Author Archives: Chris Vallee

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

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.

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.


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


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.

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:


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.


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.


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:

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
3. Can do all parts of the task. Needs only a spot check of completed work.
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.
D. Can evaluate conditions and make proper decisions about the subject.

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:


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.


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:

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.

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:

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



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?

Rust-Oleum On Site TapRooT® Root Cause Analysis Course

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


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.

Select the link below to listen.

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



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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.



Sleepy pilot caused Indian plane crash…..?

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


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?

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Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

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

Bi-State Development Corporation
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