Author Archives: Web Admin

Monday Motivation: Making a Difference

Posted: June 19th, 2017 in Career Development, Career Development Tips, Wisdom Quote

When trying to come up with a list of goals for yourself, why not start by answering the question: “What kind of difference do I want to make with my life?”

“Anyone who thinks that they are too small to make a difference has never tried to fall asleep with a mosquito in the room.” Christine Todd Whitman

With most of the great men and woman of history, making money or finding fame was not their primary goal. They wanted their life to have real meaning.

Experts say the desire to make a difference seems to have affected how successful they really were to accomplish their mission. Albert Schweitzer, one of the greatest humanitarians in history, is but one example. At 30, Schweitzer was a world-famous organist, specializing in compositions by Bach. It was during this time that he began thinking about making a greater difference with his life. He read a report on dismal conditions facing Africans in the Congo (now the Republic of Zaire) and decided to become a missionary surgeon.

“When it’s obvious that the goals cannot be reached, don’t adjust the goals, but the action steps. Confucius

Schweitzer returned to school and spent eight years earning a degree in tropical medicine and he played concerts on the side to help raise money. At 38, he loaded his medical supplies on a ship and sailed for Africa. He transferred his supplies to a small boat and traveled up the Ogooue River to a thatched village called Lambarene. There, Schweitzer established a hospital in the only building available: an old chicken coop.

“Bee to the flower, moth to the flame; Each to his passion; what’s in a name?” Helen Hunt Jackson

Within nine months of arriving in Lambarene, he treated more than 2,000 people who had never before had any access to modern health care. Albert Schweitzer continued his work there for some 50 years, fighting everything from leprosy to sleeping sickness. His compassion, dedication, commitment and vision earned him the Nobel peace Prize in 1952. He used the $33,000.00 to expand his hospital and build a leper colony. When he died at the age of 92, his village had grown to 1,500 patients and 40 doctors and specialists.

Andrew Carnegie was also a man on a mission that was much greater and larger than him. The steel magnate started out as a penniless day-laborer in a Pittsburgh, Pennsylvania steel plant (my home town and home to the six-time Super Bowl Champions Steelers), but he eventually became the richest man in the world – he sold his steel interests at the turn of the century for 480 million dollars.

“A hero is someone who has given his or her life to something bigger than oneself.” Joseph Campbell

To become rich was only half of his goal. Throughout his life, Carnegie’s main goal was to spend the first part of his life making a lot of money and the second part spent giving it all away. As early as 1868, he wrote himself a letter spelling out his goals, including a plan to resign from business by age 35 and live on an income of $50,000.00 a year.

Carnegie planned to devote the reminder of his money to various philanthropic causes and most of his time to education. He lasted in business almost 30 years longer than he planned, but as he saw it, the staggering wealth he was acquiring for his philanthropic purposes was well worth it.

“Never respect men for their riches, but rather than for their philanthropy; we do not value the sun for its height, but for its use.” Gamaliel Bailey

After the sale of his business interests, he built thousands of libraries and set up foundations to help people learn what they needed to be successful and fulfilled.

By the time of his passing in 1919 at the age of 84, Andrew Carnegie had given away nearly all his fortune.

Making a difference in other people’s lives and hence, your own, will help you find the “Meaning of Life.” The “Meaning of life” is a seven letter acronym. Those of you who had me as an instructor, or have heard me at one of my speaking engagements, probably remember the acronym. The acronym contains several principles that everybody can achieve; to be meaningful and relevant, each person must seek it and accomplish it on their own. Want to know more? You will have to contact me to find out – but I will not just “give” you the answer, because the acronym means different things to different people. Like many people in my life did for me, I’ll share how they taught me to fish for a lifetime; they didn’t give me a fish for a day.

“Each man must look at himself to teach him the meaning of life. It is not something discovered, it is something molded.” Antoine de Saint-Exupery

How many people have made a difference in your life? Do you know who they are? Have you ever taken the time to thank them? More importantly, have you been and are you now taking the legacy they gave you and making a difference in other people lives?

There are hundreds of people who helped me before my plane crash and injuries in 1970 and the hundreds since then who helped me to get back on my feet, continue on my journey and helped me find Meaning in Life. I acknowledged as many as possible in two of my books, “The Bridge Never Crossed – A Survivor’s Search for Meaning” and “Laugh You Live Cry You Die – A Burn Survivor’s Triumph Over Tragedy.” Each person in my life played a major factor in who I am today. Whatever success I’ve achieved, I owe to each one of them. I hope they know how much they meant and mean to me and how much I love(ed) and honor(ed) them. Throughout my life, I’ve tried to show them and tell them.

“I thank you God for this most amazing day, for the leaping greenly spirits of trees, and for the blue dreams of sky and for everything which is natural, which is infinite, which is yes.” e.e. cummings

I read somewhere that our memory is an indication of the kind of life we’ve lived. If this is true, and I think it is, then I’ve been Blessed to have lived a good life.

Throughout my life’s journey, I’ve ‘’gazed’ at the Headstones of the many who’ve passed and who played a major role in my life from birth to now and I think of the friends and hosts who’ve enriched me…. and who remain vertical…. the quote at the end of the movie, “Saving Private Ryan” rings in my head: “I hope I’m a good man. I hope I’ve lived a good life. I hope I’ve earned it!” Me, too!

“A whole stack of memories is never equal to one little hope. Charles M. Schulz

This article was reprinted with permission from the author, Captain George Burk, USAF (Ret), Plane crash, burn survivor, motivational speaker, author, writer. Visit his website at www.georgeburk.com  or contact Captain Burk at gburk@georgeburk.com.

Improve Communications of Lessons Learned

Posted: December 18th, 2015 in RCA Tip Videos, Summit Videos, Video Depot

Here is a great best practice tip from TapRooT® User, Rodney Bhagwandass.

(Click post title if video is not displaying.)

Dan Quiggle Shares Ronald Reagan’s Favorite Joke

Posted: July 10th, 2015 in Summit Videos, Video Depot

 

Dan Quiggle’s energy and enthusiasm was very inspirational at the TapRooT® 2015 Global Summit. In this clip he shares a favorite joke of his former boss, President Ronald Reagan, while talking about the value of optimism.

Time to Upgrade Your Web Enterprise Software to 5.3

Posted: July 10th, 2015 in Software, Software Updates

Microsoft® recently released an update that has caused some previously supported components to produce the error:

This application has requested the Runtime to terminate in an unusual way. Please contact the applications’s support team for more information.

If you are operating on an older version of the TapRooT® Web Enterprise Software (Version 5.2.3 or older) then you are at risk of seeing this error when you upgrade your network to the latest Windows Updates.

The error does not exist in any of the latest versions of TapRooT® including:

Version 5.3.0 (released in March 2014)

Version 5.3.1  (released in August 2014)

We recommend upgrading to the latest version as soon as possible.

For assistance in upgrading or for any other questions regarding this matter, please feel free to contact us at support@taproot.com or call 865-539-2139.

