Here’s a difficult investigation - how would you find the root cause(s)?
Four people were killed when the loaner Lexus 350 crashed and burst into flames. USA Today reports that:
“California Highway Patrol Officer Mark Saylor, 45, and three others were killed Aug. 28 on State Route 125 in Santee, a town near San Diego. The runaway car was doing more than 120 mph when it hit a sport-utility vehicle, launched off an embankment, rolled several times and burst into flames.“
They also report:
“Lastrella called police about a minute before the crash to say the vehicle had no brakes and the accelerator was stuck.
The call ends with someone telling people in the car to hold on and pray, followed by a woman’s scream.
The family was in a 2009 Lexus ES 350 that was loaned by a dealer, Bob Baker Lexus El Cajon, while their own vehicle was being serviced.
Investigators with the National Highway Traffic Safety Administration have determined that a rubber all-weather floor mat found in the wreckage was slightly longer than the mat that belonged in the vehicle.“
The NTSB Investigator said:
“We don’t know if the all-weather floor mat was properly secured or not. We do know that it was a floor mat from a different Lexus.“
As an investigator, how can you provide 100% assurance that you have found the root causes of this accident?
Looks like a SnapCharT® might help with the investigation (what is assumptions and what is known).
The Joint Commission on Accreditation of Healthcare Organizations (JCAHO) wrote it in the first paragraph.
The toll of this inadequate leadership is staggering - about 50,000 deaths per year. (Taking the estimate of deaths in the US from the Institute of Medicine report and multiplying it by 50%).
Another way to think about this is that perhaps 1/2 of the 5708 registered hospitals in the US have inadequate leadership. That’s 2604 hospitals that need to improve their leadership and probably should be concentrating on learning advanced root cause analysis and performance improvement best practices.
We’ve always sent information about the Eliminating Healthcare Sentinel Events Best Practice Track and TapRooT® Training to risk management, patient safety, and quality improvement professionals at hospitals. Maybe we should be sending the information to hospital administrator to reach the top of the leadership pyramid?
If you think your administrators need to know more about root cause analysis and preventing sentinel events, pass our newsletters along. Or sign them up to get our newsletters monthly at:
Also, pass along information about the Eliminating Healthcare Sentinel Events Best Practice Track at the TapRooT® Summit. They will be amazed at what they learn. See the schedule by clicking on the appropriate button on the left at:
I’m signed up for just about every root cause analysis, quality improvement, equipment reliability, and problem solving publication there is. What I’m usually surprised about is how much BAD ADVICE I get in many of the publications.
Where does the bad advice come from? People who teach 5 Whys as a root cause analysis tool.
If you’ve read this blog for very long, you have read the theoretical and practical discussions that we’ve had that explain why the “5 Why” method does not promote good root cause analysis. If you haven’t been reading for very long, check out these articles…
Now for the most recent BAD advice … An article claimed that all operators should be trained in “5 Whys.”
Why? Because they need “5 Why” skills to effectively troubleshoot and find the root causes of potential equipment problems and improve asset reliability.
Since the articles above already show that “5 Whys” is only effective if you already know the cause of the problem, I think it is highly unlikely that “5 Whys” will help operators find answers that they don’t already know.
Therefore, you are wasting your time teaching them “5 Whys” when they are only going to find answers that they already know OR they will misdiagnose problems by using “5 Whys” to troubleshoot a problem and make the analysis fit the answers that they are familiar with.
Most operators can already tell you familiar causes for problems without going through the “5 Why” process. What they can’t do is find the answers to problems that are outside their experience and knowledge.
So what technique should operators use to find the causes of problems that are beyond their current understanding?
TapRooT® and Equifactor®.
Equifactor® will help them find the reasons why equipment failed through an expert system based on Heinz Bloch’s proven troubleshooting tables.
TapRooT® has embedded experts systems that will help operators find causes and solutions that are outside their experience and current knowledge.
That’s good root cause analysis advice that’s based on two decades of research and development.
If you want to train your staff in problem solving tools that will help them go beyond their current knowledge, give us a call at 865-539-2139 or CLICK HERE to contact us by e-mail.
It’s called the “Bottleneck” Theory, because you have limited attentional resources…..yah the report is on my desk, stupid phone always rings when I’m busy, what’s for dinner tonight… oh, like I was saying we have limited attentional resources. The more attention required to focus on a task, the more the other passive actions have to wait or just happen with just a little attention to keep it going.
