Author Archives: Mark Paradies

Is there an easier way to investigate simple problems?

Posted: May 24th, 2017 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

People often ask me:

“Is there an easier way to investigate simple problems?”

The answer is “YES!”

The simplest method is:

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Of course, some methods may be too simple.

That’s why we wrote a book about the simplest, but reliable method to find the root causes of simple incidents. The title? Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Want to learn more? See an outline at: http://www.taproot.com/products-services/taproot-book

Or just order a copy by CLICKING HERE.

Have you subscribed to the TapRooT® You Tube channel?

Posted: May 17th, 2017 in Video

 

TapRooT You Tube

There is more content being posted every day … See:

https://www.youtube.com/channel/UC4db2z4nFctC5SZ-JSRxZQw

To Hypothesize or NOT to Hypothesize … that is the Question!

Posted: May 16th, 2017 in Quality, Root Cause Analysis Tips, TapRooT, Training

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

http://www.taproot.com/store/Courses/

Ready for an On-Line Risk Assessment?

Posted: May 9th, 2017 in Performance Improvement, Video

Have you ever watch NAPO videos? Here is one about an on-line risk assessment tool …

Get more information at:

https://oiraproject.eu/en

Opportunity to Improve Vision

Posted: May 9th, 2017 in Performance Improvement, TapRooT

(Taken from Book 1: TapRooT® Root Cause Analysis Leadership Lessons, used by permission of System Improvements)

The Opportunity to Improve Vision

What does the Opportunity to Improve vision look like?

If there is a problem, the people, either individually or in teams, work to solve the problem. Everyone views this as an opportunity to improve. The team doing the investigation knows better than to just address the symptoms. They are NOT looking for someone to blame. They ARE looking for the root causes. They know that if they find and fix root causes they will prevent the problem’s recurrence.

As W. Edwards Deming said:

“Management’s job is to improve the system.”

This is the Opportunity to Improve Vision. Improving the “system” is the key to improving performance.

But what is the system? The system is equipment, procedures, tools, communication techniques, training, human factors design, supervisory techniques, resources (time), policies, and rules that all impact the ability to achieve the intended goal. These are all things that management can change to improve performance.

The Opportunity to Improve Vision sees each incident as an opportunity. Not an opportunity to find a scapegoat (someone to blame). Not an opportunity to survive yet another crisis. The Opportunity to Improve Vision sees each incident as an opportunity to improve performance by changing the system.

If you are living in the Blame Vision or the Crisis Management Vision, this may seem like a fairy tale. But the Opportunity to Improve Vision exists at many sites using TapRooT® Root Cause Analysis. And TapRooT® helped them achieve the vision when they started finding the real root causes of problems rather than placing blame and using “quick fixes” that really didn’t work.

Would you like to learn more about TapRooT® Root Cause Analysis? Attend one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. See:

http://www.taproot.com/store/5-Day-Courses/

Freeze on New RMP Rule linked to the ATF announcement about the West, TX, Fertilizer Explosion

Posted: May 5th, 2017 in Accidents, Current Events

The new EPA RMP rule which had an effective date March 14, 2017, has been “frozen” under the Trump administration regulatory freeze until February 19, 2019.

The main reason for the freeze in the case of the RMP rule is that the rule modifications were largely based on the West, TX fertilizer explosion. However, two days before the comment period ended, the ATF announced that they suspected that the West, TX, fertilizer explosion was NOT an accident, but rather was an intentional act.

Now the whole rule is being reconsidered.

CSB Video of Torrance Refinery Accident

Posted: May 3rd, 2017 in Accidents, Current Events, Investigations, Video

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

Senior Management: Can Your Investigators Tell You that Your BABY is UGLY?

Posted: May 3rd, 2017 in Performance Improvement, Root Cause Analysis Tips

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This article is for senior corporate management

Can your investigators tell you that your baby is UGLY?

What do I mean by this?

Can your investigators point out management system flaws that ONLY YOU can fix?

If you say yes … I want to know the last time they did it!

Why am I bringing this up?

