Archive for the ‘Video’ Category
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TapRooT® Summit - Best Practice Presented by Buck Griffith
Wednesday, March 10th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Buck Griffith for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
Watch The Miracle on the Hudson
Tuesday, March 9th, 2010Here’s a video of a simulation of the Miracle on the Hudson. There wasn’t much time and their weren’t many options.
The controller/pilot audio plays but you can read the pilot / copilot conversations as they happen in the text boxes on the lower right of the video.
And if you attend the TapRooT® Summit, you can ask Jeffery Skiles what it was like to be in the right hand seat that day.
TapRooT® Summit - Here’s What David Burns Had to Say
Thursday, March 4th, 2010Audio 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!
TapRooT® Summit - Here’s What Ron Pryor Had to Say
Thursday, February 25th, 2010TapRooT® Summit - Best Practice Presented by William Missal
Wednesday, February 24th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by William Missal for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
TapRooT® Summit - Here’s What Theresa Guy Had to Say
Thursday, February 18th, 2010CNN Reports on Eric Cropp in Jail
Thursday, February 18th, 2010Eric was released from jail (a six month sentence for a medical error) on February 15.
Here’s the CNN video…
What do you think? Will Eric Cropp’s jail time make patients safer?
TapRooT® Summit - Best Practice Presented by Ryan Cezair
Wednesday, February 17th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Ryan Cezair for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
Here’s the Un-Cut ABC Footage of the Fatal Luge Accident
Sunday, February 14th, 2010Although the video isn’t bloody, don’t play it unless you are thinking about sources of information for an investigation of this accident.
Note: They took down the ABC footage, and all other sources I could find, but this ABC footage has a couple of pictures…
Watching the video does make one think … shouldn’t there have been more Safeguards in place?
90 miles per hour and fixed steel objects just a few feet way.
It seems the only Safeguard was the “goodness” of the luge driver.
What do you think??? Was this “safe enough”?
See a previous blog post by Dave Janney here:
http://www.taproot.com/wordpress/2010/02/13/probe-completed-in-luge-accident/
By the way, here’s the picture in case the footage above gets taken down again…
The steel post that he hit is about 1 meter to the right of the wall you can see him going over.
This is the last turn and in the video, you can see him drop down from the curve and hit the inside wall, fly off his sled, go over the short wall. and hit a steel post head first.
The fixes to the “safe” course were to raise the wall all along the section where you can see it and to move the start line down the run to reduce speeds (which were higher than in any previous Olympic luge event.)
Root Cause Analysis Tip: Understanding Human Engineering Investigations after a Fatality
Thursday, February 11th, 2010
See the Video of the Incident Investigation here: http://www2.worksafebc.com/media/fss/garbageTruck/slideshow.htm
The Workers’ Compensation Board of British Columbia do a great job of sharing lessons learned after an investigation. Watch the video in this link to learn where Controls NI, Plant/Unit Differences, Arrangement/Placement, and Fatigue Root Causes come into the picture during a fatality investigation. Do you think this was the first time the wrong switch has been selected?
We introduce these root causes in our TapRooT® Root Cause Analysis Courses, however seeing the impact of muscle memory and an almost reflex like movement in this fatality really adds strength to why these Root Causes are part of our analysis process. To help people get a better understanding of a person’s ability to feel, see, hear, smell, and move in his/her environment, I added hands on exercises in our Stopping Human Error course last year, which will be taught again in San Antonio this October at the Pre-Summit. For those students who took the course last year and asked for additional behavior changing techniques, this request was heard and will be added in this year.
So looking at the fatality above and after reviewing the video what could have been done when the two trucks were introduced to the workforce:
1. Inexpensive fix: Turn the toggle switches to match the movement of the container (↑ Up, ↓ Down, ← Out, → In); even with muscle memory from driving one truck or another, the person would get feedback when the switch did not move and the label would not need to be the only indicator.
2. Little more expensive fix: Put more space in between the switches which according to Fitt’s Law will improve speed and accuracy trade off.
Remember to use SMARTER, Corrective Action Helper®, and Root Cause Dictionary to help develop achievable and sustainable corrective actions.
TapRooT® Summit - Best Practice Presented by Renauld Washington
Wednesday, February 10th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Renauld Washington for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
TapRooT® Summit - Best Practice Presented by Stephen Wagner
Wednesday, February 3rd, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Stephen Wagner for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
See Charlie Rose Interview Jeffery Skiles (Summit Speaker)
Tuesday, February 2nd, 2010
Here a link to the interview that Charlie Rose did with Jeffery Skiles, the co-pilot of flight 1549. Jeffery will be speaking on Friday at the TapRooT® Summit so please plan to stay for his session.