Here are some of the report findings…. keep in mind that this study was performed on Guinea Pigs (college students)….who may not represent you who or me because WE always get our work done on time and never cram anymore!
The researchers studied 262 college undergraduates, dividing them into high and low multitasking groups and comparing such things as memory, ability to switch from one task to another and being able to focus on a task.
“found multitaskers are more easily distracted and less able to ignore irrelevant information than people who do less multitasking.”
“The huge finding is, the more media people use the worse they are at using any media.”
“The high media multi-taskers couldn’t ignore the blue rectangles. “They couldn’t ignore stuff that doesn’t matter. They love stuff that doesn’t matter,” he said.”
“High multitaskers just love more and more information. Their greatest thrill is to get more,” he said. On the other hand, “exploiters like to think about the information they already have.”
Now the really good part…. for those of us who usually only get to learn new things when we make a mistake and have to figure out what we messed up, You get another chance to learn about Multi-Tasking, Fatigue, our Senses, Procedures that a rocket scientists could never follow (mandated to be followed by the average worker), ways to improve Situational Awareness, and way to measure that you made a difference in Stopping Human Error.
Behind Door Number One: Our 2-Day Pre-summit Course Stopping Human Error with hands on exercises and Solutions. This course has been completely revolutionized for 2009 but the reasons to attend it are still the same… http://www.taproot.com/summit.php?t=pre-summit#humanerror
Behind Door Number Two: Our Behavior Change & Stopping Human Error Track During the 3-Day Summit
One course in particular Practical Tools to Stop Worker Error has just been added; introduces reason for human performance tools and INPO’s 8 fundamental human performance tools which should be used for every job. These include: Situational Awareness tools of Task Preview, Job Site Review, Questioning Attitude, and Stop When Unsure, Compliance tools of Self-Checking and Procedure Use/Adherence and Communication tools of Three-way Communication and the Phonetic Alphabet…. and we will also show how Critical Human Action Profile (CHAP) and Change Analysis can help you decide when these tools were not used when should have been and where Human Engineering changes should have been the long-term answer.
A building collapse is China is documented in these pictures and graphics…
(1) An underground garage was being dug on the south side, to a depth of 4.6 meters
(2) The excavated dirt was being piled up on the north side, to a height of 10 meters
(3) The building experienced uneven lateral pressure from south and north
(4) This resulted in a lateral pressure of 3,000 tones, which was greater than why the pilings could tolerate. Thus the building toppled over in the southerly direction.
First, the apartment building was constructed
Then the plan called for an underground garage to be dug out.
The excavated soil was piled up on the other side of the building.
Heavy rains resulted in water seeping into the ground.
The building began to tilt.
And thus came the eighth wonder of the world.
- - -
I don’t know if this analysis is accurate or not. I’m not a soils or a building engineer, but it seems as if the soil should not be a support for a multi-story building.
If so, please stop by the TapRooT® Booth (#205) and say hello. Mark, Linda, Michelle, Ken, and I will all be there.
Also, please attend our talk:
Wednesday, August 26: 10:30 am – 11:30 am Advanced Root Cause Analysis; Improving Investigations and Audits
This workshop will discuss how Star sites can improve their downstream investigations, proactively solve problems before incidents occur, and show year-by-year improvement in their annual reports through advanced Root Cause Analysis (RCA) and trending techniques. Attendees will learn how the use of an expert system makes investigations/audits defensible while removing blame and human bias. Ways to use RCA to strengthen the management commitment, employee involvement, worksite analysis and workplace training elements of your VPP program will also be discussed.
If you can’t make it to the conference but are interested in VPP, please look for next week’s root cause analysis tip, where I will discuss ways to strengthen your VPP program using TapRooT®.
It seems the driver was fatigued and had an accident. Prosecutors tried to convince the judge that the fatigue was the direct cause of the accident and that the management knew that the drivers didn’t have proper sleep, but used them anyway.
The driver received a four year jail term for the accident. But management was acquitted. Why? The judge was not convinced by the expert testimony that fatigue was a cause of the accident.
At this year’s Summit, there is a session about proving that fatigue is the cause of an accident. It will teach a technique to analyze fatigue using available data. This “simplified” technique isn’t qualified for use as evidence in court. But the more robust technique that it is based on is. Perhaps if this more robust technique had been presented to the judge, he would have been convinced that managers were guilty.