Recently I was talking to several “senior investigators” from a major company. We were discussing some serious incidents (SIFs). I recognized that there had been a series of management system failures over a period of over a decade that had not been fixed. SEVERAL generation of senior management had contributed to the problem by creating a culture of expediency … a “just get it done” culture that put cost containment and keeping the plant operating over process safety. 

I asked them if they had pointed this out to senior management. They looked at me if I was nuts. 

That’s when I realized … THEY couldn’t tell management that their BABY was UGLY.

I also realized that management didn’t want to hear that their BABY was UGLY.

They just wanted problems to go away with the least muss and fuss. They didn’t want to confront the investments required to face the facts and put process safety first.

TapRooT® Root Cause Analysis will point out the problems in management systems. But investigators must be willing to confront senior management with the facts (tactfully) and show them clearly that their BABY is UGLY.

Senior management should be DEMANDING that investigators point out management system flaws and asking WHY management system flaws ARE NOT being presented if a serious incident happens.

I remember pointing out a serious management system flaw that had caused a multi-multi-million dollar accident (no one had been killed but someone easily could have been killed). The Senior VP said:

“If anyone would have pointed out the problems this decision caused, we wouldn’t have made it!”

Don’t let poor management system decisions go unchallenged and unreported. When unreasonable budgets, deferred maintenance, short staffing, unreasonable overtime, or standard violations become an issue – SAY SOMETHING! Let senior management know they have an UGLY BABY.

SENIOR MANAGEMENT – Occasionally you need an outside opinion of how your baby looks … Especially if you continue to have Significant Incidents. Maybe you need to face the facts that your BABY is UGLY.

Remember … Unlike real ugly babies, management CAN DO SOMETHING about management system problems. Effective corrective actions can make the UGLY BABY beautiful.

Crisis, Crisis Everywhere…

Posted: May 1st, 2017 in Performance Improvement, Root Cause Analysis Tips, TapRooT

The Crisis Management Vision

Has your management ever said:

 “If we investigated every incident we had, we’d do nothing but investigate incidents!”

Then there is a good chance that you are living in a crisis management vision.

What are your three most common corrective actions for any problem?

  • Counsel the operator to be more careful
  • Require more training.
  • Write (or rewrite) the procedure.

Unfortunately, this type of corrective action usually doesn’t work (even though sometimes it may appear to work). The problem happens again. The vicious cycle of crisis and crisis management repeats itself. And everyone complains about having to work too hard because they are always in “crisis mode.” 

Are you tired of crisis management?

Would you like to finally solve problems once and for all?

Then it is time you tried TapRooT® Root Cause Analysis. Attend one of our publics courses listed here…

http://www.taproot.com/store/Courses/

This article was derived from Book 1: TapRooT® Root Cause Analysis Leadership Lessons. Copyright 2017 by System Improvements, Inc. Used by permission.

 

Trapped in the Blame Vision

Posted: April 20th, 2017 in Jokes, Performance Improvement, Root Cause Analysis Tips, TapRooT

From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.

The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.

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They were trapped in the Blame Vision.

The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.

The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:

I didn’t do it! 
Nobody saw me do it! 
You can’t prove I did it!

But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:

Why be fair when you can be arbitrary?

A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up. 

One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself. 

The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement. 

Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him. 

If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.

What Would You Do If You Saw a Bad 5-Why Example?

Posted: April 19th, 2017 in Performance Improvement, Root Cause Analysis Tips, Root Causes

It seems that I’m continually confronted by folks that think 5-Whys is an acceptable root cause analysis tool. 

The reason they bring up the subject to me is that I have frequently published articles pointing out the drawbacks of 5-Whys. Here are some examples…

Article in Quality Progress: Under Scrutiny (page 32)

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

That got me thinking … Have I EVER seen a good example of a 5-Why root cause analysis that I thought was a good example of a root cause analysis? And the answer was “NO.”

So here is my question … 

What do you do when you see someone presenting a bad root cause analysis where they are missing the point?

Leave a comment below and let me know the tack that you take … What do you think?

Should We Continue to Fund the CSB?

Posted: April 17th, 2017 in Current Events, Performance Improvement

The Trump Administration has cut funding for several independent agencies in their 2017 budget request. One is the US Chemical Safety Board.

The CSB has produced this video and a report to justify their continued funding.

