Author Archives: Mark Paradies
Here is a video with lessons learned about a fatal accident involving equipment (a scissor lift).
But there is an additional lesson that we can learn.
Every worksite should have a supervisor perform a quick Safeguard Analysis before people start work.
In this case, power lines were an obvious hazard (high voltage). And getting equipment with booms or lifts near them would cause the natural Safeguard (distance) to fail. If this Safeguard Analysis had been performed proactively, the worker could have been warned OR the actions (visually warnings and signage) could have been implemented to prevent the fatality.
Don’t wait for a fatality. Use TapRooT® to proactively prevent fatalities.
Would you like to learn to use TapRooT® to look for problems before accident, quality problems, and other failures happen? Then you should attend the upcoming TapRooT® for Audits Course on August 1-2 in San Antonio, Texas (just before the 2016 Global TapRooT® Summit on August 3-5). Register here:
Have you ever had a boss that you needed to fire?
A boss that is:
- hurting your company,
- damaging peoples’ careers, and
- miserable to work for.
I was making a list of the great leaders and mentors that I’ve had and that got me to think of the few really bad people that I’ve worked for.
Unfortunately, I couldn’t fire the bad ones.
In one case, I was in the military. In the military, you have no choice of who you work for. I know that movies make fragging (killing your boss) seem like an option in combat but I never considered that as an option. (Although, my Dad did during WWII. His wing commander was getting multiple pilots killed by bad calls. But he was lucky and didn’t have to choose between his commander and his fellow pilots. The Germans shot him down and the problem went away (although the bad boss survived).
In the second case, the boss was a miserable soul. His only thought was getting himself ahead – he wanted to be a VP. (Which he eventually accomplished.) Luckily, he “traded” me away (think baseball trades) for someone else to advance his agenda. It was great getting out from under his “leadership.”
I guess what really makes these two bad bosses seem even worse are the great leaders that I’ve worked for and known.
Therefore, here is my advice…
If you don’t have a great boss at a great company, fire your boss.
How do you do that?
Find a great boss at a great company that wants you. Get yourself traded.
The other possibility is to make YOU the boss by starting your own company. This has it’s own rewards and problems. (For example, you may not feel comfortable living without the safety net of a big corporation.)
Or you could just wait. (This might be a miserable existence waiting for someone to either fire, transfer, or promote your boss,)
But I’d suggest NOT waiting.
Life is too short to live with a miserable boss.
And for those living under a bad boss, here’s a song for you …
What can you learn about planning a high risk business activity from the planning for a high risk criminal activity?
Probably much more than you might think!
The Global TapRooT® Summit is all about learning from other industries and disciplines and it certainly is different learning from criminal activities and criminal investigations. This talk is based on Alan’s first hand experience with a murder investigation that will keep you riveted to his every word. Don’t miss it.
We have just scheduled a new talk in the Safety Track at the 2016 Global TapRooT® Summit. “Risk Assessing the Perfect Murder” will be held on Thursday, August 4, 2016 from 12:45 p.m. to 1:35 p.m.
Alan Smith, a former Detective Superintendant with the Grampian Police in Scotland, is now a TapRooT® Instructor and a Director of Matrix Risk Control in Aberdeen, Scotland and is leading this intriguing course.
See the complete 2016 Global TapRooT® Summit schedule by CLICKING HERE.
Register for the Safety Track at the 2016 Global TapRooT® Summit (August 1-5 in San Antonio, Texas) by CLICKING HERE. Or add Alan’s talk to another track to customize your Summit experience.
The Wall Street Journal announced that BP incurred $56 Billion in expenses from the Deepwater Horizon explosion and spill. And the end is still not in sight.
BP’s CFO said “It’s impossible to come up with an estimate [of future costs].”
Of course, those costs don’t include the lives lost and the negative PR that the company has received.
How much is a best in class process safety program worth? As BP’s CFO says …
It’s impossible to come up with an estimate.
If you would like to learn best practices to improve your safety performance and make your programs “best in class,” the at ten the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
What? You say YOUR COMPANY CAN’T AFFORT IT? Can it afford $56 Billion? The investment in your safety program is a pittance compared with the costs of a major accident. Your company should put spending on safety improvement BEFORE other investments … especially in difficult times.
If you are a senior manager, don’t wait for your safety folks to ask to attend the Summit. Send them an e-mail. Tell them you are putting a team together to attend the Summit with you to learn best practices to prevent major accidents. Ask them who would be the best people to include on this team. Then get them all registered fot the Summit.
Remember, the Summit is GUARANTEED.
Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.
Wow! A guaranteed ROI. How can we be so sure that you will return to work with valuable ideas to implement? Because we’ve been hosting these Summits for over 20 years and we know the “best of the best” attend the Summit and we know the value of the ideas they share each year. We’ve heard about the improvements that Summit attendees have implemented. Being proactive is the key to avoiding $56 Billion dollar mistakes.
So don’t wait. Get your folks registered today at:
Each year Mark Paradies, President of System Improvements, picks courses to hold prior to the TapRooT® Summit. He chooses the courses to help TapRooT® Users learn even more about root cause analysis and performance improvement… lessons that go beyond the standard 2-Day and 5-Day TapRooT® Courses.
What are the courses scheduled for August 1-2?
- TapRooT® for Audits (New)
- Effective Interviewing and Evidence Collection Techniques (New)
- TapRooT® Quality Process Improvement Facilitator Course (New)
- TapRooT® Advanced Trending Techniques
- Advanced Causal Factor Development Course
- Analyzing and Fixing Safety Culture Issues
- Risk Assessment and Management Best Practices
- Getting the Most from Your TapRooT® VI Software
- Understanding and Stopping Human Error
- 2-Day TapRooT® Root Cause Analysis Training (The revised course)
- TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis
WHICH COURSE IS RIGHT YOU?
