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Archive for the ‘Sounds’ Category

Audio and Pictures of the Miracle on the Hudson

Thursday, February 25th, 2010

Here’s another video with the audio from the Miracle on the Hudson.

Jeffery Skiles, the co-pilot that day, will tell his story and the lessons learned at the TapRooT® Summit. Don’t miss it!

Tiger Woods Accident Info for Analysis

Monday, February 1st, 2010

For those still trying to analyze Tiger Woods car accident (previous posts #1 and #2), here is the 911 call…


Friday Joke: NUCLEAR WINTER WONDERLAND

Friday, November 27th, 2009

 Downloads Snimki Wall Winter-Wonderland,-British-Columbia,-Canada

I can’t help but post this song every year during the holiday season.

 Images Games Roguespear Missions M 18 2

If you are in the nuclear industry (or just have a good sense of humor), hear the song (mp3 format) by clicking on this link:

http://www.taproot.com/blog/WorkinginNPP.mp3

 Pictures Albums North America Mexican Rx1

I don’t know where it originally came from but a nuke industry guy sent it to me by e-mail 4 or 5 years ago.

 G Globalnet Cmas Lyrics Winter-Wonderland

It brings a whole new meaning to Nuclear Winter!

 Pictures Albums North America Usa Doe Facilities Los Alamos Chuck-1

Happy Holidays to All (especially those that keep the lights and heat on when it’s cold outside)!

Mark


Monday Accident and Lessons NOT Learned - Doctor’s Mistake Kills Patient in UK - Now What?

Monday, May 11th, 2009
Dr. Daniel Ubani made a mistake. No doubt about it, he injected a patient with a fatal dose of a pain killer while making a house call. (Yes - they still do these in the UK.) David Gray, pictured below, died from the error.

200905041906.jpg

Dr. Ubani was NOT intentionally trying to kill the patient (this wasn’t a premeditated homicide).

What do we do next?

Criminal prosecution!

Will this improve the system? You tell me…

The UK Guardian reported on the sentinel event. Read about the political response here:

http://www.guardian.co.uk/society/2009/may/04/german-doctor-overdose-david-gray

There’s more information in this article:

http://www.guardian.co.uk/society/2009/may/04/german-doctor-patient-overdose

Read the Doctor’s apology letter to the family here:

http://www.guardian.co.uk/society/2009/may/04/letter-ubani-doctor-dose-apology

Hear the radio story here:

http://www.guardian.co.uk/society/audio/2009/may/04/foreign-doctor-patient-overdose

One year later, I’m not sure there’s been action to fix “the system.” One person interviewed did say that they had removed the 100 mg bottles of diamorphine from the bags that doctors carry on house calls.

But have they addressed fatigue? The language issues? Doctor qualifications? What about the reasons why the patient hadn’t been treated for the kidney stones so that he wasn’t in pain (and didn’t require a house call)? No mention is made of any of these issues.

Instead, they are arguing about whether a criminal prosecution in Germany is adequate or if the Doctor should have been prosecuted in the UK.

Monday Accident and Lessons Learned: Are Hospital Sentinel Events in Queensland, Australia a Political Issue or a Medical One?

Monday, February 2nd, 2009

49 accidents (Sentinel Events) in Queensland Hospitals in 2006-2007.

Listen to this story from ABC Australia:

Qldmedical
(click to listen - mp3)

Now ask…

Can we compare Sentinel Events rates across countries?

What national, consistent system do we have in the US?

Is a medical error a political issue or a medical issue?

Shouldn’t the story be about why the errors occur or the slow pace of performance improvement?

Comments are welcome below by clicking on the comment link.

Classic Accident Info: Sunshine Skyway Bridge Accident

Monday, December 15th, 2008

This You-Tube video tries to recreate the feeling that day.

Monday Accident & Lessons Learned: Has a “Mentally Incapacitated” Pilot Crashed a Commercial Flight?

Monday, December 8th, 2008

Previous posts about a pilot being removed from the cockpit after suffering a “mental breakdown” were posted back on February 5 and November 20.

Much of the industry press seems to downplay the safety importance of this event.

For example, here’s a pod cast on the topic:

Air-Canada-Pilot-2
(from
Airsafe.com)

Despite the reassurances (”there have been no passenger deaths or serious injuries associated with incidents where such behavior was proven“) from the Airsafe.com spokesperson, I remember that the NTSB investigators were convinced that an EgyptAir 767 crash in the Atlantic was almost certainly due to a pilots deliberate actions. (The story says: “On 31 October 1999, an EgyptAir 767 en route from New York to Cairo, crashed in the Atlantic, killing all 217 on board. The NTSB concluded that the airplane’s departure from normal cruise flight and subsequent impact with the Atlantic Ocean was a result of the first officer’s flight control inputs, but could not determine a reason for the first officer’s actions.“)

I read the complete NTSB report and the only logical conclusion was that the co-pilot deliberately crashed the plane. Anyone who would deliberately crash a fully loaded jet must be considered “mentally abnormal”. (However, if you read the report you will see considerable objections to the deliberate suicide scenario by the Egyptian investigators. I think these objections are countered by the evidence in the report. But you can draw your own conclusions after reading the report.)