REPORT LINK

The question taxpayers need to ask and answer is, what are the returns on the investment in the CSB?

The CSB produces investigation reports, videos, and a wish list of improvements.  In 2016 the agency published seven reports and two videos  (it has six investigations that are currently open). That makes it a cost of $1.2 million per report/video produced when you divide their $11 million 2016 budget by their key products.

The 2017 budget request from the CSB was $12,436,000 (a 13% increase from their 2016 budget).

Should the government spend about $12 million per year on this independent agency? Or are these types of improvements better developed by industry, other regulatory agencies (EPA and OSHA), and not-for-profit organizations (like the Center for Chemical Process Safety)?

Leave your comments here (click on the comments link below) to share your ideas. I’d be interested in what you think. Or write your representatives to provide your thoughts.

Root Cause Analysis Tip: Does Your Company Vision PREVENT Good Root Cause Analysis?

Posted: April 11th, 2017 in Performance Improvement, Root Cause Analysis Tips, TapRooT

What is your company’s vision? Does your company have a:

  • Blame Vision
  • Crisis Management Vision
  • Opportunity to Improve Vision

The only vision that leads to good root cause analysis is the opportunity to improve vision. 

We’ve been helping people “adjust” their vision since Mark Paradies gave a talk about the opportunity to improve vision at the 1990 Winter American Nuclear Society Meeting. 

How do you change your vision?

That takes more than the few paragraphs of a blog article to describe. But we did write about it in our newest book:

TapRooT® Root Cause Analysis Leadership Lessons

 

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What’s in the new book?

  • A Tale of Two Plants
  • Vision
  • What is a Root Cause and How Was TapRooT® Developed to Help You Find Them?
  • How Leaders Can Apply TapRooT® to Improve Performance
  • What Can TapRooT® Do for You?
  • What TapRooT® Books Do You Need to Read?

The new book is designed for senior managers and leaders of improvement programs to help them understand effective root cause analysis and how it fits into a performance improvement program.

Order your copy of the new book by clicking HERE and make sure your vision supports improved performance!

 

When do you need a root cause analysis?

Posted: April 5th, 2017 in Performance Improvement, Root Cause Analysis Tips

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I heard one industry guru say that EVERY loss deserves an investigation and corrective action.

Is it possible?

Is it desirable? 

I would say no.

Not every loss needs an investigation and certainly not every loss deserves a root cause analysis.

Why?

Because every investigation should have at least a chance of a positive return on the investigation investment. Many losses are too small to get much benefit from an investigation. (This is true even if you take into account the potential for even bigger problems down the road.) Let’s face it, sometimes there just isn’t much to learn from a paper cut!

Why should we avoid wasting our improvement energy on unimportant minor problems?

Because every organization has resource limitations and we should spend our resources wisely. We need to put our effort where it will do the most good.

Therefore, we must target our resources where they will get the most improvement bang for the buck.

The targeting of improvement resources should match management’s goals. This targeting of resources should guide the improvement effort by assigning resources for safety, quality, reliability, productivity, and product improvement. Of course, the division of resources is guided by the company’s risk assessment and market analysis. 

Let’s look at an interesting hypothetical example.

At a large chemical company, a budget and level of emphasis has been assigned for safety improvement. How should the company spend this budget? Where should the safety team direct their resources?

The first place to look would be the company’s real accident data. Of course, if the company has poor root cause analysis, the data will not be meaningful. If that is true, the first place to apply resources is to achieving outstanding root cause analysis of significant accidents.

What if this company has been applying advanced root cause analysis for several years and has fairly good accident data. Then they can use that data to determine where their biggest risks are and what type of root causes contribute the most to that risk. That knowledge can help them target their resources. 

If a company’s safety improvement programs are fairly ineffective (measured by the fatality count), the majority of the emphasis should be put on the investigation of significant incidents and precursors to significant incidents. These are incidents that cause fatalities and serious injuries and incidents that could have caused a fatality or serious injury if one more Safeguard had failed.

The remaining improvement effort (say 33%) would be applied to proactive improvement. This includes local safety audits, peer observations, management field observations, and outside audits.

