Author Archives: Chris Vallee

Root Cause Analysis Tip: TapRooT® is Root Cause Analysis Software … ? No!

Posted: August 15th, 2012 in Root Cause Analysis Tips, TapRooT

If I had a dime for every time I’ve heard the statement, “TapRooT® is a Root Cause Analysis Software … ”.

So I thought I would let some our customers speak on the topic when they were asked the same question on LinkedIn.

Dan Hughes”  “I am trained and I use TapRooT®. Compared to my colleagues I can reach the root cause or causes more quickly and more accurately. They use Keppner Trego (KT) and Apollo. I find TapRooT® very effective, very user friendly, easy to review and correct if you wander … I have used 5 Why’s, KT, Fault Tree and a few others but I am sold on TapRooT® and I don’t see myself using anything but TapRooT® in the future. Not long ago I was sent info from over 4K miles away. My colleague shared info by phone and email and I did the TapRooT® timeline for him and reached a root cause(s). My colleague reported to corporate using the timeline we developed and he presented our conclusions. It is the first report at the corporate level that was accepted without question. I had great support from my TapRooT® instructor who reviewed the materials we put together. TapRooT® instructional staff are outstanding and if they say ‘call me’ they mean it and they respond.”

Randy Bennett:  “TapRooT® is a process that happens to have a software program to assist in capturing information and investigation data / status of progress … I have used the process since 1996 with excellent success for a Major E&P Company. I have never conducted a serious investigation with the software first; I use the hard copy (sticky notes) for the initial SnapCharT®s and then transfer … it works much better due to the changes that can occur initially. The really crucial advantage of the TapRooT® system is the repeatability of the findings from team to team; other methods such as 5 whys and similar methods are not repeatable and results are based on the team’s experience and make up. When we believe behaviors are an issue we will add A-B-C analysis (BST Method). The other aspect of TapRooT® is it’s based on identifying process issues and problems and not fault finding which is why it has a good reputation with management and field personnel.”

Now the question is:   Where did the software comment/idea get created?

1.  People wanting software to perform an investigation do an internet search, which shows that we do have investigative software to support the process itself.

2.  Competitors sell software that is not based on a true process and compare us to them as software.

3.  People see someone investigating an incident with them using our software.

4.  People receive an incident report created in our software.

This however is like saying mathematics is a calculator because someone was using it to solve a problem.

So why elaborate on this topic? Simple:

1.  Make sure people unfamiliar with TapRooT®, understand how it actually helps you investigate a problem with or without the software program.

2.  Describe where our software actually helps you in the TapRooT® Process.

Here is an excellent article explaining what makes our process unique and not just software: 7 Secrets of Root Cause Analysis (7 Secrets of Root Cause Analysis)

When should you use the software to compliment or support the TapRooT® Process?

1. Improved Time Management of Your Investigators

A timeline called a SnapCharT® must be developed during the investigation. Key data such as Causal Factors, once identified, are sent directly to the Root Cause Tree® Analysis section and a tree is created for each one.

The TapRooT® Software walks a trained investigator through the 7 Step Process for investigations including:  Logging your investigation data; mapping your sequence of events, finding root causes, developing corrective actions, and generating reports.  Upon completion of each technique, the software takes the investigator back to the 7 Step Process to make it easier for investigators to see what they have completed and what they need to do next.

To perform a TapRooT® Investigation both our Root Cause Tree® Dictionary and Root Cause Tree® must be used. This requires flipping through sections of the dictionary manually to find what you need.  When going through the Root Cause Tree® in software, a right click at any root cause pulls up the dictionary definition for that root cause and pulls up the Corrective Action Helper® to assist you in developing corrective actions for that root cause.

2. Investigation Due Diligence

Knowing that our memory is not very accurate, investigator root cause selections must be tied directly to the evidence found and must be documented.  Without software, your company must develop spreadsheets or place facts in other programs that can be tedious and may allow for loss of data.

Built into the software Root Cause Tree® is the Analysis Comments section.  With just a right click at your chosen root cause, you have a place to document your evidence.  This is also vital because with proper documentation, this also gives the ability to audit and verify evidence findings.

3. Report Standardization

Our software produces Standard Investigation Reports that means key data is always listed in the same place on the report.  This also means less time deciphering incidents reports.

With Individual Software Licenses, there are a few fields that are customizable. With the Enterprise Version of the software, our team can work with you when you implement our software to easily develop your companies custom reports.

4. Improved Implementation of Corrective Actions

Many of our clients choose one of two options here: 1) Save the Corrective Action Report as a .pdf and attach it to their existing program; or 2) Use our program to track the progress of their corrective actions through to completion.  The Multi-User Enterprise version allows emails to be sent for assigning and tracking corrective actions.

