Category: Accidents

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Monday Accident & Lessons Learned: The Lac-Mégantic rail disaster

February 12th, 2018 by

The Lac-Mégantic rail disaster occurred when an unattended 74-car freight train carrying Bakken Formation crude oil rolled down a 1.2% grade from Nantes and derailed, resulting in the fire and explosion of multiple tank cars. Forty-two people were confirmed dead, with five more missing and presumed dead. More than 30 buildings were destroyed. The death toll of 47 makes it the fourth-deadliest rail accident in Canadian history.

 

Click image to view or download .pdf

 

What is the Fastest Way to Get Fired After an Accident?

February 7th, 2018 by

If you work at a blame-oriented company, the answer to the question above is easy. Just admit that you were the last person to touch whatever went wrong that caused the accident.

Or, if you are in the Navy, all you have to do is to be the CO of a ship that has a collision at sea.

A slower way to get fired is to be the Plant Manager or Division Manager who doesn’t have good answers when he or she is asked by the corporate VP, “What are you going to do to prevent a repeat accident in the future?” Actually, they probably don’t fire someone this high in the organization. Rather, they transfer them to a staff job where they are never heard from again.

What is the best way to avoid being fired? Don’t have the accident in the first place! Instead, have a proactive improvement program that identifies problems, finds their root causes, and effectively fixes them before an accident happens.

Want to learn more about using TapRooT® in a proactive improvement program? Attend Dave Janney’s pre-Summit course: TapRooT® for Audits.

What’s covered in the course?

DAY ONE

  • TapRooT® Process Introduction and Initial Audit
  • SnapCharT® and Exercise
  • Significant Issues and Exercise
  • Root Cause Tree® and Exercise
  • Generic Causes
  • Corrective Actions and Exercise

DAY TWO

  • The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
  • Audit Programs, Trend and Process Root Cause Analysis
  • TapRooT® Software Introduction
  • Frequently Asked Questions about TapRooT®
  • Final Audit Observation Exercise

Don’t miss this course coming up quickly on February 27-27 in Knoxville, TN. Register by CLICKING HERE.

DAveJ

Monday accidents & lessons learned

February 5th, 2018 by

Packed with 250 commuters and heading to Milan’s Porta Garibaldi station, the Italian Trenord-operated train derailed January 25, 2018, killing three people and seriously injuring dozens. The train was said to have been traveling at normal speed but was described by witnesses as “trembling for a few minutes before the accident.” A collapse of the track is under investigation. Why is early information-gathering important?

Friday Joke: Safety Pizza Party

February 2nd, 2018 by

This reminds me of a cookout safety lunch celebration. Something in the food went bad many got sick.

Carl Dixon at the 2018 Global TapRooT® Summit Reception

February 1st, 2018 by

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

January 29th, 2018 by

Screen Shot 2018 01 27 at 2 48 07 PM

On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

January 27th, 2018 by

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

NewImage

CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

Interesting Article in “Stars & Strips” About Navy Court-Martials for COs Involved in Collisions

January 22nd, 2018 by

Screen Shot 2018 01 22 at 6 30 43 PM

The article starts with:

The Navy’s decision to pursue charges of negligent homicide against the former commanders of the USS Fitzgerald and USS John McCain has little precedent, according to a Navy scholar who has extensively scrutinized cases of command failure.”

See the whole article at:

https://www.stripes.com/news/navy/few-navy-commanders-face-court-martial-for-operational-failures-1.507226

The article implies that blame and shame is the normal process for COs whose ships are involved in accidents.

Isn’t it time for the US Navy to learn real advanced root cause analysis that can teach them to find and fix the causes of problems at cause collisions at sea?

Monday Accidents & Lessons Learned

January 22nd, 2018 by

A passenger train leaving London Waterloo station and traveling at about 13 mph (21 km/h) collided with a stationary engineering train. There were no injuries, but both trains were damaged. Glean more insights from the London Waterloo rail accident investigation here.

Safety Fines Double in One Year in UK

January 18th, 2018 by

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

Is this a good idea? … Navy to have “Article 32” hearings for COs involved in collisions at sea.

January 17th, 2018 by

NewImage

Didn’t I just read (see this LINK) a Navy investigation that implied there were Management System causes of the two collisions in the Pacific? Didn’t the report suggest that the Navy needed to change it’s culture?

An article in USNI News says that both Commander Alfredo J. Sanchez and Commander Bryce Benson will face Article 32 hearings (the prelude to a court martial) over their role in the ships’ collisions in the Pacific.

NewImage

Will punishment make the Navy better? Will it make it easier for ship’s commanding officers to admit mistakes? And what about the crew members who are facing disciplinary hearings? Will that make the culture of the Navy change from a reactive-punitive culture to a culture where mistakes are shared and learned from BEFORE major accidents happen?

What do you think…

Here is the press release from the Navy’s Consolidated Disposal Authority (Director of Naval Reactors Adm. James F. Caldwell):

On 30 October 2017, Admiral William Moran, Vice Chief of Naval Operations, designated Admiral Frank Caldwell as the Consolidated Disposition Authority to review the accountability actions taken to date in relation to USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) collisions and to take additional administrative or disciplinary actions as appropriate.

After careful deliberation, today Admiral Frank Caldwell announced that Uniform Code of Military Justice (UCMJ) charges are being preferred against individual service members in relation to the collisions.

USS Fitzgerald: Courts-martial proceedings/Article 32 hearings are being convened to review evidence supporting possible criminal charges against Fitzgerald members. The members’ ranks include one Commander (the Commanding Officer), two Lieutenants, and one Lieutenant Junior Grade. The charges include dereliction of duty, hazarding a vessel, and negligent homicide.

USS John S. McCain: Additionally, for John S. McCain, one court- martial proceeding/Article 32 hearing is being convened to review evidence supporting possible criminal charges against one Commander (the Commanding Officer). The charges include dereliction of duty, hazarding a vessel, and negligent homicide. Also, one charge of dereliction of duty was preferred and is pending referral to a forum for a Chief Petty Officer.

The announcement of an Article 32 hearing and referral to a court-martial is not intended to and does not reflect a determination of guilt or innocence related to any offenses. All individuals alleged to have committed misconduct are entitled to a presumption of innocence.

Additional administrative actions are being conducted for members of both crews including non-judicial punishment for four Fitzgerald and four John S. McCain crewmembers.

Information regarding further actions, if warranted, will be discussed at the appropriate time.

Time for some advanced root cause analysis?

January 15th, 2018 by

Screen Shot 2018 01 15 at 12 52 39 PM

What do you think? Does someone in the Hawaii government need to attend TapRooT® Training?

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

We held our first on-site TapRooT Training in mid-1995. Shortly after the training we had another…

Intel

Hands-on learning is so important when learning something new. We keep this in mind when developing root cause analysis training and our course attendees appreciate it too. Here’s some feedback we’ve received lately: “Great hands on exercise [for developing Corrective Actions] and great class involvement.” ~ D. Rind “Very good to get a feel of …

Contact Us