Rackspace, a web hosting company, had a 45 minute outage on June 29th. An Article in Web Host Industry Reviews says that they are going to perform a root cause analysis of the event.
Analyzing the root causes of web outages can be very similar to other outage analyses that people do using TapRooT®.
For example, BellSouth used TapRooT® to review 911 outages, long distance network outages, and local service outages.
Another high reliability computer service provider, Tandem Computers who was later bought by HP, used tapRooT® to analyze network and computer reliability issues/outages.
It really is amazing how even with different technologies, the same proven techniques can be used to find the root causes of human error and equipment failure.
If you would like to learn advanced root cause analysis to analyze service problems, attend a TapRooT® Course. For more information, see:
TapRooT® Instructors, Chris Vallee and Dave Janney, teach a record attendance Equifactor® course in Houston last week. Chris is wearing the loud red shirt. So who attended this class you may ask?
Medical…. Power Generation…. Petro-Chemical equipment reliability leaders and safety leaders sat in the class this day. Wait, did you read safety? Just ask the safety leader sitting next you and ask how many times a piece of equipment DID NOT BREAK during a major incident. Now you as an EH&S person may not be able to answer the equipment questions asked in Equifactor® but if you were given a structured way to ask competent equipment questions to your equipment experts would you use it?
Of course aside from major Incidents why would Equifactor® be useful for the EH&S leader….. after all a 30 cent O-Ring that frequently gets replaced on a shutoff valve located in a confine space doesn’t need to be analyzed does it? See below for upcoming Equifactor® courses close to you.
Location Dates
Chicago, ILLINOIS - Sep 17
Calgary, CANADA - Oct 16
Halifax, CANADA - Nov 5
Dallas, TEXAS - Nov 6
Aberdeen, SCOTLAND - Nov 11
Salt Lake City, UTAH - Nov 12
Edmonton, CANADA - Nov 25 (more…)
I reviewed the slide show and the Executive Summary and I couldn’t find anything that I would call “root causes.”
I did see a good failure scenario that would make a good SnapCharT® and then could be used to identify Causal Factors (which are similar to the “Failure Conditions” in the presentation pdf). Their failure conditions were:
Increased Loads Due to Higher Fill
Hydraulically Placed Loose Wet Ash
Fill Geometry & Setbacks
Inusually Weak Slimes Foundation
But they didn’t analyze these factors to find the root causes behind them and they certainly didn’t look for Generic Causes.
They won’t be reopening this site so this accident won’t be repeated here. But I didn’t come away with lessons that TVA’s Management should be learning to improve their performance.
Am I missing something? Review the materials and see what you think.
The Associated Press came out with an article today about beefed up Inspections of Regional Airline Pilot Training. This increased activity is in REACTION to pilot errors listed following the New York Regional Jet Crash earlier this year. The good PROACTIVE note in this article was this comment, “Federal Aviation Administrator Randy Babbitt said in a statement they will also hold a meeting with the airline industry — both regional and major carriers — next week to seek better pilot training, cockpit discipline and other safety improvements.”
So what would you look at to determine the Training concerns:
1. “a series of critical errors by the captain and co-pilot preceded the crash of Continental Express Flight 3407 as it neared Buffalo Niagara International Airport on Feb. 12.”
2. “cockpit voice recorder showed the co-pilot describing her lack of experience flying in icy weather not long before the crash.” Did she miss training? Did the company decide not to train? Was she trained and testing needs improvement? Should there be continued training? Did practice and repetition need to be increased?
3. “captain may not have had hands-on training on a critical cockpit safety system. “Did he miss training? Did the company decide not to train? Was he trained and testing needs improvement? Should there be continued training? Was the task analyzed for this aircraft?
Then there was the Fatigue issue:
1. “co-pilot, Rebecca Shaw, lived near Seattle on the West coast with her parents and had commuted all-night to get to Newark Liberty International Airport in New Jersey on the East coast , where Flight 3407 originated”
2. “captain, Marvin Renslow, commuted to work from his home in Florida. It is not clear where either of them slept the night before the crash or how much sleep they received.”
3. “current rest rules “are less restrictive than truck drivers work under. Once you’ve been on duty for 13 hours, you are about 500 percent more likely to make an error, and once you’ve been on duty for 16 hours, you have the response rate of somebody who is legally drunk.”
Is the policy confusion or incomplete? Is the policy not strict enough? Does the communication of the Policy need improved? Is this a crew selection issue? A scheduling issue?
Now if you read the rest of the article linked below, you then have to ask about Oversight and Corrective Actions. There were “cracks” in the system? Don’t get me wrong, there are a lot of good aviation programs with good training….. maybe too many for the ratio of inspectors? What is the expectation of the controlling authority? How much is the push back from the private commercial sector when push comes to shove. After all, look at the discussion over the recent airbus accident and whether the pitot sensors needed to be replaced. According to reports, Air Bus highly “suggested” that they be replaced… and the air lines knowing that pitot sensor errors are only minor, instructed pilots to make sure they beefed their work around response for eradicate readings.
This is more than just a training issue. What questions do you have? Wonder where my questions come from? Come to one of our 5-day incident courses and walk through the early 1970 Florida aircraft crash.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training: http://www.taproot.com/courses.php#c1
Or even better, come to our Summit and Pre-Summit and talk with aviation industry experts trained in our process from Rotorcraft to Alaska Airlines. http://www.taproot.com/summit.php (more…)
Checking on the news in the town where my daughter lives I saw this article at www.kake.com, “Sno-Cone Mishap Leaves Sedgwick Co. Zoo Visitors Ill.” Turns out that the employees mistakingly used the dark colored degreaser instead of the dark colored blue sno-cone flavoring.
Here are the highlights from the article (see the link in read more to see the video):
Luckily, the bottle mix-up did not end up with any major injuries. Those involved did not ingest enough of the mixture to cause any harm. Still, they are not happy.