Tune In! Ed Skompski Shares Some TapRooT® Knowledge

Posted: May 28th, 2015 in Instructor Videos, Video Depot

System Improvements Vice President and TapRooT® Instructor Ed Skompski shares a little about himself, his teaching experience, and why TapRooT® works so well.

(Click the title of this post to view his video)

TapRooT® Software Version 5 Root Cause Tree® and Corrective Action Helper® Update

Posted: May 21st, 2015 in Software Updates

On May 1st, 2015 we released an updated version of the Root Cause Tree® and Corrective Action Helper®. These updates are now available to be added in the software. Feel free to download this update at:

taproot.com/download/TapRooT_RCT_CAH_Updater_2015.exe

TapRooT® Software Version 5.3.2 Release Announcement

Posted: August 13th, 2014 in Software Updates

We are very pleased to announce the release of our Version 5.3.2  TapRooT® Single User Software.

The majority of the enhancements in the Version 5.3.2 TapRooT® Software were to repair minor bugs or known issues.  A detailed list of these enhancements is found below.

TAPROOT® 5.3.2 ENHANCEMENTS

  • Investigation Reports display issues were resolved for those who had non-standard SQL Collation installations.
  • Custom Details fields are now visible on the display list, even when they are inactive.
  • Custom Details Currency fields are displaying the label and currency symbol properly in all cases.
  • Corrective Action Priority field is restored.
  • Corrective Action Editor now validates and prompts if you want to save your work when selecting CLOSE.
  • Root Cause Tree® validates and displays all changes when switching between front and back page.
  • Root Cause Tree® displays all Red X’s in print mode.
  • Root Cause Tree® documents can be deleted from the 7 Step Process page.

Version 5.3.1 Software Release Announcement

Posted: April 30th, 2014 in Software Updates

We are very pleased to announce the release of our Version 5.3.1 TapRooT® Software in both Web Enterprise and Single User versions.

The majority of the enhancements in the Version 5.3.1 TapRooT® Software were designed to add functionality to the user and make the navigation of the software more intuitive. A detailed list of these enhancements is found below.

TAPROOT® 5.3.1 ENHANCEMENTS
o In Single User, you can now create and edit Locations, Classifications, Custom Details Fields and Attachment Folders from the Investigation Editor. You no longer need to go to the Admin menu to accomplish these task.
o When Saving a SnapCharT® as a different season (Spring, Summer, Autumn or Winter) you no longer have to rename the SnapCharT®. The selection of a new season creates a unique name automatically.
o The upcoming new Root Cause of ‘Language’ has been introduced on the Root Cause Tree®
o Under Techniques>Manage Documents, new installations will have a SnapCharT® template to use which helps remind new TapRooT® users of the 15 questions.
o Assorted Bug fixes

This comes less than 2 months after we released Version 5.3.0 with the following enhancements:

TAPROOT® 7 STEP PROCESS FLOW PAGE

The 7 Step Process Flow and the ability to manage documents have been seamlessly integrated into one page allowing access to the entire investigation or audit from one screen.
o Manage all the information for an investigation or audit on one page
o Create, Edit, or Delete any TapRooT® technique or document with one click
o Check off the steps as you complete them
o Every time you complete a technique or document, come right back to the 7 Step Process Flow page
o Double-click to easily open existing documents
o SnapCharT® SAVE AS automatically associates with the investigation

CORRECTIVE ACTIONS

A complete overhaul to this core TapRooT® technique allows more functionality and flexibility for managing Corrective Actions.
o Easily identify the Causal Factors and Root Causes you wish to address
o Create new Responsible People and Departments with ease
o Easily identify what Root Causes have or have not been addressed by previous Corrective Actions
o Create a 2nd (or 3rd or more) Corrective Action with the click of a button

TEAM MEMBERS

Add New Team Members to any investigation by simply typing their name.
o Even non-TapRooT® users can be added to the list
o All Team Members show up on the Investigation or Audit Report, regardless of software access

IMPROVED LOOK AND VISUAL UPDATES

New buttons and Standardization across the TapRooT® Software help improve the navigation and behavior to bring the best user experience yet.
o All CLOSE Buttons have been standardized to return the user to their previous workspace
o Redesigned warning messages clarify what happened and explain what to do next
o Left Menu navigation has been simplified in Single User

SEARCH & TREND REPORTS

Increased reporting flexibility makes finding the data you want easier than ever.
o Innovative parameters unveil limitless possibilities for reports
o Revamped custom query builders and templates give the user powerful tools to generate valuable new and existing reports

MISCELLANEOUS

Numerous updates throughout the TapRooT® Software let more users perform TapRooT® investigations with their personal preferences than ever before.
o System settings can be set to 24 or 12 hour and international date format (dd/mm/yyyy) is now available as a system setting
o Deleting an investigation or an audit now allows you to delete all associated techniques/documents with one click
o Portuguese language now offered for Root Cause Dictionary®
o Check for new TapRooT® Software updates from the left menu
o Assorted Bug Fixes

Version 5.3 Software Release Announcement

Posted: March 28th, 2014 in Software Updates

We are very pleased to announce the release of our Version 5.3 TapRooT® Software in both Web Enterprise and Single User versions.

The majority of the enhancements in the Version 5.3.0 TapRooT® Software were designed to add functionality to the user and make the navigation of the software more intuitive. A detailed list of these enhancements is found below.

TAPROOT® 7 STEP PROCESS FLOW PAGE

The 7 Step Process Flow and the ability to manage documents have been seamlessly integrated into one page allowing access to the entire investigation or audit from one screen.
o Manage all the information for an investigation or audit on one page
o Create, Edit, or Delete any TapRooT® technique or document with one click
o Check off the steps as you complete them
o Every time you complete a technique or document, come right back to the 7 Step Process Flow page
o Double-click to easily open existing documents
o SnapCharT® SAVE AS automatically associates with the investigation

CORRECTIVE ACTIONS

A complete overhaul to this core TapRooT® technique allows more functionality and flexibility for managing Corrective Actions.
o Easily identify the Causal Factors and Root Causes you wish to address
o Create new Responsible People and Departments with ease
o Easily identify what Root Causes have or have not been addressed by previous Corrective Actions
o Create a 2nd (or 3rd or more) Corrective Action with the click of a button

TEAM MEMBERS

Add New Team Members to any investigation by simply typing their name.
o Even non-TapRooT® users can be added to the list
o All Team Members show up on the Investigation or Audit Report, regardless of software access

IMPROVED LOOK AND VISUAL UPDATES

New buttons and Standardization across the TapRooT® Software help improve the navigation and behavior to bring the best user experience yet.
o All CLOSE Buttons have been standardized to return the user to their previous workspace
o Redesigned warning messages clarify what happened and explain what to do next
o Left Menu navigation has been simplified in Single User

SEARCH & TREND REPORTS

Increased reporting flexibility makes finding the data you want easier than ever.
o Innovative parameters unveil limitless possibilities for reports
o Revamped custom query builders and templates give the user powerful tools to generate valuable new and existing reports

MISCELLANEOUS

Numerous updates throughout the TapRooT® Software let more users perform TapRooT® investigations with their personal preferences than ever before.
o System settings can be set to 24 or 12 hour and international date format (dd/mm/yyyy) is now available as a system setting
o Deleting an investigation or an audit now allows you to delete all associated techniques/documents with one click
o Portuguese language now offered for Root Cause Dictionary®
o Check for new TapRooT® Software updates from the left menu
o Assorted Bug Fixes

Time To Upgrade To Version 5 TapRooT® Software

Posted: March 24th, 2011 in Software Updates

Originally posted March 4, 2011

Microsoft® has released Windows 7 Service Pack 1 which does not allow installation of MSDE.  MSDE is the critical database component of the TapRooT® Version 4 Software (last revision 4.0.6). That means that people using TapRooT® Software Version 4 who want to used Windows 7 Service Pack 1 or later need to upgrade to Version 5 of the TapRooT® Software.