Tiger Woods Accident Info for Analysis
Monday, February 1st, 201024 Years Since the Shuttle Challenger Exploded on Takeoff
Thursday, January 28th, 2010
Some accidents are so historic that every accident investigator should know about them. The Challenger is one of those. It happened 24 years ago today. Dana Barclay, one of our TapRooT® Instructors with an Navy flight background, assisted with this massive investigation. Here is a link to the Report of the Presidential Commission:
http://science.ksc.nasa.gov/shuttle/missions/51-l/docs/rogers-commission/table-of-contents.html
TapRooT® Summit - Best Practice Presented by Jeffery Hubbartt
Wednesday, January 27th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Jeffery Hubbartt for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
Monday Accident & Lessons Learned: Trees Make Buncefield Explosion Worse
Monday, January 25th, 2010Bad Day for Pilot as Engine Fails on Take Off
Thursday, January 21st, 2010TapRooT® Summit - Best Practice Presented by Dan Evans
Wednesday, January 20th, 2010Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Dan Evans for his group. Watch and learn …
For information about the 2010 Summit, see:
http://www.TapRooT.com/Summit.php
Aviation Safety Network Provides Brief Overview of United Flight that Landed with Right Main Gear Retracted on January 10
Sunday, January 17th, 2010
See the accident report at:
http://aviation-safety.net/database/record.php?id=20100110-0
Friday Joke: Fear & Blame - We Need More of This to Make the Company Run Really Well!
Friday, January 15th, 2010Snow Emergency Part 2 - Picture from the Road In Front of System Improvements
Thursday, January 7th, 2010
Smashed fenders right in front of our office.
And people sliding down the road. (MPEG-4 format) Yes … those are tire tracks up onto the sidewalk.
I think I’ll wait until after Knoxville “rush hour” to go home.
Root Cause Analysis Tip: Understanding the Safeguard is just as important as understanding the Hazard
Wednesday, December 23rd, 2009
A 1959 Chevrolet crashes into a 2009 Chevrolet Malibu…. who wins? Now open the Video.
here is another link to the Video: http://www.youtube.com/watch?v=_xwYBBpHg1I
Did you get it right? How would the SMART car hold up?
During our TapRooT® course section, I often ask students whether they think Ice is a hazard (uncontrolled energy). The first answer is often yes. The next question then is whether all ice is a hazard and the answer is… only when you walk or drive on it. Now we get to the uncontrolled energy of motion. For years many have used safety checklists looking for daily “hazards” such as no safety glasses, tripping hazards, and no fall protection… just to realize that we were looking for failed safeguards and not the uncontrolled energies that they were to protect us from. So the first tip is to have all employees look for uncontrolled energy daily.
Once you identify a hazard with no safeguard it may seem easy to select a new safeguard… but is it? Follow through is just as important in safeguards as it is in throwing a ball in the right direction. Each step is vital. If you had selected the older heavy car (1959 Bel Air) because it looked stronger what would the unintended consequences of that choice have been? Final tip of the day, make sure you have a knowledgeable person help with the selection of or improvements of safeguards.
Keep Your Christmas Tree Wet … Or Get an Artificial Tree!
Monday, December 21st, 2009If during the night your Christmas Tree caught fire because of an overheated bulb or a bad wire, how long would it take you to wake up, wake up your kids, and get out of the house?
Watch this vide of a staged fire of a dry tree and then decide if keeping a natural tree wet is worth the effort and risk.
(mpeg 4 format - .mp4)
A Good and Bad Example of CRM: “Flight attendant caught wayward pilots unaware”
Wednesday, December 16th, 2009A good example of CRM (Crew Resource Management)
“A call from a flight attendant to the pilots of the Northwest Airlines plane that overshot Minneapolis catapulted the cockpit crew from complacency to confusion.
According to a statement signed by flight attendant Barbara Logan, she called the cockpit around 8:15 p.m. CDT to find out when they would be landing. She was told they would land around 12 Greenwich Mean Time. “I said I did not know the time — he said I was hosed and hung up.”
The lead flight attendant called to get gate information and was apparently also hung up on, according to Logan’s report. That flight attendant later got through to the cockpit.”
Years ago would the Flight Attendant have pushed so hard before CRM?
Read more here: http://news.yahoo.com/s/ap/20091216/ap_on_bi_ge/us_northwest_flight_overflown
Now an example where CRM would helped in the death following a scheduled surgery. An everyday medical procedure ended up in an excessive delay of needed oxygen to the patient.
Go here to see the video and see where the medical staff did not feel empowered to push the doctors involved: http://www.youtube.com/watch?v=fzPGu-Ru5H8&feature=related
Monday Accident & Lessons Learned (and a Root Cause Analysis Tip): Sometimes a Safety Feature Can Cause Unintended Consequences
Monday, December 7th, 2009Watch this video…
What was the parachute meant to do?
Save the pilot if the engine failed.
What did the parachute do?
Cause a stall during a takeoff.
Can you think of corrective actions from past incidents that could have unintended consequences?
That’s why we have the final “R” in the SMARTER tool for developing corrective actions.
You should review potential corrective actions to make sure they don’t have unintended negative consequences.
Monday Accident & Lessons Learned: Another Safeguard Example
Monday, November 16th, 2009Watch this:
Then leave a comment … What was the Safeguard that failed?
Should additional safeguards be added?
Monday Accident & Lessons Learned: One Step Away from Death
Monday, November 9th, 2009Watch this U-Tube video…
Now, what was the Safeguard that kept the pedestrian crossing the street from being killed?
