident Investigations - Tom Brower, Consultant
Is your program Good, Bad, or Ugly. Rate it and see. Compare your program to others at the session. And learn techniques to rate your company’s incident investigations.
8. Senior Executive Involvement in Safety
Bringing Safety to the Corporate Board - Dave Prewitt, VP, FedEx
What the Corporate Board Needs to Know About Safety - Bob King & Darby Alan, Woodland Grange, UK
What does the Corporate Board need to know about safety? With new corporate manslaughter laws in countries around the world, perhaps more than they currently know. Part of the Chemical Safety Board’s investigation of the explosion at BP’s Texas City Refinery implied that senior management and the Corporate Board needed to know more about safety and the impact of budget decisions upon safety. because of these issues, we invited Dave Prewitt, VP at FedEX, and Bob King and Darby Alan of Woodland Grange in the UK to speak about getting senior management, and even the Corporate Board, involved and aware of safety.
9. Planning Your Improvements - Facilitated by TapRooT® Instructors
A session that allows time for you to develop your improvement plans, get them reviewed by an experienced TapRooT® Instructor, and then benchmark them with other Summit participants.
Beyond the Safety & Risk Management Best Practice Trach sessions, there are five interesting Keynote speakers:
Marcia Wieder, Nikki Stone, Lt Col Ralph Hayles, Carolyn Griffiths, and Ed Frederick. For more information about their talks, see:
So if you are interested in improving safety and managing risk, sign up for the TapRooT® Summit and register for the Safety & Risk Management Best Practices Track. See:
Some call it a vision. Some call it a dream. But every improvement program needs a goal. Do you have a vision of what performance would look like if you could achieve the ideal state at your company? Achieving that vision is what Marcia Wieder, America’s Dream Coach, is all about. As the closing Keynote Speaker at the TapRooT® Summit, she will show you how to achieve your dreams and make your vision a reality.
To hear a little of the type of advice America’s Dream Coach will provide at:
I take pride in my time served in the Nuclear Navy and the two ships I served aboard (USS ARKANSAS and USS LONG BEACH). It’s difficult to write about failings in leadership in the Nuclear Navy. But I wrote about it before (blog article 1, 2, 3) and predicted the outcome. By looking at the failings that occurred aboard USS HAMPTON, we may be able to understand how hard achieving operational excellence is in the demanding world of submarine operations and how people can fall short of demanding expectations.
It started out just fine. Commander Mike Portland (right) takes command of the USS HAMPTON, SSN-767.
His command ended in scandal as a ORSE Board discovered that reactor chemistry logs had been gun-decked (faked). This led to a Judge Advocate’s General Manual investigation and a Commodore’s Mast that uncovered many minor and some major “integrity violations.”
The Navy Times reported on the failures in various articles, including the most recent article:
To my eye, the trail of “evidence” reminds me of a witch hunt where one of the accused is caught in a minor indiscretion and then must offer up others who they think may be more or equally guilty. Some of the most guilty are likely to name many others to provide the appearance that “everybody was doing it.” Even in the Nuclear Navy, anyone may have a slight indiscretion. A chief may have heard a rumor he didn’t report. An officer may backdate a form that was completed, but that he forgot to sign at the time. An Officer may use an old exam to prepare for an upcoming exam, and then, when he’s not sure if this practice (studying from old exams) is allowed, lie about it when he sees everyone getting disciplined (end of career) for a variety of “integrity violations.”
Let those who have never sinned throw the first stone.
But the indiscretions aboard the USS HAMPTON were more than petty indiscretions. Reactor chemistry logs were faked for an extended period of time. And the disciplinary report - that claimed that reactor safety was never compromised - didn’t seem to explain the root causes of this failure.
Rear Adm. Joseph Walsh, Pacific Submarine Force Commander, wrote in his endorsement of the report. “The specific deficiencies identified during this investigation resulted in no unsafe operations or maintenance of reactor or propulsion plant systems and no loss of radioactive material.”
First, if reactor samples were never taken … this IS unsafe reactor operations. One of the Safeguards to maintain reactor safety - sampling - was compromised. The later samples verified was that the reactor was not damaged. These later samples did not restore the “safety” that was compromised by the previous lack of samples.
If anyone thinks differently, then let’s QUIT taking samples while operating at sea (since not taking samples does not compromise reactor safety) and just take a sample when the ship gets back to port. This would save a lot of work.
Reactor safety can only be assured by following the rules and taking the samples that are designed to catch failures BEFORE major damage can occur. If you don’t take the samples, reactor safety is unknown - this is a compromise. Taking later samples doesn’t restore the integrity of those who falsified the records or restore reactor safety. It just confirms the fact that other, redundant safety factors worked even though the samples were skipped.
The Nuclear Navy’s uncompromising enforcement of the rules is one of the things that sets it apart from other organizations that accept shortcuts. Word games in statements for the press meant to reassure the public do little. These types of statements seem like a cover-up for performance that is clearly substandard.
Now for the corrective actions. Much is “redacted” from the report (names are crossed out). But this much we do know:
The Commanding Officer, Mike Portland, was “detached for cause” (fired).
Why? The endorsement by Rear Adm. Joseph Walsh says:
“Commander Portland set unachievable standards for his crew, was intolerant of failure, and publicly berated personnel.”
For those who have served in the Nuclear Navy, leaders with these attributes are not rare. It sounds like my first CO. Or maybe Admiral Rickover. I’d guess (from my limited experience) that about 50% of senior Nuclear Navy leaders use this style. However, it also says:
“He failed to exercise oversight of personnel and processes … “
Oversight is a keystone of the Nuclear Navy. Was he really absent from “back aft?” Was he isolated from the crew? Is this a “Cain Mutiny” situation on a nuclear submarine?
It continues to say:
“… failed to train his leadership team to effectively manage issues under their cognizance.”
That is especially worrisome. Shouldn’t the crew be trained to manage issues BEFORE they join the ship? Shouldn’t his XO and Department Heads coach the Junior Officers and train them? Does the CO need to train everyone or should he make sure that everything is working and make adjustments as needed?
However, the CO wasn’t the only one punished.
The Engineering Officer was fired.
Two officers were “de-nuked” (the end of their career - but let’s make them serve out their time in some obscure job in a bad place).
Two sailors were stripped of their naval enlisted classification codes (de-nuked).
Several junior sailors, including ELTs, were “masted” (disciplined) or referred for additional review by their current commands (because they had already left the ship).
Note that at least two officers chose to “take the 5th” when it was their turn to participate in the witch hunt.
Let’s take one more look at the CO’s job.
What if everything wasn’t working when he took over in the shipyard? With a demanding shipyard schedule followed by pre-deployemnt work-ups and deployment operational commitments, when was the CO and crew suppose to get the time to train in leadership and managing things under their cognizance if they didn’t already have those skills when they reported to the ship? Then add in a surprise deployment.
Could a good CO turn around a poor crew without much help in a demanding environment? Maybe.
What about an average CO? Maybe not.
What about a screemer who was doing all he could just to keep his head above water (oops - not required on a sub)? Very unlikely.
So the report seems to imply that:
1. The CO didn’t do his job.
2. The Officers didn’t do their job.
3. The Chiefs didn’t do their job.
4. The sailors didn’t do their job.
According to the Navy statement, THIS HAS NOTHING TO DO WITH THE REST OF THE SUBMARINE FORCE.
It was just one bad boat.
It doesn’t indicate a reactor safety issue.
The failures of the crew aboard USS HAMPTON are isolated incidents.
The punishment of the CO and crew addressed the root causes of these leadership failures by getting rid of a few bad apples.
But the Navy Times article goes on to say:
The Submarine Forces commander, Vice Adm. Jay Donnelly, questioned whether the integrity violations had gone beyond Hampton, and last fall ordered “Deep Dive” teams to the fleet to look more closely at morale and retention woes.
Experienced submariners say they believe the investigations revealed a broader practice of questionable reports and shady practices across the force. One called the Hampton situation “a failure of the worst kind.”
So is this just an isolated incident? Has the submarine force been pushed beyond their limits? Have the strong traditions that Admiral Rickover established been broken? Can trying to do too much with too little for too long eventually result in a cultural meltdown? Will the Nuclear Navy follow the pattern at BP and eventually have their own “Texas City” style incident?
