Author Archives: Ken Reed

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.


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:
















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!











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:

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:

Latest news article here:

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:  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!

How To Test the Accuracy of Your “Why” Root Cause Analysis

Posted: June 1st, 2012 in Human Performance, Performance Improvement, Root Cause Analysis Tips

I recently received an inquiry asking me, “What is the test to assure true root cause is found?  We use the “Why-Why” Analysis.”

    Using one of the “why” methods (“Why-Why”, 5-Why’s, etc) unfortunately leads many investigators to question their methodology.  That’s because, after using it once or twice, it becomes pretty obvious that these methods are 100% dependent on the experience and biases of the investigator.  If you’re a training person, amazingly enough, your “why” analysis leads you to training problems.  If you’re a quality person, you end up with quality-related issues.

    That’s because these methods do not give you any expert guidance to get beyond the investigator’s current level of knowledge.  For example, if you don’t know anything about “human engineering” (what color should an alarm light be? what shape valve hand wheel should be used?), you will never look for these problems.  You will only find problems you’re already familiar with, and therefore you will only put corrective actions in place that you have probably already tried in the past.

    The question posed is exactly the right question.  “How do I know I’ve found the real root cause?”  The bad news is that only a highly-trained human performance expert can answer that without some type of expert guidance.  The good news is, TapRooT® was designed to give you exactly that expert guidance.

    TapRooT® was designed by human performance experts to guide the normal investigator toward the true root causes that a highly-trained expert would find.  It does this by supplying a series of simple “yes/no” questions that you answer in the course of your investigation.  The answers to those question will quickly narrow you down to the true root causes of human performance or equipment failures that actually led to the accident.  Once you have these root causes, you can then apply effective corrective actions to eliminate them, preventing similar human performance mistakes in the future.

    Now, instead of ending up with corrective actions like, “Counseled the operator on the importance of opening the correct valve” (like he doesn’t already know that!), you can now find out why he opened the wrong valve.  You can be confident that the root causes you have found are real, proven root causes… the real reasons good people make mistakes.

     To directly answer the question, “why” methodologies will not consistently get you to true root causes.  There is no test built into those methods to verify root causes are found.  There’s no electronic “magic bullet” that can work around the weaknesses in those systems.  You’ll have to go outside those methodologies to get there.  Give TapRooT® a try!  We guarantee you’ll be satisfied with the results.

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

Posted: June 1st, 2012 in Courses

Gran Tierra hosted a 5-Day TapRooT® class last week in Bogotá, Colombia.  Piedad Colmenares and Nelson Suarez taught the course.

Let us know if we can schedule a course for your company.  We can teach in either English or Spanish!

Fire Ravages Submarine: Accdent Investigation Underway on USS MIAMI

Posted: June 1st, 2012 in Accidents, Current Events

A fire broke out on board the fast attack submarine USS MIAMI (SSN 755) at the Portsmouth Naval Shipyard in Kittery, Maine last week.  The fire took over 10 hours to put out, requiring 75 waves of firefighters to enter the ship in 10-15 minute shifts.  The forward compartment of the ship, containing the control room, living quarters, torpedo room, and auxiliary machinery spaces, was severely damaged by both the fire and the nearly 3 million gallons of water that were used to fight the fire.  The cause of the fire is under investigation by 3 separate teams.

Here’s a link to one of the stories.

Although not assigned as a crewmember, I actually rode on board MIAMI  at one time.  I was also assigned to several 688-class submarines during my career.  I can just imagine what it must have been like to fight a major fire onboard the submarine.  Next to flooding, fire is the most serious casualty a submarine can suffer in peacetime.  The power goes out, it becomes pitch black, you’re in tight quarters wearing bulky firefighting and respiratory gear, with no way for the heat to escape.  It rapidly becomes an oven.

Luckily, the submarine was in port conducting an overhaul.  All weapons had been removed, and no crewmembers were actually living on board.  7 crewmembers and local firefighters suffered minor injuries fighting the blaze.

TapRooT® and Equifactor® Root Cause Analysis and Equipment Troubleshooting Course in Pittsburgh

Posted: May 16th, 2012 in Courses

Teaching a 3-Day public course in Pittsburgh this week with Ken Scott.  We had a great group for the first 2 days:

I’ll be starting off with Equifactor® equipment troubleshooting tomorrow.

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

Posted: May 8th, 2012 in Courses

Just to mix it up a little, we just completed an ENGLISH LANGUAGE TapRooT® course in Cartagena last week.  We had a great group.  Diana Munévar made all the course arrangements.  I taught the course. 
Here’s the class picture:

Let us know if you need a course in Central or South America, in Spanish, Portuguese, or English.

TapRooT® 2-Day Incident Investigator Root Cause Analysis Course in Papua New Guinea

Posted: May 1st, 2012 in Courses

Oil Search Limited hosted a series of 5-Day and 2-Day courses in PNG this month.  Here are a few pictures from one of the courses:

View photos from the 5-Day in Papua here.  This course was taught by Michael Podgorny from Practical Solutions Group, one of our providers in Australia.  He’s based out of Perth.
Congratulations to the new TapRooT® users!

TapRooT® 5-Day Advanced Root Cause Analysis Class in Lima Peru

Posted: May 1st, 2012 in Courses

We held a public TapRooT® course last week in Lima, Peru.  The course was planned by Diana Munévar of T&PS out of Bogotá, Colombia.  The instructors were Piedad Colmenares and Nelson Suarez.  Looks like they had a VERY successful class.  Congratulations to all the graduates!

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

Posted: April 24th, 2012 in Courses

We held another full TapRooT® course in Bogotá last week.  Colombia is certainly a popular place for improvement programs!

Thanks to Nelson Suarez and Marco Flores for teaching the course, and Diana Munévar for setting up the great venue!

Let us know if you are interested in attending or hosting a TapRooT® course in your area.

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

Posted: February 17th, 2012 in Courses

We completed another successful course in Bogotá this week. Diana Munévar (far left) organized the course, with Marco Flores (next to Diana) and Piedad Colmenares (far right) providing excellent instruction.  Great Job!

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