5. Single User versus Multi-User Software

When you have many trained employees, we recommend you get the Multi-User Enterprise version to centralize all reports and reduce duplicate data.  Also, this allows your employees and managers to do searches in the database to see how investigations are progressing as well as to look for trends in root causes.  It also allows you to set up periodic reports for managers and to set up custom incident reports.

Root Cause Analysis Tip: When an Investigation Doesn’t Reveal Root Causes …

Posted: August 8th, 2012 in Root Cause Analysis Tips

As a TapRooT® Instructor and Incident Facilitator, I hear these phrases occasionally:

We did our investigation and could not find any root causes.

Nothing was done wrong, so we have no corrective actions to implement.

I hear these phrases often from people not familiar with the TapRooT® Root Cause process.  But sometimes … even us experienced users need a little nudge. So if you get stuck …

1. After identifying the worst thing that happened or the specific problem that you need to focus on, ask a few key questions up front based on your industry:

Manufacturing: What were the quality escapes?

EHS or Process Safety: What were the uncontrolled energies and exposures?

Project Planners: What were the bottlenecks or gaps in the project?

Medical: What were the patients’ hazards or exposures?

Note: We are not brainstorming here nor are we troubleshooting yet, we are just defining the problem.

2. Next, we pull out our safeguard analysis questions that we learned in our 2-Day, 3-Day or 5-Day TapRooT® Root Cause Training and fill in the blank. For example:

What error allowed the bacteria to be there or grow too large?

What error allowed a safeguard to control the bacteria to fail or be missing?

I will not go through all the questions that you learned to ask, but just asking these first two questions tells us that we need to track the bacteria in our timeline, look for evidence and take samples of bacteria growth.

This technique works, because it forces the facilitator to break down the problem.   This incident (in the example above) could have easily been a ventilator-associated pneumonia issue.  Bacteria, Bundling and Secretions are just some of the hazards and exposures that had to be present for this incident to occur, and they need to be in our timeline, (we call a timeline a “SnapCharT®”).

3. Once we map out the events in our SnapCharT®, define our Causal Factors, and perform our Root Cause Analysis, we may find that no one broke a rule or policy and still allowed the bacteria to grow.  The simple answer is that processes were not adequate.

Yes I know that some hazards are very difficult to control, (like fleshing eating bacteria from a lake that enters through a cut on a human body), but once identified, we still use the safeguard analysis process to increase hazard risk reduction for the future.

Also, during the root cause analysis, please ensure that you do not lightly review the human engineering basic cause category.  Some of your root causes for seemingly mysterious issues are identified here.

I hope this helps get your investigation jump-started.

Root Cause Tip: Need to Take a Refresher Course?

Posted: July 11th, 2012 in Root Cause Analysis Tips

Your TapRooT® Root Cause Analysis Training occurred a while ago … what can you do?

Depending on when you took your TapRooT® training here are a few Public Course Options to get back into your TapRooT® mind:

1. Take another 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. You will benefit from a refresher and get to see additional investigation skills that we have introduced.

2. If you have never been introduced to our equipment and system troubleshooting course, you should register for our 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course.

Important: You can only attend this 1-day course if you have previously attended a 2-day or 5-Day course taught by us.

3. If you took a 2-day course previously, take the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. You get a refresher plus learn about all the optional tools that we teach. You also become a mentor or lead facilitator for your company. Did I mention that you also get a discount?

If you have at least 10 peers in the same boat as you, we can set up an onsite course for any of the options above!

Here are a few tips that you can read right now to get you back on track:

Video Recording from your peers sharing their best practices with TapRooT®

Secrets of Good Root Cause Analysis

Root Cause Analysis Tip: Let the TapRooT® 7-Step Process take you to the Root Causes…. Don’t force it!

Root Cause Analysis Tip: Using Equipment’s Role to help Build a Better SnapChart®

Root Cause Analysis Tip: Failed Safeguards = Causal Factors

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?

Of course, if you need assistance and a jump start now, call our office at 865.539.2139 and ask for one of our instructors.  We love to help!

TapRooT® in Trinidad: One week, Two Companies

Posted: May 15th, 2012 in Courses, Pictures, TapRooT, Uncategorized

Learning how to perform an Audit... it is not just about compliance!

Covering Step 2 of the 7-Step TapRooT® Process

Often when teaching Onsite TapRooT® Root Cause Analysis Courses, we get to teach two different companies in back to back courses. Doing this actually saves our clients on instructor airplane travel costs. Last week in Trinidad, I had the opportunity to work with IPSL (pictured above) and Tucker Energy (pictured below).

Learning about the SnapCharT®

Working on the Root Cause Analysis

Working on final excercise

Working on Root Cause Analysis

Just some of the Testimonials after the final exercise:

“Very engaging, eye opening! Be neutral!”   (bias kills an investigation every time the students learn)

“Today’s session was detailed and gave a clear idea on how to investigate an incident totally and fair.”