“They need to be more careful, especially serving food. Pay attention to what you’re grabbing because this could have turned out tragic,” the victim said.
The zoo says it will now stop serving blue sno-cones completely to make sure this kind of mix up never happens again.
Now do you think that the zoo officials have truly found the causal factors, identified the root causes, and found the failed safeguards? I am surprised they were not fined for having cleaners stored with food products.. that would be a failed safeguard and root cause of arrangement and placement… but everyone seemed to focus on the mistake made by the sno-cone machine attendants.
What about the other sno-cone machines and food service areas, this may be a generic issue. Why was the issue not caught with proactive audits? If you want to reduce the possibility of this type of incident in the food industry come to our TapRooT® Summit in Nashville this October 5-6 (for the Pre-Summit) and October 7-9 (for the Summit). Found out about our proactive risk assessments and industry best practice tracks at this link: http://www.taproot.com/summit.php (more…)
I read a current event today titled, “Mountain Lion Escape At Great Bend Zoo Blamed On Staff Error”. Now for anyone who has ever read our TapRooT® book Changing the Way the World Solves Problems, this should remind you of the Thailand student’s Tiger and safeguards example. For those just purchasing the book it is in Chapter 10 on page 375.
Here are some of the facts as reported:
1. A double-gated entryway was left unsecured.
2. A 150 pound Mountain Lion with unpredictable and aggressive behavior strayed 150 feet from the cage.
3. Authorities shot and killed the Mountain Lion.
With a TapRooT® root cause analysis we would have to define the worst thing that happened as the incident. Would that be the Mountain lion escaping, being shot and killed, or the fact that the park staff left the cage open? I would define it as the Mountain Lion being killed. Next we would list the events before and following the incident and include as many conditions (supporting facts as possible).
It also helps to determine the hazard (uncontrolled energy), the safeguards (failed, successful, and absent), and the targets. Review the article and see if you can determine these items and what other questions you may have. While the park staff did error in leaving the cage open it took more Causal Factors for this Mountain Lion to be killed. (more…)
According toa story in Army Times, Defense officials will be charged with performing a root cause analysis of major cost overruns in military acquisition programs. Here’s the parts of the story dealing with root cause analysis:
“Under the conferees’ proposal, the department would be required to ‘perform a root cause analysis’ on each breaching program.”
“Further, the House-Senate bill, if approved and signed by the president, would require the secretary to designate one defense official in charge of conducting program-specific performance studies and ‘root cause analyses.’”
“The summary says this official would be ‘responsible for issuing guidance related to performance assessment for acquisition programs and for analyzing the root causes of poor performance, including reviews conducted after Nunn-McCurdy breaches.’”
We all know that some forms of root cause analysis are no more than a witch-hunt looking for someone (usually down the chain of command) to blame. This has been true in many military accidents. If you were at last year’s Summit, you heard thefirst hand account (from Lt.Col. (Ret.) Ralph Hayles)of a Army cover-up during an investigation into a friendly-fire accident. Or you can read the bookSilent Knightsby Alan Diehl to find out how facts are covered up to keep system problems causing military aviation accidents from being exposed (and fixed). Or you can look into the botched 1989 Navy investigation of the explosion of a gun turret on the USS Iowa (that killed 47 sailors). Or more recent investigations that have been discussed here:
[You might look at the list and assume that the Navy has the worst root cause analysis. I think the preponderance of posts about the Navy is because I'm a Nuclear Navy veteran and I watch press stories about the Navy more closely and post more about them.]
But let’s assume that the military can get beyond the blame game (the Military Healthcare System has gone beyond blame and adopted TapRooT® to make significant patient safety improvements). The next fault in many root cause analyses is using root cause analysis system that is too simple. Examples? 5-Whys, Fishbones, Cause-and-Effect, and Fault Trees. See some reasons why they are too simple here:
So what should this new military directorate do? What system is robust enough to handle potentially politically sensitive cost overrun investigations? As a reader of this blog, I hope you already know the answer.
TapRooT® has already been proven effective in many industries for a wide variety of types of problem solving/root cause analysis. I can still remember talking to the former Commanding Officer of the USS Greeneville,Scott Waddle, after he attended 2-Day TapRooT® Course. [You may remember that Scott was blamed for the collision of the USS Greeneville with the fishing vessel Ehime Maru (nine crew members of the Ehime Maru died). He also spoke about the collision at the TapRooT® Summit in 2005.] What was his comment about using TapRooT® to investigate military accidents? He was amazed. He started to see the system causes that were involved in the collision of the USS Greeneville and the Ehime Maru. He could see that the blame that was placed on him and the guilt that he felt after the accident were insufficient to improve the system that caused these types of accidents. He was amazed that such powerful technology - TapRooT® - wasn’t already being applied by the military to stop accidents and save lives.
Unfortunately, the military has not changed much since 2005. The blame culture still exists. Cover-ups still happen. Lives are still being lost needlessly. But if the military adopted real, advanced root cause analysis - major improvements are possible. Especially with the support of Congress. Maybe real positive change in the defense procurement system - change based on advanced root cause analysis … TapRooT® - could actually occur. Change that saves taxpayers money … potentially saves troops lives … and increases our defense stature. That could beanother real success storyabout the effective application of TapRooT®.
The New York Times reports that after an accident that killed 25 people and injured 130 more, the Metrolink Board of Directors has voted to authorize $975,000 to install hidden video cameras on Metrolink commuter trains.
Last year train engineer Robert Sanchez ran a “red light” and hit an oncoming Union Pacific freight train. He was “texting” when he should have been driving the train.
Now Metrolink wants better forensic evidence to perform better investigations of accidents, incidents, and near-misses. The new cameras are a step in that direction.
What do you do to make incident investigation evidence collection and interviewing better? Have you thought about this important piece of an accident/incident investigation?
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Also, if you are interested in improving your incident investigations, consider attending the Investigation and Root Cause Analysis Track at the TapRooT® Summit in Nashville on October 7-9.