I’ll provide some background on each course so that you can choose the course that will provide the knowledge you need to help your facility reach the next level in improving safety, quality, patient safety, root cause analysis, trending, or equipment reliability.
Are you responsible for equipment troubleshooting and root cause analysis?
Do you need to improve your plant’s equipment reliability?
This course has been completely redeveloped and focused on solving equipment problems. Ken Reed, Vice President at System Improvements and lead for Equifactor® will be one of the instructors.
The course is equipment focused, but you don’t have to be an engineer to attend. Anyone who looks into the causes of equipment failures as part of:
- equipment troubleshooting
- safety investigations
- environmental releases
- quality issues
can benefit from this systematic approach to discovering why equipment failures occur.
The course teaches techniques for equipment troubleshooting developed by equipment expert Heinz Bloch. It combines those techniques with the world-renowned TapRooT® Root Cause Analysis System to make a best-of-class system for finding the causes of equipment troubles.
The text for this course is the new book: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
2-Day TapRooT® Root Cause Analysis Training (The revised course)
The 2-day TapRooT® Course has been around for over 20 years. This year we decided to go back to the basics and focus the course on performing investigations of low-to-medium risk incidents. We developed a new 50 page book (Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents) that goes with the course.
The course teaches the essential TapRooT® Techniques in an easy to use new simplified 5-Step Investigation Process. You will learn to:
- Use the SnapCharT® Diagram to collect and organize information and understand what happened.
- Identify Causal Factors using the new, simplified three question method
- Use Safeguard Analysis to help quickly identify Causal Factors.
- Find root causes using the latest TapRooT® Root Cause Tree® and Dictionary.
- Develop effective but simple fixes to improve performance.
- Identify Generic Causes if you want to go beyond the simple process.
You will practice each of these skills to become proficient. In this new course you get more practice than you did in the old course. And each team will take one of their own incidents through the process to find root causes and develop effective fixes.
If you want to learn to use a state-of-the-art root cause analysis process to perform quick investigations of low-to-moderate risk incidents, THIS COURSE IS FOR YOU.
If you are a Certified TapRooT® Instructor, you may want to attend this course to see all the new things you will be teaching (including new animated examples).
Dr. Joel Haight, a TapRooT® User since 1991 and a Professor at the University of Pittsburgh, will teach you to analyze and understand human error. This course teaches many of the techniques covered in a university human factors course in a modified short course format.
Topics covered in the course include:
- Basic understanding of visual, auditory, tactile and vestibular senses.
- Understanding reaction time and decision making.
- Understanding physical human performance (ergonomics).
- Factors that influence human error (stress, fatigue, equipment design,/automation, training, and social factors)
- Nuclear industry human performance tools (attention to detail, questioning attitude, and error traps/precursors, peer checking, 3-way communication, procedure use, peacekeeping, pre-job brief/SAFER, post-job brief, observation/coaching, STAR, and time out)
- Practical questions for incident investigators
- Quantitative/Qualitative methods (THERPS, MAPPS, OAT, and FTA)
If you are interested in an overview of techniques focussed on human error to augment your standard incident investigations, this course is for you.
To continue to the other course descriptions click on the link MORE below.
TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.
The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.
But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.
One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.
The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.
For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).
For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):
- Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
- Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
- Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?
If you get a “Yes” then you have a problem to solve.
How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.
The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.
The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.
Are you using a tool or a system?
If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:
2-Day TapRooT® Root Cause Analysis Training
2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Training
For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.
To hold a course at your site, contact us by CLICKING HERE.
(Note: Copyrighted material shown above is used by permission of System Improvements.)
The following is a video of a fatal accident. The vehicle drove around a tow truck sent to block the underpass and past a worker waiving his arms to stop her. She drove into water about 17 feet deep. DON’T watch the video if it will upset you. For others, hopefully you can use this to teach others to avoid standing water during flooding.
The explosion at the West Fertilizer Plant was thought to have been a tragic accident. However, the Associated Press has reported that the Alcohol, Tobacco, and Firearms, and Explosives Agency (ATF) has said that the fire that caused the explosion was “intentionally set.”
Here is a TV report link:
This is a TV report from 2007 …
Truthfully, we could make the same video today.
Why haven’t we made more progress to improve patient safety?
Each year we have a Track at the Global TapRooT® Summit about improving patient safety. If the good practices we present each year had been implemented across the country … we would be much better off.
Interested in learning best practices to improve patient safety? Sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas (August 1-5). See the complete schedule by CLICKING HERE. And see the Pre-Summit Courses at this link: http://www.taproot.com/taproot-summit/pre-summit-courses.
Then register for the summit at:
Harrison Ford was hit by a heavy, hydraulically operated door while filming the new Star Wars movie. He suffered a broken leg. The UK Health & Safety Executive charged Foodles Productions (UK) Ltd. with four criminal violations and the company will have it’s first court hearing on May 12th.
Now the question – or lesson learned …
- Will criminal charges make movie actors safer?
- Do studios already have incentives to keep their actors safe?
What do you think? Leave your comments here…
This video has a few four letter words so turn your sound off if you would be offended … but the footage is spectacular.
We had some great final presentations at the Dayton 2-Day TapRooT® Root Cause Analysis Course. Here’s a few pictures…
Linda Unger teaching at the 2-Day TapRooT® Root Cause Analysis Course in Dayton, Ohio.
Do you need an advanced system to find and fix the root causes of safety, quality, equipment reliability, and production problems? See out public courses at: http://www.taproot.com/courses