“The course highlighted that we used the wrong approach for incident investigations in the past.”  (They found conflicting evidence that had not been verified yet)

“Very good hands on approach; assistance from the facilitators (instructors) was very helpful throughout the course.”

 

 

 

Day one of Nalco’s interstate 2-Day TapRooT® Root Cause Analysis Course

Posted: March 8th, 2012 in Courses, Pictures, Root Causes, TapRooT

Brian Dolin, teaching below, and I had the great opportunity to work with Nalco employees from different states here in Illinois this week.

Great Human Factors: When a Hand Control is Called a "Suicide Shifter"

Posted: February 16th, 2012 in Great Human Factors, Human Performance, Pictures, TapRooT, Uncategorized

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I am a sucker for a 1948 Indian Chief motorcycle.  So I  thought … what a great opportunity to talk about Human Factors Design and show off a little nostalgia. The topic of today is the Suicide Shifter.

The Suicide Shifter is located on the left side of the fuel tank and was used to shift gears while riding. Called a Suicide Shifter because you had to take your left hand off the handle bar grip to shift it.

So the question for you today is how many equipment control designs used today at your work area are not placed in the safest area to use while operating?

Great Human Factors: The New Windows 8

Posted: February 9th, 2012 in Current Events, Great Human Factors, Human Performance, Pictures, TapRooT, Uncategorized

In the human factors world there is an acronym, HCI. This stands for Human Computer Interaction. A subset of the human factors field, HCI is where computer software programers meet the computer user’s needs by design BEFORE they sell it. So…… have you seen the marketing and pre-beta download for Windows 8?

  • Will the new version frustrate new or experienced window users? or both?
  • Will Microsoft help experienced users transition?
  • How will Microsoft help experience users transition (if they do) to the new version?
  • Will software developers who have software used on Microsoft help transition their existing customers?

Windows 8 Developer Preview is available for you to try now: http://msdn.microsoft.com/en-us/windows/apps/br229516

Root Cause Analysis Tip: Why Wait for a Problem to Use CHAP?

Posted: February 8th, 2012 in Courses, Human Performance, Investigations, Quality, Root Cause Analysis Tips, TapRooT

In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and in our TapRooT® book, TapRooT® Changing the Way the World Solves Problems, we introduce the Critical Human Action Profile (CHAP) tool to help collect more information to analyze any type of problem at the process task level.  I like to call this looking at a problem at the 1 foot level as opposed to many investigations that analyze their problems at the 100,000 mile view only.

The tip here, however, is “why wait for a problem to use CHAP?”

Identify, Evaluate and Improve before it is too late!

Using a very over simplified list of procedure steps on How to Remove a Fuel Pump, found on the internet, I would like to show you how to use CHAP proactively to improve Safety and Quality during a task.

WARNING: The steps listed in the demonstration example below on removing a fuel pump shall not be used. They are incomplete and not necessarily accurate.

Where to start? First off you already perform  JHA, AHA, JSA, Observations…. So Going Out and Looking (GOAL) should not be new or require a lot more additional resources. The difference is that you will be utilizing your resources more efficiently.

1. Start by identifying a task performed by employees that are critical to:

a. Customer/client satisfaction

b. Product Quality

c. Project Timeliness

d. Employee Safety

e. Customer Safety

f. Environmental Exposure

2. Once the task is identified, list the steps to be performed like listed in the image below.
Note: Do not forget to use the Basic Cause Category Procedure in our TapRooT® Root Cause Tree to look for missing best practices as well when listing the steps.

3. Identify each step of the task that is critical to the items listed in step 1 criteria of this article.
Which steps listed above for the fuel pump removal do you think would be listed as critical?

4. For each critical step in the task perform a CHAP Profile.

Note: For each of the items listed below, do not forget to include the Best Practices listed under the Human Engineering Basic Cause Category in our TapRooT® Root Cause Tree.

Great Human Factors: Can Intuitive Tool Design Override Previous Training?

Posted: February 2nd, 2012 in Great Human Factors, Human Performance, Root Cause Analysis Tips, TapRooT, Uncategorized, Video

Watch the chimpanzee vs. human child in a learning experiment.

Here is the video link: http://youtu.be/nHuagL7x5Wc

We are all trained, or learn, by trial and error on how to use equipment or how to use it “properly”. What happens when you get a better “understanding” of how the equipment works? Here are some of the choices that we could make:

1. Ignore the previous training and just get the prize (work done faster, like the chimpanzee)

2. Continue the rules that you learned or were trained to do (at least in front of the bosses like the children).

3. Stop and ask what’s up?

4. Stop using the tool all together and do not tell anyone.

Often the previous training and experience overrides the new operation steps needed … ever been totally frustrated every time someone changes your computer’s Microsoft Windows version? And no, training by itself does not override experience, practice and repetition does!

I had a discussion not too long ago that OSHA forklift training requirements were met when people were retrained after changing forklifts. Unfortunately, the controls worked exactly opposite on the new forklift and the quick review did nothing to override the past knowledge and muscle motor memory.