What will you learn?
First, you will see three accident presentations that will help you learn best practices from the presenters (including how to investigate multiple accidents to learn generic lessons).
Second, hear two best practice investigations from TapRooT® Users. Dennis Ward, from the Alaska Medallion Foundation, will share his experience using TapRooT® to find common causes of aviation accidents. Next, Ron Pryor of Alcoa will explain how TapRooT® was used in a Kaizen project to improve product quality.
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
3 rules for improving investigation questions,
who to get someone to share more information, and
how to confirm understanding.
Fourth, learn if your investigation system is “The Good, The Bad, or The Ugly” and what you can do to improve it.
Fifth, attend the one-and-only session where TapRooT® Users share their best ideas … the TapRooT® User Best Practice Sharing Forum. You will participate in a session that is always rated as one of the most helpful to TapRooT® Users who are looking for innovative ways to make investigations more efficient and effective.
Sixth, learn how to use new, free on-line software to evaluate if fatigue was a cause of a human error. Bill Sirois, COO of Circadian Technologies will share this important, innovative software.
Seventh, learn new ideas for defining Causal Factors from Ken Turnbull, an experienced investigator and TapRooT® Instructor.
Eighth, Steve Hawkins, a very experience fatality investigator who is the Assistant Director of Tennessee OSHA, share the lessons he has learned in many investigation.
You will find that these sessions aren’t boring and dry. Instead, they are packed with ideas that you can use to make your investigations more effective and more efficient.
But these sessions are NOT the whole Summit.
There are five Keynote Talks that will provide even more information and motivation.
There are other Tracks that you can pick from to make your own custom Summit experience.
There are networking and social events to make the Summit fun and to help you add to your list of industry contacts.
Want more info? see this list of “frequently asked questions” …
So, if performing world-class accident/incident investigations to prevent future accidents is business critical to your company, I look forward to seeing you there!
People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator. But it’s always nice when you are a new investigator to start off with some easy incidents before diving into a politically sensitive accident or a legally difficult fatality. Plus some investigations are better when facilitated by an outsider. Therefore, here are some suggestions of when to ask for help facilitating, investigating, and analyzing the root causes of an incident.
Legal: Could this accident end up in court? If so, you need the help of your company’s attorney. They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.
Customer Dispute: It’s always tough when a customer has a problem and blames your product/service. What do you do if you think that the product/service was OK but instead, the customer’s actions caused the problem? Root cause analysis could be a big help. But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective.
Union Issue: Ever had an investigation that gets contentious with a union? This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement.
Just Learning: TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations. What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.
Overwhelmed: Too many accidents to investigate? Augment your staff with outside facilitators to help investigate incidents and provide your investigators with valuable feedback.
SI has 40+ experienced TapRooT® investigators around the world to provide help when you need it. Contact us at the link above or call 865-539-2139.
2 openings - 1 in Quebec and 1 in Saskatchewan - Health And Safety Manager - 10 yrs exp
apply to jobs@entirehire.com
SAFETY MANAGER
Quebec Chemical company needs fluently bilingual French/English Safety Manager for plant
Saskatchewan location needs English - Safety Manager for plant
Position Summary :
The Safety Manager ensures site compliance with Government Regulations and Safety Standards, coordinates and maintains Site / Transport Emergency Response, Process Safety Management and Security Plans. (more…)
Note that due top a previous crash, these helicopters were required to have their magnetic drain plugs inspected for metal. This particular helicopter had been inspected (34 flying hours prior to the accident) and a small chip of metal was found. However, the report by the AAIB states:
” … during the period between the discovery of the chip and
the accident, no signs of an incipient gearbox failure were detected.”
So far, the AAIB’s failure analysis of the crash damaged epicyclic reduction gearbox (the module that failed and is thought to have caused the crash) shows no signs of how the failure started or what caused the failure.
If there was no further evidence, this might be a case of “Other” when analyzing the Causal Factor “Gearbox failed.”
What does the Corrective Action Helper® say to do in this case? The applicable sections say:
If you cannot progress further down the tree, then consider performing a Safeguards Analysis (Chapter 10 of the TapRooT® Book, 2008) to identify potential Safeguards that you could add to reduce the likelihood of this incident recurring.
If you could not progress down the tree due to lack of information, consider adding additional systems to record more information in future incidents so that your analysis can more effectively pinpoint the Root Causes. Video and voice recordings, as well as data recorders, should be considered.
In this case, the AAIB is recommending that the European Aviation Safety Agency (EASA) develop an inspection procedure for the internal components of the main rotor gearbox epicyclic module.
What’s the difficulty in developing a good procedure for this inspection? How do you know what to tell the inspector to look for?
If you had developed a Equifactor® Troubleshooting Checklist for the main rotor gearbox epicyclic module, you could use it as a tool to help develop the inspection procedure.
Safety experts believe that about 20% of workers cause 80% of accidents.
It then went on to say that these “accident prone” employees were most likely:
* Irresponsible, aggressive, and easily distractible people
* Stoic “tough guys,” who work through any injury or illness and consider it a sign of weakness to do otherwise
* Risk-takers, who think accidents happen to other people and who are often young and male
* Angry people, who let emotions distract them from their work because, as the old saying goes, they are “so angry they can’t see straight”
* Shy workers, who don’t want to draw attention to themselves by reporting an incident or near miss
* Tired people, including shiftworkers, whose lifestyles don’t give them enough energy or alertness to work safely
* Disinterested workers, who frankly don’t give a damn about the job and simply don’t care enough to be careful
Wow! The article made me stop in my tracks and think:
First, who are these “safety experts” who say that 80% of the accidents are caused by 20% of the workers and this makes them “accident prone”?
Of course a small percentage of workers cause most of the accidents. How could it be any other way? If 100% of the workforce was involved in accidents, everyone would be injured!
