Search Results for: Fitzgerald

  • USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

    Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis: As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You […]

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  • US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

    The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is: Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish? After all, they knew who the CO, XO, and Command Master Chief […]

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  • What is the Root Cause of the USS Fitzgerald Collision?

    As a root cause analysis expert and former US Navy Officer who was qualified as a Surface Warfare Officer (SWO) and was qualified to stand underway steaming Officer of the Deck watches, I’ve had many friends ask me what was the root cause of the collision of the USS Fitzgerald. Of course, the answer is […]

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  • Remembering an Accident: SS Edmund Fitzgerald Sinks on November 10, 1975

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  • Weak Signals or Deaf Leaders?

    What is a Weak Signal? Weak Signals … What are they? There are many articles that define the term weak signals. Here are two… EHS Today Terry Mathis – Safety & Performance Excellence: Weak Signals…“… being sensitive to subtle and less obvious aspects of safety.” SITRAMikko Dufva – What is a weak signal?A weak signal […]

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  • Must-See Keynote Speakers at the 2022 Global TapRooT® Summit

    2022 Dream Team of Speakers… Every year we had a great team of speakers – both Keynote Speakers and Best Practice Session Speakers – at the Global TapRooT® Summit. In 2022, the Summit is being held on on May 2-6 in Knoxville, TN. Years ago I realized I get to pick the Summit Keynote Speakers […]

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  • Wind Farm Fatality: 5 Receive Manslaughter Charges; 3 Companies Pay $549,874 in L&I Fine

    The Washington State court case of the fatality of wind farm worker Jonathan Stringer has seen three companies pay out $549,874 for violating worksite safety. A wind farm construction worker, Jonathan Stringer, age 24, died in January 2020 as a result of the collapse of an unreinforced trench. Prior to the trial, The News Tribune […]

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  • Navigation & Piloting Training Corrective Actions – Are They Enough?

    Blame Oriented Investigation Includes Training Corrective Actions Four years ago the Navy had two fatal ship collisions and the investigations included discipline for the ship’s Commanding Officers and other watchstanders. See these articles for more information: Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea. […]

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  • How Can Blame Cause Accidents?

    Can Blame Cause Accidents? Yes, blame can cause accidents. You might ask … But How? How can blame cause accidents? That’s a good question. In the following sections, we will explain the link between blame and accidents. Can Blame Change Behavior? We all know what blame looks like but here is an example of blame […]

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  • Will Making Criminals of Executives Stop Accidents?

    At the 2020 Global TapRooT® Summit, Marcus Miller, VP at System Improvements, talked about a recent string of incidents where people were either disciplined or had actual criminal charges brought against them after an accident. Marcus talks about the USS Fitzgerald collision, the fire at the Arkema plant in Texas that occurred during Hurricane Harvey, and […]

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