Just something to think about when you think “Great Human Factors.”

Great Human Factors: Prescription Windscreens for Cars?

Posted: January 25th, 2012 in Human Performance, TapRooT, Video

Is the Human Factors Design at it’s best or worst?

However often would you need to change the windshield?

What if you wanted someone else to drive the car?

Should passengers be able to see out the windshield too?

Great Human Factors: Wrong Tools, Bad Access by Design, Per “Ingenuity” or All of the Above?

Posted: January 19th, 2012 in Accidents, Equipment/Equifactor®, Human Performance, Pictures, Quality, Root Causes, TapRooT

As an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:

Wrong Tool?

Bad Access by Design?

Mechanic’s Ingenuity?

Or a little bit of them all?

Finally, ever have one of your modified tools bite you back?  Share your stories in the comment section.

cone-wrench-mod

DSC08955

Oil Cooler Line Wrench #2 009 (Medium)

Summit Week Quality and Corrective Action Programs Best Practices Track

Posted: January 11th, 2012 in Best Practice Presentations, Best Practice Presenters, Pictures, Quality, Summit, TapRooT

 Images Karen.Migliaccio-1

Karen Migliaccio has done a tremendous job setting up this first TapRooT® Summit Quality Track. From cross industry representatives to demonstrating field successes all the way up to company process changes, you will find this Summit Week Track interesting and applicable.

Wednesday

TapRooT®; Implementation Success Stories:

Successful Implementation of TapRooT® at Steris (Kevin McManus)

High Quality TapRooT® Implementation (Dennis Osmer)

Using the Baldrige Criteria to Achieve Performance Improvement (Kevin McManus)

Root Cause Analysis of Quality Problems:

Challenges in Biotech Quality Root Cause Analysis (Michael Gorman)

Root Cause Analysis of Incidents Occurring in the Pharmaceutical

Industry (Debbie Riley)

Thursday

CAPA in Quality: The Strong and the Weak (Karen Migliaccio)

Quality Issues:

Quality Initiatives That Lead To Continuous Improvement Efforts (Bryan

Ward)

Using a Quality Plan to Drive Improvement (Zena Kaufman)

The 7 Secrets of Incident Investigation & Root Cause Analysis (Mark Paradies)

Designing Your Continuous Improvement Program (Kevin McManus)

Friday

How Pfizer Achieves Operational Excellence (Gerry Migliaccio)

Planning Your Improvements

To read more about each session see:

http://www.taproot.com/summit.php?t=schedule.

Then select the Quality and Corrective Action Programs Track.

Screen Shot 2012-01-11 At 12.14.18 Pm

But there’s more!

Before the Summit we have a special nTapRooT® Root Cause Analysis Course focused on finding the root causes of quality issues.

When you attend both the pre-Summit course and the Summit, you save $200 off the course fee.

Just click on the link below for more information…

TapRooT® Quality/Six Sigma/Lean
Advanced Root Cause Analysis Training

Summit Week: Human Performance & Behavior Change

Posted: January 11th, 2012 in Best Practice Presentations, Best Practice Presenters, Performance Improvement, Summit, TapRooT

What is it that produces a safe environment with safe workers? Is it people with the right attitude… is it a reduced risk environment… or is it both? Do we need reward or punishment… or both? How do different cultures interact successfully to work safely? What is the best environment for a person to work in physically? How does one know?

Listening to a radio show recently about people trying to get out of debt, the host said this, “it is not the math that got them in the situation it is the behavior; that is why changing the behavior is the first step.” It was in reference to people who wanted to know why the had to pay off small debts first and not the large credit cards with high interest.

Point being, that the more one practices a behavior, the higher the probability that the behavior becomes habit. Providing a better environment with the right tools increases the ability to perform the behavior. It is with this in mind that the sessions below were put together:

Wednesday

  • Proactive Prevention of Injuries and Accidents Due to Human Error
    Ergonomic and Human Performance Improvement
    Working Across Languages and Cultures

Thursday

  • Changing Behavior By Praising the 49 Character Traits
    Criminal Prosecution of Accidents
    Using Training Simulation to Improve Human Performance
    Design for Reliable Performance

Friday

  • Using FACT to Measure & Analyze Fatigue (Both Reactive & Proactive)
    Planning Your Improvements

To read more about each session go here: 

http://www.taproot.com/summit.php?t=schedule

One more thing …

Before the Summit there is a pre-Summit course that you should be considering …

Stopping Human Error

Just click on the link above for more info.

The course and the Human Performance and Behavior Change Best Practice Track make a great one-two punch for improving human performance. Plus, you will save $200 off the course fee when you attend both.

Don’t miss the remarkable knowledge available in the course and the Summit. Register today!

