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Using a 5-Why to Start Your Root Cause Analysis Investigations

Posted on: April 20, 2017

Would you like to learn more about how to effectively use 5 Whys? The 5-Why Approach | ASQ World Quality Conference Please join us at the ASQ World Conference on Quality and Improvement in Charlotte, NC on May 1. Mark Galley will be presenting “5 Whys: How to Fully Utilize a Powerful, but Confused Tool.”…

Rocking the Baby

Posted on: March 31, 2017

When the bough breaks, the cradle will fall?  By Jon Bernardi As much as we thought we had reduced the risk of injury to small children, there has been a most disconcerting issue rearing itself. It has come to our attention that some parents are placing their children in boughs, of all places, resulting in…

The $150 Million Typo

Posted on: March 9, 2017

Typo takes down Amazon’s cloud storage  By Kim Smiley On February 28, 2017, thousands of websites and apps experienced performance issues after a failure of the popular cloud computing platform S3, provided by Amazon Web Services. The outage started around 9:30 AM PST and the S3 platform wasn’t fully functioning until just before 2 PM…

Great Molasses Flood of 1919

Posted on: January 13, 2017

Inadequate design and warning signs missed  By Kim Smiley In 1919, a tank holding about 2 million gallons of molasses collapsed in the North End neighborhood of Boston, Massachusetts. The resulting flood of molasses was two stories tall and killed 21 people, injured 150 more, and did 100 million dollars of damage (in today’s dollars)….

After fatal mid-air collisions, NTSB recommends use of collision avoidance technology

Posted on: December 29, 2016

Technology should be used to ensure aircraft separation before aggressive evasive maneuvers are required  By Angela Griffith *This is the third in a series of 3 blogs. The first blog captures the details behind a mid-air collision near Moncks Corner, South Carolina on July 7, 2015. The second blog captures the details behind a mid-air…

Mid-air collision kills 5

Posted on: December 19, 2016

Controller errors, limitations of “see-and-avoid” cited by NTSB investigation  By Angela Griffith *This is the second in a series of 3 blogs.  The first blog captured the details behind a mid-air collision near Moncks Corner, South Carolina on July 7, 2015.  This blog captures the details behind a mid-air collision near San Diego, California on…

Mid-air collision kills 2

Posted on: December 1, 2016

Mid-air collision due to controller errors, limitations of “see-and-avoid”  By Angela Griffith *This is the first in a series of 3 blogs. This blog captures the details behind a mid-air collision near Moncks Corner, South Carolina on July 7, 2015. The second blog captures the details behind a mid-air collision near San Diego, California on…

Lack of Antivenom Raising the Death Toll from Snakebites

Posted on: November 18, 2016

“It’s the most neglected of the world’s most neglected tropical diseases.”  By Angela Griffith On September 8, 2015, during a session in the European Congress on Tropical Medicine and International Health, Médecins Sans Frontières (Doctors Without Borders) sounded a warning that stockpiles of the antivenom which is most effective against several of Africa’s poisonous snakes would…

Fatality after pipeline explosion

Posted on: November 10, 2016

Excavation equipment hits pipeline causing explosion that killed 1  By Kim Smiley On October 31, 2016, a piece of excavation equipment hit a gasoline pipeline near Helena, Alabama, causing an explosion that killed one and injured 5 others.  The equipment was being used for repairs related to a large leak found on the same pipeline…

Epinephrine Administered Incorrectly

Posted on: November 3, 2016

Hospital in state of “immediate jeopardy” after epinephrine administered incorrectly  By Angela Griffith A Minnesota hospital was placed in a state of “immediate jeopardy” by federal authorities as the result of a medication error that seriously injured a patient, requiring a plan of corrective action to be created by the hospital. In order to create…