Version 4.0.6, which was released in 2005, was released for the Windows XP operating system.  Over the past few years our technical support associates have been helping clients force installations in Windows Vista and Windows 7.  It looks like that practice will be coming to an end with this latest news.

In addition, since MSDE is no longer being supported or allowed by Microsoft, we have no choice but to discontinue support for Version 4 of the TapRooT® Software which has been replaced by Version 5.

What this means to you….

  • If you are a LICENSED SOFTWARE USER using VERSION 5, have no fear!  The Version 5 software is continuously updated to stay compatible with the latest Microsoft® technologies.  You will continue to receive support and upgrades and HotFixes as long as you maintain your license.
  • If you are a LICENSED SOFTWARE USER using VERSION 4,  you need to plan your upgrade to Version 5  as soon as possible!  If your license is in good standing, you are entitled to this upgrade FREE of charge.
  • If you have an EXPIRED LICENSE, you will need to update your license to get upgraded to Version 5.

For more information on the TapRooT® Software products click here

If TapRooT® Version 4 Software Users have any questions about upgrading to Version 5, please contact us at CLICKING HERE.

Using TapRooT To Improve the Quality of Root Cause Analysis at Nuclear Power Plants

Posted: March 15th, 2011 in Success Stories

Challenge
The quality of root cause analysis at our five nuclear power plants was criticized by reviewers such as the Nuclear Safety Review Boards, Nuclear Oversight (Quality Assurance), and corporate executives. Our critics noted repeat failures, and stated that the investigations often missed the mark and had weak corrective actions. We needed to find a system that would produce consistent quality root cause analysis.

Action
An improvement plan was developed and implemented. Elements of the improvement plan included process improvements to increase line manager involvement, use of an Events and Causal Factor chart, use of an investigation charter, use of a root cause report checklist, and implementation of the TapRooT system.
We obtained a TapRooT License Agreement for the five Commonwealth Edison nuclear plant sites, plus the corporate office. Since we were in the midst of a merger, and some of our merger-partner sites were also TapRooT customers, the final License Agreement includes all 10 nuclear plant sites plus the corporate office. We also sent a core group of investigators to a 5-day advanced class.
We replaced our in-house 5-day root cause analysis class with the 2-day TapRooT class and installed SnapCharT and Root Cause Tree® software programs on the Local Area Network at each site. We also conducted orientation sessions for plant senior managers.
By the end of April 2001, we had conducted at least one 2-day TapRooT? class at each plant site.

Results
The initial reaction to the TapRooT system by investigators, line managers, and reviewers has been positive. Investigators like the structured approach. Line managers like the consistent results. Reviewers like the consistent quality. Investigators and line managers also like the savings of time for the 2-day class rather than a 5-day class. The investigators also like the SnapCharT® software.
Our reviewers use a 10-question checklist to grade our root cause analysis reports. Prior to the introduction of the TapRooT system in September 2000, the average report score was about 50%. Since the introduction of the TapRooT system, the average report score has risen to about 75%. We anticipate continued improvement as we train additional investigators.
The improvement in the report ratings and the investigators’ and managers’ opinions about our new system (TapRooT) might not seem like a major improvement, but we have been working for years to improve our root cause analysis and have tried several other systems. Getting this consistent and significant improvement this far along in our quest for better root cause analysis clearly demonstrates to us the value of the TapRooT System.
One more piece of evidence that shows how much we value the progress that we have made. Our energy delivery districts (transmission and distribution) needed improved root cause analysis to analyze human performance problems that result in outages for our customers. They have been looking for a way to effectively and consistently evaluate their incidents. The corporate nuclear staff presented the TapRooT? System to the corporate energy delivery staff, and they decided that the system would help them effectively improve performance. They are obtaining a license to implement TapRooT and install the software for the 10 mid-West energy delivery districts to provide our customers with increased power reliability while Exelon realizes cost savings.

Improving Worker Safety By Fixing the Root Causes of On-The-Job Hazards

Posted: March 15th, 2011 in Success Stories

Challenge
Our ongoing, sustained effort is to make jobs safer and to reduce (and eventually eliminate) on-the-job injuries. Our mechanics were faced with complex procedures, electrical energy, and the potential for falls and hazards that Otis does not completely control (since we are working on the customer’s site). However, in Russia our mechanics also faced hazardous elevator ?emergency? controls and a lack of regulation that made it more difficult to be safe while working.
Our Otis internal audits (a proactive way to find problems) produced scores that showed that improvement was possible. But how do we analyze and fix the real causes of the problems?

Action
In 1998, one of the corporate staff members attended a course on root cause analysis. The staff member used the systematic root cause analysis techniques he learned to solve problems. He found that a structured process helped identify real problems that were previously being overlooked. He also found that the system, called TapRooT®, helped identify fixable causes for these problems that, when corrected, were effective in improving safety.
In 1999, Otis decided to adopt the TapRooT System around the world. Courses were held in the United States, Holland, Singapore, and Brazil . I was one of the environment, health, and safety professionals that attend the course in Amsterdam . We decided to use the process to analyze our safety problems and develop improvements that would reduce risk to our employees and improve the results of our audits.

Results
We started applying TapRooT to analyze our safety problems in 1999. One of the first problems we attacked was the failure of our mechanics to comply with safety instructions in our procedures. The question and answer process in the TapRooT Root Cause Tree® helped us identify the root causes of the problems with the procedures. This helped us simplify the procedures and make them easier for the mechanics to use.
We also found that we needed to improve the enforcement of the use of safety instructions in the procedures. Supervisors now use their regular conversations with the mechanics to reinforce adherence to the safety instructions. We also instituted safety audits to measure compliance and take additional actions to improve compliance (if needed).
But our efforts were NOT just focused on procedures. We also found that we needed to improve the processes and devices that were being used for isolation of electrical energy and for fall protection.
Because electrical isolation devices are no longer required by law, Otis customers often do not want to pay for these devices. Our root cause analysis showed that these devices were essential for our employees? safety. Therefore, we decided to supply these devices at our own cost to provide the highest possible safety for our mechanics.
Root cause analysis also helped us discover and fix a problem with our fall protection equipment. The old equipment sometimes caused internal injuries due to the sudden jerk when the person?s fall was stopped. We developed new gear that had an extra absorbing mechanism to reduce internal injuries.
Finally, we had problems with the safety of workers on top of elevator cars when the ?emergency call? system (a special problem in Russia ) was used. We developed special procedures based on our root cause analysis to help protect our workers.
We have now used TapRooT for over a year and a half. We have eliminated or reduced hazards and we have improved the usage of our safety instructions.
This improvement can be seen in our audit evaluation scores. Each month and quarter each Otis facility evaluates the risks that employees face and submits a report to corporate headquarters. These reports are then evaluated by a committee and a score is assigned. Better results get a higher score.
In 1999 (our first year of using TapRooT), our average score improved to 173 out of 240 possible points. In 2000, our average score improved still further to 200 out of 240 possible points (a good score by comparison with other European Otis facilities). We believe that using TapRooT to find root causes has been an essential element of our improvement efforts, and we will continue to use it to improve even more in the future.

