I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.
Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!
(Spare time maintenance.)
SOMETHING FOR NOTHING
Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:
- Poor investigations & corrective actions
- Repeat incidents
- Increased risk of big accidents
- Risk of regulatory action after a big accident or because of repeat incidents
- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents
- Overworked, disheartened investigators
- Investigators trying to dodge investigation assignments
- Disenchanted employees who look at investigations as a waste of time
- Inaccurate investigation statistics
- Loss of management’s faith in root cause analysis
That’s quite a list.
Perhaps economizing on investigations isn’t a good idea.
(Climb the ladder to work on the roof. A reasonable assignment?)
REASONABLE ASSIGNMENTS
If investigating incidents in your spare time is bad, what is a good practice?
A measured response with a wise allocation of resources.
Let’s look at three examples.
Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.
Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.
In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.
HOW MUCH WORK?
For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.
Management needs to keep asking, “Is there any help that you need?”
(Benchmarking at the Summit.)
BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES
Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!
Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.
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.
If you think that some root causes were missed, what is your evidence?
Here’s a tip.
Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.
What Causal Factors led to this fatality?
Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.
One final question…
How do you assess the thoroughness of investigations at your facility?
For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).
After being introduced to TapRooT® through a public course, GPIC decided that they were ready to train key employees in TapRooT® Root Cause Analysis onsite. Pictured above and below after teaching the course in the Kingdom of Bahrain is Steve Swarthout (TapRooT® Root Cause Analysis Instructor & President of Performance Improvement of Virginia) with the key GPIC employees who made this course happen and GPIC course attendees.
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.
Makes you think though…. what would you invest in if it would prevent an accident, production loss, or loss of a customer? Upon purchase and “LITTLE” effort, you could throw away all your post-investment prevention programs. After all, prevention would come overnight…. silly, but don’t some mangers expect quick fixes with little effort to make problems go away? Sorry, even removing this curse took 5 hours of digging through freshly poured concrete to remove the curse.
On the other hand, all effort is not equal. investing in a robust reactive and proactive process to prevent problems from occurring would reward your efforts. Many have already invested in the TapRooT® System for finding the root causes of problems PLUS the Equifactor® Equipment Troubleshooting Technique for Root Cause Failure Analysis of Equipment Problems. If not ready yet to expend the effort, then you must believe that there are shirts buried under all our favorite teams’ stadiums and company facilities.
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.
The BBC reported that an accident in Scotland caused by a 30-ton digger falling off a truck while being moved and hitting car (killing a passenger) would have been prevented if the truck driver had been properly trained.
“I express surprise and some concern at the absence of any requirement for compulsory training for drivers of heavy goods vehicles in relation to loading and securing of loads.”
“It seems to me that if such training had existed prior to July 5 in 2006 then there is at least the possibility that the accident which occurred might not have taken place.”
Training always seems like a potential solution after an accident with 20/20 hindsight. Without additional details of the sequence of events, the causal factors, and a thorough root cause analysis, the actual root causes may never be known.
Spaceflight Now says that $150 million will be paid by an insurance company after a DISH Network satellite failed to reach its required orbit. The failure was caused by a rocket shutting down prematurely.
The article also said that a Russian Board is looking into the failure of the Proton’s Breeze M upper stage engine and is “close to determining the failure’s root cause.”
The FBI concluded that the crash of Senator Joe Lieberman’s web site WAS NOT a dirty trick from the opposing camp (Ned Lamont).
According to the FBI the data logging indicates a simple overload of the site combined with a misconfiguration of the server by the administrator. The FBI concludes that:
“The system administrator misinterpreted the root cause…”
For the complete story see The New York Times article:
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.
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?
Last week I spent a couple of days working on the IEEE Root Cause Analysis Standard for Nuclear Power Plants. The picture about is four of the collaborators “relaxing” after a hard day of standard development.
Kay Gallogly (second from the right), founder of The 42 Group, will be describing the progress made so far at the TapRooT® Summit in Las Vegas (June 25-27). See: http://www.taproot.com/summit.php for more information about her talk and the rest of the Summit.
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.
John Richter, the EHS EnCana Corporation Team Lead in Wyoming, invited his contract operators to two back to back 2-Day TapRooT® Incident Investigation and Root Cause Analysis courses this week in Rock Springs, Wyoming. We had a good turn out with operators and EHS leads attending, some even on their days off. For those not familiar with Rock Springs, last Friday there was new snow on the ground and only one day to test drive the 2009 snowmobiles.
Mark Olson, a System Improvements Inc. Instructor, leads the class in understanding how to group problems during an investigation.
The class and Chris Vallee, a System Improvements Inc. Senior Associate, listen attentively to John Richter on what EnCana Corporation would like to see from them after attending this class.
This group takes a picture of their SnapCharT® for documentation…. not a bad idea.
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:
This job oportunity includes an interesting application of root cause analysis. Manager needs to perform root cause analysis of scope changes in projects to reduce the likelihood of future scope changes. Great idea.
This short newspaper article starts to provide the information needed to draw a SnapCharT® that would have many Causal Factors. Read the story and then try drawing a SnapCharT®.
