Author Archives: Ken Reed

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!

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

Posted: February 14th, 2012 in Courses

We are busy in Colombia!  We just completed 2 courses in the past 2 weeks in Bogotá.  Here are some pictures from one of the courses:

Great looking group of root cause analysis experts!

Russian Missile Submarine Accident More Serious Than Originally Reported

Posted: February 14th, 2012 in Accidents, Current Events

On December 29 of last year, the Russian Submarine Yekaterinburg suffered a fire while in drydock.  The fire sent flames 30 feet into the air and took many hours to extinguish.  This submarine is a Delta IV class ballistic missile submarine, with 2 nuclear reactors for propulsion and power.

Original reports said that the fire originated in wooden scaffolding around the outside of the ship, with the fire spreading to the rubber acoustic coating on the exterior of the hull.  Russian authorities said that all weapons had been removed, and the fire was limited to the exterior of the vessel.

However, recent reports indicate that the torpedoes and missiles were in fact on the ship.  The fire appears to have occurred in the free-flood area on the exterior of the torpedo room.  A large hull cut is visible.  It appears they needed external access to the torpedo tubes or sonar system, which are outside the main pressure hull, but inside the ballast tank / free-flood area.  The hull cut in the pictures looks quite extensive.

Sailors allegedly had to manually remove torpedoes from the tubes (hydraulics had been deactivated for the maintenance) to prevent explosions.  According to the reports, while the torpedoes and missiles are normally removed from the the ship prior to dry-docking, the military wanted to get the ship back to sea quickly, so they left the torpedoes and missiles on board.

This may be a great example of taking short-cuts to get the job done quickly.  The military had requirements to remove ordinance prior to dry-docking, but decided it would delay the schedule too much.  A minor fire in a wooden scaffolding ended up nearly destroying the submarine.

5-Day TapRooT® Advanced Team Leader Root Cause Analysis Course for T.D. Williamson in Tulsa, OK

Posted: February 13th, 2012 in Courses

Tommy Garnett (one of our outstanding TapRooT® instructors) just finished teaching a course for T.D. Williamson.  What a terrific group.  Thanks for your enthusiasm!

Rocket Barge Hits Bridge in Kentucky

Posted: January 27th, 2012 in Accidents, Current Events

The Delta Mariner struck the Eggner Ferry Bridge in southwest Kentucky, knocking down 2 spans of the bridge.  Motorists almost didn’t notice the missing spans as they came up to it in the dark.

The barge is designed to carry Delta 4 and Atlas V rocket stages from the assembly plant in Decatur, Alabama.  No word if there were any rocket components on board.

A later report indicates that the barge took the wrong channel.  It apparently attempted to use the recreational channel (for small private boats), instead of using the main navigational channel. 

On-Site TapRooT® / Equifactor® Root Cause Analysis Course in Bogotá, Colombia

Posted: January 20th, 2012 in Courses

ARP Colpatria hosted a 3-Day TapRooT® and Equifactor® Root Cause Analysis and Equipment Troubleshooting course this week.  They had a great class with lots of learning, with some fun thrown in for good measure.

Here’s some creative solutions during the Marble Drop game:

Looks like a full class!

2-Day TapRooT® Root Cause Analysis Course in Houston, TX

Posted: January 17th, 2012 in Courses

It’s the Ken and Ken show here in Houston!  Ken Turnbull and I are teaching a great group here at the Four Points Hotel in Memorial City.  Great turnout, and an outgoing class.
Ken T is teaching the class about Generic Causes.  Trust me, he is NOT sending a bad student out into the hall!

Investigation, Troubleshooting, & Root Cause Analysis Track at the 2012 Global TapRooT® Summit

Posted: January 10th, 2012 in Summit

We’re counting down to the 2012 Global TapRooT® Summit in Las Vegas on February 29 to March 2.  Don’t miss the opportunity to be part of the growing improvement trend by attending the premier root cause analysis event.

One of the exciting tracks this year is the Investigation, Troubleshooting, & Root Cause Analysis Track.  We have lots of outstanding sessions included in this track.  You can see the full schedule by clicking this link.  Here is a quick run-down of the sessions:

1.  TapRooT® Implementation, Investigations, and Process Improvements. This session will include talks by 3 different speakers, describing how they have been successful implementing TapRooT® at their facilities.  Janis Chartier (PPL Electric), Mike Ezzell (Price Gregory Construction), and Mark Eliopulos (Prevention Opportunities) will give specific examples of how TapRooT® has been used to effectively investigate problems at their facilities.  There’s nothing better than actual examples to give you great ideas for improvements at your own facilities.

2.  What is “Culture” & How Do You Identify & Solve Culture Problems Using TapRooT®? Brian W. Tink, Brian A. Tink (yep, father and son), Richard Mesker and Clare Solomon will discuss company culture and how that directly relates to the TapRooT® process, with direct relationships to the Root Cause Tree®.  How do you actually measure and define your company’s culture?  How do you communicate a message to help change a culture?Think you understand “culture”?  Check out this session for a terrific explanation of how culture and TapRooT® fit together.

3.  Troubleshooting Equipment Problems as Part of a TapRooT® Investigation. Many investigations end up with an equipment failure as one or more of the Causal Factors.  How do these failures fit in with the general investigation process?  I’ll be discussing how machinery failures, while often a piece of the puzzle, are often more a symptom than a cause.

4. CAPA in Quality: The Strong and the Weak. Where are those quality managers out there?  Karen Migliaccio will host a lively on discussion on how quality issues can be investigated using TapRooT®.

