Author Archives: Ken Reed

SpaceX Rocket ALMOST Lands – Equipment Failure?

Posted: January 18th, 2016 in Current Events, Equipment/Equifactor®

So close!

SpaceX attempted to land the first stage of their Jason 3 launch vehicle on their Autonomous Spaceport Drone Ship this weekend. The video shows the stage softly touching down, and then toppling over. Elon Musk tweeted that the leg did not fully latch prior to touchdown, and folded up when the stage weight was applied. He said it looks like the collet between the leg extension tube segments did not hold due to icing prior to launch.

While this is a cool video, it got me thinking about using the correct type of equipment for the application. for example, Musk said they use a “collet” between the leg segments. A collet is a friction device that holds 2 tubes together. Not necessarily a positive locking device. It appears that ice prevented full extension and therefore full friction from being applied, and the leg collapsed.

What do you think? Is a collet the correct type of device to hold a static load like this in place? My thoughts: I think a more simple locking pin that drops into place, or a circumferential collar that drops into a slot, would be a much more reliable locking device, rather than something that depends on friction for support.

Still, what an awesome landing attempt!

Safeguard Analysis for Finding Causal Factors

Posted: November 25th, 2015 in Investigations, Root Cause Analysis Tips, Root Causes

 

A Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening.

Once you’ve gathered all the information you need for a TapRooT® investigation, you’re ready to start with the actual root cause analysis. However, it would be cumbersome to analyze the whole incident at once (like most systems expect you to do). Therefore, we break our investigation information into logical groups of information, called Causal Factor groups. So the first step here is to find Causal Factors.

Remember, a Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening (or at least made it less severe).  So we’re looking for these mistakes or failures on our SnapCharT®.  They often pop right off the page at you, but sometimes you need to look a little harder.  One way to make Causal Factor identification easier is to think of these mistakes as failed or inappropriately applied Safeguards.  Therefore, we can use a Safeguard Analysis to identify our Causal Factors.

There are just a few steps required to do this:

First, identify your Hazards, your Targets, and any Safeguards that were there, or should have been there.

Now, look for:

– an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;

– an error that allowed a Safeguard to be missing;

– an error that allowed a Safeguard to fail;

– an error that allowed the Target to get too close to a Hazard; or

– an error that allowed the Incident to become worse after it occurred.

These errors are most likely your Causal Factors.

Let’s look at an example.  It’s actually not a full Incident, but a VERY near miss.  This video is a little scary!

Train Pedestrian Incident from TapRooT® Root Cause Analysis on Vimeo.

Let’s say we’ve collected all of our evidence, and the following SnapCharT is what we’ve found.  NOTE:  THIS IS NOT A REAL INVESTIGATION!  I’m sure there is a LOT more info that I would normally gather, but let’s use this as an example on how to find Causal Factors.  We’ll assume this is all the information we need here.

Picture1 Picture2

Now, we can identify the Hazards, Targets, and Safeguards:

Hazard Safeguard Target
Moving Train Fence Pedestrians
Pedestrians (they could have stayed off the tracks)

Using the error questions above, we can see that:

– An error allowed the Hazard to be too large (the train was speeding)

– An error allowed the Targets to get too close to the Hazard (the Pedestrians decided to go through the fence, putting them almost in contact with the Hazard)

These 2 errors are our Causal Factors, and would be identified like this:

Picture3 Picture4

We can now move on to our root cause analysis to understand the human performance factors that lead to this nearly tragic Incident.

Causal Factors are an important tool that allow TapRooT® to quickly and accurately identify root causes to Incidents.  Using Safeguard Analysis can make finding Causal Factors much simpler.

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.

TapRooT® Summit – Get Amped Up in the Investigator Track!

Posted: October 28th, 2015 in Best Practice Presentations, Root Cause Analysis Tips, Summit

 

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Join us in San Antonio, Texas August 1 – 5, 2016 for the Global TapRooT® Summit!