Using TapRooT to Quickly Investigate & Learn from a Production Incident

Posted: March 15th, 2011 in Success Stories

Challenge
To quickly (within two weeks while repairs are being made) and without requiring excessive support of plant personnel, investigate and learn how to prevent the recurrence of the collapse of a process tank that caused severe damage to the tank and significant costs for its replacement.

Incident Summary
During the T&I period for a large petrochemical manufacturing process, a large tank collapsed due to the rapid condensation of steam that was being used to steam out the tank for maintenance work.
The rapid condensation occurred when the deluge system was accidentally activated when an electrician removed a faulty bulb in one of the relays for the deluge system’s electrical power supply.

Investigation

The investigation was performed at a facility that was licensed to use the TapRooT System. Although the license included the right to use the TapRooT System training materials, none of the people involved in the incident had received the training before the incident. Therefore, the investigation started by providing the participants a brief introduction to the TapRooT System and the tools they would use.
A TapRooT trained facilitator was chosen to lead the investigation. He had been to the TapRooT 5-Day Team Leader Course. He decided to use lunch hour (lunch was being catered) to conduct meetings with plant personnel participating in the investigations to save their time and avoid interruptions to the turnaround.
At the first meeting the team members learned about TapRooT and drew their first E&CF Chart to better understand what happened. It took four sessions one to three days apart (a total of 9 hours) to complete the investigation and develop corrective actions that will help prevent this type of incident from recurring.

Results

In this short period of time interesting problems were uncovered and difficult issues were addressed. TapRooT helped us logically and quickly lay out what happened and understand the specific root causes.
The two most impressive items about this investigation were:

  1. The generic problem that was uncovered that we are convinced we would not have uncovered if we had not been using TapRooT. We found an issue of the reluctance to remove any safeguard from service (like the deluge system) when a system is removed from service for maintenance. Issues uncovered included how to decide when a safeguard should be disabled and the timing of when to disable the safeguard.
  2. The efficiency of the investigation process and the ability of the team to quickly adapt to using TapRooT. Just nine hours of team time were used to investigate a fairly complicated production problem. This investigation was conducted during hectic “turnaround” tempo operations with minimal impact on the operations and maintenance organization.

As a result of this investigation we instituted a new checklist to be used during preparation for taking systems out of service. This checklist addresses the effect of safeguards that will be left in service, the hazards posed by safeguards left in service, and, if a safeguard is to be taken out of service, the process and timing for removing the safeguard from service.
We believe that this new checklist will fill an important gap in our maintenance planning process. After reviewing our past experience, we estimated that the insight from lessons learned from this one incident could save Huntsman over a million dollars a year by eliminating the sometimes expensive and dangerous unplanned events that happen during maintenance.
Improving performance is never really completed. This is just one example that demonstrates how we will continue to use the TapRooT System to improve safety, productions, and maintenance. But I think it clearly demonstrates that all investigations don’t have to be long drawn-out affairs to learn lessons of great value.

Using TapRooT to Reduce the Severity of Ergonomic Illnesses and Cut Workers’ Comp Costs

Posted: March 15th, 2011 in Success Stories

Challenge
I took over responsibility for HSE at a research, production, administration, and distribution facility that was having problems with ergonomic illnesses. These types of illnesses were especially troubling in our order entry and distribution areas. I had previously been trained in TapRooT® and knew how it could help people to quickly find root causes without the negative connotations usually found in investigations. Therefore, I thought that this would be an excellent candidate for a pilot program.

Action

We licensed our facility and had System Improvements personnel train a core group of 25 investigators from the various organizational units that would be investigating these and other incidents. We then performed root cause analysis of the ergonomic incidents and implemented immediate corrective actions. One of the actions was to encourage earlier reporting of these injuries/illnesses.

Results

Reporting of ergonomic illnesses increased by up to 40% in some areas. This was even higher than expected, but the early reporting of ergonomic illnesses helped us reduce the illness’s severity. By fixing the root causes and getting early treatment, we could avoid surgery. This was a positive step for employees and our company. The severity of ergonomic incidents for the entire facility was reduced while the frequency of reporting the incidents increased. The most dramatic improvement was in the customer service department. The severity decreased from 96.4 to 0.0 !
The impact of this improvement is significant. It means much less pain and suffering for our employees by fixing problems early – before significant injuries occur. Long term it also means reduced cost for ergonomic illness related surgeries and lost time during rehabilitation. This is reflected in the the cost of our self-insured workers compensation costs which we have saved on average over $1 million per year for the past six years.

Using TapRooT to Improve Quality & Network Reliability in the Telecommunications Industry

Posted: March 15th, 2011 in Success Stories

Challenge
In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages caused by procedural errors. A special Quality Action Team was formed to work with an outside company that was hired to investigate the reason for the increased outages. I was a member of the Quality Action Team and worked for six months with this team and the outside company looking into the procedural incidents. When the outside company reported their findings, I believed that the report missed several items. It was incomplete. Several other members of the Quality Action Team had similar feelings. They thought the team should do more. I began to talk with several people in the industry and found out about System Improvements and the work they had been doing in the field of procedural incidents.

Action
I contacted System Improvements, got information about the TapRooT System, and convinced my boss that both he and I should attend one of their courses. Once we attended the course, we decided that TapRooT would help BellSouth truly identify our procedural problems. We had several Quality Action Team members from each of the Regional Technical Support Systems Groups to attend the 2-day class.
Immediately after this class the information began to change about the causes of the outages. The Analyst doing the interviews had new tools and, for the first time, BellSouth began to hear about problems not mentioned in the report.
The TapRooT System proved to be such a big help that BellSouth bought a license for the TapRooT System and trained all 98 Analysts in the Regional Technical Support Groups.
Since then BellSouth has made changes in the databases associated with service interruptions and outages to include information gained from a TapRooT System investigation. We then use that information to look for and solve network reliability issues.

Results
We continue to use TapRooT to identify problems and improve performance. And the results have been outstanding.
For example, in the first ten months of 1997, BellSouth has found 10 vendor document errors (which deal with procedures) and 14 internal procedure errors. Since implementing TapRooT in 1996, we have cut the procedural incident rate by 12% leading to improved network reliability.
The TapRooT System has given BellSouth the tools needed to correctly review and write procedures as well as report the incidents to upper management. The TapRooT System has also given BellSouth the knowledge to write reports in a more clear and precise manner (including what information should be in the reports to upper management).
I believe the TapRooT System has been a complete solution for BellSouth from finding “root causes” to developing fixes to reporting of the causes (and the fixes) that we find. This helps us in our quest to provide outstanding local and long distance telephone service to our customers. Just how good is our service? Well, in 1996 and 1997 we received the J.D. Power customer satisfaction award for having the best local residential telephone service. Perhaps it is a coincidence that we started using TapRooT® in 1996. However, I think it is more a reflection of the best companies will use the best tools for improving performance.

