Author Archives: Chris Vallee

Root Cause Analysis Tip: Improving the Use of TapRooT® through Knowledge

Posted: June 15th, 2011 in Courses, Documents, Human Performance, Performance Improvement, Root Cause Analysis Tips, Root Causes, TapRooT

If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.

To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:

  • Specifically designed on-site training for gaps identified as additional needs in your trending and proactive assessments.
  • Feedback for our investigators through our Advisory Board and one-on-one.
  • A Summit for system experts, which include our clients, to share best practices from multiple industries.

The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:

1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)

Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.

Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:

Task Performance Levels

1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
Proficient)
3. Can do all parts of the task. Needs only a spot check of completed work.
(Competent)
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)

Task Knowledge Levels

a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)

Subject Knowledge Levels

A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
(Analysis)
D. Can evaluate conditions and make proper decisions about the subject.
(Evaluation)

By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).

Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:

1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.

2-Day TapRooT® Incident Investigation and Root Cause Analysis
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis

2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.

3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.

4. Develop in-house group sessions to discuss lessons learned.

5. Schedule refresher training to give competency levels high.

Good luck on your quest for knowledge!

Root Cause Analysis Tip: Trending your Trending Program … a Love-Hate Relationship with Numbers

Posted: June 1st, 2011 in Courses, Performance Improvement, Quality, Root Cause Analysis Tips, TapRooT

I often hear, “We trend lots of issues … see all the numbers and charts?” Heck, I have even said it myself a few times in my life. Then we go and check our “numbers” ask, “what does it show us today?” Or even worse, the boss asks, “can you show me ……….. ?”

Here are some of the reactive action items that I have had to follow up on in order to try and answer a question for someone else:

1. “Everything was just fine and now things seem to be out of control; show me where it went wrong?”

2. “After starting YOUR new metric, things really got bad, why?”

3. “Looking at both of these charts, show me the correlation.”

4. “But we have only had 5 incidents in 5 years (infrequent data), how can we trend that?”

5. “Look at these great trends … , what did WE… I mean  you change?”

As I started this post, this article appeared in the news discussing the Numbers Game:

Just because we’ve seen an increase in the number of tornadoes doesn’t mean there has actually been an increase in the number of tornadoes,” said Greg Carbin, the warning coordination meteorologist with the Storm Prediction Center in Norman, Okla.

Decades ago, when the country was more sparsely populated — and not everyone had a camera-equipped cell phone — there were simply fewer people around to spot and report tornadoes, Carbin said.

In addition, Carbin said, many initial tornado tallies include tornadoes that are counted more than once.

According to NOAA’s preliminary count, April saw 875 tornadoes. “That’s a gigantic number,” Carbin said. “It may turn out there were that many tornadoes, but I can guarantee that many of those were not significant tornadoes, but they get into the database now because everyone has a tornado they want to report.”

The highest number of tornadoes on record for any month is 542, from May 2003. Carbin said he suspects that once all the data are compiled, April’s numbers will be closer to the May 2003 numbers.

In addition, both Carbin and Crouch pointed to the fact that with increasing urbanization, more people are affected when storms do hit, putting tornadoes in the spotlight.

Numbers and climate conditions aside, one thing is for certain, the scientists said — this tornado season has been unusually violent, as the horrific images splashed across the evening news attest, and it’s not even close to being over.

But it is not hopeless, I promise. The first step is to back out of your numbers and ask:

1. Where did these numbers come from?

2. What were the numbers originally designed to measure?

3. Are these numbers part of the same set of behaviors and tasks or are they independent?

4. Were the numbers created with limited bias and not driven by a reward or discipline factor?

5. Are these numbers occurring frequently or is this intermittent and infrequent data?

6. Finally, do you understand your numbers and does the boss know what the numbers mean when you show the charts and trends or lack of trends?

Does this mean I think you need to go back to school for six weeks of statistics … no!

Does this mean that you need to throw all your old numbers away and start from scratch … maybe!

Does this mean that you may need a couple of days to reassess what you use and how you use it to trend … yes!