If your company does business in the UK, are you prepared for accidents in light of the Corporate Manslaughter Act?
Our UK instructors teach a course to prepare your managers for their new responsibilities and risks under the Corporate Manslaughter Act. They are experienced detectives and can share with your management the challenges they will face and the preparation they need to take to be ready if a fatal accident occurs,
Contact us by using the link below for more information:
The Federal Aviation Administration directive gives operators of the popular airliner three years to install an automatic fuel pump shut-off system for the center fuel tanks on 767s. The concern is that if fuel in the tank dips too low while the pump is still operating, that could ignite fuel and air vapors in certain conditions.
In the meantime, flight crews are supposed to close the pumps themselves when fuel gets low.
From another report: Boeing spokeswoman Liz Verdier said the Chicago-based aircraft manufacturer sent operators of 767s a service bulletin two years ago recommending the changes in Wednesday’s FAA order. Compliance with service bulletins is voluntary. Verdier said she didn’t know how many operators may have already installed the automatic shut-off systems.
FAA has no authority to order foreign carriers operating 767s to install the shut-off systems, but most operators usually comply voluntarily or are ordered to do so by aviation authorities in their countries. There are about 960 of the 767s in operation worldwide, including 414 in the U.S., Verdier said.
Being an ex-fuel tank mechanic and a current frequent flyer, I am all about making the airplane safer for flight. But I have to question is this grasping for straws, making decisions to make it safer because no other finding could be found with recent center wing tank explosions? If this is an issue with 767’s why not with other aircraft? After all, many fuel pumps are similar in specification and type. What makes this one situation special?
Granted each aircraft has its own characteristics and even act differently in different parts of the world. This fix also reminds me of a not so old report where it was believed that ice choked the fuel supply to a large airframe. Only problem is that investigators could duplicate the incident. So when developing corrective actions you should have the root causes first. If the risk is present then why does it not affect other similar systems? If it is a danger to one then it is a danger to all. So make them all safe.
Too Narrow Trench Could Cost Port Of Seattle $1M. “The Seattle Times reports Wednesday that a contractor at the port’s Terminal 30 near Safeco Field dug a trench for an electrical cable that was 0.02 of an inch too narrow. That meant the cable wouldn’t fit, and a new cable for the terminal’s giant cargo cranes had to be ordered for about $200,000.”
Now I can imagine that the plan went through a document and review transactional process…. which can be mapped out just perfectly on a SnapCharT® (Sequence of Events with an Incident). I wonder where the gap in the hazard and safeguards analysis will show up. I know, hazards are often thought of as uncontrolled safety of life energies like electricity. However, isn’t getting it wrong a hazard… think of the hazard of uncontrolled dimensions or stack up of tolerances. Think of it this way: if a bolt is just a little oversized and the bushing is just a little undersized and then I put a coating of corrosion control on it, it just won’t fit. Don’t laugh.. it took a long time to get that stuck rudder back off the aircraft with seized parts.
So for those of you who have taken our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training or 2-Day TapRooT® Incident Investigation and Root Cause Analysis courses pull out your workbooks and look up defining Casual Factors using Safeguard Analysis. You know the questions, just think about the Target and Hazard as it relates to Business or Work Processes. What safeguards are in place or which ones should have been in place? How did the product get too close to the customer? What made it worse when your client called you with a complaint? (more…)
While you can complete your own TapRooT® Root Cause Incident Analysis as soon as you leave the course, as a TapRooT® Instructor sometimes it is good to get a validation that the 7-step process is correctly used without taken a shortcut. How do we do that? By having students call us when they need a little advice or nudge. The help does not stop when you walk out of the classroom.
For others, you may have let the TapRooT® Process sit on your shelf collecting dust waiting for a “big” incident to happen to use it. If this is you, give us a call at 865.539.2139 and ask for one of our Instructors. If it has been a few years since your last class we have a 1-Day TapRooT® Refresher Course taught on-site or you can come to our 2-Day Advanced TapRooT® Techniques taught during the Summit this October in Nashville. Not only will it be a refresher but it will also teach you techniques used by our facilitators during investigations.