Because only a small percentage of people are injured, people start thinking that they just had “bad luck.” But this isn’t right either.
The small percentage of employees being involved in accidents (”causing the accidents” as the article claims) is simply a result of modern safety systems that keep most of the employees safe most of the time.
Second, where could anyone get reliable statistics about the types of employees involved in accidents across the country that are grouped into the categories suggested above? I’ve never seen this type of report from the National Safety Council, OSHA, or the Bureau of Labor Statistics. My guess is that someone made this stuff up - which could be why the data was completely un-sourced in the article.
What can you learn from this article?
1. Don’t believe everything you read about safety. Look for the sources of statistics. “Experts believe” isn’t a good enough reference.
2. Think about statistics that are presented in articles. If they don’t seem right, they probably aren’t. Remember, over 50% of all statistics are made up (like this one).
3. Yes, a small percentage of employees are involved in accidents. But this doesn’t necessarily mean they are bad people. Stop looking to blame people (who caused this?) and start looking for system causes that you can correct to improve performance.
If you need a systematic process to find the human performance and equipment related causes of accidents and incidents, attend a TapRooT® Course and learn to apply the TapRooT® System to develop effective corrective actions to stop accidents and improve performance.
“Human error was listed as the cause of 12 out of 34 incidents.”
“Equipment failure was listed as the cause of 17 out of 34 incidents.”
“Information that is missing includes the experience and training of the personnel involved in the accident; operator/contractor training and maintenance programs; job procedures; condition of the equipment; and maintenance and training records. We believe that this type of information holds the key to accurately identifying the causes of many accidents.”
“Right now the reports do an adequate job of telling us what happened, but they don’t do a good enough job of explaining why it occurred. In our opinion, MMS must significantly improve the method of investigating, analyzing, and reporting the root and contributing causes of accidents if MMS is going to use these reports in understanding why accidents occur.”
Mark Paradies and I are in Manchester holding a course today. We have a great turnout of very smart and committed people who want to solve problems in their organizations in attendance.
Many companies are still investing in safety and quality despite the downturn. Take their lead and attend a course soon, here is the schedule: http://www.taproot.com/courses.php
“A 28-year-old South Weber woman who allegedly drove while on the sleep medication Ambien has been charged with automobile homicide after an accident that killed a couple.”
Not sure if the driver above in video was just fatigued or if there was medicine involved. Would you have asked if they were taking legal medicine?
What if this had been an employee delivering a package or operating a grinder…. could they be charged with Substance Abuse with your current drug and alcohol Policy? Would you as the employee even have discussed legal medicine use during work?
If you were using TapRooT® Root Cause Analysis to investigate the incident you would have to ask,
“Could a properly trained supervisor detect the aberrant behavior and, therefore, the supervisor should not have assigned the worker to the job (or should have taken steps to keep the worker out of harm’s way)?” and that is why the worker operated the machinery in an unsafe condition?
If you were using TapRooT® Root Cause Analysis to perform an audit of your Substance Abuse Policy and Program you would have to ask the same question above to find whether this could be a Significant Issue.
When is the LAST TIME YOU took legal medicine, drove to work, and operated machinery……….. to learn more about effective audits, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. Look for my Root Cause Analysis Tip on March 25th for more discussion on audits and risky processes.
You have the opportunity to prevent an incident or production defect before it is too late. So what is the first step you take…. Go Out and Look (GOAL). First problem you realize is that you are missing a few experts to ask questions (Human Engineering, Quality Control, Procedure, Management System, Work Direction, Training, Communication). Potash Corporation of Saskatchewan recognized this and has been a leader in integrating TapRooT® Incident Investigation and Root Cause Analysis into its everyday operations.
Now with experience you realize that lack of communication between different organizations is a Root Cause for many incidents. London-headquartered AMEC has been awarded a four-year contract with PotashCorp to provide engineering and project management services during the $1.8bn expansion of the Rocanville Potash mine in Saskatchewan, Canada. The expanded mine will be capable of producing an additional two million tonnes of potash per year.
So this week I had the opportunity to teach employees from both companies in one location for a combined 2-Day TapRooT® Incident Investigation and Root Cause Analysis and 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course.
The Rocanville potash mine is 16km north east of Rocanville and approximately 200km east of Regina, south-east Saskatchewan, Canada. So how do you Go Out and Look (GOAL)… actually it is GOAL and Go Down and Look (GDAL). After discussing current investigations in the final exercises of our TapRooT® course, Potash Corporation of Saskatchewan gave me a tour of where Potash is mined. I thought you would like the opportunity to see what many have not.
Dave, a Production Supervisor, on the left and me on your right standing in front of the elevator door at 3,100 plus feet undergound…. too late to turn around now!
In our truck with the lights off …. to the left lights on, watch your head!
A typical load vehicle and conveyor belt system.
Freshly cut Potash…. so what made this awesome cut…. look below.
If one of the altimeters fail, like it did on the Turkish Airlines Flight 1951, then the automatic throttles will slow the plane down. (Like it did on that flight dropping them from 2000 ft into a muddy field.)
“Boeing recommends operators inform flight crews of the above investigation details and the (Dutch Safety Board) interim report when it is released. In addition, crews should be reminded to carefully monitor primary flight instruments,”
Be careful? Is that enough?
How many other automatic features do they need to “be careful” about?
Is this adequate corrective actions?
Do they need a better engineering fix?
Is “be careful” just a temporary interim corrective action?
Accident investigations often cite “fatigue” as a root cause. Seems like a simple corrective action, right? More rest. Unfortunately, the answer is not always so simple. Take a look at this article in the New York Times concerning airline flight crew fatigue. Even trying to do the right thing with your corrective actions may cause unintended consequences without a carefully thought-out review of your plan of action.
If you are interested in the root causes of the financial crisis, this is an excellent show by CNBC.
It’s a long show, but worth watching.
It may change your view that “deregulation” was the cause. Actually, our politics and financial policy was much more the cause.
