Went out to dinner at the Temple Bar Street area after day 1 of the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dublin and there was great street entertainment. Here’s a sample …
(Quicktime .mov format)
Archive for the ‘Sounds’ Category
Dublin Street Music
Thursday, June 3rd, 2010
Top Kills Fails – BP to Try New Plan
Monday, May 31st, 2010Various media sources have announced that the “top kill” effort to stop the leaking well in the Gulf has officially failed. Here’s one:
Next step? Looks like BP is planing on trying the remote sub slice and collect approach.
And if that fails? The only answer left is relief wells which probably won’t be completed until August.
Here’s a link to the press conference that declares defeat and discusses options (audio only):
http://cgvi.uscg.mil/media/main.php?g2_view=core.DownloadItem&g2_itemId=891718
BP/Transocean Rig Explosion: Amazing Accident Pictures and Interview with Survivor
Wednesday, May 5th, 2010First, hear a survivor account of the accident…
There are two parts. Both are interesting.
Then see these pictures …
Here’s the pdf that was sent to me from an oil industry source that has the pictures in it…
This will be a difficult investigation. My guess is that there is more thane one Causal Factor – more than just a failure of the blowout preventer – that led to this disaster.
It’s interesting to watch management statements that are initially blaming an “equipment failure” for the accident.
Let’s hope unbiased data is released so that we all can make up our own minds.
Audio and Pictures of the Miracle on the Hudson
Thursday, February 25th, 2010Here’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, 2010Friday Joke: NUCLEAR WINTER WONDERLAND
Friday, November 27th, 2009
I can’t help but post this song every year during the holiday season.
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
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.
It brings a whole new meaning to Nuclear Winter!
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, 2009Dr. 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.
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, 200949 accidents (Sentinel Events) in Queensland Hospitals in 2006-2007.
Listen to this story from ABC Australia:
(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, 2008Monday Accident & Lessons Learned: Has a “Mentally Incapacitated” Pilot Crashed a Commercial Flight?
Monday, December 8th, 2008Previous 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:
(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
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:
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:
Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) Talks About Operational Excellence
Saturday, September 15th, 2007Friday Joke – Nuclear Winter Wonderland
Friday, December 15th, 2006NUCLEAR WINTER WONDERLAND
I can’t help but post this song every December.
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
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.
It brings a whole new meaning to Nuclear Winter!
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, 2006The 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, 2005A nuclear industry TapRooT(R) User sent me this song with a holiday tune and a nuclear theme.