Below are recent comments and questions from some of our students during and after their course. I have been involved in Health and Safety for nearly 20 years and have taken many Professional Development courses but I have to say the the 3 day TapRoot Investigation course was taught with the utmost respect for the unlearned and well learned alike! I have studied other Incident Investigation Techniques and TapRoot is incomparable and exceeds any other investigative process to discover and correct Root Causes!!
Steve LeBlanc P.GSC
Just wanted to tell you how much I enjoyed your class. You and Richard really kept us going and the enormous amount of experience you both pull from really adds to the class. I will not hesitate to contact you guys when I run into questions or problems!
Thank you,
Donna
I just wanted to let you know how much I appreciate all the work you and Richard put into the excellent Tap Root seminar you just completed in San Antonio. I learned a lot and can’t thank you enough for the time you put in on the program and the extra hours the two of you spent helping me (and the others) before and after the regularly scheduled time of the course each day. Your expertise and knowledge of the program is very obvious and I am so thankful you were the instructor on this course. I hope to see you soon at another Systems Improvement event.
Again, thanks for everything.
Lloyd Biggers
President
Knight Consulting LLC
I have gone through the root cause trees for three causal factors. Please take a look at the attached file and let me know what you think. I have also written up a report which is still in the process of being checked but I have attached it as well for your comment and review.
Best Regards,
Vicky Green Samuelsen
Risk Manager
Thanks for the e-mails over the months, haven’t forgotten your offer for assistance and to be honest could have made use of it if time had allowed. Had a number of investigations (biggish ones!) to get my teeth in to with several extended discussions with others on site on Causal factors and conditions. if I get a chance in the future I will run some of them by you.
You may have heard about the risks of distracted driving before, but a New York Times article certainly makes the study of the problem a political issue.
I remember a very interesting study of car accidents that was performed using several cameras mounted on cars, accelerometers, a satellite link, and computer monitoring to spot accidents and refer them to analysts to accurately identify the causes.
What did they learn?
Fatigue was a much bigger problem than the official accident data showed. (Watch the movie above.)
Also, the most risky behavior (10 times more likely to have an accident) was reaching for something that was moving in the car.
Constant cell phone use is obviously a problem (4 times more likely to have an accident) but before we start outlawing cell phone use, we should think of all the other things that can distract the drive - reading billboards, tuning the radio, reading a newspaper, or putting on makeup) and make sure that we aren’t getting rid of one activity that will be replaced by another.
People need to understand that multitasking behind the wheel is dangerous and needs to be minimized. But making it a criminal act? What do you think?
Let’s see which of these distracted driving behaviors that you would criminalize:
Dialing a cell phone.
Talking on a hand-held cell phone.
Talking on a hands-free cell phone
Texting on a cell phone
Using a computer.
Programming a GPS device.
Tuning the radio.
Talking to a passenger.
Reaching for something that is moving.
Smoking.
Eating.
Drinking from a container.
Changing the air conditioning using a computer screen in the car.
Getting something out of a purse.
Putting on makeup.
Reading a newspaper.
Reading a billboard.
Singing to a tune on the radio,
Taking off a piece of clothing.
Looking at the occupants of another car.
Note that all of these require some amount of attention and are, therefore, somewhat “distracting.”
Vote for the ones that you would make illegal by leaving a comment by clicking on the comment link below. Also, consider leaving a comment about your reasoning why some should be legal and others illegal.
Just a few pictures of students working on their final exercise in a 5-Day course. Now how much energy would you have after 5 days of intensive root cause analysis hands on training? This group of 17 students showed no hesitation in getting to needed answers about some of their own incidents.
Our instructors work with the groups one on one. See TapRooT® Instructor Richard Mesker sitting in the middle of an energized group. He is the one with the mustache and wearing the tie.
Here are just a few of the many comments we received during and after the class.
“I just wanted to let you know how much I appreciate all the work you and Richard put into the excellent TapRooT seminar you just completed in San Antonio. I learned a lot and can’t thank you enough for the time you put in on the program and the extra hours the two of you spent helping me (and the others) before and after the regularly scheduled time of the course each day. Your expertise and knowledge of the program is very obvious and I am so thankful you were the instructor on this course. I hope to see you soon at another Systems Improvement event.” Lloyd
“Systematic way of analyzing proactive and reactive events. Initially will use on incidents and near misses and then on proactive issues and tasks.” Donna
“…. to get a non-ambiguous root cause for clear corrective action.” Luis
“I liked the real world hands on experience. It helped in the classification of a causal factor.” Alicia
“Worked with people from different industries.” Jesse
Don’t miss out on your soonest chance to attend a TapRooT® course. Safety and business problems wait for no one.