5. TapRooT® Users Share Root Cause Best Practices. Linda Unger and Michele Lindsay will be facilitating an interactive session for all users.  Come and give your ideas, or just sit back and absorb the ideas from others.  Always a great session!

6. The 7 Secrets of Incident Investigation & Root Cause Analysis. While many companies are reaping the benefits of sustained, productive investigations, some companies still struggle.  Mark Paradies’ session will share secrets and lessons learned about what makes investigations fail, and more importantly, ways to improve your investigation performance.

7. Investigation Process Best Practices. This is a 2 for 1!!
– Does your investigation process seem to take too long?  Don’t blame TapRooT®!  I’ll be hosting a discussion on how to optimize your investigation process.
– Karen Gallogly will then be presenting an overview of the IEEE Nuclear Root Cause Analysis Standard.

8. The Day 29 Miners Died: The UBB Mine Explosion.  When a tragedy strikes, it is imperative that we learn from the mistakes that were made.  Ken Scott (former MSHA inspector) will lead a discussion on the explosion that took the lives of 29 miners.

These sessions are not to be missed.  Sign up for the 2012 Global TapRooT® Summit, and see how 2012 can be the year you make a difference!

Ken Reed
Track Leader

2-Day TapRooT® Incident Investigation Course in Lake Charles, LA

Posted: December 5th, 2011 in Courses

Tommy Garnett and I just finished teaching a great group in Lake Charles.  Nice accommodations, good food, and an energetic class make the course just that much better.

Mystic, CT 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Posted: October 30th, 2011 in Courses

We completed a 2-Day TapRooT® course in the historic Mystic Seaport area in Connecticut last week.  Here are some pictures from that course:

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

Posted: October 30th, 2011 in Courses

We held an Advanced TapRooT® Root Cause Analysis Course last week in Bogotá.  We had a great showing, and it looks like they had a great time learning TapRooT®.

Here’s a class picture:

and a picture of our instructors and course planner:

(Nelson Suarez, Diana Munévar, Piedad Colmenares, and Marco Flores)

The class is hard at work:

and working on exercises:

Let us know if you are interested in learning the TapRooT® techniques, anywhere in the world.

2-Day TapRooT® Root Cause Analysis Course in El Tigre, Venezuela

Posted: October 24th, 2011 in Courses

Tesco just completed a 2-Day TapRooT® Course with our Colombian instructor (Piedad Colmenares).  Here are some pictures from the course.

Marble Drop fun:

Working with the software:

More root cause analysis:

Final exercise:

Good looking group!

Thank you, Tesco, for a great class!!

3-Day TapRooT® Root Cause Analysis and Equipment Troubleshooting Course in Kuala Lumpur

Posted: October 17th, 2011 in Courses

This is the 3rd of 3 sessions of TapRooT® classes hosted by Hess Oil and Gas in Kuala Lumpur.  This final class includes the basics of using TapRooT®, plus an additional day dedicated to using the Equifactor® module for equipment troubleshooting.

Let us know if you are interested in any of these courses.  We can teach just about anywhere!

2-Day TapRooT® Incident Investigator Course In Kuala Lumpur

Posted: October 13th, 2011 in Courses

Hess has continued their TapRooT® training this week with a 2-Day Root Cause Analysis course:

Hess will continue with a final 3-Day course, which will include the 2-Day TapRooT® Root Cause Analysis course, plus an additional day of Equifactor® equipment troubleshooting training.

(VIEW MORE course photos from Kuala Lumpur here and here.)

5-Day TapRooT® Advanced Root Cause Analysis Course In Kuala Lumpur

Posted: October 12th, 2011 in Courses

We completed a 5-Day TapRooT® course for Hess last week.  Great class, and awesome participation:

We are continuing with a 2-Day Incident Investigator Course, and then a 3-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course this week.  Hess is showing terrific commitment to performance improvement.

5.3 Million People Lose Power Due to Routine Maintenance

Posted: September 9th, 2011 in Accidents, Current Events

People in San Diego and parts of Arizona and New Mexico lost all electrical power yesterday afternoon.  See links here and here.

The results?

Shut down of the San Diego Airport.
Huge traffic snarls (this occurred at around 4:00pm local time).
Shut down of 2 nuclear reactors (the shutdown was per procedure for a loss of load).
Over 1 million gallons of sewage spilled into the ocean due to loss of sewage treatment capability, closing San Diego beaches.

Was this caused by a huge lightning strike?  An enormous traffic accident?  A transformer explosion at a substation?  Nope.  In this case, it was a maintenance error.  A maintenance worker was changing out a piece of monitoring equipment, and for some reason (not yet determined) the power tripped.  Of course, there are safeguards that should localize this trip to a small area.  However in this case those safeguards did not work (not sure why), and a 500,000 volt power transmission line also tripped off-line.  This main feeder dropped power to a significant portion of the southwest U.S.

The company is initiating a root cause analysis to understand the reasons for the outage.

Air Traffic Errors Climb – Root Cause?

Posted: September 6th, 2011 in Accidents, Current Events

I found an article discussing the rise in air traffic control system errors, including near misses.  See the article here.

A few ideas were discussed, and several lines caught my eye:

A new FAA Air Traffic Controller training company has taken over training duties, with cost overruns and training staff lay-offs.  One former trainer says, “When you cut training, your incident rate goes up.”

Another trainer discusses reactive performance measures.  This may seem a little sensationalist, but it really hits home:  “A lack of body bags does not indicate safety.’’

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