Since two days is not too much out of a busy schedule there are three resources that can help in you in your love-hate relationship with trending and metrics:

1. Read Chapter 5 in the TapRooT® book, TapRooT®, Changing the Way the World Solves Problems by Mark Paradies and Linda Unger

2. Read the Making Sense of Data by Donald Wheeler

3. Attend our upcoming Advanced Trending Techniques course where you receive the Making Sense of Data book, Course Workbook and hands on exercises taught by experts in the field who use real world applicable trending.

Monday Accident & Lessons Learned: Worker drowns in sump; what is in a “good” work plan?

Posted: May 9th, 2011 in Accidents, Current Events, Documents, Investigations, Pictures

Read the Investigation Report published by here Work Safe Alberta:

http://www.employment.alberta.ca/documents/WHS/WHS-PUB-FR-2009-10-04.pdf

Events:

1. While replacing a sump pump, an experienced work dropped the assembly parts into a sump (pictured below) that was filling continuously with water.

2. In an effort to retrieve the parts that could not be reached within arms length, the worker fall into the sump getting his head and upper body stuck.

3. Workers once finding him in that condition were unable to remove the jammed worker (suction most likely an issue) and had to call rescue.

4. The worker was pronounced dead at the scene.

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Findings and Actions from the Report:

7.1 Direct Cause

7.1.1 Worker 1 got stuck head first in the sump and drowned while trying to retrieve a check valve and a rubber hose adapter that had fallen into the sump.

7.2 Contributing Factors

7.2.1 Worker 1 got stuck in the narrow opening of the sump housing.

7.2.2 Worker 1 was unable to safely retrieve the check valve and rubber hose adapter by hand.

7.2.3 At the time of the investigation, water was continually draining into the sump.  The depth of the water in the sump was approximately 76.2 centimeters.

8.2.3 GSS conducted a hazard assessment for sump pump work, developed a “Safe Work Practice for Repair/Replacement” of sump pumps and provided a copy to Occupational Health and Safety.  GSS trained all affected workers in the safe work practice.

8.2.4 GSS complied with all orders issued by Occupational Health and Safety.

So if you were reviewing this report, what should the new Work Plan have included?

… one issue not identified is not blocking the sump access area to prevent assembly parts from being dropped in.

If this were a TapRooT® investigation we would start with a SnapCharT® (a  sequence of events) and then look for the missing best practices that were related to the Causal Factors by using the Root Cause Tree®. These missing best practices would be the foundations of an adequate Work Plan.

Day Two in a Sold Out Edmonton 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Posted: April 27th, 2011 in Courses, Pictures, Root Causes

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A great group of students for Kevin Palardy and I to work with and teach. With 32 being the maximum for a course, we had 7 on the waiting list. Make sure you are not on the next waiting list.

See our upcoming courses here:

http://www.taproot.com/courses.php

A rescue team works to find a missing miner at a northern Idaho silver mine

Posted: April 16th, 2011 in Accidents, Current Events, Root Causes

The mine is in Mullan, Idaho, a historic mountain mining town of 840 people in Idaho’s Panhandle. Baker said additional equipment was being flown in so crews could use a front-end loader remotely to dig away material clogging the tunnel.
(more…)

AP release: "Super jumbo jet clips, spins plane at JFK Airport

Posted: April 12th, 2011 in Accidents, Pictures, Root Causes, Sounds, TapRooT, Video

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“The world’s largest passenger aircraft clipped a much smaller commuter plane on a dark, wet tarmac at New York City’s Kennedy Airport, spinning it like a toy as hundreds of passengers sat in both planes. No one was injured.”

See the video here: http://news.yahoo.com/video/us-15749625/amateur-video-shows-air-france-collision-at-jfk-24877570

Retraining is the Solution to a Toddler receiving a mixed drink instead of juice?

Posted: April 12th, 2011 in Accidents, Medical/Healthcare, Pictures, Root Causes, TapRooT

 

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Alcohol or Juice?

Interesting article today titled: “Restaurant to retrain staff after mixed-drink mixup”

On Friday, Taylor Dill-Reese went to an Applebee’s in Madison Heights, Michigan, where — among other things — she ordered her 15-month-old son Dominick an apple juice.