Root Cause Analysis Tip: "Procedures" Best Practices Are Good For Everything You Write

Posted: January 4th, 2012 in Human Performance, Root Cause Analysis Tips, TapRooT

In our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course, we introduce you to the Basic Cause Category “Procedures.” In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training,  we teach how to write a good procedure. The question is, “how many of you have used the best practices listed under Procedures to write training lessons, policies ……?”

Knowing that policies guide what “how to’s” and “do what’s” need to be created, trained and used, why do they have to be so convoluted and difficult to read? Not to pick on lawyers, but have ever tried to understand a legal document? Aren’t legal documents supposed to keep you out of trouble and not get you in trouble?

Interestingly enough, we even pass policies on policies found in this article.

“On October 13, 2010, President Obama signed into law the “United States Plain Writing Act of 2010.” Thirteen years after President Clinton issued his own “Plain Writing in Government” memorandum, the revised set of guidelines states that by July of this year all government agencies must simplify the often perplexing bureaucratic jargon used in documents produced for the American public. Gone are the grammatically longwinded sentences, replaced with simpler English words, grammar and syntax”

Take this excerpt from a policy; what missing best practices can you identify from the TapRooT® Root Cause Tree?

“The amount of expenses reimbursed to a claimant under this subpart shall be reduced by any amount that the claimant receives from a collateral source in connection with the same act of international terrorism. In cases in which a claimant receives reimbursement under this subpart for expenses that also will or may be reimbursed from another source, the claimant shall subrogate the United States to the claim for payment from the collateral source up to the amount for which the claimant was reimbursed under this subpart.”

Using the Basic Cause Category “Procedures,” I look forward to your missing best practices in the comments section.

Root Cause Analysis Tip: What Can Go Inside the Event Shape when Mapping out your SnapCharT®?

Posted: December 14th, 2011 in Pictures, Quality, Root Cause Analysis Tips, Software Updates, TapRooT

Whether doing it by hand or in our TapRooT® Software, what can go into the Rectangles that we call Events (Who did whats or what did whats that occurred during the timeline that you are investigating)?

 

DSC03851-450x337SnapCHart_Popular_Posts

Who s:

Actions by the Operator, Mechanic, Manager, Vendor, Supplier, Contractor, Technician, Customer Service Rep, Engineer, Designer, Nurse, Doctor … as you can see the list is unlimited but understanding the who (we use job titles only) helps us to see if the who was setup for success prior or during the action he/she performed.

Whats:

Caution ( … this may not be what you expected or have been doing)

Equipment Actions: Relay opened when energized, Butterfly valve stuck shut, I.V. bag port become blocked with debris, fuel gravity fed into container through piping …

Hint: If working with equipment, pull up the equipment and system functional diagram up immediately to help you map out the Events.

Chemical Process Actions: Catalysts heated up, hot mix heated up …

Transactional Process: Purchased order received by customer service, SAP sent late warning to warranty …

Hint: Yes, you can follow a piece a paper, hazardous material shipment.. that is handed off from person to person just like you would a person.

Hopefully, this should open up your investigation options even more! By the way, I even mapped out the actions of a horse and a monkey which was analayzed under Human Engineering.

Aurobindo Pharma taking their Root Cause Analysis to World Class Standards

Posted: December 13th, 2011 in Investigations, Medical/Healthcare, Performance Improvement, Pictures, Quality, TapRooT

For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.

Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.

Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.

It was a pleasure to teach and work with this group personally in Hyderabad, India.

If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February.  Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.

Go here to register for the 2-day http://www.taproot.com/courses.php?d=1709&l=1

See the public courses and root cause articles for India:

http://www.taproot.com/content/archives/25773

http://www.taproot.com/content/archives/24854

http://www.taproot.com/content/archives/24348

http://www.taproot.com/content/archives/22733

http://www.taproot.com/content/archives/20033

Root Cause Analysis Tip: Investigation Team Facilitation

Posted: September 21st, 2011 in Accidents, Human Performance, Performance Improvement, Root Cause Analysis Tips, TapRooT, Video

You get the call that there has been an incident that needs to be investigated. So, you begin mapping out the SnapCharT®, performing the root cause analysis or developing the corrective actions and this happens (Watch Video):

(Link to video if unable to click on the video: http://youtu.be/LDYyv-iLmRY.)

Never fails, too many Type “A” personalities in the room, and you are the one who has to facilitate the team. It does not matter whether you have a Type “A” or “B” personality, it can get ugly if it is not handled correctly, especially if someone was hurt (or worse) or if the company lost a lot of money. So what to do …

Here are a few facilitation hints:

1. Define who the team lead is upfront. (This prevents an Accountability NI issue.)

Note that the investigation facilitator does not have to be the one who is in charge. After all, the facilitator’s true role is to facilitate the TapRooT® 7 Step Root Cause Analysis Process, not necessarily the team members themselves. It can also help if the facilitator is a neutral person not familiar with the incident or process being investigated.