Thus my conclusion is that in this case, there HAS been a case where a flight originating in the US was deliberately crashed by an unstable pilot. I think that the Airsafe.com spokesperson on the pod cast is overaly reassuring when he said:

“…there have been no passenger deaths or serious injuries associated with incidents where such behavior was proven

A more accurate statement is that “there have probably been two prior accidents caused by mentally abnormal pilots but that these types of problems are very difficult to prove.”

So what is the lesson learned?

That a pilots mental stability really is important. A mentally unstable pilot really is a major problem.

But what can we do? That’s not very obvious.

You might start thinking about what your company does to assess the mental stability of people in key jobs that could cause major accidents with loss of life.

Amazing Audio of Accident Interview

Wednesday, September 10th, 2008

 Images George

George Burk, plane crash and burn survivor, spoke at our Summit several years ago. The story of his survival ordeal is impressive.

Today he sent me a link to a tape of one of his original accident investigation interviews. Click on the link and hear the actual interview of a man who they thought would died at any time from his injuries. To read the story of his ordeal, order the book:

A Bridge Never Crossed

George is truly an inspiration. You can hear him struggle in pain to answer the investigator’s questions. Deep inside, he knew he was dying - yet he continued to struggle to answer their questions. He even throws in a occasional “Yes Sir!”

The questioning techniques used are rather rudimentary. If you would like to learn an advanced interviewing technique, attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and learn the TapRooT® 14-step cognitive interviewing process. For more information about the 5-Day Course, see:

http://www.taproot.com/courses.php?d=2

Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) Talks About Operational Excellence

Saturday, September 15th, 2007

Click here to listen to Kevin…

Friday Joke - Nuclear Winter Wonderland

Friday, December 15th, 2006

NUCLEAR WINTER WONDERLAND

 Downloads Snimki Wall Winter-Wonderland,-British-Columbia,-Canada

I can’t help but post this song every December.

 Images Games Roguespear Missions M 18 2

If you are in the nuclear industry (or just have a good sense of humor), hear the song (mp3 format) by clicking on this link:

http://www.taproot.com/blog/WorkinginNPP.mp3

 Pictures Albums North America Mexican Rx1

I don’t know where it originally came from but a nuke industry guy sent it to me by e-mail 3 or 4 years ago.

 G Globalnet Cmas Lyrics Winter-Wonderland

It brings a whole new meaning to Nuclear Winter!

 Pictures Albums North America Usa Doe Facilities Los Alamos Chuck-1

Happy Holidays to All (especially those that keep the lights and heat on when it’s cold outside)!

Mark



working in a nuclear power plant song

“Tired Doctors Continue to be a Problem” … Says NPR

Wednesday, December 13th, 2006

The following link is to an audio of an NPR report about tired doctors, fatigue, and error rates at hospitals:

http://www.npr.org/templates/story/story.php?storyId=6612904

Is the hospital industry the only industry that has normal shifts that last 24 hours or more?

What would you think if you were a patient and you knew your surgeon had been working for 24 hours straight?

Imagine yourself trying to diagnose a complex disease after working for 20 hours. Do you think you would be able to perform the difficult thought processes required?

Could these long hours explain some of the 98,000 deaths per year due to medical errors (the 98,000 is an IOM estimate)?

The impact of fatigue and investigating that impact is just one of the breakout sessions at the TapRooT® Summit.

This session is included in the following Summit tracks:

- Medical Error Reduction Best Practices

- Corrective Action Best Practices

- Human Error Reduction and Behavior Change Best Practices

- Investigation and Root Cause Analysis Best Practices

For a complete Summit schedule by track, click on this link:

http://www.taproot.com/summit.php?sched=1

Use the Display buttons on the lower left part of the page to see the various track schedules.

Friday Joke - Holiday Song with a Nuclear Theme

Friday, December 9th, 2005

A nuclear industry TapRooT(R) User sent me this song with a holiday tune and a nuclear theme.

Workinginnpp

Simple Military Instructions to Determine Error

Friday, August 5th, 2005

Sound File
NOTE: This file is in WAV format
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Song - Working in a Nuclear Power Plant

Friday, August 5th, 2005

Click the icon to download!

music_icon.gif
NOTE: This file is in mp3 format
(more…)