What the little boy apparently got instead was a margarita. His mom told WDIV-TV that she only realized something was wrong when Dominick “kind of laid his head on the table and dozed off a little bit and woke up and got real happy.”

The little boy reportedly began hailing strangers, too.

According to the article the restaurant stated, that it would begin to serve apple juice to children only from single-serve containers at the table and would “retrain all severs on our beverage pouring policy, emphasizing that non-alcoholic and alcoholic beverages must be stored in completely separate and identified containers.”

…. for our TapRooT® trained investigators, can you think of any other root causes than training?
(more…)

Rust-Oleum On Site TapRooT® Root Cause Analysis Course

Posted: January 27th, 2011 in Courses, Pictures, Root Causes, TapRooT

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Question: What do the wonderful group of people above and the four words below have in common?

Product, Equipment, Vendor, Employee………..

Answer: Ways to improve quality of product internally and externally and make work tasks safer were discussed and evaluated during an on site 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course held last week in New Jersey.

Kevin McManus (standing in back in Red with the group) and I had the pleasure to share manufacturing quality and safety best practices with a very passionate group of Rust-Oleum leaders in problem solving.

Root Cause Analysis Tip: Is this a "Line of Fire Incident"?

Posted: January 6th, 2011 in Best Practice Presenters, Human Performance, Investigations, Root Cause Analysis Tips, Root Causes, TapRooT, Video

The following is an excerpt of a Safety Video that I watched years ago as an aircraft mechanic in the Air Force.

It reminds me of the aircraft specific hazard training that I received:

1. Avoid Bleed Air Boundary Zones… places where hot engine bleed air was directed to improve air flow over moving wing surfaces.

2. Avoid Moving Flight Surfaces… Flaps, Rudder and such

3. Avoid egress explosive exit points…. and the egress seats themselves if not pinned.

4. Be aware of possible hydraulic leaks in pressured systems…. 3,000 psi in many cases

5. Avoid landing gear being released when on jacks…. whether under power or quick released

6. And of course avoid engine intake and exhaust zones…. yes I have had to pull another airman back that was too curious.

Now I review incidents resulting from “line fire issues” and have to ask myself, “if I were just told to avoid line of fire issues on aircraft would that have sufficed?” No, neither should it be as a policy or corrective action.

A Medical Tale: When following the current standard practice can kill you!

Posted: December 28th, 2010 in Accidents, Human Performance, Medical/Healthcare, Quality, Root Causes, Sounds, Video

Ever thought about volunteering to be a test subject for medicine….. would you be concerned if you were in phase 1 of a new drug trial?

Listen to this pod cast where the standard practice become a practice because no one had become very ill until this study. Each reinforcing non-injury becomes the reinforcement that this must be a good process.

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Select the link below to listen.
http://www.bbc.co.uk/iplayer/console/b00v1qrz/Thinking_Allowed_Drugs_trial_calamity_McCarthy_stigma

What do you do with unexplained discrepancies? FDA uncovers more problems at J&J Fort Washington plant

Posted: December 16th, 2010 in Accidents, Current Events, Investigations, Medical/Healthcare, Performance Improvement, Quality, TapRooT

“In an inspection report released late on Wednesday, the Food and Drug Administration said a recent visit uncovered multiple quality control problems, including a failure to properly handle customer complaints.”

“Inspectors also found “a failure to thoroughly review any unexplained discrepancy” in batches of products and a lack of proper record keeping, according to the report from an inspection that ran from October 27 to December 9.”

The Washington Plant is closed and the article reports that J&J has continued making improvements. The question is whether the handling of unexplained discrepancies is unique to this industry?

In the US Air Force we named it CND, “Could Not Duplicate”; A CND could only be signed off in the aircraft forms by the appropriate personnel. If a CND occurred three times on the same aircraft, the aircraft was grounded.

