I’ve heard of cutting off the branch you are sitting on, but this is a little bit different.

(.wmv format)

Here’s a video of the crash that caused the investigation we previously reported on.

I’ve seen the pictures of landings over this beach, but this is the first video…

Use Safeguards Analysis to analyze this “event.”

(Click on the picture above to ply the .wmv format video)

If the truck tumbled down the hill, killing the driver and perhaps spectators, what would the Causal Factors and Root Causes be?

Be careful! If your class doors are too clear, bad things can happen…

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

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).

Just a slight miscommunication …

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:

http://www.prevent-it.ca/index.php?q=see-it-tv-spots

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.

What do you think?

I know shooting birds at jets is a topic of Jeff Foxworthy’s jokes, but somethime performance improvement includes engineering for expected hazards.

This video shows the testing of bird impacts on jet engines. Dead birds were used, but some of the slow motion videos are still pretty gruesome.

The video isn’t an accident. It is a 1993 United Airlines safety video for the ground operations personnel. But accidents of this type have happened.

What lesson can you learn from this video? Think about how are you training your employees to recognize hazards in the workplace. Before they can report and avoid hazards, they need to be able to recognize them.

One of the pre-Summit courses (June 23-24 in Las Vegas) is the:

HAZARD RECOGNITION BEST PRACTICES TRAINING

Peter Burkholz, one or our TapRooT® Instructors from Australia with 25 years of industrial and mining experience, will teach tried and true methods of hazard recognition including at risk or safe behavior, legislation implications, and hazard identification and rectification. The course includes a site visit to a Caterpillar site for practical application of the theories learned.

To register, see:

http://taproot.com/courses.php?d=19

At least I don’t think so…

Click on the video below (wmv format) for the joke:

Power lines sometimes provide their own fireworks show.

Do you perform trenching operations? Then you should watch this video.

(click to play video .wmv format)

For everyone who has seen a trenching fatality, you know this was a near miss.

Before

After

The 7 of the crew of 15, including the Captain and his 14-year-old son, perished.

The Norwegian Ministry of Justice has released a report on the sinking of the Bourbon Dolphin. See:

http://www.regjeringen.no/en/dep/jd/Press-Center/pressemeldinger/2008/report-on-the-loss-of-the-bourbon-dolphi.html?id=505100

Here is a new report from STV news:



(QuickTime .mov format)

Here are the links to the video sequence simulations in the report:

http://qstream-down.qbrick.com/05688/podcast/JD/seq1.mpg

http://qstream-down.qbrick.com/05688/podcast/JD/seq2.mpg

After some accidents you wonder, “What were they thinking?”

Watch this and see what I mean…

Every company should have a Retro-Encabulator (and perhaps an installed spare for plant reliability). Watch this video and see why!

Oops…

Oh No!

And the root cause is…

Here’s an interesting CBS News video on sleep, fatigue, and human performance:

One of our speakers at the TapRooT® Summit is Bill Sirois of Circadian Technologies. Bill will be speaking about fatigue and human performance. He will also share a scientific way to evaluate fatigue in an accident investigation (called FACT). For more Summit info, see:

http://www.taproot.com/summit

Here’s part II:

Here’s the Reporter’s Notebook:

See:

http://www.cbsnews.com/stories/2008/03/13/60minutes/main3936412.shtml

A famous video of an accident aboard a carrier…

A bad day was had by all these workers…

I don’t think I would be ready for a second try if I was the deck hand back by the tail or the pilot.

Dramatic footage of a maintenance error…

The news crew was almost too close when they caught this footage…

What happens when the natural gas line leaks into a house being used to train firefighters?

Watch and see:

This is footage that I had never seen before of the Enshede, Netherlands fireworks factory explosion.

The lesson to consider is…

How far away do you need to evacuate when a fire starts?

Dramatic explosions …

He was just standing around, minding his own business when…

Time for some simple root cause analysis?

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)

7. 2-Day Equifactor® Equipment Troubleshooting & Root Cause Analysis Course (8th year)

8. 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course (13th year)

That makes 11 courses with a wide variety of topics to choose from. Where can you find out more information? See:

http://www.taproot.com/pre-summit_courses.html

And here are a couple of videos where previous course attendees share their experience…

(more…)

Be careful the next time you choose a place to park in the snow.

At least she picked the shallow end of the pool!

Winning an Olympic Gold Medal sets you apart. You are the best on the planet at your event.

But Nikki Stone’s story goes beyond being the best. She showed exceptional dedication & persistence to come back from a career-ending injury (that prevented her from standing, much less skiing).

Why is Nikki a TapRooT® Summit Keynote Speaker? Because people leading performance improvement initiatives need to overcome obstacles that seem insurmountable.

After being inspired by Nikki’s determination and courage, these obstacles won’t seem so large. You can achieve success!

Don’t miss Nikki’s Keynote address. And talk to Nikki one-on-one at the Summit reception.

To see an interview with Nikki, click on the YouTube video below:

Watch the sailor come out of a door on the fantail. Just another day at sea until …

Would you call this a “near-miss”?

(Watch the right lane…)

(.mpg format)

Did the ship not wait it’s turn or did the bridge operator lower the bridge too soon? The SnapCharT® for this accident would be interesting…

(more…)

You need to be a professional stuntman to do this…

(more…)

Watch the videos and hope your flight doesn’t land in these conditions…

I see snowflakes in Tennessee! Let’s run and get some bread and find a ditch to slide into!

Here’s a dramatic example of the problems people (and pedestrians) have when driving in the snow…

(Click the Read More link to see it!)