Perhaps the “Deep Dive” teams know. Without more information, we could only guess.
Is there a lesson that can be learned here? I think so.
Sadly two people lost their lives this Friday from a tornado in Atlanta. This unexpected weather is of concern to me for two reasons. My brother and his family live in Atlanta. Also, I was sitting in the Hartsfield-Jackson Airport waiting to board my aircraft when the tornado passed through. Returning from a very energetic 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, I thought about the fact that we include natural disasters and sabotage in our root cause process.
Yes, you can’t prevent an external event such as a tornado, but this should not be the focus of the fatalities. What human engineering and training was developed to improve the odds of survival? Do you think the thought “we never or very rarely have tornados here, so we did not plan for this” occurred? Not that this may be the case here, but I have heard this statement too many times concerning hazard assessments. If this sounds familiar to you in your company, are you performing robust proactive audits? If you jump from identifying issues and go straight to corrective actions, you are not doing justice to your time spent. These typical type of audits are often led by prioritizing on a single problem and deciding on the best feel good or discipline action. If you want to stop this poor practice, call System Improvements, Inc. at 865.539.2139.
(Not everything is excitement in the Nuclear Nayy - Shutdown RO at S1W)
I can still remember when I first heard about the accident at Three Mile Island. I was on a bus heading out to S1W (a Nuclear Navy Prototype Reactor in the desert in Idaho). I was partly snoozing and the bus driver had a transistor radio playing. The music was interrupted for breaking news. The commercial nuclear power reactor at Three Mile Island was having some sort of problem - perhaps a meltdown! The on-the-scene reporter was interviewing a farmer near the plant. He said his cows weren’t acting right and that morning he could “…taste the radiation…”.
Ed Frederick, Keynote Speaker at the TapRooT® Summit, was a member of the Control Room crew at the onset of the Three Mile Island Unit 2 accident on March 28, 1979. The decisions made, and actions taken by Mr. Frederick and the rest of the crew on that morning resulted in a partial meltdown of the reactor core. The accident is the only General Emergency and evacuation associated with nuclear power in the United States. The accident at TMI was the subject of intense public interest and is still remember each year in television news.
But the accident at TMI happened back in 1979. What could we possibly learn that’s new from such an old accident?
(Picture of Three Mile island)
Look at the various “facts” that are available at various places on the internet:
The causes for the accident at TMI and the experiences related by someone who was “investigated” after the accident are just as applicable today as they were back in 1979. And they are applicable across industries around the world. That’s why I’ve been asking Ed to speak at the Summit for years - the lessons are important for everyone who is interested in investigations and performance improvement to learn. And this year Ed will share his inside view of the accident and the aftermath.
Ed will also conduct a Best Practices Session that allows investigators to practice their skills by drawing and revising a SnapCharT® based on what they “know” and answers from the person involved - Ed Frederick.
For more information on the rest of the sessions and Keynote Speakers at the Summit and to register, see:
Agricultural/food accidents aren’t all that uncommon. In this case an auger claimed a life. When I was in college, a friend lost his leg in an auger accident. He was trapped for hours in a remote field before anyone found him and he almost died.
Could agricultural companies apply advanced root cause analysis to improve performance and reduce deaths and injuries? You bet. Some already have.
Could this audit be performed by an internal auditor?
Would it be possible to conduct an audit like this if the Hospital Administrator was still there? (He quit before the audit was conducted.)
Could the Board be more independent and should have they found the problems and forced the Administrator to Change (or fired him) before it came to the point of losing Medicare certification?
The UK RAIB is an independent investigative organization that by law investigates the UK’s railway accidents and incidents. The purpose of their investigations is not to apportion blame or to enforce laws, but rather to improve railway safety and prevent future accidents. For questions about the UK RAIB see:
Carolyn is a Keynote Speaker at the TapRooT® Summit in Las Vegas on June 25-27. She will speak about her experiences starting up the UK RAIB in 2004/2005 and some investigation lessons learned from the RAIB’s initial investigations.
What can you learn?
Every investigator or head of an investigation organization can learn from the experiences of others. In talking to Carolyn, I found that her approach to getting good investigations, the training she requires for her investigators, and the challenges of getting investigations completed were all interesting topics to hear about.