However, the show doesn’t give you a very good feeling about the corrective actions taken so far. Perhaps we should pay more attention to the root causes.
3 More Mine Shaft Holes Open in Galena reported KAKE News in Kansas. “Lead and zinc mines operated in and around Galena for decades, and the abandoned mines have caused a continuing problem of sinkholes in the town.”
Shutting down a process takes a thorough proactive look at what unintended consequences could be developed by the action itself. With our TapRooT® root cause analysis system and training, we actually walk you through a SMARTER method before you implement your actions. Feel free to contact us at 865.539.2139 or review our success stories on this http://www.taproot.com/about.php… then contact us.
Sadly tonight, Continental flight 3407 crashes with no survivors. Some eyewitnesses reported that the Bombardier DHC may have been on fire before it crashed through trees and into a neighborhood. One person on the ground was also reported as a fatality.
It is always scary when a large number of people are killed simultaneously. After instructing a TapRooT® course in Phoenix this week, I am flying home tomorrow on 3 different airplanes by the time I get home. And yes I pray I make it safely to my family.
What gives me peace of mind is that after 18 years working on or building aircraft and knowing that I had six Alaska Airlines’ safety auditors in our course this week, i know that these types of incidents are not typical. Because of rotor burst designs, tire burst designs and fuel lines designed not to break during hard landings the aircraft world is safer than most think. The life cycle stress tests are also another reason why the recent aircraft crash in the Hudson allowed the aircraft to stay intact.
My heart is saddened for the families of the 49 that died. I truly am eager to see what caused the accident so that it can be prevented and the airways remain safe for all.
Brainstorming is often successfully used to develop new ideas, increase employee moral and unfortunately… even to attempt to find Root Causes for problems. Lets start with the basics. Who should be sitting at the brainstorming table? When should brainstorming be used and more importantly when should it NOT be used? If you solve problems what can you use that has been successful?
So let’s start with roll call… say present if here:
Human Engineering Expert?
Procedure Expert?
Quality Control Expert?
Communication Expert?
Management Systems Expert?
Work Direction Expert?
Training Expert?
What… someone is missing? Who? Why would this matter you may ask? Let’s take a missing Training Expert. When is the last time a new training idea was suggested, developed and THEN handed off to the Training department to run with? Have you seen new training ideas getting stopped in their tracks because no one understood the process… after your brainstorming team invested all that time? After all, time is money. Why do we at System Improvements, Inc. think these are the right experts? Just take a look at our TapRooT® success stories and their companies’ return on investment and reduction of incidents.
One caution from experience, once you get the experts in the room you must also have a facilitator present to help the team keep the same perspective and reference. Try this if you don’t think so: ask everyone in a team to close their eyes and point North… which way do we go? TapRooT® has a way to solve arguments and to keep people on track, use our Root Cause Dictionary & Laminated Root Cause Tree. These tools will standardize your points of reference in your problem solving session.
When should brainstorming be used… Now that seems like it might be a tough question to answer, but it’s not. Use it when you first need to develop possible venture ideas, develop new ways to work a process or to communicate what others may have successfully done. Sometimes brainstorming can be used to develop corrective actions on GOOD problem Root Causes. System Improvements, Inc. has also developed a Corrective Action Helper® to use with our SMARTER technique. This guide includes best practice examples from multiple industries and includes references to allow you to dig even deeper.
When should brainstorming NOT be used… DO NOT use it to solve problems or to find Root Causes for problems. Why not you may ask? Brainstorming requires you to ASSUME that you know why a problem existed. Think about it, how many brainstorming sessions have you been in where you were called in as group for a company crisis… did it go a little like this:
“We are here today to solve the XYZ crisis. Write down your ideas on yellow stickies as to what the problem could be. We will affinitize these ideas and vote as a group on what the problem is and put a team on it to fix it.”
Whoa… how can you solve a problem when you don’t have the facts nor do you know the sequence of events of the problem you are attempting to solve? It CAN NOT be done from behind a table and you must GO OUT AND LOOK (GOAL)? If you are using brainstorming and other similar tools to solve your major issues and the problems continue to repeat or even get worse, then it is time to CHANGE. Look at our TapRooT® success stories and then talk to us at System Improvements, Inc. to see when the next Public class starts.
“Most of the team members underwent two 45-minute sessions last week to increase their concentration…… The next night, the St. John Tigers beat the Western Plains Bobcats 53-43 in Ransom.” Read more here: http://www.ksn.com/news/local/39078062.html
Now if we could just hypnotize people to prevent all human performance problems. Click here to see video: Hypnotize Yourself on YouTube
KSN News Extra: “Battling reckless teen driving with technology”
“If the driver brakes hard, accelerates too fast, swerves or hits something, the camera is activated. It makes a movie of everything that was happening 10 seconds before and 10 seconds after the incident. Then, a built in cell phone uploads the video. All that data that’s recorded then goes to the Internet for mom and dad to see.” Read More: http://www.ksn.com/news/extra/38610792.html
With my own 18 and 19 year old daughter and son sitting behind a steering wheel now, this article made me think of the numerous TapRooT® clients we have dealing with vehicle accidents involving their employees. There are black boxes and video cameras in many cars like in airplanes but they are usually used after the incident.
Often the thought about not wearing seat belts to not driving safely falls in the realm of I can’t enforce it when I am not present. Funny thing is that I used to not wear a seat belt while driving until the U.S. Air Force said they would not pay my medical bills if I got hurt while not wearing it. So if your driver (teen or employee) knows that you will get a phone call with video during certain risky maneuvers maybe you can implement the policy.
A press release from the US Chemical Safety Board:
Statement of CSB Investigations Supervisor Don Holmstrom Updating the Public on the Investigation of the Silver Eagle Refinery Fire in Woods Cross, Utah
Good morning, and welcome to the Chemical Safety Board’s - the CSB’s - news conference. The CSB is an independent federal agency charged with investigating chemical accidents at fixed facilities. We are modeled after the National Transportation Safety Board, and our offices are located in Washington, D.C. We have a professional staff of engineers and other specialists with industry and government experience.