 

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Ken Reed

Our 2016 Global TapRooT® Summit is just around the corner, and I’m REALLY excited about the session line-up we’ve set up for you. I’m the track leader in the TapRooT® Investigator Track, and we’ve got some excellent sessions planned to help you become a better investigator:

We’re going to start off with a session that lets our TapRooT® Users Share Best Practices with you. What better way to learn about best practice ideas than to get them directly from other users who are successfully implementing at their company? This session is always one of the most useful, hands-on sessions at our Summit.

Are your investigations any good? Mark Paradies is going to run a session on how to properly Grade Your Investigations. He’ll give you industry best-practice ideas on what really matters in an investigation. This isn’t just a high-level thought experiment; you’ll walk away with a grading sheet that you can customize for your company that will allow you to put an actual number grade on each investigation. This is a great way to improve each and every investigation.

Are you ready to implement TapRooT® at your company, but not sure how to get started? Ed Skompski will be leading a session on How to do a New Implementation of TapRooT®. We’ve helped many companies figure out what they need to do for a successful, long-term TapRooT® implementation, and he’s ready to share those ideas with you. Wouldn’t you love to have an implementation checklist?!

Barb Phillips is going to have a couple of sessions on individual investigator techniques. Interviewing Behaviors and Body Language will help you learn advanced skills to perform more effective interviews. The Investigation Team Leader session will give you pointers on how to lead more complex investigations from the perspective of the lead facilitator. These are both going to be terrific sessions for all TapRooT® investigators.

Wouldn’t it be nice to ask all the right questions at your very first interview? In addition to Barb’s topic on body language, we’re going to look even more deeply at how to use The 15 Questions To Identify Interview Topics. This will help you better plan your interviews to ensure you minimize the number of follow-up interviews required during your investigations.

We’ve had many requests to speak in more detail about the intricacies of a few of the Root Cause Tree® Basic Cause Categories. This year, we are going to Deep Dive into Procedures and Management Systems. We’ll show you where some of these root causes come from, and how to recognize them during your investigations.

I’m really excited about my track this year. If you are a TapRooT® investigator, you will not want to miss these sessions. Plan on being in San Antonio next year; don’t miss out on this opportunity!!

Learn more: http://www.taproot.com/taproot-summit/

Are Your Corrective Actions Designed to Prevent Future Incidents?

Posted: October 14th, 2015 in Root Cause Analysis Tips, TapRooT

I had a great conversation with one of our clients today. He mentioned that, with the price of oil below $50/barrel, his company is being proactive and looking at ways to improve their processes.  One thing that they’re doing is reviewing old incidents and seeing where the commonalities lie.  One item of interest that they found:  They have discovered several instances of repeat problems.  They found root causes, but they seem to pop up again.

What they are doing is what we call a Generic Cause analysis.  They are looking deeper at their data and finding opportunities for improvement.

A review of the corrective actions found quite a few that seemed to be more akin to immediate actions than corrective actions.  For example, if there was a production shutdown that was caused by a failed valve, the corrective action was, “Remove and repair the faulty valve.”  Now, I’m not saying that this is necessarily a bad idea.  However, is this corrective action aimed at preventing future recurrence of the incident?  This corrective action, by itself, is designed more to restore plant operation, not prevent future issues.

Remarkably, this turned out to be more a terminology issue than a failure of their system.  When asked about this, the Corrective Action team said, “Oh, you want actions that will prevent the incident in the future?  Then you aren’t asking for ‘corrective actions’; you are asking for ‘preventative actions.’  You have to be clear what you want.”

TapRooT® does not really distinguish between these types of fixes.  We expect all of these actions to be developed.  We find that the “corrective actions” noted above are designed to fix the Causal Factor (“Valve failed to open.  Therefore, repair the valve.”).  This is as far as most other “root cause analysis” systems go, since they normally only get to the causal factor level.

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While you DO need to fix these issues, we also want you to continue to assign corrective actions to actual root causes.  If the valve failed because the repair procedure specified the incorrect part (in TapRooT®, this root cause would be “facts wrong”), and you would therefore put a corrective action in place to fix this human-performance problem (“Update repair standard to indicate the correct gasket part number 885-33425”).  This will fix not just this particular valve, but any valves in the future that are repaired using this same repair procedure.  Without this corrective action, you will see this same issue pop up again as we continue to improperly repair valve failures.

Make sure you and your investigation teams are all on the same page.  We use the term “Corrective Action” to indicate any and all actions that are designed to fix problems.  Corrective Actions include those actions that fix the general issue (failed valve), and those that are designed to prevent the issue from occurring again in the future (procedure wrong).  Take a look at your systems and make sure you are fixing both types of problems.

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.

4 Root Cause Analysis Timesavers

Posted: September 23rd, 2015 in Root Cause Analysis Tips, Root Causes

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I know how this works.  You get the notification that “something bad” happened, and you are assigned to perform a root cause analysis.  Your initial reaction is, “There goes the rest of my week!”

However, there is no reason that a relatively simple analysis needs to take an inordinate amount of time.  There are several things you can do to make sure that you can efficiently conduct the investigation, find solid root causes, and implement effective corrective actions.  Here are a few ideas to help you make the process as smooth as possible.

1.  The first thing that needs to be in place is a Detailed Investigation Policy for your company.  When does a RCA need to be performed?  What types of problems trigger an RCA?  What is the decision-making chain of command?  Who makes the notifications?  Who is notified?  Who will be on the team?  All of these questions need to be easily answered in order to quickly get the process started.  I have seen investigators receive notification of a problem over a week after the actual incident.  By this time, evidence has been lost, key players are no longer available, and peoples’ memories have faded.  All of this makes the investigation just that much harder.  If you can streamline this initial decision-making and notification process so that the investigation can start within hours, you’ll find the actual investigation goes MUCH more smoothly.

2.  Probably the biggest timesaver is to Be Proficient in the TapRooT® Process.  We recommend you use TapRooT® at least once per month to maintain proficiency in the system.  You can’t be good at anything if you only use it sparingly.  I often hear people tell me, “Luckily, we don’t have enough incidents to use TapRooT® more than once per year.”  Imagine if I asked you to put together an Excel spreadsheet using pivot tables, and you haven’t opened Excel since 2014!  You’d have to relearn some key concepts, slowing you down.  The same is true of an investigation process.  If you only do an investigation once each year, you aren’t looking very hard for incidents.  I’ll guarantee there are plenty of things that need to be analyzed.  Each analysis makes you that much better at the process.  Maybe go back to point #1 above and update your investigation trigger points.

3.  When you actually get started on an investigation, the first thing you should do is Start A Spring SnapCharT®.  This initial chart gets your investigator juices flowing.  It helps you think about the timeline of the incident, identifying holes in your knowledge and questions you need to ask in order to fill those holes.  It is the first step in the process.  As soon as you get that initial phone call, start building your SnapCharT®!

4.  Finally, although it is optional, The TapRooT® Software can really speed up your analysis.  The SnapCharT® tool is extremely user friendly, and the Root Cause Dictionary is only a right-click away.  It guides you through the investigation process so you don’t have to try to remember where you’re going.

You won’t perform an investigation in 5 minutes.  However, by following these tips, you relatively quickly and efficiently move through the process, with terrific results.

To learn more about learning all of the essential techniques to perform a root cause investigation, read about our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

Don’t Waste A Good Crisis

Posted: August 19th, 2015 in Career Development, Career Development Tips

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Yep, oil prices are still down.  With oil below $50/barrel, revenues in the oil exploration business side are nowhere near what they were when oil was at $100/barrel.  Many are struggling to stay afloat.

So what do you do?

One of our clients had a great thought.  He said, “Don’t waste a good crisis.”  What he meant was, while revenues are down, you may find yourself cutting back on your core business.  For the exploration guys, this might mean less drilling.  Fewer rigs probably means less opportunity to cause incidents associated with drilling.  Therefore, your investigation teams are NOT performing as many root cause analyses, and therefore, proficiency drops.  Your options are:

1) Stop performing root cause analyses

2) Exercise your investigation teams on other items.

He had mentioned that this is a prime time to do things that you may not have had time to do before.  For example, his company is going back to review old incident reports.  They’re doing a deep analysis, looking for commonalities and repeat issues.  In other words, they are taking this time to improve their processes.  When business picks back up, they want to be in even better shape than they were before.  They want to be leaner, make fewer mistakes, waste less time, keep their people and the environment safer, and save money.

How many times have you seen companies stumble when they ramp back up?  They are less proficient, they’ve let their equipment languish, they’ve let their skills degrade.  Suddenly, business picks up.  They go through a period of rapid hires, bringing on new people that may or may not still be proficient at their jobs.  The investigations teams suddenly find themselves busy, but they, too, have lost their proficiency.  Investigations take longer, and they’re not as in-depth.  Lots of wasted time, money, reputation, and (worst case) lives.

All of this can be avoided by taking advantage of the down-time.  Use your skilled workers to their fullest.  I know those engineering teams have sharpened their pencils, looking for better, safer, and cheaper ways of extracting oil.  Your investigation teams should be doing exactly the same thing.  They should be looking at your processes, finding the repeat failures and incidents, and putting more robust corrective actions in place right now.

Where are the inefficiencies in your processes?  What repeat mistakes have your people made in the past, and how can we prevent them from happening again tomorrow, when business is again booming?

I thought that was a great attitude.  Don’t waste this great opportunity.  Don’t waste a good crisis.

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Do you like reading quick yet empowering tips like this? Contact Barb at editor@taproot.com and have them delivered to your inbox every Tuesday.  Just type “subscribe” in the subject line.  Our eNewsletter has career development tips, root cause tips, job postings, and even a joke to keep it light.

Root Cause Analysis Tip: 6 Reasons to Look for Generic Root Causes

Posted: July 22nd, 2015 in Investigations, Performance Improvement, Root Cause Analysis Tips, Root Causes

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“Allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.”

You have established a good performance improvement program, supported by performing solid incident investigations.  Your teams are finding good root causes, and your corrective action program is tracking through to completion.  But you still seem to be seeing more repeat issues than you expect.  What could be the problem?

We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations.  But many companies are skipping over the Generic Cause Analysis portion of the investigation process.  While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.

6 Reasons to Look for Generic Root Causes

Here are 6 reasons to conduct a generic cause analysis on your investigation results:

1. The same incident occurs again at another facility.

2. Your annual review shows the same root cause from several incident investigations.

3.  Your audits show recurrence of the same behavior issues.

4. You apply the same corrective action over and over.

5. Similar incidents occur in different departments.

6. The same Causal Factor keeps showing up.

These indicators point to the need to look deeper for generic causes.  These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents.  When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present.  Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.

Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis.  There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.

Learn more about finding and fixing root causes in our 2-day or 5-day TapRooT® Root Cause Analysis courses!

TapRooT® Terms and Definitions

Posted: December 5th, 2014 in Root Cause Analysis Tips, Root Causes, TapRooT

When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.

Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.

Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.

SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.

Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.

Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.

Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.

Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).

Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.

Generic Cause: A systemic problem that allows a root cause to exist.

How to Contact Your TapRooT® Staff – LinkedIn

Posted: December 5th, 2014 in Meet Our Staff, TapRooT® Instructor, Uncategorized

The staff at System Improvements really enjoys working with our customers. One great way to keep in touch with our staff is to connect with them on LinkedIn. You can see what they’re up to, where they are, and read about the great ideas they have for you. It’s also an easy way to contact them if you need assistance or answers to any questions.

We invite you to connect with us! Here’s a list of some of our staff and their LinkedIn contact link:

Mark Paradies (President): www.linkedin.com/in/markparadies
Linda Unger (Vice President): www.linkedin.com/pub/linda-unger/8/950/2a1
Ed Skompski (Vice President): www.linkedin.com/in/edwardskompski
Ken Reed (Partner): www.linkedin.com/in/kenreedprofile
Chris Vallee (Senior Associate): www.linkedin.com/in/christophervallee
Dave Janney (Senior Associate): www.linkedin.com/in/davejanney
Becky Marambio (Sales Associate): www.linkedin.com/in/beckymarambio
Benna Dortch (Sales Associate): www.linkedin.com/in/bennadortch
Michelle Wishoun (Licensing Associate): www.linkedin.com/pub/michelle-wishoun/14/191/b35
Barbara Phillips (Editorial Director): www.linkedin.com/in/barbaracarrphillips
Steve Raycraft (Tech Support): www.linkedin.com/pub/steve-raycraft/37/472/3a2
Cherie Larson (Accounting Director): www.linkedin.com/in/cherielarsontn
Judy Potok (Public Course Planner): www.linkedin.com/in/judypotok
Natalie Tabler (On-site Course Planner): www.linkedin.com/pub/natalie-prendergast-tabler/21/438/691

Why doesn’t training prevent medical accidents?

Posted: February 11th, 2013 in Medical/Healthcare

How many times have you seen a corrective action to “conduct more training”? Why is this often such a poor corrective action?

Unfortunately, even highly-trained people can make mistakes. A recent article illustrates this nicely.

Link

If you haven’t seen the “basketball” video before, take a look at it at the link above.

This article describes how highly-trained radiologists, people who have an incredible eye for detail, can still make glaring errors based on what they are asked to do. It’s a great example of why “training” may not always be the best corrective action.

3-Day TapRooT® / Equifactor Root Cause Analysis Course in Bogotá, Colombia

Posted: November 26th, 2012 in Courses

Marco (orange shirt) and Piedad (bright blue shirt) taught another successful course in Bogotá last week.  Thank you Diana (on Marco’s right with the gold shirt) for planning this course.  And of course, the attendees did a wonderful job!

5-Day TapRooT® Advanced Root Cause Analysis Course in Copenhagen

Posted: November 1st, 2012 in Courses

Harry Thorburn and I are teaching a 5-Day TapRooT® course in Denmark this week.

 

Thanks to our new TapRooT® users for a great class!!

Ken Reed

3-Day TapRooT® / Equifactor® Equipment Troubleshooting and Root Cause Analysis Course in Bogotá, Colombia

Posted: October 15th, 2012 in Courses

Diana Munévar (in the photo in the middle row, right) hosted an Equifactor® course in Bogotá last week.  The instructors were Marco Flores (Back left) and Boris Risnic (Back right).

Please contact System Improvements if you are interested in attending or hosting a TapRooT® course in your area.

TapRooT® Root Cause Analysis Course In Lima, Peru

Posted: October 5th, 2012 in Courses

Another great class in the America’s.  this time, we taught a Spanish class in Lima:

 

Check out our website for other courses being taught all over the world!

Advanced TapRooT® Root Cause Analysis Course In Salt Lake City

Posted: September 14th, 2012 in Courses

Bob Koonce and I just finished teaching a great course in SLC.  Here are some pictures:

Bob, hard at work:

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2-Day TapRooT® Root Cause Analysis Course for San Antonio Internacional in Bogotá

Posted: September 5th, 2012 in Courses

We completed a course for one of our clients in Bogotá, Colombia last week.  Piedad Colmenares taught this Spanish course.  Another happy group!

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3-Day TapRooT® / Equifactor® Equipment Troubleshooting and Root Cause Analysis Course in Bogotá

Posted: September 4th, 2012 in Courses

We’ve completed another great course in Bogotá this month.  Here are some pictures from the course:

3-Day TapRooT® / Equifactor® Incident Investigation Course in Bogotá, Colombia

Posted: August 15th, 2012 in Courses

We just completed another great course in Bogotá this week.  Sounds like they had an excellent class!

Thank you to Marco Flores and Piedad Colmenares (our terrific instructors), and Diana Munévar, who did an awesome job hosting the course for us.

Bird Strike on 737 Causes Equipment Damage and Emergency Landing

Posted: August 2nd, 2012 in Accidents, Current Events


A flight descending into Denver experienced a bird strike.  Some significant external damage, but apparently no breach of the pressure hull.  The pilots appear to have done a good job responding to the strike.

Some external sensors were also damaged, with backup systems kicking in.  Aircraft equipment design needs to be robust enough to handle failures.
Here’s a link to one article:
Link

UPDATE: Fire On Submarine USS Miami was no accident

Posted: July 23rd, 2012 in Current Events, Investigations

Seems the fire that broke out on board USS MIAMI on May 23 was a deliberate act of arson.  One of the civilian workers was stressed, taking prescribed medications, and wanted to go home early.  He set fire to some rags on a bunk in one of the berthing areas.

A few weeks later, he apparently set a second fire in the same drydock outside the sub, but it was much less severe.

See previous blog article:    http://www.taproot.com/archives/32046

Latest news article here:  http://news.yahoo.com/worker-charged-arsons-maine-sub-fire-145702234.html

The fire caused over $400 million in damage.  The Navy is still deciding whether the ship is salvageable or not.  Luckily, no one was injured, although it took over 10 hours and dozens of firefighters working in near-zero visibility to control the blaze.

As an aside, the original “cause” of the blaze was thought to be a fire in a vacuum cleaner that ingested something hot.  A solid investigation, along with good evidence gathering, helped narrow down the real issue.  Of course, I’m not convinced they are still at the final cause, but at least it looks like they are making progress on the investigation.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Shaw Group

Posted: July 23rd, 2012 in Courses

We held a 5-Day TapRooT® root cause analysis class for Shaw Group in Jenkinsville, SC last week.  Good to see nuclear construction ramping up, and starting off on the right foot with corrective action development and implementation.  Way to go Shaw Group!!

Nice t-shirts, too!

TapRooT® / Equifactor® Root Cause Analysis and Equipment Troubleshooting Class in Bogotá

Posted: July 9th, 2012 in Courses

Here are some pictures from a recent 3-Day TapRooT® / Equifactor® class held in Colombia:




2-Day TapRooT® Root Cause Analysis Investigation Course in Stamford, CT

Posted: June 14th, 2012 in Courses

Mel Lager and I just finished a great course in Stamford.  We had students from a wide range of industries (pharmaceutical, oil drilling and pipeline, airline, aerospace, fossil and nuclear power generation, etc).  Great class!



Let us know if you are interested in attending either one of our public courses, or if you would rather have us come right to your facility to teach TapRooT® to your team!

How Long Does an Investigation Take? How About 14 Years!

Posted: June 6th, 2012 in Current Events, Investigations, TapRooT® Instructor

One of our UK TapRooT® instructors (Alan Smith) was the lead investigator looking into the murder of Arlene Fraser in Scotland in 1998.  Her husband has just been convicted a second time for her murder. 

In 1998, Arlene Fraser was attacked by her husband Mat.  He was out on bond, and 5 weeks later, Arlene disappeared.  He apparently paid someone to kill his wife.  He was convicted of that murder in 2003, but then a technicality caused the conviction to be set aside.  This new trial has now again found him to be guilty, and he is back in prison.

You can see the story at this link:  http://player.stv.tv/programmes/news-at-six-aberdeen-north/2012-05-30-1800/.  At the 5:20 mark, you can see Alan describe his thoughts on the case.

This is an example where tenacity and attention to detail can finally win a result. 

5-Day TapRooT® Advanced Root Cause Analysis Course in Bogotá Colombia

Posted: June 4th, 2012 in Courses

We finished another Spanish-language TapRooT® course in Central America last week.  Here are some pictures from that course:





Let us know if you would like to arrange for a Spanish-language TapRooT® Course!

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