2. Allow all members to introduce themselves … often new people are introduced into an established team. The introduction gives a person, new or shy, the platform to speak up later.

3. While developing the SnapCharT®, (or time line for friends new to our process), ensure that all the people, equipment, and process actions that occurred are listed, whether people think they are an issue related to the incident or not. You can make a movie with a good time line of events.

Note that this enables the good actions of all members, divisions, contractors, clients and owners to be listed as well and removes some of the blame and finger pointing that can occur.

4. While using the Root Cause Tree Dictionary, Root Cause Tree and SnapCharT® to find Root Causes for your Causal Factors, it is never an “I am right ” or “You are wrong” discussion. Unknown to untrained TapRooT® team members, the facilitator has carried in the “Arbitrator”!

Great, another “A” type in the group you say? Well, yes and no, the “Arbitrator” is the Root Cause Tree Dictionary.

The Root Cause Tree has lots of experience and knowledge to gently nudge any group into the right choice. It comes with some explicit rules … facts, facts, facts! You select a root cause because it related to or impacted a particular Causal Factor. A Root Cause is not selected because you have already decided on what you want the corrective action to be. It is also not ignored because you think you cannot change it. Root causes are just the facts.

Here is an example of how the Root Cause Tree Dictionary arbitrates and removes the emotion for the Causal Factor of “Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.” This is just one of the Causal Factors for the Incident of a motor being damaged with lots of downtime costs.

Two team members are in a heated discussion as to whether the Operator could detect or could not detect the contamination while opening the valve …

One team member who believes that the Operator had the knowledge of the contamination in the line is focused on what was seen after the fuel supply system was opened up.

The other team member believes that the Operator could not see inside the system while opening the valve.

You, (as the facilitator), walk up to the arguing pair and without telling either member who may be right or may be wrong, you say, “Open up the Root Cause Tree Dictionary and tell me which fact (condition on the SnapChrarT®) matches the bullet in the Root Cause Tree Dictionary.”  Now state the fact and say, “this relates to why the Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.”

By focusing on the facts as known by the operator at the time he was opening the valve, the contamination was unknown and not detectable. The contamination was identified after the fact and only after taking apart the manifolds and valve.

The “Arbitrator” saves the day again with emotions and opinions removed!

Try these steps and also let me know in the comment section, what else you have done to reduce bias and emotions during your investigation facilitation.

Want to learn more about leading investigation teams?  Attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Training.

India Information Technology (IT) and TapRooT® Software Developers all in one room? If close to India, Here is Your Invite!

Posted: August 24th, 2011 in Courses, Current Events, Quality, TapRooT

When you need TapRooT® Root Cause Analysis Software implementation advice or have other technical IT needs, who do you call? Easy… our clients call 1.865.539.2139 and ask for Steve, Zach or Dan. When the IT experts here or at your place of business need help, what do they do for help? Simple, they map out the issue using TapRooT®’s SnapCharT® first and then find out where the equipment or human performance difficulty issue needs to be addressed.

Why tell you all this today you may ask? Because Dan Verlinde, Director of Information Technology & Software Development, and several U.S based and India based software developers will be attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in New Delhi this September.

New Delhi, India Sep 5 – Sep 9 Register

If you are the IT TapRooT® Software Lead based in or Near New Delhi, sign up for the September course before it is too late.

Rocanville, Canada Onsite TapRooT® Root Cause Analysis Course for PotashCorp during a heatwave

Posted: August 5th, 2011 in Courses, Current Events, Pictures, TapRooT

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Above was just one of two classes that we taught on the PotashCorp Rocanville Mine Site this week. Like many of our customers, they are going into full production with the newest version of our Web Enterprise Software. The students above were already trained in our process and wanted to learn how to use the new software upgrade in a 4 hour software class.

We also held a 2-Day Plus 3-Day TapRooT® Course. It is our 2-Day TapRooT® Incident Investigation and Root Cause Analysis and
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training put together in one week. How does that work you may ask.. simple:

Have all students attend the first 2 days and then allow a select few employees who need to be lead facilitators and mentors stay for the remaining 3 days.

Brian Tink, taught this course with me and also got to go for a tour in the mine. If you have never been in a Potash Mine here is link to my first visit a few years back….http://www.taproot.com/content/archives/5885

Interestingly enough I learned two things this trip. Just because your not at home in Tennessee does not mean that the heat will not follow you. We had a wonderful heatwave. A sizzling heat wave broke 16 records in communities across Canada Wednesday, despite cooler temperatures in Alberta and Saskatchewan. Markham, Ont., was the day’s hotspot at 35.9 C, breaking the record of 35.6 set back in 1991.

My second lesson is that when fishing for Wall-Eye or in Canadian words, Pic, as seen below, the man in the white truck with a badge, wants to know if you have a license…. and you can not fish within 23 yards of a dam. Do not ask me how I know.