My name is Don Holmstrom, Investigations Supervisor for the CSB. This morning we will be providing you with an update on our investigation into the January 12 fire at the Silver Eagle Refinery in Woods Cross, Utah.
As most of you know, two refinery operators and two contractors were engulfed by the flame front and suffered serious burns. All four were hospitalized and are now recovering.
Since arriving in Utah the investigation team has conducted over 40 interviews, gathered process samples, collected hundreds of pages of refinery records and extensively examined the accident scene.
To date, our investigation has found that on the evening of January 12, 2009 at approximately 5:20 pm a large vapor cloud was released from an atmospheric storage tank, known as tank 105, which contained an estimated 440,000 gallons of light naphtha.
Witness interviews state that vapor was seen escaping from atmospheric vents on the west side of the tank.
Through an examination of the damage to the area surrounding the tank the CSB has determined that the vapor cloud found an ignition source - for example a utility room with a gas heater or an electrical outlet connected to a conventional refrigerator - and the ensuing flash fire spread up to 230 feet west of the tank farm.
Two structures were damaged as a result of this fire, a shed and a lab facility located approximately 140 feet and 160 feet respectively, from the site of the release.
On the day of the incident, tank 105 was receiving up to three different streams of hydrocarbon liquids from the refinery, including ‘light’ or low-boiling substances. The primary feed into tank 105 had been sent from the #1 crude unit pre-flash accumulator for approximately three weeks prior to the incident. Feeding tank 105 directly from this unit was a recent process change and the feed from this unit had undergone a different form of processing. Workers were also purging equipment with nitrogen to remove flammable liquid, with the intent to pressure the liquid into tank 105.
We have established sampling protocols, taken samples from storage tanks and from process vessels, and will be instituting the appropriate testing procedures.
The CSB is investigating reports from plant personnel indicating a history of vapor leaks from tank 105 both prior to and following tank repairs.
The CSB will be investigating if the floating roof on tank 105 was equipped with the appropriate seal for use in the storage of light hydrocarbons of the type sent to the tank. Our investigation will examine possible failures within tank 105 such as gaps between the seal and the inner tank wall, the integrity of the seal, and the design and structural integrity of the tank.
Currently the CSB has identified two additional issues that are of particular interest to our ongoing investigation. The first is an examination of changes to the process unit sending liquid to tank 105 and possible effects that these changes had on the incident.
We will also review facility siting issues relating to this release and fire. Specifically, the occupied lab was affected by the flash fire. This structure is located in close proximity to operating process units.
The CSB’s investigation into the March 2005 explosion and fire at BP Texas City examined facility siting of portable work trailers. All of the fifteen contract workers killed in that incident had been working in or near portable trailers located near hazardous process equipment.
As a result of our findings, the CSB issued an urgent recommendation to the American Petroleum Institute to update their guidelines for portable work buildings such as trailers.
Today, the CSB investigative team is returning to Washington, D.C. to brief agency officials and analyze the information we have gathered during our visit to the site. Depending on the course of the investigation, we expect to return periodically to Woods Cross to gather more information.
The CSB’s investigations seek to identify the root cause of an accident. As new information becomes available, we will keep the community, public officials and the industry informed. We do all this, of course, in an effort to prevent serious chemical and refinery accidents that cause injuries, destroy property, and jeopardize public safety.
Our ultimate product will be safety recommendations designed to prevent a recurrence of this type of accident, here or at refineries located in cities across the country.
Thank you for attending today, and we will be happy to answer your questions.
For more information, please contact Hillary Cohen at (202) 446-8094 cell or Daniel Horowitz at (202) 261-7613.
From Columbia University’s Mailman School of Public Health:
January 22, 2009 - Researchers at Columbia University’s Mailman School of Public Health have released findings identifying factors that affected evacuation from the World Trade Center (WTC) Towers on September 11. A research methodology known as participatory action research (PAR) was used to identify individual, organizational, and structural (environmental) barriers to safe and rapid evacuation.
PAR is a research approach in which the researchers actively engage and collaborate with members of the study population on all phases of the project — from study design to the presentation of results and discussion of implications. According to Robyn Gershon, DrPh, professor of clinical Sociomedical Sciences at the Mailman School of Public Health and principal investigator for this study, “PAR has been used extensively in occupational health research but not, to our knowledge, in disaster research.”
For this WTC Evacuation study, the WTC evacuees, study investigators, and consultants with a wide range of expertise worked together collaboratively to develop a set of recommendations to improve high-rise evacuation of business occupancies. The PAR teams identified key risk factors associated with three major outcomes: length of time to initiate evacuation, length of time to complete evacuation, and incidence of injury. WTC evaluation initiation was delayed by lack of awareness and experience in evacuation procedures; making phone calls; seeking out co-workers; and personal concerns about one’s own ability (e.g. health and stamina) to descend multiple flights of stairs. Workers also delayed their evacuation because they were waiting for their supervisor’s permission to leave. The length of time for the entire evacuation process was lengthened by inappropriate footwear; confusion about where the staircases were located and where they terminated; and periodic congestion on stairs. Injuries were associated most often with physical disabilities (i.e., those with physical disabilities were more likely to be injured during the evacuation process).
The researchers make recommendations that focus on the need for a greater emphasis on emergency preparedness for high-rise workers. Specific measures recommended by PAR team members include mandatory training and drills, such as full-building evacuation drills. PAR team members also suggested that employees keep comfortable footwear and emergency supplies at their desks.
“One of the most important recommendations the teams made was to encourage the development of a clear cut emergency preparedness climate that is communicated to personnel,” noted Dr. Gershon, “Emergency preparedness is a shared responsibility.”
