Author Archives: Mark Paradies
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioPosted: September 16th, 2014 in Courses, Pictures, TapRooT
Final presentations by the teams after performing a root cause analysis on their incident that they brought to the course…
He didn’t die … but his boss was fined £5,000 by the HSE.
Linda Unger Teaching the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioPosted: September 15th, 2014 in Courses, Pictures, TapRooT
Need root cause analysis training at your site? Contact us to set up a TapRooT® Course by CLICKING HERE.
Teams Working on Their SnapCharT®s at the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioPosted: September 15th, 2014 in Courses, Pictures, TapRooT
You have to understand what happened before you can understand why it happened. The SnapChart helps you do just that. These folks at the 2-Day class in Dayton are practicing their newly learned skills…
For the next public TapRooT® Course near you, click on your continent at:
The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.
To see the report and the one lesson learned, CLICK HERE.
A man can be as great as he wants to be.
If you believe in yourself and have the courage,
the determination, the dedication, the competitive drive and
if you are willing to sacrifice the little things in life and
pay the price for the things that are worthwhile,
it can be done. ~ Vince Lombardi
Mark Paradies Teaching a Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioPosted: September 15th, 2014 in Courses, Pictures, TapRooT
Want to find out more about TapRooT® Root Cause Analysis Training? Then visit our web site:
I heard an interesting speaker last week talk about technology adoption. He spoke about how valued brands developed a “tribe” of users who often networked and shared best practices. This often made the technology (the brand) better and more valuable.
That’s when I realized that TapRooT® Users were a tribe that constantly made TapRooT® a more valuable technology/brand.
And once a year, the tribe gets together at The Global TapRooT® Summit.
Think of this like the tribal meetings of old. Or mountain men getting together at the rendezvous. Or, if you are from a Norse heritage, a þing (things).
If you’ve never been to the Summit, now is the time to start planning to attend. Mark out the dates (June 1-5, 2015) on your calendar. Get any budget requests to travel authorizations started (or at least planned for). See if you can get a team of your best performance improvement experts to register as a group.
You’ll return to work from the Summit energized to make improvement happen with great ideas and best practices from around the world. General Summit information is available HERE. The Summit schedule of events will be posted shortly.
Looking forward to seeing you and the rest of the tribe next June.
President, System Improvements
The TapRooT® Folks
One broken hydraulic hose…
Monday Accident & Lessons Learned: NTSB Investigation – Grounding and Sinking of Towing Vessel Stephen L. Colby”Posted: September 8th, 2014 in Accidents, Current Events, Investigations, Pictures
Below is the NTSB investigation PDF. Read it and see what you think of the “probable cause” of the accident … “The National Transportation Safety Board determines that the probable cause of the grounding and sinking of the Stephen L. Colby was the failure of the master and mate to ensure sufficient underkeel clearance for the intended transit through the accident area.“
See the whole report here:
You measure the size of the accomplishment
by the obstacles you had to overcome to reach your goals. ~ Booker T. Washington
Here are some pictures sent to me by Jim Whiting, one of our Australian TapRooT® Instructors…
This is big news in that the fines for the spill are multiplied and could reach $18 billion dollars. See the whole story at:
Root Cause Analysis Tip: Rate Your Root Cause Analysis / Incident Investigation System – The Good, The Bad, and The UglyPosted: September 3rd, 2014 in Documents, Performance Improvement, Pictures, Root Cause Analysis Tips
Over a decade ago, I developed a rating sheet for root cause analysis implementation. We had several sessions at the TapRooT® Summit about it and it was posted on our web site (and then our blog). But in the last web site crash, it was lost. Therefore, I’m reposting it here for those who would like to download it. (Just click on the link below.)
Instructions for using the sheet are on the sheet.
I’m working on a new rating system for evaluation of individual incident investigations and corrective actions. Anyone have any ideas they would like to share?
Halliburton’s agreement caps the amount of money it will pay and significantly cuts into the legal liabilities it faces. See the story at:
Monday Accident & Lessons Learned: RAIB Investigation Report – Road Rail Vehicle Runs Away, Strikes ScaffoldPosted: September 1st, 2014 in Accidents, Current Events, Investigations, Pictures
Here is the summary of the report from the UK Rail Accident Investigation Branch:
At about 03:00 hrs on Sunday 21 April 2013, a road rail vehicle (RRV) ran away as it was being on-tracked north of Glasgow Queen Street High Level Tunnel on a section of railway sloping towards the tunnel. The RRV ran through the tunnel and struck two scaffolds that were being used for maintenance work on the tunnel walls. A person working on one of the scaffolds was thrown to the ground and suffered severe injuries to his shoulder. The track levelled out as the RRV ran into Glasgow Queen Street station and, after travelling a total distance of about 1.1 miles (1.8 kilometres), it stopped in platform 5, about 20 metres short of the buffer stop.
The RRV was a mobile elevating work platform that was manufactured for use on road wheels and then converted by Rexquote Ltd to permit use on the railway. The RRV’s road wheels were intended to provide braking in both road and rail modes. This was achieved in rail mode by holding the road wheels against a hub extending from the rail wheels. The design of the RRV meant that during a transition phase in the on-tracking procedure, the road wheel brakes were ineffective because the RRV was supported on the rail wheels but the road wheels were not yet touching the hubs. Although instructed to follow a procedure which prevented this occurring simultaneously at both ends of the RRV, the machine operator unintentionally put the RRV into this condition. He was (correctly) standing beside the RRV when it started to move, and the control equipment was pulled from his hand before he could stop the vehicle.
The RRV was fitted with holding brakes acting directly on both rail wheels at one end of the vehicle. These were intended to prevent a runaway if non-compliance with the operating instructions meant that all road wheel brakes were ineffective. The holding brake was insufficient to prevent the runaway due to shortcomings in Rexquote’s design, factory testing and specification of maintenance activities. The lack of an effective quality assurance system at Rexquote was an underlying factor. The design of the holding brake was not reviewed when the RRV was subject to the rail industry vehicle approval process because provision of such a brake was not required by Railway Industry Standards.
The RAIB has identified one learning point which reminds the rail industry that the rail vehicle approval process does not cover all aspects of rail vehicle performance. The RAIB has made four recommendations. One requires Rexquote to implement an effective quality assurance system and another, supporting an activity already proposed by Network Rail, seeks to widen the scope of safety-related audits applied by Network Rail to organisations supplying rail plant for use on its infrastructure. A third recommendation seeks improvements to the testing process for parking brakes provided on RRVs. The final recommendation, based on an observation, relates to the provision of lighting on RRVs.
To read the whole report, see:
Develop success from failures.
Discouragement and failure are two of the surest stepping stones to success. ~ Dale Carnegie