Using TapRooT to Improve Incident Investigation and Identify Fixable Causes

Posted: March 15th, 2011 in Success Stories

Challenge
Prior to implementing TapRooT in 1993, we performed incident investigations but we often stopped at a level above the root cause; we missed root causes that were important; we placed blame rather than finding fixable system problems; and we didn’t have a consistent, convincing means to present our information to management. Therefore, our challenge was to improve our investigation system so that we could better prevent repeat incidents (that can be dangerous and expensive) by implementing effective corrective actions that would be approved by management and implemented in the field.

Action
In 1993 we trained six people in a 5-Day TapRooT Course. The training helped us to decided to go forward with implementing TapRooT, rewriting our investigation procedure, and training a large number of people to use TapRooT to investigate problems.
We decided to license our site to use TapRooT so that we could conduct our own courses based on the System Improvements copyrighted training material. One of the initial trainees became a certified instructor and over an 18 month period he trained about 200 people to investigate problems by using TapRooT.
After our initial implementation, we also developed the capability to record our results in a database and trend the incidents’ causes over time.
Specific Example of How TapRooT Helped
How did TapRooT help us? The best way I can explain the impact of TapRooT is to describe some specific incidents that the TapRooT System helped us investigate and prevent (by identifying root causes that we could fix by implementing practical fixes).
One example was the investigation of a large fire in a process unit. The fire resulted in a complete unit shutdown. The systematic TapRooT investigation helped us identify the misapplication of steel in the process as one of the causes.
But TapRooT didn’t let us stop there. We continued to look for the system causes that led to why the wrong metal was used. This allowed us to prove that we needed to perform a complete material verification (PMI or Positive Material Identification) to make sure that there were no other misapplications of steel in other similar parts of the process.
This verification was expensive. Without the detailed proof and logical presentation tools that are built into the TapRooT System, management might not have perceived the need to spend the money needed (and commit to the plant down time needed) to complete this verification.
What did we find? The inspections identified three additional areas that needed repair. Any one of these could have resulted in an additional fire and unexpected shutdown. Worse yet, a large fire could cause injuries or fatalities. By using TapRooT we avoided these future problems that would have eventually occurred.
As part of the TapRooT process we institutionalized our corrective actions by updating the PMI Policy. We also looked beyond the specific problem of this application of metallurgy to the generic problem of pipe wall and pipe joint thinning. (Having a database helps you develop a convincing argument that this isn’t just a one-time problem but rather is a repetitive problem that needs a refinery-wide system fix.)

Longer Term Results
In January 1997, when performing the inspections implemented as a result of our previous TapRooT investigation, we found thinning of a piping joint on a process unit furnace. We shutdown the furnace to make repairs that cost about $270,000. If the inspection (implemented after the incident investigation described above) had not been performed, the pipe would have failed. The cost of repairing a catastrophic failure would have been much higher (possibly ten times as much) and could have led to personnel injuries.
The total impact has been so broad and pervasive that it’s hard to measure in dollars. Why? Because some improvements are made by people in the field and aren’t “documented” as being attributed to implementing TapRooT. Also, it would be unfair to say that the only improvement initiative is TapRooT. Therefore in any large facility the total progress being made is not the result of a single initiative but rather the cumulative impact of all improvement initiatives. Therefore we can’t just look at our improved performance and attribute it all to TapRooT.
However, I can point to specific incidents (like the one I described here) that TapRooT helped us develop effective corrective actions that would not have been developed before we started using TapRooT.

Lessons Learned
Here at the Torrance Refinery, we are firm believers that the TapRooT System provides us with the necessary tools to determine the true root cause of an incident. This saves us investigation time and saves us the pain of having repeat incidents that we know would cost millions of dollars and cause personnel injuries.
We have also learned that we needed to apply TapRooT “across the board.” If we tried to apply TapRooT only occasionally, we lost proficiency and missed opportunities to catch problems when they were small (before big accidents happened).
We also learned that we needed to trend root cause data from the incidents so that we could identify problem areas (generic causes), allowing us to eliminate whole classes of incidents by implementing generic system fixes. The database also helps us make a convincing argument that helps management see the need to implement fixes that we previously would have failed to convince them of their desirability.
We are expanding the use of TapRooT beyond safety and production issues to problems with project planning and implementation. This is leading us to new ways to improve our project initiation and approval processes and save even more money by stopping problems before they are “set in concrete.”

Using TapRooT to Improve Incident Investigations, Root Cause Analyses, and to Reduce Incident Rates at Fernald

Posted: March 15th, 2011 in Success Stories

Challenge
The Fernald Environmental Management Project (FEMP) is a former uranium processing facility located approximately 18 miles northwest of Cincinnati and operated by Fluor Fernald, Inc. for the U.S. Department of Energy (DOE). In 1994, the FEMP had implemented a relatively new process of reporting occurrences to the DOE via the Occurrence Reporting and Processing System (ORPS). However, our processes for investigating and analyzing our occurrences were inconsistent and fragmented in multiple departments. Our incident investigation methods were criticized because they were too subjective and incomplete. We searched for a system that would give us an objective, comprehensive, and defendable process for incident investigations that would satisfy the DOE.

Action
In March of 1994, two of our investigators were sent to the TapRooT 5-day Incident Investigator Team Leader Course in Knoxville, Tennessee. Upon their return from the course, efforts began to obtain a site license and to implement the TapRooT system for our ORPS-related incidents.
Site-specific investigation procedures were developed and implemented that required the use of the TapRooT system for reportable occurrences. Training courses were developed and given to hundreds of managers, supervisors, union leaders and employees across the site. In concert with the implementation of TapRooT, a centralized Incident Investigation Team was created with the sole purpose of conducting all ORPS-reportable occurrence investigations, in order to promote even more consistent investigation and reporting practices.
The DOE, FEMP Management, and our Union Leadership were all immediately impressed with the TapRooT process for many reasons. Collectively, they could see that TapRooT was not only an effective process for investigating and analyzing incidents, but that it could also promote better management-employee relations, improve procedures, and be used proactively to prevent incidents before they occurred.