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Orlando 5-Day TapRooT® Root Cause Analysis Course Class Pictures

Posted: August 5th, 2011 in Courses, Pictures, Root Causes, TapRooT, Uncategorized

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After an intensive but fun two days of work invested already in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (as seen in the photos above), the students needed a duck break at the Peabody Hotel in Orlando.

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Truck spills 14 million bees on Idaho highway… how would you have responded?… Would you have planned for it?

Posted: July 13th, 2011 in Accidents, Courses, Pictures, Root Causes, TapRooT

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From the articles:

“Cleanup crews in Idaho have finished clearing honey and an estimated 14 million bees that got loose after a delivery truck overturned on a highway.

Fremont County Sheriff deputies say several workers were stung during the first few hours of the cleanup Sunday.

And some observers told The Post-Register about seeing a strange black cloud and roaring noise above the spill area before realizing it was a massive swarm of bees.”

To make matters worse… more bees not contained may mean an increase of more bears.

http://news.yahoo.com/truck-spills-14-million-bees-idaho-highway-142147287.html

http://www.dailymail.co.uk/news/article-2013995/Truck-spills-14-MILLION-bees-honey-Idaho-road-crash.html

Root Cause Analysis Tip: Measurements … "Smeasurements"! Who Needs Them?

Posted: July 13th, 2011 in Performance Improvement, Quality, Root Cause Analysis Tips, Summit, TapRooT

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If today was Wednesday … what measurements (metrics) could be used to describe it:

1. There are 52 Wednesdays in the Calendar Year of 2012.

2. There were 53 Wednesdays in the Calendar Year of 1873.

3. Wednesdays make up 14% of the Days of a Calendar Year.

4. There are 9 letters in the word Wednesday: 2 e’s, 1 w, 2 d’s, 1 s, 1 n, 1 a and 1 y to be exact.

5. There are two syllables in the word Wednesday.

The point of my number parade? Simple, we can measure anything … but does it provide value or predictability? Are the numbers representative of what one is truly trying to measure?

In the Changing the Way the World Solves Problems book provided to all our TapRooT® students, there is a section titled A Guide to Improving the Use of TapRooT®. The tip today from this guide focuses on Topic 1: Measurements. With the first question being, has your company agreed on a reliable measurement system?

Why a measurement system and not standalone metrics that represent individual problems in individual departments? The answer is because no one person or one department works in true isolation. Measurements of money savings, defect reductions, tool repair or tool selection reported by one department may actually cause an increase of those measurements in another department. So no actual money saved for the company!

Developing a Reliable Measurement System starts with the developing and defining the fundamental components and rules for your company. I caution against generic one-fits all Systems developed outside of your company.

Components:

Measurement: An observable (observed either by human or equipment) behavior (behavior of equipment, people or process) that can be measured quantitatively or qualitatively.

Rules for Measurements:

  1. Only used to measure for what it was intended to measure. Nothing worse than using someone else’s numbers for your own needs just to find out it does not measure what you thought it did.
  2. Collected and Documented using the same method with the same types of tools (equipment, forms). Not sure of the consistency of your measurement collection process? Perform a Measurement System Analysis (MSA) on it.

Types Measurements (Just to mention a few):

  • Operation
  • Production
  • Human Resources
  • Safety
  • Customer
  • Warranty
  • Financial (Fringe or Burdened)
  • Maintainability and Reliability
  • Regulatory
  • Direct or Indirect Labor/Costs

Purpose for Measurements:

  1. Predictive Indicator- Can tell you what could happen before it happens. Note: No predictor is 100% correct but many are very reliable.
  2. Lagging Indicator- Too late! Good or bad news, it already happened but it is a necessary to know. Note that some Lagging indicators can be a leading indicator for another lagging indicator. For example, an increase in near misses can be a predictor of a severe incident if not corrected.

Measurement System: A system allows good measurements to produce good indicators. Of course it also allows junk in junk out, even with the best system in place. So to help define what a measurement system is or could be, answer these questions:

  1. Based on the measurements input, can you see the company “big picture” and can you then break down these indicators to their lowest input level?
  2. Are reports and graphs pulled from one central location to prevent duplication?
  3. Are measurements pulled from the same set of numbers to increase consistent trending?
  4. Is the system audited for consistency and accuracy?

Seems like a lot to make sure you know where your company is going and where it has been doesn’t it? Did I also tell you that you should also be able to translate all measurement indicators into company production and operation dollars? As the our book says, “dollars are the language and measuring stick of management.”

If this post gets you to think … “Why does this make so much sense and why did I not think of this before with the same perspective”?

If the answer is yes, then I have some options for you that appear once a year in a public setting this February:

Advanced Trending Techniques
TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training

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Chris Vallee joined System Improvements in 2007 and is a Senior Associate, TapRooT® Instructor, and Investigation Facilitator.