That’s what’s great about the Summit. You will not only hear the RAIB’s Chief Inspector talk, but also, you will have the opportunity for one-on-one conversations to ask questions, share best practices, and make a new contact in your network of professional associates.
Rich Fairfax, OSHA’s Director of Enforcement, says that the National Emphasis Program to inspect refineries will continue. 17 of 81 refineries have been inspected resulting in 146 violations and $896,300 in fines. He said:
“I have no intention of ending it after two years based on what we’re finding.”
(He didn’t say that it was a money maker, but its seems like they are producing a pretty good return on their audit time investment.)
But beyond that, he wants to expand the program to chemical plants.
The program was started after OSHA was criticized for not preventing the BP Texas City explosion even though there had been previous deaths at Texas City. BP refineries accounted for 20 of 29 refinery deaths that occurred from 2005-2008. Fifteen of those were due to the BP Texas City explosion.
Not all refineries are scheduled to be audited because some refineries are in programs (like VPPPA STAR) that exempt them from these inspection and others are in states with their own programs.
In his book Mastering the Art of Creative Collaboration (1997, McGraw-Hill Book Company), Robert Hargrove claims that the most valuable person in any industry is a “Knowledge Broker“.
Knowledge Brokers are people who know enough about an industry to learn the best practices and also know enough about a second industry to show that industry how they could apply the best practices from the first industry to improve performance at their facility in a different industry.
This is “lessons learned” on a cross-industry basis. And being “Knowledge Brokers” is what we do at System Improvements.
The TapRooT® Summit (June 25-27 in Las Vegas) is your chance to become Knowledge Broker at your company and bring exciting, effective, new ideas to improve performance back to your workplace.
How exactly does this work?
Let me explain by use of an example.
Let’s say that you were a Safety Manager at an industrial manufacturing plant (you make left-handed widgets). You’ve had several nagging safety problems that also face others in the widget industry. You’ve been to the standard industry safety meeting and even the big cross-industry safety meetings but none of the sessions you attended provided any new ideas to help you solve your problem.
That’s what happens to people who are NOT Knowledge Brokers. They don’t have access to practices outside their discipline and outside their industry.
How does the TapRooT® Summit fix this?
It is an improvement conference based on cross-industry, cross-professional-discipline, cross-cultural networking.
Let’s attack these “cross” ideas one at a time.
1. Cross-Professional-Discipline
In the example above, safety people at the mega-safety conference are taking to other safety people. They are in the same profession. Therefore, there is no cross-professional-discipline networking. That’s why you hear the same ideas over-and-over again at these types of conferences - everyone is coming from the same point of view - the same profession.
I’m not trying to knock the mega-conferences in any profession. They are great way to find out what is going on INSIDE the profession. I’m just pointing out a fact. They are rather incestuous (be it a safety, quality, human factors, industrial engineering, healthcare risk management, or other professional society conference). If you attend the same conference two or three years in a row, you start to say … “I’ve heard that before.”
What types of “professions” will be represented at the TapRooT® Summit?
Here’s a sample of previous year’s participant’s professions and the professions of speakers at this years Summit…
Professional Background 2008 Speakers:
Rail Safety
Nuclear Safety/Operations
Military Aviation
Olympic Sports
Psychology
Industrial Safety
Nuclear Regulation
Mining Management
Aviation Manufacturing
Equipment Reliability Improvement
Mine Safety
Management Education
Anesthesiology & Medical Error Prevention
Management Consulting
Patient Safety
IT Performance Improvement
Equipment Troubleshooting
Oil Industry Safety
Performance Measurement
Utility Safety
Risk Management
Industrial Engineering
Operational Excellence
Human Factors
Aviation Safety
Submarine Operations and Engineering Management
Fatigue and Shiftwork Management
Environmental Consulting
Fire Protection
Electrical Engineering
Six Sigma/Lean
Training
Professional Background 2007 Participants:
Construction Safety
Construction Management
Performance Measurement Research
DOE Safety
Process Safety Management
Oil Production Safety
Oil Drilling Management
Industrial Safety
Fire Protection
Semiconductor Manufacturing
Utility Safety
Petrochemicals Manufacturing
Mining Management
Mine Safety
Instrumentation Engineering
Human Factors Engineering
Electrical Engineering
Nuclear Engineering
Environmental Consulting
Risk Management
Nuclear Safety
Fertilizer Manufacturing
Training Management
Explosives Safety
Petrochemical Operations
Utility Transmission & Distribution Maintenance
Equipment Troubleshooting/Engineering
Patient Safety
Military Aviation
Site Security
Operational Excellence
Operations Management
Maintenance Management
Quality Assurance
Emergency Management
Quality Management
Maintenance Scheduling
Maintenance
Petrochemical Purchasing
Aviation Maintenance Safety
IT Improvement
Food Safety
Gas Operations Management
Pharmaceutical Quality
Petrochemical Engineering
Submarine Operations & Engineering Management
Financial Management
Flight Safety
Environmental Safety
Public Safety
Hospital Management
Management Consulting
Equipment Reliability Consulting
Manufacturing Management
MIS Project Management
Physician
Legal
Aviation Maintenance
That’s an impressive amount of cross-profession networking opportunity! And that’s why you will hear ideas and best practices that are NEW because they come from outside your profession.
2. Cross-Industry
Next “cross” topic is cross-industry networking.
For example, the nuclear industry has several “inside-the-industry” conferences that cross professional boundaries but don’t provide opportunities to look outside the industry. Again, these “inside-the-industry” conferences become incestuous - everyone is looking at things from the same industry perspective.
What types of “industries” will be represented at the TapRooT® Summit?
Here’s a sample of previous year’s participant’s industries and the industries of speakers at this years Summit:
Military Aviation
Olympic Sports
Rail Transportation
Utility (Nuclear Power)
Public Speaking
Consulting
Mining
Refining
Fertilizer
Education
Anesthesiology
Management Consulting
Healthcare/Hospitals/Medical
Manufacturing
IT
Equipment Consulting
Oil Exploration & Production
Utility (Transmission & Distribution)
Food Production
Natural Gas
Shipping
Explosives
Aviation
Submarine Operations
Equipment Reliability Consulting
Terminals
Aviation Manufacturing
Construction
DOE
Petrochemical/Chemical Manufacturing
Pipeline Transportation
Semiconductor Manufacturing
Utility (Coal/Gas/Hydro Power Generation)
Gas Processing
Aluminum
Government
Military
Freight
Financial Consulting
Pharmaceuticals
Electronics
Contract Maintenance
That’s an impressive cross-industry representation! And that’s why you will hear ideas and best practices that are NEW because they come from outside your industry.
3. Cross-Cultural
One of the surprising parts of the TapRooT® Summit is the amount of international representation. Here are the counties represented at the 2007 Summit:
Argentina
Australia
Brazil
Canada
Jordan
Kazakhstan
Kenya
Malaysia
Mexico
New Zealand
Norway
Qatar
Saudi Arabia
South Africa
Thailand
Trinidad
UAE
UK
USA
For a conference of 250 people, that’s a lot of cross-cultural representation. And we expect even more cross-cultural representation in 2008! And that’s why you will hear new best practices that you haven’t considered because they come from outside your CULTURE!
4. One-on-One Networking
The other problem with any mega-conference is this…
Even if there are 10,000 attendees, how many do you actually meet?
And when a speaker stops talking and asks for questions, do you get a chance to ask yours? Do you get a chance to talk one-on-one with the speaker?
That’s where the smaller venue of the TapRooT® Summit comes in.
Plus, we have devised ways to help you meet new people both inside and outside your industry. And we make this networking fun!
You will have to attend the Summit to see how this works. But you will be pleasantly surprised by the amount of new friends you make at the TapRooT® Summit. And that is a big part of any networking meeting.
This is your chance to become the most valuable employee at your company - a Knowledge Broker with creative ideas to improve performance that you gain by on-on-one cross-industry, cross-professional-discipline, cross-cultural networking at the TapRooT® Summit.
And one more reminder. If you want to be even more innovative when you return to work, consider taking the Innovation and Creative Thinking class being held on June 23-25 before the Summit.