Results
As stated earlier, the primary purpose of purchasing the TapRooT system was for analyzing ORPS-reportable incidents. In the five years prior to purchasing the license, the FEMP experienced an average of over 100 reportable occurrences per year. In the five years after licensing, we have reduced our incident rate to about 46 per year.
Furthermore, the safety significance of our incidents has also been reduced. In ORPS, there are some reporting criteria that are very subjective in nature. In the first five years, incidents classified in the subjective criteria accounted for only 16% of the total incidents. Today, subjective reporting has increased to about 60% of the total number of incidents. This means that our process has worked to eliminate “significant” events and raise the significance of events that were previously considered to be minor in nature. In effect, we have taken great strides in “melting the process safety iceberg,” as illustrated in the TapRooT training.
Given the success of using the TapRooT process in ORPS, we have expanded its application to other areas, including Price-Anderson Reporting, OSHA injuries, and self-identified Concerns. As with ORPS, incredible improvements are now being realized. For example, we recently broke the site record for Safe Work Hours (8 million) and also passed the 8 year mark without a lost time injury to our construction contractors. In the area of Price-Anderson, our performance has also been exemplary in that we are one of the few DOE sites without an enforcement action on our record.

Path Forward
While our results in our targeted areas have been beyond our initial expectations, we can now envision improvement of all our processes to a previously believed unattainable level. Our goal now is the complete elimination of all incidents and injuries, no matter how small or relatively insignificant. In other words, we will strive to COMPLETELY melt the iceberg! Our Management has seen the tangible benefits of our efforts in reduced costs in insurance premiums, reduced project down-times, and the prevention of civil penalties for poor QA and Radiological Control performance.
Given our success in improving safety, performance, and reliability in our target areas, we feel that nothing is beyond our grasp. With the addition of the TapRooT® software and the Trending programs, we are well-equipped to meet our ultimate goal.

Using TapRooT to Improve Investigations by Focusing on Fixable Causes Rather Than Blame

Posted: March 15th, 2011 in Success Stories

Challenge
Many of us investigate accidents that the cause seems intuitively obvious: the person involved just “goofed up.” And what is the natural corrective action for this type of problem? Because they are to blame, the most frequent corrective actions are a warning, a reprimand, or some other kind of punishment.
We hoped that for most accidents there was more to the causes than just simple human error. Why did we hope this? Because we wanted to improve performance and if “to err is human,” then we needed to find fixable causes beyond human error so that we could make improvements to the system and thereby get improved performance.
The following is an example of a typical accident that on the surface seems to be a simple human error. However, by using TapRooT® we found system causes that, when corrected, will help us prevent similar accidents.

Accident
A truck carrying 30 tons of steel rolled over while rounding a corner. The load spilled next to and under a NGL (natural gas liquid) pipeline. The driver was uninjured. Obviously this accident could have been much worse.
The natural assumption for an accident of this type on the North Slope is that either the driver was traveling too fast or the driver ran off onto a soft shoulder. Our challenge was to find out what really happened and how it could be effectively prevented in the future.

Accident Investigation
The only witness to the accident was the driver. Therefore to find out what really happened, it was essential to have his complete cooperation. Therefore we started out by explaining to him that we were going to draw a simple chart (an Events & Causal Factors Chart) to lay out the complete sequence of what happened. That we would start out by letting him tell us in his own words what happened from start to finish. Then, once he was finished we would draw the chart and ask questions. He seemed very comfortable with the approach so we continued.
The result of using this simple process (part of the TapRooT System) was amazing to both of us (the two investigators). The more he talked the more we realized how little we really knew about what had occurred.
After he completely told us his story and we started to draw up the E&CF Chart and ask him questions, it became obvious to us that the driver felt that he was completely responsible for the accident and that he wanted to help us so that we could keep similar accidents from happening to other drivers.
The driver told us that he had a minor breakdown and was concerned about being a little late. So he called his boss on his cell phone. When he hung up the phone he realized that he was in the middle of a sharp corner. He jerked the wheel to stay on the road. Jerking the wheel caused the load to shift (it wasn’t properly secured). The sudden shifting of the load caused the truck to flip.
We focused on two factors: the distractions that caused the driver to not fully be aware of the curve until he was already well into it and the shifting of the load that led to the truck flipping.
Our first concern was cell phone usage while driving. We looked into the problem and found that 14 states and numerous countries have pending legislation regarding the use of cell phones in moving vehicles. Developing a policy preventing the use of cellular telephones by the driver of a moving vehicle is not a popular idea on the North Slope or elsewhere. Rather than fix this problem, there are those who would much rather simply blame the driver, dismiss him, and get back to business as usual. But this wouldn’t solve the problem. So we are going to move ahead with a recommendation to not allow the use of cell phones by the driver of a moving vehicle and to raise the awareness of this hazard (as is the Alaska Truckers Association).
Our second concern was the improperly secured load. Our roads on the North Slope are non-DOT regulated. We found that the drivers had no guidance or formal training for securing loads on our type of roads. Therefore many loads were not “properly” secured because the guidelines for properly securing a load had not been developed. Therefore we are going to develop guidance for properly securing loads on the North Slope’s non-DOT regulated roads.

Results
Was this incident simple human error? Our answer is that there was much more to it than that.
On the North Slope vehicle accidents have been the leading cause of fatalities. Investigations that look for correctable causes (like inappropriate cell phone usage and improperly secured loads) and get corrective action implemented will help us reduce hazards and improve our vehicle safety record.
As for the driver, he was not fired. His employer recognizes that he is a valuable asset to his company. And he is one of the people in his organization that is helping raise the awareness of the hazards of cell phone usage by drivers.

Using TapRooT to Improve Root Cause Analysis & Safety at Intel

Posted: March 15th, 2011 in Success Stories

Challenge
We experienced a rather severe incident early in 1995 and recognized the need for better root cause analysis to improve our accident investigations. Our challenge was to find a better system, apply it, and thereby improve safety at our facility.

Action
We held our first on-site TapRooT Training in mid-1995. Shortly after the training we had another incident that allowed me to use the skills I had learned at the TapRooT Course. It was evident to everyone participating in the investigation that the TapRooT® System was a really useful tool to help us identify the causal factors and ultimately the root causes and corrections. Our management was impressed enough with the results of the system to send two of us to a 5-day TapRooT Team Leader Class.
When we returned from training we performed several investigations using TapRooT to help us identify fixable root causes. Our investigation work and the results we were getting came to the attention of other groups. The decision was made for our facility to obtain a TapRooT License so that we could conduct our own on-site courses using the TapRooT training material. We could then spread the techniques to a large number of employees.

Results
We held our first on-site course taught by Intel instructors in May of 1997. Within 18 months we had trained 132 employees. How did the classes go? We get frequent comments like:
“This is the best training I’ve ever had.” and
“Great class – this should have been provided years ago.”
But positive comments on course critiques is not the reason we chose to use TapRooT. We decided to use TapRooT® to improve our root cause analysis and improve safety at our plant. And we think that the results we’ve achieved show that we made a wise decision.
First, we are frequently asked to help with investigations. The most impressive part of these investigations are the results we’ve accomplished. When we investigate an incident using the TapRooT® System and get the corrective actions applied, the incident does not repeat.
Second, it has become common for management to ask key TapRooT trained investigators to review other investigations (that didn’t use TapRooT) so that they would be assured that the real root causes were identified. This is a pretty impressive indicator all by itself!
Third, TapRooT has been so successful helping us improve safety that we are now using it to investigate other types of incidents: yield loss, misprocessing, and audit findings.
So how successful have we been in improving performance using TapRooT? Naturally, I can’t give TapRooT credit for all the improvement we’ve experienced, but it is a part of some key programs that produced the following results:

Plan Safety Indicators

1995 1996 1997 1998 1999 2000 2001
Lost Day Case Rate 1.88 0.44 0.33 0.08 0 0.08 0
Recordable Injury Rate 5.33 2.47 1.17 0.61 0.27 0.16 0.08
Safety Bulletin Incidents 1 0 0 0 0 0 0

I think that these results speak for themselves.
Thanks for the great system.
John Carpenter
Safety/ERT/Microcontamination Manager (retired)
Intel Corporation

Using TapRooT to Improve Process Reliability

Posted: March 15th, 2011 in Success Stories

Challenge
Our Acrylates Area Oxidation Reactor was experiencing frequent unplanned shutdowns (trips) that were causing losses of large fractions of our plant capacity. Previous corrective actions seemed to have little lasting impact. Our challenge was to form a team of operators, mechanics, and an engineer and come up with ways to reduce and eventually eliminate these unnecessary shutdowns.

Action
A team was formed to study the problem. We decided that we needed better data (not conjecture) to study the reasons for the plant unreliability. We had heard about the TapRooT System and so the whole team attended an open 2-day course.
We went back and started performing a root cause analysis of each reactor trip. Using the root cause information, we developed solid corrective actions for each problem. We also collected statistics (a rolling three month average) about the causes of the shutdowns and looked into the generic (systemic) causes for the top three causes and developed additional systemic corrective actions for these.

Results
In less than 12 months we saw a constant, dramatic improvement in our plant reliability. Due to the reduction of the number of shutdowns and the estimated capacity available with the improved reliability, in the past two years we saved about 40 million dollars. These savings will continue to accumulate so the total saved will be even more.
Besides saving money, our team received the highest corporate award possible for these improvement efforts. It easy to see why we believe that learning and using the TapRooT® System is an excellent investment.

Improving Investigations to Provide Management with the Information They Need to Support Corrective Actions

Posted: March 15th, 2011 in Success Stories

Challenge
The Bi-State Development Agency is a progressive rail and bus transit system whose service area includes metropolitan St. Louis, Missouri and expands over the Mississippi River into St. Clair County, Illinois.
In December of 1998 I became the Manager for Bus and Rail Safety. In discussions with the new Executive Director one of my challenges became clear. I needed to improve the investigation and reporting of accidents so that management would have the information they needed to improve performance and support effective corrective actions.
Before my arrival, a member of the Safety Department would go to the scene of an accident and, within four hours, write a “Fact Sheet” (a boilerplate consisting of the events leading up to the accident and the response efforts). Management recognized that this method of investigation just was not providing the information needed to develop effective corrective actions.

Action
Fortunately, I already had a plan. I had previously used TapRooT to improve investigations and I knew how fast it could work to improve investigations and corrective actions. So I introduced TapRooT as the Safety Department’s investigative tool and sent our investigators to TapRooT Training.

Result
Within weeks of instituting TapRooT as the investigative tool, we had dramatically improved the investigation of accidents. The Safety Department drew Events and Causal Factors Charts as part of the investigation and used the charts to explain what happened to management. We also used the TapRooT Root Cause Tree to consistently identify the accidents’ root causes. These two techniques helped us understand the details of what happened and look much deeper into the system causes that needed to be corrected.
Of course, this was much more difficult than just blaming the driver. But the effort is very worthwhile. The Safety Department can now answer questions as to why human error or mechanical failure occurred.
Upper management was pleased with the wealth of knowledge gleaned from the TapRooT System. People that I hardly knew were stopping me to say that the reports were much more informative and that now they now understood Safety?s role in accident investigations. Using TapRooT, our department provides an unbiased resource to dig into the factors that caused the accident, find the system causes, and recommend effective corrective actions.
Since implementing TapRooT, the Executive Director praises our accident reports saying that they ?now add value in terms of reducing accidents and improving the way Bi-State does things.
Our next challenge is to ensure that the corrective actions are implemented quickly and documented when completed. But with upper management?s support for problem investigation and rapid implementation of corrective actions, I?m sure our efforts will be successful and that we will have even more impressive successes to report in the future.

Improving Investigations and Root Cause Analysis

Posted: March 15th, 2011 in Success Stories

Challenge
As the Supervisor of Health and Safety at Enmax Corporation (a municipal electric utility), I reviewed all incident reports. My observations were that quality of the reports varied greatly depending on the training, experience, and diligence of the investigator. There was little consistency in format and content from one report to the next. And the investigators tended to identify immediate causes (actions that went wrong) rather than root causes (the causes for the actions that went wrong).
Perhaps these problems were related to the investigation system we were using. It was time consuming and not very user friendly. And it didn’t provide us with a tool to clearly explain what happened and why it happened. Nor did it effectively track the status of corrective actions.
To me the challenge was obvious. If we wanted to learn more from the dear bought experience derived from accidents and incidents, then we needed to improve our investigation and root cause analysis.

Action
Fortunately, I had just been introduced to a system for incident investigation and root cause analysis called “TapRooT.” The action to take seemed clear. I needed to hold training for the people performing investigations so that they could use TapRooT to improve our investigation performance.

Result
The feedback from the participants in the training was that they left the course feeling confident that they had the skills they needed to use TapRooT to find the root causes of our incidents. They now had a new vocabulary of root cause analysis, a clear goal for their investigations, and the tools they needed to reach that goal.
However, the real test would be when they applied the techniques. What would I get? The answer was clear and obvious. I immediately noticed improvement in the quality and thoroughness of investigations and reports. This improvement and consistency meant that all the investigations were well above the minimum that I expected.
The software also helped improve the consistency of the reports and our analysis and the database helps us maintain our incident records. The Corrective Actions Reports are essential in completing the investigation loop by tracking the status of corrective actions and providing documentation that improvements have been implemented.
We are in the process of implementing the improved corrective actions that we are developing thanks to TapRooT. As time passes I’m sure that I will be sending you an additional success story with the statistical data that shows the impact of improved root cause analysis on our already good health and safety record.

Improved Medication Administration By Using FMEA and TapRooT to Proactively Analyze the Process

Posted: March 15th, 2011 in Success Stories

Challenge
Our challenge was to further improve the medication administration process at our facility by proactively analyzing the process using FMEA and TapRooT. Our goal was to find ways to help prevent errors and increase patient safety by identifying error prone points in the system and anticipating what might cause these failures so they could be eliminated or minimized whenever possible. The medication administration process had already been reviewed for ways to decrease medication errors and increase patient safety. Therefore, we were starting with a system that many people thought might not present easy improvement targets.
A practical constraint to our efforts was that because of the fiscal constraints that all healthcare facilities face in these days of tight budgets, we knew it would be difficult to make large capital investments. Therefore, complex or costly systems for automation of the medication administration process were not a possibility.
However, we thought that by the use of systematic evaluation tools – FMEA and TapRooT – we might find ideas for improvement that others had missed.

Action
We formed a core team of nurse managers and pharmacists to analyze the process. As the analysis progressed, others were asked to help where they had more familiarity with or a better working knowledge of the process in a particular area. Each of these team members had been trained in the past in the use of TapRooT (TapRooT has been used at our institution for the last 5 years).
We started by diagramming the process using the SnapCharT Software from the TapRooT System. This helped the team visualize the whole process and break it down into manageable pieces for further analysis.
As we performed the FMEA for various parts of the process, familiarity with the TapRooT System’s Root Cause Tree helped team members ask better questions and identify potential failures that they may not have thought of without the TapRooT Training. The TapRooT Training also increased the team’s awareness of how problems at a particular unit might be generic (applicable to the whole organization).
Once the team had identified problems and their root causes, it was time to develop corrective actions. This is where the training that we had received at the TapRooT Course about developing ?SMARTER? corrective actions came in. As we looked for ways to improve, we considered the caregivers and what it takes to provide that care. We made sure that safeguards that we put in place to improve patient care didn’t actually introduce new types of errors by making the process too complicated or difficult to follow. Therefore, each corrective action was reviewed (the final “R” of SMARTER) to make sure that there were not any unintended negative consequences from the proposed improvement.

Results
How did we improve our medication administration process to improve patient care? Here are some of the ideas that we implemented:

  • Medication carts ordered for the bigger units that will enable medications to be prepared closer to the patient decreasing distractions.
  • Medication references easily accessible at the point of administration and pharmacy phone numbers posted bold and bright encouraging communication and questions.
  • Rearranging of floor stock medications in smaller units where storage is a problem.
  • Changing labels where labeling was not clear in some areas.
  • Chemotherapy administration sequence references made readily available.
  • Standardize transcription on the major units to decrease transcription error potential.

None of these changes look like a radical departure from our old practices. None of the changes were extremely expensive. But people involved in the analysis believe that the changes address issues that could have caused errors and had previously been overlooked in our improvement efforts. Therefore the analysis was both useful and worthwhile.
Our institution has a strong commitment to continuous improvement of patient safety and the quality of care. Use of systematic tools – like TapRooT and FMEA – helps us recognize the potential opportunities for improvement proactively.
As a healthcare professional I feel that this proactive approach (instead of waiting for accidents and analyzing the failures after the fact) allows us to manage our processes and provide better care. We aren’t victims of the system with no control to change or improve things. We can systematically analyze, manage, and improve our processes. And TapRooT is a key part of that proactive analysis and improvement process.

Improved Investigations and Enhanced Management Interest and Acceptance by Using TapRooT

Posted: March 15th, 2011 in Success Stories

Challenge
We wanted to improve our incident investigations, root cause analysis, and corrective actions.

Action
In 2002, we decided that to reduce accidents, prevent injuries, and ultimately save money, we needed to do a better job investigating accidents. We investigated various improvement options and decided to try using the TapRooT System for investigation and root cause analysis.
Several of our staff attended System Improvements’ 5-day Advanced TapRooT Investigation Team Leader Training and received an individual user version of the TapRooT Software as part of the course. After the course we returned to apply the tools that we had learned to investigate bus and rail accidents, employee safety incidents, and safety issues.

Results
We immediately noticed improvements in our investigations.
The SnapCharT diagram drawn using the SnapCharT Software helped us understand the circumstances surrounding an incident.
The Root Cause Tree part of the TapRooT Software helped us analyze the root causes to a much greater level of detail. This better analysis and the Corrective Action Helper® Module of the Software helped us develop more effective corrective actions.
An unexpected but very valuable side benefit of our efforts has been the effect the TapRooT System has had on the interest of management in our investigations and their acceptance and support of the investigations and corrective actions.
Management has a much better understanding of what happened when we use the SnapCharT technique to present the incident to them. The presentation of the Safeguards (found using Safeguards Analysis) helps them understand how many or how few things had to fail to cause the incident. And management has commented that they now see corrective actions that they believe will be much more effective than before we started using TapRooT.
Because management support to pay for and assign resources to implement corrective actions is so important (because without implementation of corrective actions, your analysis effort is wasted) the new enhanced support by management may be the most important benefit that we have seen.
In summary, by using TapRooT we have achieved our goal of improved investigations, root cause analysis, and corrective actions. We also achieved a perhaps even more important benefit of enhanced management interest and acceptance of investigations and greater support for implementation of our corrective actions. This is helping us improve transit safety and operations and will eventually lead to cost savings.

Using TapRooT to Improve Root Cause Analysis, Cut Our Incident Rate, and Our Workers’ Compensation Costs

Posted: March 15th, 2011 in Success Stories

Challenge

At our phosphate mining and chemical plants located in White Springs, Florida, we had been improving our safety processes throughout the 80’s and into the 90’s. We had recognized a need for improved consistency in our root cause analysis. With this in mind I attended a 2-day TapRooT Course in October of 1995 and was convinced that the TapRooT System offered us the mechanism for improving our incident investigation system and ultimately achieving our goals in safety excellence.

Action

We began in 1996 by having System Improvements conduct two on-site 2-day TapRooT Courses for 50 people (including frontline Supervisors, Superintendents, Safety Specialists, and our four Chief Shop Stewards from the union who serve as Safety Committee Chairmen). In addition, we held a four hour overview class for our upper management including our Vice President of Operations.
We started by applying TapRooT to analyze the root causes of our OSHA/MSHA recordable injuries and significant near-misses. As our confidence and experience with the system grew, root cause analysis and TapRooT became “household words” for our employees and were used for a variety of analysis and improvement efforts. The techniques were highly valued by management and employees. The acceptance of the TapRooT System by our bargaining unit was an unanticipated benefit. This was at least partially due to the Chief Shop Stewards attending the same training as our Superintendents so that both groups had a clear understanding of the process and both could easily see that in TapRooT there are no hidden agendas.
In 1997 and 1998 we have increased our skill in applying TapRooT and increased the scope of the investigations in which we apply TapRooT. We now consistently apply TapRooT to all incidents including near-misses and first aid incidents. Looking for and fixing root causes for these smaller problems represents a paradigm shift for line management and employees alike. It also provides many more opportunities for our employees to hone their skills in the use of TapRooT.

Results

Improvement in a single element of a safety process will normally not bring success for the total program. Also, increasing the number and scope of root cause investigations is only worthwhile if you can see results that justify the effort. However, we have seen a direct link between the improvements we have made to our incident investigation process by using TapRooT® and our total safety process results.
First we have seen two improvements in our injury incident rate. Before implementing TapRooT our injury incident rate was 2.66. By 1997 it had declined to 1.75. After increasing our use of TapRooT to analyze near-misses and first aid incidents, our injury rate was cut in half (from our 1996 rate) to 1.27 for the first three quarters of 1998.
During the same period we have achieved two safe work milestones for our site by working 1 million and 2 million hours consecutively without a lost time accident.
These incident rate records have also led to financial rewards in the form of decreased workers’ compensation premiums that have more than paid for the cost of the training.

Path Forward

Perhaps the best way to judge our belief in the effectiveness of the TapRooT System is to observe that we are have licensed the use of TapRooT System and Software for our entire company.

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Success Stories

We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…

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Fortunately, I already had a plan. I had previously used TapRooT to improve investigations…

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