Calgary 2-Day TapRooT® Public Course… EVENT SOLD OUT

Posted: July 12th, 2011 in Courses, Pictures, Root Causes, TapRooT

Day One of our 2-Day TapRooT® Incident Investigation and Root Cause Analysis in Calgary, Canada.

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Kevin Palardy, one of our Canadian based instructors, introducing the SnapCharT® Process. As you can see below, the course is not just a sit down and lecture course… you have to apply what you learn on each of the 7 Steps learned.

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Monday Accident Lessons and Learned: A review of the Mangalore Air India Crash.. when do you reopen an investigation?

Posted: July 11th, 2011 in Accidents, Current Events, Investigations, Root Causes

158 lives were lost on May 22nd, 2011, when Air India Express Flight 812 crashed after not aborting a landing. According to an article by Indian Aviation News,

“The court of Inquiry determines that the cause of the accident was Captain’s failure to discontinue an “Un-stabilised approach” and his persistence to continue with the landing, despite three calls from the First Officer to “go-around” and a number of warnings from the EGPWS”

According to the article being reviewed, the Government of India had inserted vide GSR No. 168(E) a very important rule to ‘The Aircraft Rules 1937′, which govern everything aviation in this country On 2009 March 13.

The rule:

75A. Reopening of Investigation – Where it appears to the Central Government that any new and material evidence has become available after completion of the investigation under rule 71, 74 or 75, as the case may be, it may, by order, direct the reopening of the same.

The article then references the findings that should reopen the case:

Here is a list of new and material evidence:

1. The fact that a huge portion of the wreckage was taken away from the crash site by locals and was sold as scrap metal. What the Court of Inquiry was inspected and studied (if at all they had done any study) was the remaining wreckage.

2. The reconstruction of the wreckage was never actually done by the CoI. The image of the reconstructed wreckage included in the report was a computer generated one.

3. While testifying before the court of Inquiry at Mangalore airport, Six survivors of the crash were made to answer a totally biased and misleading question by the CoI. The question was, “Do you think the accident occurred because of the fault of the pilot?” This was in plain violation of Rule 7.2.1 of the Manual of Accident/ incident investigation: ‘ The investigation of aircraft accidents and incidents has to be strictly objective and totally impartial and must also be perceived to be so’.

4. The “Hard Landing” circular issued by Air India is a major contributor to the accident. The CoI had chosen to ignore this vital fact.

Of course some of the issues from the article’s author stem from the investigation itself and are items that we teach our clients to avoid:

1. Spoliation of Evidence

2. Interviewing in a less effective manner which could have induced bias…. (leading the interviewee)

3. Focusing on what TapRooT® would define as a Causal Factor only and not the root causes for the Causal Factors

So the question for today’s Monday Lessons Learned is when would you, or when have you reopened an Investigation?

For More Reading:

Indian Aviation News 6/14/11

Indian Aviation News 6/08/11

Root Cause Analysis Tip: You Know How to Perform a TapRooT® RCA but Where Do You Target Your Resources?

Posted: June 29th, 2011 in Accidents, Courses, Performance Improvement, Quality, Summit, TapRooT

Let’s be honest, all companies want a good Return on Investment (ROI) on any investment. This is exactly why Mark Paradies and Linda Unger provide a section in our TapRooT®, Changing the Way the World Solves Problems book titled A Guide to Improving the Use of TapRooT®. The tip today focuses on Topic 2: Target Selection.

If you have set up good metrics to measure, you can start by looking for your Top Drivers in a Pareto Chart. The idea is that if 80% of your issues are caused by or correlated to 20% of a sampled set of categories, then start there first for more ROI. Review the Chart below and then read the cautions below:
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Cautions:

1. “Never Ever Ever” define a category as “Miscellaneous” or “Other”! I promise you that it will always be in the Top Three every time.

2. When it comes to the y-Axis on the Chart, do not just use Cost as a measurement, also use Risk and Frequency. One near miss may not have cost any money but it could have killed someone. If you look at Cost or Frequency only, this would not show up as a Top Driver.

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Another Quick Way to decide where to Target your resources is to use a Plot Map. Read more here as to how this map reduced illnesses from the water supply in certain areas.

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Finally you may want to measure how accurate and precise your improvements have been. In earlier trending articles  we introduced the Process Behavior Chart. Below is one more example of how to measure Risk Reduction using a scatter and bulls-eye chart.
Here is a quick description on what the charts represent:

1. The Center (Bulls-Eye) of the chart represents that the risk targeted has been eliminated.

2. Each subsequent ring of the target indicates risk mitigation at lower levels (the outside rings do show risk mitigation but not as strong as the inner rings).

3. The dots indicate the actual risk level mitigated for each RCA performed with corrective actions implemented and verified for effectiveness (sounds like SMARTER technique from class don’t it?).

Looking at charts above, which two Charts would you be happy with and why?

To find out where to receive hands on training for the next TapRooT® Trending Course look here: http://www.taproot.com/courses.php#c7

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