What is your Industry Rule? (more…)

If it was good safety training in my last company, why would others not do it too? Severed Ring Finger

Posted: December 14th, 2010 in Accidents, Current Events, Investigations, Pictures, Root Causes, TapRooT

 

 

Hand 001

This was posted on WorkSafeBC

Injury Type : Severed finger
Core Activity : Public school district
Location : Vancouver Island
ID Number : 2010110750411
Date of Incident : 2010-Jun

While washing the floor in a doorway, a worker slipped on the wet floor and fell. The worker was wearing a ring, which caught on the striker plate of the door, severing the worker’s finger.

For 12 years while enlisted as an Aircraft Mechanic in the United States Air Force, we were taught and had to practice “No Jewelry while working certain tasks.” Granted certain jewelry was allowed for office type work but not for what I had to do.

Then I left the service and saw that not many were practicing this concept.  Now don’t get me wrong, many of the other safe practices were there but not for hand and finger jewelry.  I would hear when I asked why, “the Air Force had too many rules; how did you have get work done?”

I wonder if the employee listed above is thinking that today?

Lesson of the day: Share and utilize good practices; do not wait until something bad happens.

ConocoPhillips Bayway Refinery in New Jersey holds a 2-Day TapRooT® Root Cause Analysis Course

Posted: December 10th, 2010 in Courses, Pictures, Root Causes, TapRooT

What a great group of passionate safety and operation employees to work with this December in New Jersey. With Union Teamsters and Company Employees working together as one team, our instructors Michele Lindsay and Chris Vallee were able to hear great questions and answers from all.

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RCA in India: Do not miss the February 2011 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Posted: December 2nd, 2010 in Accidents, Courses, Human Performance, Investigations, Medical/Healthcare, Performance Improvement, Pictures, Root Causes, TapRooT

Look closely into India until you get to Mumbai. What do you see?
A 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course Open to all companies; similar to the New Delhi Onsite Course shown below held for BW Fleet Management.

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The benefits:

1. You get the benefit of our course in India without needing 10 of your people trained at the same time.

2. You do not have to fly your India based employees to another country to be trained.

3. If you are one of our international customers, you do not have send one of your trained investigators to India to complete an Investigation for defects, incidents or sentinel events.

4. Because the students will receive individual software to document their findings, you will receive a consistent report.

Register today to make sure your employee does not lose a seat in the course.

Mumbai, India Feb 21 – Feb 25 Register

“Expect the unexpected” ….. Good Safety Advice or Not Being Prepared?

Posted: December 2nd, 2010 in Accidents, Current Events, Root Causes, TapRooT, Video

Found a number of Safety Story Videos on AEPtv and wanted to share one with you. Make sure you read the comments that run at the end of the video.

Learning TapRooT® Root Cause in Knoxville, TN

Posted: November 17th, 2010 in Accidents, Courses, Pictures, Root Causes, TapRooT

Just a great group of students working their final class exercise in a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Also meet one of our new instructors below wearing red, Karen Migliaccio.

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Sleepy pilot caused Indian plane crash…..?

Posted: November 17th, 2010 in Accidents, Current Events, Investigations, Pictures, TapRooT

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From the AFB news article:

A Court of Inquiry probe concluded the Air India pilot Zlatko Glusica, from Serbia, was asleep for much of the three-hour flight and was “disorientated” when the plane started to descend, the Hindustan Times reported.

I am Confused… how did they determine he was asleep? The article also stated that the report sent to the Civilian Aviation Ministry was not released to the public yet. Maybe the “facts” are in the report. (more…)

A Case of Metrics Leading the Behavior… did the problem get fixed on the Tarmac

Posted: November 9th, 2010 in Current Events, Performance Improvement, Root Causes, Summit, TapRooT

1 – 6 – X = a good job?

The government says there were four planes that sat on the tarmac for more than three hours in September.

That’s up from one in August, but down from six in September a year ago.

and now the rest of the story:

Airlines canceled more flights in September than they did a year ago, but slightly less than they did in August when the peak summer travel season was winding down.

Overall, flights run by the nation’s biggest airlines were also delayed slightly more often in September from a year earlier. But airlines did a better job of getting passengers to their destinations on time than in August.

Did they really do a better job if they canceled more flights?