(more…)

Watch the video below and see how NOT to make a quick turn at sea…

A man was struck and killed by the red line Luas Tram last weekend. The tram operator, Veolia Transport, is conducting an investigation in coordination with the Irish Railway Safety Agency. This is the first fatal accident since the tram was inaugurated in 2004. There were 17 “contact” incidents between people and the tram in 2007. A December 2007 incident caused serious head injuries to another man.

For a video report see:
http://www.rte.ie/news/2008/0225/luas_av.html

The following accident took place in Denmark during a storm on 2/22/08.

Here’s the first view:

Here’s the second:

Yes - that is a truck at the base of the windmill when it self-destructs. I’m not sure if I can see people near the truck in the video or not.

The “cause” of the accident was the failure of the brake that limits the speed of the windmill during a storm. The speed of the blades were approaching the speed of sound when they failed.

Click on the video below and watch the short takeoff and landing demo.

Yes - people can produce amazing human performance!

Link to the story:

http://www.cnn.com/2008/US/02/11/refinery.blast/index.html

Link to video:

http://www.cnn.com/2008/US/02/11/refinery.blast/index.html#cnnSTCVideo

Want to learn more about the TapRooT® Summit? Then listen to past attendees tell their experience.

Introduction to the Summit:

http://www.taproot.com/download/summit08_discussion.mov

Networking at the Summit:

http://www.taproot.com/download/summit08_networking.mov

Breakout Sessions at the Summit:

http://www.taproot.com/download/summit08_breakouts.mov

Best Practices Learned at the Summit:

http://www.taproot.com/download/summit08_bestpractices.mov

Pre-Summit Courses:

http://www.taproot.com/download/summit08_presummit.mov

Summit Fun and Refreshing/Reenergizing:

http://www.taproot.com/download/summit08_fun.mov

Where can you learn more about the Summit? See:

http://www.taproot.com/summit.php

Car accidents usually are NOT funny. but add a little music, and speed it up to sound like the chipmunks, and … anything can be funny.

For the story from ABC see:

http://www.wjla.com/news/stories/0108/490262.html

For a video report, see:

http://www.wjla.com/news/stories/0108/490262_video.html?ref=newsstory

Watch this and then think about the accident investigation …

The Chemical Safety Board has completed their root cause analysis of the explosion at the Synthron facility at Morganton, North Carolina. The report is available at:

http://www.csb.gov/completed_investigations/docs/Synthron%20Final%20Report.pdf

In addition to the report, the CSB has produced a video titled:

Reactive Hazards: Dangers of Uncontrolled Chemical Reactions

It is available by clicking on the safety video link at:

http://www.csb.gov/index.cfm?folder=news_releases&page=news&NEWS_ID=389#

What do you (or should you) be video taping to have documentation after an accident occurs? get your systems in place now and be ready after an accient occurs. Here is an example to get your planning started…

Head-on Train Collision

Posted Sep 04, 2007

Look carefully to see people jumping from the oncoming train just before impact.

(QuickTime Movie of Explosion from a Coast Guard Camera.)

(Aerial view of facility after explosion.)

CSB Investigation Press Release:

Statement by CSB Investigator-in-Charge Robert Hall Updating the Public on the Investigation of the T2 Laboratories Explosion and Fire

Jacksonville, FL, January 3, 2008 - Good afternoon.  I am Robert Hall, Investigator-in-Charge for this U.S. Chemical Safety Board (CSB) investigation.  The CSB is an independent federal agency that investigates major chemical accidents at industrial sites.

We are currently conducting an investigation to determine causes of the fatal chemical explosion that occurred on December 19th at T2 Laboratories Inc. here in Jacksonville.  The Board does not issue fines or citations but does produce investigative reports and recommendations that are widely used to prevent future accidents.

The team of CSB investigators from Washington, D.C., worked here through the holiday week and remains in Jacksonville interviewing survivors and surveying damage.

T2 is a small company with about a dozen employees and the single production site in Jacksonville.  The explosion at T2 occurred at about 1:30 p.m. on December 19th and killed four workers.

One worker remains in the hospital, and a number of other people were injured both on and off site.  The blast at T2 was among the most powerful ever examined by the Chemical Safety Board.  In addition to the tragic loss of life among T2 workers, injuries off-site requiring medical attention occurred as far as away as 750 feet from the reactor site.

The explosion occurred during the production of a gasoline additive called methylcyclopentadienyl manganese tricarbonyl.  This additive was first developed in the 1950s and is widely used to boost the octane rating of gasoline.  The company began producing the chemical for commercial sale a few years ago, using a batch reactor.

(more…)

Here’s a video of an accident. A jet clips a parked truck while taxiing. Are your ready to perform a root cause analysis?

http://view.break.com/423733 - Watch more free videos

Will the results of your root cause analysis be more of the same? You know what I mean … More Training, More Firings (or demotions), and/or More Procedures.

Or will you find the real root causes and develop effective corrective actions?

If you haven’t attended our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, you need to soon to be ready to investigate accidents, incidents, quality problems, equipment failures, and other operational issues and find and fix their true root causes.

Where can you attend a course in the near future? You can have a course at your site (contact us by clicking here). Or you can attend one of our public courses:

Edmonton, Canada    January 21-25
San Diego, CA    January 28-February 1
London, England    February 4-8
New Orleans, LA    February 4-8
Singleton, Australia    February 4-8
Halifax, Canada    February 25-29
Vancouver, Canada    March 3-7
Charleston, SC    March 3-7
Galveston, TX    March 10-14
Amsterdam, The Netherlands    March 10-14
San Antonio, TX    March 31-April 4
Knoxville, TN    April 21-25

For complete course info see: