Root Cause Analysis Blog

Linda Kenney’s Story - Hear Her Speak at the TapRooT® Summit

Mark Paradies — Wed, 17 Mar 2010 14:24:58 +0000

What do you do after an accident for those that are impacted by the accident? Linda will talk at the TapRooT® Summit about her medical sentinel event and how people involved need to be supported.

Here’s a video that will provide you some background about Linda and MITSS.

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Could the jogger have saved his own life..”Beach jogger killed by plane likely never heard it”

Chris Vallee — Wed, 17 Mar 2010 14:03:42 +0000

“HILTON HEAD ISLAND, S.C. – The kit-built single-engine plane was gliding quietly as it came down for an emergency landing on a beach. Pharmaceutical salesman Robert Gary Jones, listening to his iPod while jogging, likely never saw or heard it before the aircraft hit him from behind Monday evening and killed him.”

Should we ban headphones from public beaches or post a warning jog with headphones at your own risk?

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Ideas for Leading Investigation Teams

Barb Phillips — Tue, 16 Mar 2010 11:00:36 +0000

Once you attend a TapRooT® course and learn how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? Questions like these are why so many course attendees plan to attend the TapRooT® Summit. The Summit is a place where TapRooT® users gather to discuss best practices, like innovative ideas for leading investigation teams. In 2010, Ken Reed will be teaching “Ideas for Leading Investigation Teams.” In this talk, he’ll discuss:

- Preparations required before an incident occurs
- The first steps when you receive that phone call
- How you actually use the TapRooT® tools during the course of a real-world investigation

Ken Reed is a Senior Associate at Sytem Improvements, and brings 21 years of US Navy nuclear operator and supervisor experience having served on numerous fast attack, ballistic missile, and research submarines. He is currently the Project Manager for the Equifactor® Equipment Troubleshooting module of the TapRooT® software, overseeing course and software updates and revisions. He holds a B.S. in Electronics Management from Southern Illinois University. He was born and raised in Watertown, NY, and currently resides in Knoxville, Tennessee.

Come to the Summit to learn advanced techniques like these and many more. Join us on the Riverwalk in San Antonio, Texas, October 27-29. (Learn more!)

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Wisdom Quote

Barb Phillips — Tue, 16 Mar 2010 11:00:09 +0000

“The time to repair the roof is when the sun is shining.” ~ John F. Kennedy (1917 - 1963)

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Statistical Analysis of Toyota “Acceleration” Accidents

Mark Paradies — Tue, 16 Mar 2010 07:40:35 +0000

Megan McArdle wrote an interesting article about the age statistics of the drivers involved in Toyota acceleration accidents. It seems older people (above 60 years old) are much more likely to be involved in an acceleration accident.

She then hypothesizes that this “age discrimination” means that these accidents are driver caused and not “Toyota caused.” Or at least that this is the reason that Toyota did not discover their problems sooner.

Interesting article. See:

http://www.businessinsider.com/a-deep-dive-into-toyota-sudden-acceleration-accident-stats-2010-3

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Is “Failure to Test” a “Root Cause”?

Mark Paradies — Mon, 15 Mar 2010 17:31:01 +0000

The Sydney Morning Herald reported:

“Failure to test a cement casing at an oil well in the Timor Sea was a root cause of a blowout that caused Australia’s worst offshore oil spill, an inquiry has heard.“

See the article at:

http://news.smh.com.au/breaking-news-national/casing-test-failure-cause-of-oil-spill-20100315-q99q.html

It sure seems like there were many more “root causes” to me and that the analysis should have led to root causes that were much more in-depth. And it would be a big help if there was a SnapCharT® to help identify all of the Causal Factors.

What do you think?

Here’s the March 15 meeting transcript:

http://www.montarainquiry.gov.au/downloads/Transcripts/Transcript%20Montara%20COI_Day%20001_15-Mar-2010.pdf

And here’s the link to the Commission’s web site for more information:

http://www.montarainquiry.gov.au/index.html

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Monday Accident & Lessons Learned: Pressure Relief is NOT Enough. Remember Vacuum Relief Too!

Mark Paradies — Mon, 15 Mar 2010 14:06:03 +0000

Watch the accident above.

The rail car had been steamed out and it started to rain.

A vacuum formed inside the car.

A great demonstration of the fact that pressure relief isn’t the only thing to consider when designing a vessel.

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Learn Critical Coaching Skills at the TapRooT® Summit

Barb Phillips — Mon, 15 Mar 2010 11:00:17 +0000

We’ve scheduled two sessions at the October 2010 Summit where attendees will have the opportunity to learn valuable coaching skills:

1) Coach for Improved Corrective Action Development Implementation

Participants walk away with coaching skills and a coaching model that can be used in any work environment to support improving human performance in the workplace.

2) Coaching Skills to Sustain Behavior Change

Participants walk away with coaching skills and a coaching model that can be used in any work environment to support creating behavioral change in the workplace.

Both sessions will be taught by Jennifer Mounce. Jennifer is the founder of Coach Effect, Inc., a leadership coaching & organizational development boutique in San Francisco, California. With more than fifteen years of corporate experience in human resources and in coaching senior executives, Jennifer uses her expertise to partner with companies and increase their overall effectiveness by coaching, training, and consulting with mid– and senior level managers. Jennifer is a published author of two books and a professional speaker. Jennifer is a graduate of the Coach University Coach Training Program. Jennifer received her Bachelor’s in Speech Communication from University of Illinois and Master’s in Human Resource Management from Loyola University Chicago. She is a certified Senior Professional in Human Resources and is currently working toward her Professional Coach Certification.

Are you ready for the 2010 Summit? Learn more on our website!

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Navy CO of USS Cowpens Loses Job After “Drag Racing” Incident - A Lesson in Bad Leadership?

Mark Paradies — Sun, 14 Mar 2010 22:01:01 +0000

The Navy must have changed a lot since I was in it.

Here’s a quote from an Associated Press article printed in Military.com:

“A Navy inspector general report said investigators had substantiated that Graf assaulted subordinates (pushing one, grabbing another and once throwing wadded-up paper at another Sailor) and that she regularly verbally abused subordinates by publicly berating them, belittling them and using profane language.“

A Navy CO using profane language and berating crew members in public … sounds like the first ship I was on in 1980.

And, of course, assault should never be tolerated. But the female CO, Captain Holly Graf, (pictured above) pushed someone, grabbed someone, and throws a wadded up piece of paper at someone? This hardly seems like serious offenses. But perhaps it does show a lack of judgment. After all, the CO’s job on a ship is quite serious and there needs to be a certain amount of formality and separation maintained to maintain good order and discipline. Grabbing sailors (or officers) and throwing things at them isn’t setting a good example for your crew.

Then there is the drag racing.

I’ve seen two ships line up side by side to run a one mile race. We won! Our nuclear powered cruiser beat a gas turbine powered cruiser.

The AP story said this about the drag race:

“One sailor said that during the race, aimed at boosting morale, the McCain got ahead of the Cowpens and began drifting to the left into the path of the Cowpens. Though the report did not question that the race took place, it said the allegation of “hazarding a vessel” was unsubstantiated.”

One sailor said?

If every CO was relived because they swore, had sailors that didn’t like them, or even made occasional judgment failures (grabbed a sailor), we probably couldn’t keep our fleet at sea. But maybe there’s more to this story than what was printed in the Associated Press article?

I decided to look a little further and did a Google search on “Captain Holly Graf”.

WOW! What an eyeful! Lot’s more information was posted on-line about how bad Captain Graf was!

Of course you can’t believe everything you read on-line, but … read the comments at this blog:

http://www.susankatzkeating.com/2010/01/captain-holly-graf-plows-down-whale.html

Then a picture of the “drag race” at this blog site:

http://www.militarycorruption.com/hollygraf5.htm

(Can’t tell if it is photoshopped or not.)

And a legal review of the charges against Captain Holly Graf:

http://admiraltymaritimelaw.blogspot.com/2010/03/navy-inspector-generals-report-on-holly.html

After reading the material available, I would conclude that Captain Graf was an awful person to work for and a terrible leader. The Navy is lucky that no one was killed as a result of her leadership failings. (Having your crew be scared to talk to you is a great way to get a ship into deep trouble.)

But some of the charges seem silly. Guilty of having a Junior Officer play a Christmas Carol on the piano at a Christmas Party at the CO’s house? Or another charge that a Junior Officer walked the CO’s dog willingly? Come on.

But what about Navy leadership? How did she get to such a position of power? Why weren’t her poor leadership traits detected earlier?

Man or woman, I don’t care. Men and women can be great leaders. Or not.

Poor leaders at sea can have dreadful consequences. Our sailors deserve good leadership. Seems like the poor leadership qualities of Captan Holly Graf might indicate a generic problem with the way that leaders are developed and promoted inside the Navy. Certainly this isn’t the first “bad CO” that I’ve heard about. Perhaps a more in-depth analysis is required?

Plenty to dig into when analyzing the root causes (and generic causes) of a poorly led ship.

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Job Opening: Portland, OR - Field Services Electrical Engineer - Needs Root Cause Analysis Skills

Mark Paradies — Sat, 13 Mar 2010 05:31:24 +0000

See:

http://www.webbyslist.com/jobs/electrical-engineer-field-services-client-confidential-portland-or

Maybe they should send a recruiter to the upcoming 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Failure Analysis Course that’s coming up in Portland on April 14-16?

To register, see:

http://www.taproot.com/courses.php?d=910&l=1

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