Author Archives: Dave Janney

Are you attending the NSC conference?

Posted: September 6th, 2017 in Current Events

If you are attending the conference, please come by the TapRooT® Booth (3536) and say hello. Barb and I will be there, so we hope to see you!

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

Posted: July 24th, 2017 in Current Events, Human Performance, Investigations, Quality, Root Cause Analysis Tips, Root Causes, TapRooT

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

Causal Factors and remembering one of the worst incidents in American history

Posted: July 5th, 2017 in Accidents, Root Cause Analysis Tips

We just returned from enjoying our Independence Day Holiday here in the US.

There were many good shows over the weekend about American History and during one I watched I was reminded of one of the worst events in our history (from a workplace safety standpoint); the Triangle Shirtwaist Fire in 1911.

Most safety professionals know of this incident as the Life Safety Code was partially born from the tragedy. I started to think about the incident in terms of TapRooT®, Causal Factors in particular. In our courses, we teach the concept of initiating errors, and chances to stop/catch/mitigate. There were many failures that day and many lost opportunities to stop and mitigate the event.

Possible causal factors that would be identified if TapRooT® would have been used:

CF – fire started (initiating error)

CF – egress blocked/not sufficient for the number of people to escape

CF – exit doors locked

CF – fire escapes collapsed

CF – fire hoses did not work

CF – ladders from fire department did not reach higher floors

I am sure there are more, but these are the ones that jumped out at me while watching the show.

It is a real shame that so many had to die for better conditions to become the norm.

Triangle Shirtwaist Factory fire escape collapsed during the March 15, 1911 fire. 146 died, either from fire, jumping or falling to the pavement.

For more on Causal Factors and stop/catch/mitigate, see this earlier POST

Are you attending Safety 2017 (otherwise known as ASSE)?

Posted: May 30th, 2017 in Current Events

If you are attending, please stop by the TapRooT® Booth (#508) and say hello. Barb Phillips and I will both be there.

Ask Barb about the new course and book for Interviewing and Evidence Collection that will be out soon.

Ask me about the new TapRooT® for Audits Course and book.

Free gift for the first 500 people!

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

Posted: May 10th, 2017 in Current Events, Human Performance, Medical/Healthcare, Quality, Root Cause Analysis Tips, TapRooT

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Are you attending the ASQ World Conference on Quality in Charlotte?

Posted: April 19th, 2017 in Courses, Pictures, Quality, Root Causes, Software, TapRooT, TapRooT® Instructor

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

TapRooT® around the world

Posted: April 7th, 2017 in Courses

One of our instructors down under, Peter Berkholz, sent me a class picture from the course he taught this week in Melbourne, AU. Looks like a great group!

IMG_3176

Interested in holding an onsite course at your company (for 10 or more people)? Please contact us at info@taproot.com for more information.

Why do Audits fail and why do I have so many repeat findings? Take a detour!!!

Posted: March 27th, 2017 in Courses, Quality, Root Cause Analysis Tips, Root Causes

Have you ever performed an audit and got frustrated when you found the same issues as the last audit? I feel your pain….we all have. Why does this happen so much? Because most companies audit programs look a little like this:

Screen Shot 2017-03-27 at 4.00.54 PM

Q: What is missing from this picture?

A: Root Cause Analysis, of course!!

Many companies actually have good programs for FINDING problems without having a good program for FIXING problems. If you want problems fixed, root cause analysis has to be part of it. So on the road to improvement, take a DETOUR to Root Cause Land!

Screen Shot 2017-03-27 at 4.13.20 PM

For your program to be effective, it should look more like this:

Screen Shot 2017-03-27 at 4.04.23 PM

The best way to do root cause analysis on audits? TapRooT®.

We have a new course, TapRooT® for Audits, that we will be holding in Charlotte, NC on May 4-5. Why not join us? For more information and to register, click HERE

Calling all Auditors! NEW TapRooT® for Audits Course

Posted: March 17th, 2017 in Courses

We’ve scheduled our new course specifically designed for auditors on May 4-5 in Charlotte, NC.

We have always taught auditing in our courses but we wanted a course that auditors could attend to learn the Essential TapRooT® techniques.

All attendees get a copy of the newly released book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement as well as a Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper®.

Audits Kit

I hope to see you there! For more information and to register, please go HERE

How can TapRooT® help with your ISO programs (or other management system issues)?

Posted: January 25th, 2017 in Current Events, Quality, Root Cause Analysis Tips, Root Causes

Happy Wednesday and welcome to this week’s root cause analysis tips.

Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.

Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.

While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.

PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.

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As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.

Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.

Audits Kit

Thanks for reading the blog, and best of luck with your improvement efforts.

The 7 Secrets of Root Cause Analysis – Video

Posted: December 12th, 2016 in Great Human Factors, Human Performance, Jokes, Root Cause Analysis Tips

Hello everyone,

Here is a video that discusses some root cause tips, common problems with root cause analysis, and how TapRooT® can help. I hope you enjoy!

Like what you see? Why not join us at the next course? You can see the schedule and enroll HERE

Root Cause Tips – Causal Factors: initiating errors and stop/catch/mitigate

Posted: December 7th, 2016 in Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s root cause analysis tips column. This week we will talk about Causal Factors.

The TapRooT® Definition of a Causal Factor is:

“A mistake, error, or failure that directly leads to (or causes) an Incident or fails to mitigate the consequences of the original error.”

This definition is one major thing that distinguishes TapRooT® from some other methods. We don’t just find the first thing that went wrong, we find EVERTHING that went wrong. I’ve had people say to me that “but if I fix the first problem the incident would not have happened.” That is actually true, but if I only focus on the first thing that went wrong (which is sometimes the most obvious), then I do not address everything else that is wrong with my system. It also allows people to fall into the trap of determining “the causiest causal factor” and ignoring everything else.

Consider this diagram:

Screen Shot 2016-10-11 at 8.07.26 AM
Is it possible to have an incident with only one error? Yes. But more often than not, once we’ve made a mistake, we have chances to stop/catch the problem before it becomes an incident. We also sometimes have chances to mitigate the consequences.

So when looking for Causal Factors, I find the first error/failure (initiating error), and they look for chances to stop/catch/mitigate. Each time I fail to stop/catch/mitigate, it is a new Causal Factor.

You will also notice that we could have an initiating error later in the timeline was well. It could be completely unrelated but allowed the hazard to reach the target.

Here is an example:

*Someone turns the wrong valve and allows a hazard (this is an initiating error).

*A second check of the valve configuration was not completed as required (a chance to stop/catch the first error).

*Someone lights a cigarette in an unauthorized area (another initiating error).

*Emergency response team did not arrive for 30 minutes (chance to mitigate the consequences).

Each one of these would be a Causal Factor.

Defining Causal Factors does not have to be difficult. The more you do it, the more comfortable you will be. I find that the concept of stop/catch/mitigate can really be helpful in making sure you find ALL the problems that led to an incident.

So thanks for visiting our blog. I hope you don’t have an incident anytime soon, but if you do, I hope you find the information helpful. If you’re interested in learning more about identifying causal factors and finding the root causes of incidents, register for our 2-Day TapRooT® Root Cause Analysis Training.

Root Cause Tips – All Safeguards are not created equal… or, why do corrective actions fail?

Posted: November 9th, 2016 in Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s Root Cause Analysis Tips. The topic this week is strength of safeguards.

We teach a lot of great stuff in our TapRooT® courses. In fact, our 5-day course is over 400 slides. In my opinion, this concept is the most important, and this is my favorite slide:

Screen Shot 2016-10-07 at 11.48.42 AM

The diagram shows that the best corrective action is to remove the hazard; if we cannot do that, maybe we can reduce it (chemical substitution, for example).

If we can’t do a #1, possibly we can move the target away from the hazard (moving a desk in the warehouse away from forklift traffic, for example).

We keep moving down the list from strongest to weakest. But we start at the top.

So here is my question: If I were to pull out of random stack of investigations from any company, anywhere, what kind of corrective actions do you think I would see? What about your company? If you said 5’s and 6’s, you now know the reason that you have repeat incidents.

Please do not misunderstand me; I am not saying training and supervision are not needed, what I am saying is they are weaker safeguards. They can be good corrective actions and sometimes are the only ones feasible, but we should always start at the top of the matrix and work our way down.

In my last column I talked about layers of protection. Pretty simple, more layers means more protection. However, since all Safeguards are not equal, many layers of weak safeguards does not equal a few layers of strong ones.

If you just did this one thing in your company, I am confident that you would improve a great deal. Remember, corrective actions are the output of your investigation. You can do a great job on the investigation, but if you have weak corrective actions, you are WASTING YOUR TIME.

So please think about it. Thanks for visiting the blog, and enjoy your week.

Root Cause Tips – Defense in Depth (layers of protection)

Posted: October 12th, 2016 in Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s Root Cause Analysis Tip.

The topic this week is the concept of “Defense in Depth.” You may have also heard terms such as Barrier Analysis or LOPA (layer of protection analysis). In TapRooT®, we use the term Safeguards.

Take a look at this diagram (courtesy of Mark Paradies, the creator of TapRooT®):

Screen Shot 2016-10-07 at 10.43.31 AM

What the diagram depicts is an incident where several layers of protection have been breached. You may have also heard of Reason’s “Swiss Cheese Model.” In these models we can see that we only have incidents when all layers are breached. So the amount of layers and strength of those layers determine if (and how often) we have incidents. It is also why sometimes things go wrong but we do not have an incident; because one or more layers worked.

So our goal in developing processes is to make sure we have enough layers and that the layers are functioning the way we want. Remember that every Safeguard has a hole in it, it is not infallible. So we want to make the holes as small as possible.

The same applies to corrective actions. Do we need new layers? How can we strengthen existing layers?

The concept is easy. What is difficult is determining just how much is enough.

Risk really is the main driver of that in my view, but business realities come into play as well. The easy ones are the ones on either side of the spectrum. For example, something is fairly difficult but low risk – probably all you need is a procedure and some training (we refer to these as Quasi-Safeguards).

If something is difficult AND high risk, we need a lot of layers, and hopefully many of them are engineering controls.

The hard ones are the ones in the middle; a process is very easy and there is very little chance of a problem… BUT, the risk is very high – in this case determining what you need can be very difficult.

In my November column, I will talk about the strength of Safeguards.

In closing, I urge you to think about Defense in Depth when developing processes. Audit them to make sure the layers are functioning. And if you do have an incident think about Safeguards and Defense in Depth when developing your corrective actions.

Have you been to our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?  Learn more about advanced techniques like Safeguards Analysis, Change Analysis, Critical Human Action Profile (CHAP) and Cognitive Interviewing.

Thanks for visiting the blog, and enjoy your week.

Root Cause Analysis on Trends

Posted: June 2nd, 2016 in Courses, Current Events, Root Cause Analysis Tips, Root Causes

Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.

One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…

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Sometimes people try to investigate everything and end up doing poor investigations.

First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.

So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):

• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations

If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.

Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:

A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.

The data for the yearly compliance is presented on a Pareto Chart below.

Screen Shot 2016-05-10 at 4.02.03 PM

The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:

Screen Shot 2016-05-10 at 4.02.24 PM

Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.

I hate to use clichés, but WORK SMARTER NOT HARDER!

If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on May 4-5.

Thanks for taking the time to read the blog, and happy auditing.

Using TapRooT® for Audits

Posted: May 18th, 2016 in Courses, Quality, Root Cause Analysis Tips, Summit

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Happy Wednesday, and welcome to this week’s root cause analysis column.

This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.

“An Ounce of Prevention is Worth a Pound of Cure.”
Ben Franklin

Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place?

Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.

Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:

  • Time (perceived at least)
  • They don’t have a reason to (not enough pain)
  • They do not have the buy-in (management and employee support)
  • Procrastination (human nature!)
  • They don’t know how (this is where TapRooT® comes in!)

TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.

Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE

Will public shaming lead to better safety?

Posted: May 12th, 2016 in Courses, Current Events, Investigations

This is old news to most (or should be) but OSHA finally published the long awaited rule on injury reporting:

https://www.osha.gov/recordkeeping/finalrule/index.html

So now that information will become more public will companies improve their records to stay out of view? Some things to think about:

*If they did not care about worker’s safety before, why would they care now?
*Will anyone even pay attention?
*Will management put more pressure on the operation to reduce rates?
*Will management give the operation additional resources to accomplish it?
*Will the media misuse the information? Will it be used politically?
*Did you just become your PR Department’s best bud or worst enemy?
*Will it actually help companies choose better business partners? (many companies have been requiring rates during the RFP process anyway)
*Is everyone else in the organization now throwing in their 2 cents on how you run your business?

I look at this a few ways:

*If you already have a good program and record, this should be of little concern to you from the public information standpoint.
*Assuming that is the case, as a former corporate safety manager, I see this as a HUGE cost for companies to comply. But there has been (and still is) plenty of time to get things in place.

At the end of the day, you cannot control regulations. But can you control your injuries? You bet.

Two of the best ways to lower your injury rates? Do better investigations and audits. Why not join us for a future course? You can see the schedule and enroll HERE

Calling all Quality People!

Posted: May 9th, 2016 in Courses, Quality, Summit

I had a couple of things I wanted to share with our clients who work in quality:

First, Chris Vallee and I will be at the ASQ World Conference on Quality and Improvement starting Sunday. We will be in Booth 507, so please come and see us!

Second, we will be launching our new course, TapRooT® for Audits, at our 2016 Global TapRooT® Summit. The course will be on August 1-2 in San Antonio. I hope you can join us, and don’t forget to stick around for the summit itself on August 3-5. To register, visit HERE

The course will include a copy of our new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.

By the way, the new course is not just for quality people, it is for anyone who wants to learn to use TapRooT® for audits. Safety, Quality, Food Safety, Operations, it does not matter. And you do not to be previously trained in TapRooT® to attend.

If you already know how to use TapRooT® for auditing, but work in Quality and want to learn more about process improvement, Chris will be teaching the TapRooT® Quality Process Improvement Facilitator Course at the summit as well.

3 Things You MUST Do When Finding an Incident’s Root Causes?

Posted: March 30th, 2016 in Root Cause Analysis Tips

Hello and welcome to this week’s root cause analysis tips column. So what are the 3 Things You MUST Do When Finding an Incident’s Root Causes?

  • You must know WHAT happened before you can determine why.
  • You must know WHY before you can write corrective actions.
  • You must FIX the root causes.

Let me elaborate:

You must know WHAT happened before you can determine why.

Too many investigators try to jump ahead and try to determine why things happened in an incident. But until you have all the facts, this is premature, and can lead to missing important data and letting the investigator’s bias drive the rest of the investigation. In the beginning of your investigation, you want to understand what happened. This is why evidence collection is so important.

Remember the old TV show Dragnet? The star of the show, Joe Friday, had a famous line:

“Just the facts, Ma’am, just the facts.”

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Once you understand the facts, you can then move to why.

You must know WHY before you can write corrective actions.

If you do not have good evidence you will miss causal factors and root causes. Your root cause analysis results are based on two things; the evidence you collected, and the guidance in the Root Cause Tree® Dictionary. If you do not have both, you do not have a strong case.

This is actually the easy part of TapRooT®, because the dictionary is all based on research.

Last but not least, you must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

How many times have you seen a corrective action that has nothing to do with the root cause? The Corrective Action Helper® has a check at the beginning of each section to make sure you are clear on what you are fixing. It does not matter how good something sounds, it has to directly apply to the root cause it is fixing. Otherwise it is extra work for no gain. And it likely means another investigation in the future.

And of course, it has to be implemented. Do you have a way to follow-up to make sure? And do you have a plan to judge the effectiveness?

Corrective actions are the OUTPUT of your investigation. Good investigations with weak corrective actions are a WASTE OF TIME.

Hopefully this gives you some things to think about. Thanks for visiting the blog, and if you want to learn how to do good investigations, join us at a future course.

CLICK HERE to view our upcoming course list.

New TapRooT® for Audits course to debut August 1-2, 2016

Posted: March 21st, 2016 in Courses, Quality, Summit, TapRooT

We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.

TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.

Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.

TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:

DAY ONE

TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Generic Causes
Corrective Actions and Exercise

DAY TWO

The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise

Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”

We hope to see you in the course! To register:

REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).

REGISTER for this 2-day course only (August 1 – 2, 2016).

Safety Track at the 2016 Global TapRooT® Summit

Posted: March 21st, 2016 in Best Practice Presentations, Best Practice Presenters, Summit, TapRooT

We are busy preparing for this year’s summit, which will be held August 3-5 (with pre-summit courses on August 1-2) in San Antonio, Texas.

I’m very excited about the lineup for this year’s Safety Track. We have some great speakers and topics:

7 Deadly Sins of Human Performance – Mark Paradies, Creator of TapRooT®

Weatherford’s Global Journey to HSE and Quality Improvement with TapRooT® – Mitch Miller, David Smith, Shawn Holden

Proactive Use of TapRooT® – Dave Janney

Interviewing Behaviors & Body Language – Barb Phillips

Marathon Galveston Bay – Ken Bloch

Arc Flash Loss Prevention – Scott King and Terry Butler

TapRooT® in What If Analysis – Joel Solomon

In addition to the speakers in the safety track, all tracks with attend the keynote sessions each morning and afternoon, with top-notch speakers. We also have the famous Wednesday night reception with great food and drinks and featuring live entertainment from Carl Dixon (of the Guess Who, April Wine, and Coney Hatch). And the best part of the summit? Getting to meet other like-minded professionals; we hear every year from attendees that the Global TapRooT® Summit is the best networking opportunity of the year.

So please join us for the Safety Track at this yea’s summit. For more information and to register, go HERE

See you in San Antonio!

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5 Day TapRooT® Advanced Root Cause Analysis Team Leader course in Dubai

Posted: February 14th, 2016 in Courses

Dr. Sami Amarneh and I are teaching the 5 day course this week in Dubai. Here are some pictures of day 1.

It started with an unbelievable sunrise (my iphone pictures do not do justice):

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Picture of Sami teaching:

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And pictures of students working on their first exercise:

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Why not join us for a future course? You can see the schedule and enroll HERE

Root Cause Tips – What Should You Investigate?

Posted: January 13th, 2016 in Investigations, Root Cause Analysis Tips
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What if you have more than you can possibly investigate?

Hello and welcome to this week’s root cause analysis tips column.

One of the questions I am asked often is “what should we investigate?”

The answer is it really depends on your company, your numbers, and your resources. I have some ideas, and these apply to anything, but I will use safety as an example.

First of all, your company may have a policy on what has to be investigated; for example, all lost time injuries or all recordable injuries. So you already know you are required to do those. But what if something is not required?

What I say is investigate as much as possible based on your numbers and your resources. If you work at a site that has 10 injuries a year but only 2 are recordable, if you have the resources to do all 10, I certainly would. It is likely the only difference between the 2 and the other 8 is……LUCK.

What if you have more than you can possibly investigate? Then you should do a really good job at categorization, and do investigations on the TRENDS. In other words, I would rather have you do one really good investigation on a trend than dozens of sub-standard investigations. You will use less resources but get better results.

How do you do an investigation on a trend? It is really very simple – instead of mapping out an incident with a SnapCharT®, you map out the process. You can leave the circle for the incident off the chart or you can make the circle the trend itself. The events timeline is simply the way the process flows from start to finish, and this is very easy to do if you understand the process. If you need help from the process owner, an SME, or employee, you can do that too. For conditions, you add everything you know about the process, as well as any data (evidence) available from the reports or other sources. You mark significant issues (the equivalent of causal factors) for things that you know have gone wrong in the past. You can take it a step further any also mark as significant issues things that COULD go wrong (think of this as potential causal factors). You then do your root cause analysis and corrective actions. This is not hard, it is just a different way of thinking.

Just a few more thoughts about what to investigate; basically, anything that is causing you pain. Process delays, customer complaints, downtime, etc. can all be investigated. But by all means, make sure it is worth your time and that there is really something to learn from it. Please don’t investigate paper cuts!

I hope my ideas give you some food for thought. Keep pushing the boulder up the hill and improving your business. Thanks for visiting the blog.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

 

Arc Flash Safety Talk at the 2016 Global TapRooT® Summit

Posted: December 29th, 2015 in Best Practice Presenters, Summit

Yes, I know we are not quite into the new year yet, but we have been busy planning the next summit (August 1-5 in San Antonio TX).

As the coordinator of the safety track, I am really excited about the line-up we have for speakers. I will be posting information about the track and the different sessions on the blog as the date nears.

One session I am very excited about is a talk on Arc Flash Safety by Scott King and Terry Butler from Hallam-ICS. With relatively new NFPA guidelines, this is a hot (no pun intended) topic from a compliance standpoint. More importantly, it is a major consideration from a safety standpoint, so whether your country complies with NFPA 70E or not, this is a talk you will not want to miss. The talk is scheduled for Thursday, August 4th at 1:50. We hope to see you there.

In the meantime, if you are interested in getting some of your people trained in this important topic, here is a link to an upcoming event Hallam-ICS is holding in February:

http://www.workplace-safety-nc.com/training/trng-NFPA.html

Thanks for reading the blog and we look forward to seeing you in San Antonio!

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Only at a TapRooT® course!

Posted: October 29th, 2015 in Courses

I am in Iceland this week teaching the 5 day course. The class has been having a great time learning about TapRooT® and each night we take the 4 hour tour in our quest to see the Northern Lights, which we have not yet seen. Maybe tonight!

But not to worry, today during our final exercise we looked out the window of the classroom, and who do we see? David Cameron, the PM of the United Kingdom, who is making the first head of state visit from the UK to Iceland since Churchill.

So if you want some excitement in your life, you should attend a TapRooT® course!

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