The BBC reports that Senior Judge Lord Gill has found that a 2004 blast that killed 9 people at ICI Plastics was caused by a pipe carrying liquid petroleum gas into the factory was “out of sight and out of mind”.
Other interesting quotes from the article include:
“In 2007, ICL Plastics and ICL Tech were fined a total of £400,000 for breaching health and safety laws.”
“The inquiry, which was held over two sessions in July and October last year, was told that the damaged pipework would have cost about £400 to replace.”
“After meeting with some of the families affected, Scottish Secretary Jim Murphy said: ‘What is clear from the report is that this disaster could and should have been avoided.’
“‘It lays out a litany of failings and it is imperative that we take on board Lord Gill’s recommendations for a better and more effective safety regime surrounding LPG installations to ensure an unnecessary and preventable fatal incident such as this never happens again.’”
I haven’t had time for more than a cursory review of the reports. The analysis of the causes starts at about page 106 of the full report. There seem to be lot’s of causal factors and many chances to have prevented this accident. If you have time to review them. let me know what you think of their root cause analysis.
Here’s the YouTube Video of the start of the fire (from a security camera) …
Analysis shows that a military flare what shot over the building, exploded, and landed on the building. It started a fire that caused $50 million in damage.
The police say there is no indication that the military fired any flare so they are looking at this fire as a crime. (The Wisconsin fire marshal announced a reward of up to $16,000 for information leading to the arrest and conviction of the person or people responsible for the fire.)
Since no security system for a meat packing plant could reasonably be expected to prevent this kind of attack (thus, no chance for a “Human Performance Difficulty” on the Root Cause Tree®), this type of incident would have a “root cause” that gets no further down the tree that the first level. It would stop at “Sabotage”. Thereafter, the investigation becomes a criminal investigations.
From all reports that I’ve read, the firefighting after the fire started was superb. Thus there are no Causal Factors after the Incident on the SnapCharT®.
That makes this a rare case where there wasn’t anything under management’s control that could have stopped this accident.
Here’s more info about the fire from press coverage:
The article portrays the equipment troubleshooters as being fairly baffled by continued unreliability in the automatic control system. They seem to be in the “replace something and see if it works” mode.
Equipment troubleshooting, especially of advanced, digitized, complex systems, can be extremely difficult. That’s why pre-thought out troubleshooting tables are so important at the beginning of troubleshooting.
That’s why we licensed Heinz Bloch’s troubleshooting tables and added them to TapRooT® to create the Equifactor® Troubleshooting Tables back in 1998. Since then, we’ve added to the troubleshooting tables and even created a way for companies to develop their own custom tables for their own specialized equipment.
You can’t find the root causes of problems before you fully understand what happened. That’s why troubleshooting equipment problems is an important part of the root cause analysis of an accident that involves an equipment failure.
A good root cause analysis should explain what happened, how it happened, why it happened, and what can be done to prevent similar accidents in the future. But according to the Knoxville News-Sentinel, the recent contractor who provided root cause analysis of the TVA fly ash spill does none of the above. See:
As reported in the article, a worker was emptying pieces of solid chocolate into the melting vat when he slipped from a platform into the 2.5m (8ft) deep unit. He appears to have died instantly from a blow to his head by a paddle mixing the chocolate. The company is looking into why and how it happened.
Some things to think about. He was a temporary worker. How much safety and on the job training did he receive prior to being assigned the task? What barriers were there to keep someone from falling or in place to stop the machine from running when a control plane was breached? Did he have to reach over too far to dump the chocolate in the vat?
With the economy the way it is many people are working for temporary job placement companies or as a contractor. If you as the hiring company are training the temporary workers less than you would a permanent employee you may want to change the practice.
Not sure whether this is an issue in your company? Invite your contractors to attend a public or onsite TapRooT® Root Cause Analysis course with your managers and see what gaps in communication and training are present and learn solutions to fix the issue. Read more about our courses here: http://www.taproot.com/courses.php (more…)
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
Unusually 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!
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I’m signed up for just about every root cause analysis, quality improvement, equipment reliability, and problem solving publication there is. What I’m usually surprised about is how much BAD ADVICE I get in many of the publications.
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 