As a TapRooT® and Equifactor® instructor for System Improvements, I get the opportunity to meet quality, engineering, safety, manufacturing, operations and medical company experts from around the world. In two or five days these experts learn the basics of the TapRooT® System for finding the root causes of problems PLUS some attend one day of Equifactor® Equipment Troubleshooting Technique for root cause failure analysis of equipment problems. These are grueling days of lecture and hands on application that does not allow much time to teach people the science behind good root cause analysis. Just as important, I do not get to show people why being an expert in your field of work can actually impede your investigation due to “tunnel vision” of the mind.
Experts who are now using TapRooT®, have learned how to investigate with an open mind based on tons of research in human and workplace system interactions. But with all the knowledge our experts bring to the table why was this a limiting factor before TapRooT® use? After presenting at the ASQ Automotive Conference in Michigan this February, audience members wanted to know more about root cause tool limitation and expert use of rules-of-thumb. So if you want to understand more of our thinking processes in problem solving and why we have a tendency to assume we know why an incident occurred before we really know what occurred, link to the paper below.
For those that aren’t aware, I am the Summit Chair and with the help of the TapRooT® Advisory Board, the Track Chairs, the staff at System Improvement, and previous year Summit participants (that a lot of help!), I plan the TapRooT® Summit.
I also hand pick the courses that are offered prior to the Summit - this year on June 23-24. I pick these courses based on the experience I have with performance improvement programs around the world. My goal is to put together a world-class selection of courses that will help people solve their toughest problems.
Each year I bring back some old favorites and some brand new courses.
The old favorites are based on previous attendance and feedback.
The new courses are based on requests from participants and problems that I observe in my extensive travels.
This year there are three new courses:
1. Hazard Recognition Best Practices
2. Engineering Equipment Reliability Techniques
3. TapRooT® and FMEA for Healthcare Root Cause Analysis
There are also, eight returning veterans:
1. Advanced Trending Techniques (10th year)
2. Innovation & Creative Solutions (2nd year)
3. Stopping Human Error (5th year)
4. Risk Management Best Practices (5th year)
5. Interviewing and Evidence Collection (3rd year)
6. Getting the Most from Your TapRooT® Software (2nd year)
The FAA is proposing $10,2 million in fines. The article says:
The FAA alleged that between June 18, 2006, and March 14, 2007, Southwest operated more than 59,000 flights without complying with a 2004 order requiring repetitive inspections of fuselage areas to detect fatigue cracking.
Further, the FAA charged that the airline flew nearly 1,500 more flights using the same planes in March 2007, even after it determined that it had not done the necessary inspections.
“The FAA is taking action against Southwest Airlines for a failing to follow the rules that are designed to protect passengers and crew,” Nicholas Sabatini, the FAA’s associate administrator for aviation safety, said in a prepared statement.
The fine is the largest levied against an air carrier, FAA spokeswoman Laura Brown said.
The missed inspections were discovered by Southwest and self-reported to the FAA. The missed inspections were then performed in the month of March 2007. Cracks were found and corrected in 6 or the 46 jets that were inspected.
What were the root causes of the missed inspections and have they been corrected?
Fines do little good if the problems root causes aren’t effectively addressed.
My hope is that both the FAA and Southwest thought of this. Why didn’t the reporter dig deeper to find this out and include it in the story?
Reporting on the politics of a fine is one thing, but assuring passengers of their safety by verifying that an effective root cause analysis was performed is quite another.
A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.
Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.
What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).
Interested in learning lessons about accidents, accident investigation, and root cause analysis? Then attend the TapRooT® Summit in Las Vegas on June 25-27!
There are some great sessions in the Investigation & Root Cause Analysis Best Practices Track, including:
Root Cause Analysis of Major Accidents - This session will have three presentations about investigations. The first presentation (Lexington Airport Runway Mixup) shows how TapRooT® can be applied to publicly available information to analyze a real aviation accident’s root causes. The second (Cameco Cigar Lake Mine Flood) presents the investigation of an accident that was investigated using TapRooT®. The third (investigating Fatalities) shares experiences of an investigator from Cal OSHA.
Investigations Learned from the Field - Three experienced investigators (Ken Turnbull, Brian Locker, and Barry Baumgardner) will share lessons that they have learned over their extensive experience investigating accidents and incident.
FACTS - Computerized Analysis of Fatigue as the Cause of an Incident - Bill Sirois, VP & COO of Circadian Technologies, will share the results of research they have performed that has helped them build a tool for accident analysis of fatigue as a cause of an accident.
What’s New in Investigations and Corrective Actions - This session has three talks that share information of interest to investigators. First, Brian Locker will share the latest methods for defining Causal Factors that was developed as part of the 2008 TapRooT® Book. Next, Kay Gallogly will share the progress being made by an IEEE committee that is developing a root cause analysis standard for the nuclear power industry. Third, Bryce Donaldson will show some advanced multimedia techniques for sharing lessons learned after an investigation.
Root Cause Analysis of the Accident at Three Mile Island - This interactive session will provide an opportunity for investigators to use their investigative skills to analyze the root causes of the accident at Three Mile Island. The session will be facilitated by one of the operators present at the time of the accident.
That’s just a sample of the sessions in the Investigation & Root Cause Analysis Best Practices Track. For the complete schedule, click on the track title at:
