September 14, 2009 | Mark Paradies

Monday Accident & Lessons Learned: Accidents to be Discussed at the Summit – Will You Be There?

The TapRooT® Summit has 12 tracks and many sessions but several will highlight discussions from accidents. Here’s a quick run down on what you could participate in if you attend (there’s still time to sign up at .)

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First, there is the General Session talk on Wednesday by Jim Thompson, Brian Tink, and Dr. Joel Fish. They will discuss how the investigation of an electrocution accident cause the whole province of Ontario to change their practice for return to work of electrocution accident victims. That’s an investigation lesson that everybody needs to hear.

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Next, there’s a best Practice Session in the Investigation and Root Cause Analysis Track where there will be three accident/incident analyses presented. First, Shane Deichman will present an analysis of the Attack on the USS Stark. Next, Ken Scott will present an analysis of the Crandall Canyon Mine accident. Then, Buck Griffith and Kevin McManus will present how they investigated 230 environmental incidents in just five months. There will be some great lessons learned shared in these talks.


At the same time in the Eliminating Healthcare Sentinel Events Track, there will be three sentinel event investigations presented. Once again, much can be learned from these real analyses.


On Wednesday after lunch in the Investigation and Root Cause Analysis Track, Ron Pryor of Alcoa will present how a quality incident promted his site to start a proactive Kaizen project using Safeguards Analysis to prevent future quality incidents. This is a great proactive Success Story.

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On Thursday, in the Safety, Process Safety, and Risk Management Track, there will be a panel discussion titled: “Some Less Than Obvious Lessons Learned from the BP Texas City Refinery Explosion.” Mike Kelley, Ken Turnbull, and Mark Paradies will provide short discussions of their “less than obvious” lessons and then the session participants will discuss their ideas and ask questions.


The final session that includes lessons learned from accidents will be the talk by Steve Hawkins, Assistant Administrator for the Tennessee Occupational Safety & Health Administration. Steve has probably investigated more fatalities in his career at TN OSHA than anyone else in the state. He will share the valuable lessons that he has learned in these difficult investigations.

What’s the lesson learned from this article? If you are interested in learning lessons from others accidents and incidents, get to the TapRooT® Summit!

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