What would the people in our recent Pre-Summit Advanced Trending Techniques course say?
(more…)

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

Posted: November 9th, 2010 in Accidents, Investigations, Quality, Root Cause Analysis Tips, TapRooT

We all have a natural tendency to push an investigation to the answer we “knew all along or really want to see”. Stop the urge and collect the facts first! The 7-Step Process was designed to fight this “urge”. So how do you know the “urge” may be trying to get back in power:

1. You only put the bad things on the Spring and Summer SnapCharT® and filter out want you assume to be non-important too early.

Solution: Have someone unfamiliar with the process being investigated read your Summer SnapCharT® out loud.

2. You select root causes because you feel that it would be a great corrective action.

Solution: Select the root causes based on whether that fact was on your SnapCharT® only.

3. You do not select a root cause even though the fact was on your SnapCharT® because you do not think management would do anything about it.

Solution: Example, if you selected “Noisy” and you know that management will not get rid of those loud two-story banging machines, still mark “noisy” as a problem. You will check it with a corrective action that can mitigate the “Noisy” situation.

4. You go through the 15 Human Performance Questions and flip the Root Cause Tree over. Instead of Red “X” ing anything with no blue check mark (tied to a yes from the 15 questions), you decide to look through the basic cause category anyway.

Solution: Use the process as taught and it will save you time.

What hints would you have added?

Engine Failure: Qantas’ chief said Friday a design fault or mechanical failure was probably……u

Posted: November 5th, 2010 in Accidents, Current Events, Root Causes, TapRooT

“International air safety officials are investigating what caused the engine failure that ripped metal on the left wing, littered debris on the ground far below and prompted the most serious safety scare yet on the world’s largest and newest airliner.”

and the article continues on to say,

“But Qantas CEO Alan Joyce told a news conference that the national carrier believed the plane’s Rolls-Royce-made engine was at fault, not the level of maintenance to the plane.”

“This is an engine issue and the engines have been maintained by Rolls-Royce since they were installed on the aircraft,” Joyce told a news conference in Sydney. “We believe this is probably most likely a material failure or some type of design issue. We don’t believe this is related to maintenance in any way.”

So the protective-redirection-I don’t want to get blamed-we don’t have facts yet policy is now in effect!

Wonder what this will do to the data collection phase……
(more…)

Join the TapRooT® LinkedIn Group Discussion about companies that have a great lessons learned process

Posted: November 5th, 2010 in Equipment/Equifactor®, Human Performance, Investigations, Performance Improvement, Quality, Root Causes, TapRooT

This question was posted on our TapRooT® LinkedIn Group and it be great for all with questions and examples to comment.

I have a question that I hope you can help a client with. Do you know of any organizations/companies who have a great lessons learned process, including communication of lessons learned?

The client is developing a formal process titled “Lessons Learned Communication”. This will become part of the Safety Management System (SMS) at the Business Line level of Exploration and Producing (E&P).

This document will drive all of the lessons learned and related communication that results from serious and potentially serious incidents within E&P. The client would like to get a few good inputs rather than creating something completely from scratch.

Please post online for all to learn. Also, send me your contact info offline or publicly and I will share it with the client.

If not a member of the group yet join here: TapRooT® Root Cause Analysis Users and Friends Group

Influencing Without Authority TapRooT® Session…. People at Work!

Posted: November 5th, 2010 in Best Practice Presentations, Best Practice Presenters, Pictures, Presentations, Summit, Video

Often people have the right ideas, the right plans and a need to get it done. Problem is that it is not always you who can drive the change. During the Summit we held a session that generated discussion on Stakeholders and Influence Centers.

Check out the multiple active group discussions during this workshop. Click on the Image to play the Video.

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For the link to the slides that generated these active discussions and a link to more formal analysis go here: http://www.taproot.com/content/archives/17099

Bugs, Infection and TapRooT® Root Cause in Philadelphia

Posted: November 5th, 2010 in Accidents, Courses, Pictures, Presentations, TapRooT

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When is the last you used TapRooT® Root Cause Analysis to investigate a Caterpillar?

The people below in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training held in Philadelphia got to talk about this one.

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