The study was funded by the Centers for Disease Control and Prevention through a cooperative agreement with the Association of the Schools of Public Health.
About the Mailman School of Public Health
The only accredited school of public health in New York City, and among the first in the nation, Columbia University’s Mailman School of Public Health provides instruction and research opportunities to more than 1000 graduate students in pursuit of masters and doctoral degrees. Its students and more than 300 multi-disciplinary faculty engage in research and service in the city, nation, and around the world, concentrating on biostatistics, environmental health sciences, epidemiology, health policy and management, population and family health, and sociomedical sciences. www.mailman.hs.columbia.edu
I was reading an article in a daily e-mail publication and an entry caught my eye. It said “Safety experts believe that about 20% of workers cause 80% of accidents”
It then went on to say that these “accident prone” employees were most likely:
Irresponsible, aggressive, and easily distractible people
Stoic “tough guys,” who work through any injury or illness and consider it a sign of weakness to do otherwise
Risk takers, who think accidents happen to other people and who are often young and male
Angry people, who let emotions distract them from their work because, as the old saying goes, they are “so angry they can’t see straight”
Shy workers, who don’t want to draw attention to themselves by reporting an incident or near miss
Tired people, including shiftworkers, whose lifestyles don’t give them enough energy or alertness to work safely
Disinterested workers, who frankly don’t give a damn about the job and simply don’t care enough to be careful
Wow! The article made me stop in my tracks and think…
First off, who are these “safety experts” who say that 80% of the accidents are caused by 20% of the workers and this makes them “accident prone”?
Of course a small percentage of workers cause most of the accidents. How could it be any other way? If 100% of the workforce was involved in accidents … Everyone would be injured!
Because only a small percentage of people are injured, people start thinking that they just had “bad luck.” But this isn’t right either.
The small percentage of employees being involved in accidents (”causing the accidents” as the article claims) is simply a result of modern safety systems that keep most of the employees safe most of the time.
Next, where could anyone get reliable statistics about the types of employees involved in accidents across the country that are categorized into the categories suggested above? I’ve never seen this type of report from National Safety Council, OSHA, or the Bureau of Labor Statistics. My guess is that someone made this stuff up - which could be why the data was completely un-sourced in the article.
What can you learn from this article’s lessons from accidents.
1. Don’t believe everything you read about safety. Look for the sources of statistics. “Experts believe” isn’t a good enough reference.
2. Think about statistics that are presented in articles. If they don’t seem right, they probably aren’t. Remember, over 50% of all statistics are made up (like this one).
3. Yes, a small percentage of employees are involved in accidents. But this doesn’t necessarily mean they are bad people. Stop looking to blame people (who caused this?) and start looking for system causes that you can correct to improve performance.
If you need a systematic process to find the human performance and equipment related causes of accidents and incidents, attend a TapRooT® Course and learn to apply the TapRooT® System to develop effective corrective actions to stop accidents and improve performance.
“The Documented Safety Analysis for Tank Farms provides technical safety requirements that, if properly implemented, would preclude an overpressure situation in the dilution line.”
“Of particular concern is the failure of tank farm management to properly consider the potential for chemical vapor exposure in the initial response to the accident or in the initial medical actions. The potential chemical vapor exposures were not adequately addressed until site management received reports of symptoms among workers following the accident management.”
This is an interesting read, and there are multiple things that should have been done better. However, just a few comments:
How often do we consider equipment failures just that and not dig deeper to find that human performance problems actually were the reason the equipment failed? In this case, it was a very serious event, and I’m glad they got to the bottom of it; however, what if a plant does not have a serious event but a series of smaller incidents such as downtime for repairs? These types of events disrupt the business and over time can cost millions of dollars in repairs, wasted time, and lost production. Our Equifactor® module in TapRooT® can help you troubleshoot equipment issues so you can find the root causes of equipment failures and the underlying human performance issues that caused them. For more information on Equifactor®, see http://www.taproot.com/courses.php?d=3
Next comment - in this case, the initial response to the incident left employees in harms way. They did have an Emergency Response Plan; however, the plan was in need of improvement. Again, an organization such as the DOE with a site this hazardous has to have a plan; however, how many worksites in general industry do not have a robust plan for responding to emergencies? The time to develop a plan is not during an event!
Last point - I know this is a long report to read but I want to call your attention to the matrix on page 19 that shows corrective actions from a previous NOV (Notice of Violation) were not addressed. Would you say this is common? Whether it is a regulatory response, an audit finding, or an investigation corrective action, my opinion is this is where we many times drop the ball. If you want a problem fixed, follow-up has to happen, or all of the work done prior to that is for naught. The corrective action techniques learned in a TapRooT® course include the requirements for verification (was it completed) and validation (did it work as intended). To learn more, attend a course today - here is the schedule:
Two passengers are alleging that the pilot should not have aborted the takeoff. I wonder if they are pilots or how they made that determination?
Their lawyer says “Continental knows what happened. They have access to all the records. They have access to the pilots.”
World’s quickest investigation perhaps? I don’t know if they should have aborted or not, because the NTSB has not finished their investigation, and won’t for months. What I will say is that I would rather be on the ground than in the air if there is something wrong with the aircraft. One day we should know.
Of course there is an agenda here; however, we’ve probably all been guilty of jumping to conclusions and finding things that support our own views while performing an investigation. Since we are only human, how do we avoid bias in our investigations? The answer is, by using a proven expert system that is based on research - a system like TapRooT®. Learn more by attending a course this year - see the schedule:
“With the number of accidents growing, and influx of students coming, Tempe and light-rail officials are calling on Valley residents, especially those who travel near the Tempe campus, to pay closer attention as they learn to navigate roads that as light rail’s Dec. 27 launch, are frequented with trains.”
“Christina Sternberg, an ASU graduate who now works with the university’s intercollegiate athletics department, said she was driving in the area when the train and truck collided last week.”
“People are used to walking around here and now there’s these trains coming and I don’t know that it’s necessarily enough just to ticket people,” she said. “They need a few big signs posted at the major crosswalks. Something that says, ‘Be reminded that the trains are here.’”
Hmm……am I the only one who read this story and thinks they should fix the systemic issues rather than relying on the general public? Maybe they should hire the lady that was quoted to give them some ideas.
As someone who worked for airlines for 27 years (the last 10 in safety and compliance) before joining System Improvements, I can attest to the professionalism of all the employees, from mechanics to pilots to operational folks and beyond. Safety is ingrained in the culture of this industry; after all, the smallest problem can be devastating. Congratulations to all the airline employees, suppliers, manufacturers, and air traffic controllers for getting it right over and over, day after day.
On the other side of the coin, medical mistakes have been blamed for thousands of deaths per year in the US. The same best practices for human performance used by the airlines and countless other industries can be used to reduce this alarming problem.
The Joint Commission http://www.jointcommission.org/AboutUs/ is working to address these issues, but the data clearly shows there is a long way to go. In the meantime, at least you can feel good about getting on an airplane, as long as you don’t eat the food!
Healthcare Professionals - take a stand and fight against these preventable errors! Attend a TapRooT® course in 2009 - here is the schedule:
Arrangement/placement, broken lights, and a change involving the timing of the lights to increase traffic flow are all issues as the article describes.
If you have been to a TapRooT® course, you have learned about applying the SMARTER Matrix to your corrective actions. For those that have not, SMARTER stands for:
Let’s talk about R (Reviewed) for a second - making sure corrective actions are reviewed for unintended consequences is crucial. Solving one problem while creating another is not good…..
If you would like to learn more about using SMARTER, as well arrangement/placement and other human factors issues that cause accidents, attend a TapRooT® course in 2009 - here is the schedule: http://www.taproot.com/courses.php
Someone in our office got a red light camera ticket. In Knoxville it’s a $50 fine and no points (doesn’t go on your record). They remembered the yellow light was “kind of short.” And they could access a video of the “infraction.”
After watching the video about 4 times I noted:
1) It was a close call. The vehicle was right at the crosswalk when the light turned red.
2) The yellow was set at about 4 seconds (maybe slightly less - I didn’t have a stopwatch and the video didn’t have a time stamp).
3) The person’s break lights came on just as they entered the intersection (when they say they noticed the light changed to red.
That got me interested in yellow light times, standards for yellow light times, and intersection safety in general.
First, I came upon this discussion page on yellow light timing on the Federal Highway Administration web site:
All this reading about improvement makes me think … Are they really addressing the ROOT CAUSES of people running red lights.
It seems to me that the T-bone accidents (high chance of a fatality) are the ones that we should be addressing.
Are these caused by “enforcement NI”?
Are people intentionally breaking the rules?
Or are they distracted, inattentive, blinded by bright lights, confused by background lights, …
It seems to me that an enforcement solution will only work if there is an enforcement NI root cause.
And if cities are shortening yellow lights to increase revenue … This is an obvious case of creating red light runners to enhance ticket revenue.
So be careful when creating corrective actions. Make sure that the corrective actions are effective (the E in SMARTER) in preventing the recurrence of the root cause. Otherwise you will be implementing corrective actions that may fit some agenda item, but won’t prevent the recurrence of the accident.
10% of the people surveyed reported having been diagnosed with a sleep disorder, while:
- 35 % wake up in the morning feeling unrefreshed,
- 33 % report that they snore,
- 31 % cannot sleep through the night, and
- 25 % complain that they have problems falling asleep.
The CDC says that these results may reflect the nation as a whole.
Can sleep problems lead to accidents? The CDC web site says:
“People who don’t get enough sleep, or have poor quality sleep, can present a hazard on the roads and in their jobs. Their sleep-related problems may also be associated with a reduced quality of life.”
“This is the sixth fatality in an enclosed space that the MAIB has investigated since September 2007. In view of these, and many other fatalities occurring in similar circumstances worldwide, the MAIB issued a Safety Bulletin in July 2008.”
I’m glad they took action, but it should have happened sooner. Don’t get caught in this trap - be proactive and use TapRooT® to investigate incidents and to audit performance before accidents occur. For course information, visit http://www.taproot.com/courses.php
“An engineer driving a Staten Island Railway train that derailed December 26 may have fallen asleep at the switch, multiple sources with knowledge of the investigation told the Advance.”
I am always leery of statements such as “sources close to the investigation.” At any rate, fatigue is something you would want to investigate in such a case, so I’m glad they are on it.
The article also contains interesting information about some safeguards (barriers that protect targets from hazards) that were implemented previously. In trying to understand why this accident occurred, you would want to review the safeguards to see if they worked as intended. In the corrective action phase of the investigation, you would look to see if additional safeguards could be implemented or existing ones strengthened.
Would you like to learn more about investigating human performance problems (including fatigue?) and safeguards analysis? Of course you would! Plan on attending a TapRooT® course in 2009 - here is the schedule: http://www.taproot.com/courses.php
I hear what he is saying about experience being needed to know what to do to avoid accidents. Good judgement comes from experience. And experience comes from bad judgement!
Perhaps there are some other causes of accidents other than “bad judgement” that could be addressed if advanced root cause analysis was being applied to really learn from accidents rather than just passing along sea stories…
We have several barge, tug, and shipping companies (including Reinauer) applying TapRooT® to analyze the real root causes of accidents, incidents, and near-misses and implementing effective corrective actions to improve performance and greatly reduce accidents. Let’s hope we get to the point that experience is not the only teacher or the only safeguard between a good day and a tragic accident.
Remember, every near-miss with potential serious consequences is an opportunity to learn and prevent a major, costly accident.
We blog about problems occurring all over the world, but this one really hits home, since our company is located in Knoxville, TN, and our drinking water could be at risk.
Here is a link to the TVA (Tennessee Valley Authority) information about the incident:
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
There are other 