As the company improves, their safety performance and the time between significant incidents will improve significantly (do you trend this?). As this happens, effort is shifted from reactive investigations (because there are less of them) to targeted proactive improvement. This tends to cause an excelleration in the improvement progress. 

What happens if you don’t have good root cause analysis of significant incidents?

If a company does NOT do a good job investigating and fixing their serious incidents, the proactive improvement efforts tend to be miss-directed. The lessons learned from significant injuries and potential significant injuries are inaccurate. The data produced misdirects the proactive improvement efforts. The significant injuries continue even though the minor incidents targeted by the misdirected proactive improvement efforts tend to improve.

This misdirection of proactive improvement efforts has been written about extensively. Proactive behavior based safety improvement efforts produced good trends in lost time injury data with little improvement in fatality and significant injury data. This should not be a surprise. It is the reason that many companies hit a plateau of improvement for major accidents while having world-class lost time injury rates. 

I believe an excellent example of this misdirection of improvement efforts could be seen in the BP Texas City Refinery explosion. Management thought their improvement efforts were working because of a decrease in the LTI rate but the fatality rate (that included contractors) was unchanged (or maybe slightly worse). 

Where are you????

Are you trending the time between serious injuries and fatalities?

Is that time increasing significantly?

Do you know how to tell if the time between incidents is increasing significantly?

We can help you learn how to mathematically prove that improvement is occurring (or that things have taken a turn for the worse). 

Are your less significant incidents improving without making much impact on your significant injury rate? This is a sign of a misdirected improvement effort and a need to improve your root cause analysis of significant injuries.

We can review your program, point out potential improvements, and  teach your folks how to apply the best root cause analysis techniques reactively and proactively to make improvement happen.

We can also help your management understand their impact on improvement. How they directly influence the quality of the root cause analysis. (You can’t have excellent root cause analysis without management understanding and involvement.) Even the best root cause analysis systems can’t succeed unless management asks for the appropriate investigations and provides the resources needed to implement effective performance improvement fixes.

Once all of this is on track, we can help you see how to effectively apply your resources to get the most bang for your improvement buck. This includes targeting of improvement efforts and deciding when a root cause analysis is needed and when the effort should be applied elsewhere.

Call Per Ohstrom or Mark Paradies at 865-539-2139 (or CLICK HERE to contact us) to discuss your improvement efforts and see how we could help focus your program to get the best return on your improvement investment.

REVIEWING STATISTICS: How Much Did Safety Really Improve?

Posted: March 30th, 2017 in Performance Improvement

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I was reading an article that congratulated the safety profession for improving industry safety statistics in the USA. These statistics were provided from the US Bureau of Labor Statistics:

Year          # of Fatalities          Fatality Rate          Number of Workers (in millions)

1971              13,700                         17                               81

1981              12,500                         13                               96

1991                9,800                           8                              123

2001                5,900                          4.3                            137

2009                4,551                          3.5                            130

2013               4,585                          3.3                            139

What’s missing from the stats above?

The TYPE of work being performed.

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Between 1971 and 2013 there was a major change in the type of work performed in the USA. We changed from a production economy to a service economy. Plus, we implemented extensive automation. Therefore, the risk per hour worked decreased as higher risk work was replaced by office jobs and other service related work. (Yes … the picture above is well before 1971, but you get the point.)

How much did the risk change? I don’t think anyone knows for sure.

Did it account for 10% of the improvement? 25% of the improvement? 50% of the improvement? 90% of the improvement? Picking a number would be guessing.

Here is another question …

If President Trump brings back manufacturing jobs to the USA, will the number of fatalities increase with the return of higher risk work? Or will factory automation reduce the risk and keep the numbers permanently lower?

Again, this question is difficult to answer.

What can we say for sure?

There is always room for improvement and advanced root cause analysis can help you make that improvement happen.

Why Does TapRooT® Exist?

Posted: March 28th, 2017 in Human Performance, Performance Improvement, Root Causes, Success Stories, TapRooT

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

http://www.taproot.com/archives/category/success-stories

What’s Wrong with this Data?

Posted: March 20th, 2017 in Accidents, Current Events, Medical/Healthcare, Performance Improvement, Quality, Uncategorized

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

Root Cause Tip: What is the minimum investigation for a simple incident?

Posted: March 20th, 2017 in Investigations, Root Cause Analysis Tips

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What is the minimum investigation for a simple incident?

Before you can answer this question, you need to decide the outcome you are looking for. For example:

  • Do you just want to document the facts?
  • Would you be happy with a simple corrective action that may (or may not) be effective?
  • Do you need effective corrective actions to prevent repeats of this specific incident?
  • Do you want to prevent similar types of incidents?

The answers to these questions depend on two factors that determine risk:

  1. What were the consequences of this incident and could things have happened slightly differently and had much worse consequences?
  2. What is the likelihood that this type of incident will happen again?

Of course, before you start an investigation, answering these two questions may be difficult. Before you start an investigation, you don’t really know what happened! But in spite of this lack of knowledge, someone must decide if an incident is worth investigating and the resources to dedicate to the investigation.

I’ve seen simple incidents that, when investigated, revealed complex problems that could have caused a serious accident. Therefore, if a thorough investigation is not performed, the investigator may never know what they could have discovered. That’s why I caution management that something that seems simple may not be simple.

However, some incidents ARE simple. I’ve seen many incidents that people were investigating that were similar to this one:

An employee stumbles, falls, and sprains
his wrist while walking down a flat sidewalk.
He had on simple shoes with adequate tread.
He was not particularly preoccupied
nor was he entirely paying attention to each step
(just normal walking).

How much can be learned by investigating this incident? Probably not much. I would suggest that even though the person sprained his wrist, this incident should not be investigated beyond a simple recording of the facts so that the incident could be recorded for safety records (OSHA logs in the USA) and included in future incident trending.

You might ask:

“But what if the employee had stumbled and fell in front of an oncoming car and the employee killed?”

In that case, because of the consequences, a detailed major investigation would be required.

In either case, the TapRooT® Root Cause Analysis System could be used to complete the investigation.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix complex accidents, quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and effective corrective actions.

Learn more about when to investigate a simple incident by attending our 2-Day TapRooT® Root Cause Analysis training.  Click here to view the upcoming schedule.

 

The Joint Commission Issues Sentinel Event Alert #57

Posted: March 6th, 2017 in Current Events, Medical/Healthcare, Performance Improvement, Pictures, TapRooT

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

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To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

Do you believe that ignorance is bliss?

Posted: March 6th, 2017 in Performance Improvement, Pictures, TapRooT

Ignorance is Bliss

From many people’s actions, you might believe that they think “ignorance is bliss” is true. We need to ignore the real root causes of problems and just attack the symptoms.

Screen Shot 2017 03 02 at 11 53 09 AM

Even the cartoon, Calvin and Hobbs, commented on it. See the cartoon on my Facebook page …

https://www.facebook.com/ateneobookbench/photos/a.169772396396266.33963.169770589729780/472291752810994/?type=3&theater

Is this the way you treat your root cause analysis?

Would you rather have a simple BUT WRONG answer?

For over a decade, I’ve explained the shortcomings of 5-Whys for root cause analysis but some still believe that easy is better than right.

What if you could find and fix the real root causes of what you think are “simple incidents” with a robust, advanced system (TapRooT®) and not make a career of the investigation? You would put in only the effort required. Your investigation would be as simple as possible without going overboard. And your corrective actions would be effective and stop repeat incidents.

That’s what the new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about.

Have you read the new book yet?

Once you read the book you will want to start implementing TapRooT® for all the “simple” investigations that are worth being done.

Get the book today and find out what you should be doing. Order the book at:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Do Your Folks Know What to Keep After an Accident?

Posted: February 22nd, 2017 in Uncategorized

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A failure occurs. It could be:

  • a safety related accident
  • an equipment failure
  • a patient safety event (sentinel event)
  • a quality issue
  • a shipping screw up
  • a cost overrun
  • a process safety related near-miss

What people do next can make a world of difference.

First, is the failure (incident or near-miss) reported? Or is it covered up?

If you are reading this you probably think that your company should learn from its mistakes to keep the mistakes from happening again. (Or to keep something even worse from happening – like the picture above.)

But if mistakes and failures are hidden, learning is unlikely.

People must know that it is safe to report a problem and that, once a problem is reported, something will be done to improve the process to make the problem go away.

Punishing the person who reported the problem or punishing someone else involved in the failure IS NOT the kind of action that will promote more reporting of failures.

OK … You have established a culture where the reporting of problems is not punished. You may even have a culture where the reporting of problems is an expected part of how you do business. NOW WHAT?

Do people know how to preserve the evidence of the failure so that an effective root cause analysis can be performed?

You might be surprised that most folks don’t know how to preserve the scene of an accident.

They don’t know that disassembling broken equipment may destroy the evidence of why the equipment broke.

They may not collect the names of everyone involved (including contractors and first responders).

They may “clean things up” to get back to normal housekeeping standards.

They may let vital fluid samples slip away.

They may even collect “souvenirs” to take home.

Reporting the failure really doesn’t help if the evidence of the failure is destroyed before the root cause analysis starts.

What are you doing to train your supervisors to preserve the scene of a failure?

I have two suggestions.

1. Have training for them on evidence collection and interviewing.

We have a TapRooT® Course that can help supervisors secure the scene of an accident and have a much better idea of what they need to do when responding to a failure.

The course can be customized to teach just the information that you think your supervisors need.

The complete 2-Day TapRooT® Effective Interviewing & Evidence Collection Course has essential information that supervisors need to stop evidence destruction and help conduct interviews of those involved. See the course outline at:

http://www.taproot.com/courses#2-day-evidence

Barb Phillips, the course designer, will be happy to talk to you about customizing the course for your supervisors to give them the knowledge and practice that they need to be ready to effectively respond to a failure. To talk to Barb, call 865-548-8990. Or email her by using this LINK.

2. Your equipment folks need training in equipment troubleshooting and failure analysis.

We have another course designed for equipment troubleshooters to help them avoid the destruction of evidence when they respond to an equipment failure. The 2-Day Equifactor® Equipment Troubleshooting and TapRooT® Root Cause Analysis Course will help them develop a troubleshooting plan that will preserve the evidence they need to troubleshoot the problem and find the problem’s root causes.

Again, the Equifactor® Course can be customized to meet the needs of your troubleshooters. Call Ken Reed, the course creator, at 865-539-2139 to discuss ways to make your training targeted to your workforce. Or contact him by e-mail at this LINK.

Whatever you do … DON’T sit back and wait for the next accident and assume that your folks will respond appropriately. I can assure you that if hoping for the best is your strategy … you will be sadly disappointed.

Tip for Safety and Environmental Regulators – If a Refinery is being sold, INSPECT!

Posted: February 15th, 2017 in Uncategorized

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Saw an interesting article in Hydrocarbon Processing titled:

Rosneft faces $100-MM bill to boost safety at Bashneft refineries

That reminded me of the Amoco refineries that were sold to BP and had a horrible safety record.

Regulators should have a red flag for any assists covered under a PSM program. If they are being sold, INSPECT!

Perhaps this could stop management from excessive cost cutting pre-sale to boost the bottom line at the expense of safety and the environment.

TapRooT® Users Ahead of California PSM Regulations

Posted: February 14th, 2017 in Uncategorized

You may have reviewed the new regulations for process safety at California refineries. This is a major change to the standard PSM rules in the USA for California refineries. 

Here is the section from the “Incident Investigation” portion of the rule…

– – – 

(o) Incident Investigation – Root Cause Analysis.

  1. The employer shall develop, implement and maintain effective written procedures for promptly investigating and reporting any incident that results in, or could reasonably have resulted in, a major incident.
  2. The written procedures shall include an effective method for conducting a thorough Root Cause Analysis.
  3. The employer shall initiate the incident investigation as promptly as possible, but no later than 48 hours following an incident. As part of the incident investigation, the employer shall conduct a Root Cause Analysis.
  4. The employer shall establish an Incident Investigation Team, which at a minimum shall consist of a person with expertise and experience in the process involved; a person with expertise in the employer’s Root Cause Analysis method; and a person with expertise in overseeing the investigation and analysis. The employer shall provide for employee participation pursuant to subsection (q). If the incident involved the work of a contractor, a representative of the contractor’s employees shall be included on the investigation team.
  5. The Incident Investigation Team shall implement the employer’s Root Cause Analysis method to determine the initiating causes of the incident. The analysis shall include an assessment of management system failures, including organizational and safety culture deficiencies.
  6. The Incident Investigation Team shall develop recommendations to address the findings of the Root Cause Analysis. The recommendations shall include interim measures that will prevent a recurrence or similar incident until final corrective actions can be implemented.
  7. The team shall prepare a written investigation report within ninety (90) calendar days of the incident. If the team demonstrates in writing that additional time is needed due to the complexity of the investigation, the team shall prepare a status report within ninety (90) calendar days of the incident and every thirty (30) calendar days thereafter until the investigation is complete. The team shall prepare a final investigation report within five (5) months of the incident.
  8. Investigation reports shall include:
    (A) The date and time of the incident;
    (B) The date and time the investigation began;
    (C) A detailed description of the incident;
    (D) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the Root Cause Analysis;
    (E) A list of any DMR(s), PHA(s), SPA(s), and HCA(s) that were reviewed as part of the investigation;
    (F) Documentation of relevant findings from the review of DMR(s), PHA(s), SPA(s) and HCA(s);
    (G) The Incident Investigation Team’s recommendations; and,
    (H) Interim measures implemented by the employer.
  9. The employer shall implement all recommendations in accordance with subsection (x).
  10. The employer shall complete an HCA in a timely manner for all recommendations that result from the investigation of a major incident. The employer shall append the HCA report to the investigation report.
  11. Investigation reports shall be provided to and upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided to employee representatives and, where applicable, contractor employee representatives.
  12. Incident investigation reports shall be retained for the life of the process unit.

– – – 

TapRooT® Users already find management system, organizational, and cultural related root causes or generic causes that contributed to incidents they investigate. They also know about the hierarchy of controls (part of HCA analysis) and Safeguard Analysis (part of SPA) when developing corrective actions. 

TapRooT® has always been ahead of its time in finding human factors related causes of incidents. Thus, TapRooT® Root Cause Analysis fits well with the Human Factors section of the California regulation…

– – –

(s) Human Factors.

  1. The employer shall develop, implement and maintain an effective written Human Factors program within eighteen (18) months following the effective date of this section.
  2. The employer shall include a written analysis of Human Factors, where relevant, in major changes, incident investigations, PHAs, MOOCs and HCAs. The analysis shall include a description of the selected methodologies and criteria for their use.
  3. The employer shall assess Human Factors in existing operating and maintenance procedures and shall revise these procedures accordingly. The employer shall complete fifty (50) percent of assessments and revisions within three (3) years following the effective date of this section and one hundred (100) percent within five (5) years.
  4. The Human Factors analysis shall apply an effective method in evaluating the following: staffing levels; the complexity of tasks; the length of time needed to complete tasks; the level of training, experience and expertise of employees; the human-machine and human-system interface; the physical challenges of the work environment in which the task is performed; employee fatigue and other effects of shiftwork and overtime; communication systems; and the understandability and clarity of operating and maintenance procedures.
  5. The Human Factors analysis of process controls shall include:
    (A) Error-proof mechanisms;
    (B) Automatic alerts; and,
    (C) Automatic system shutdowns.
  6. The employer shall include an assessment of Human Factors in new operating and maintenance procedures.
  7. The employer shall train operating and maintenance employees in the written Human Factors program.
  8. The employer shall provide for employee participation in the Human Factors program, pursuant to subsection (q).
  9. The employer shall make available and provide on request a copy of the written Human Factors program to employees and their representatives and to affected contractors, employees of contractors, and contractor employee representatives, pursuant to subsection (q).

– – – 

These initial drafts of the regulation have been slightly modified at a public hearing last Fall. The modifications can be viewed at: http://www.dir.ca.gov/oshsb/documents/Process-Safety-Management-for-Petroleum-Refineries-15day.pdf

The California Occupational Safety and Health Standards Board is set to review the revisions and comments on a meeting being held after the comment period expires on March 3, 2017.  

While the new rule is being modified prior to adoption, California TapRooT® Users should be happy to know that they are already using a system that helps them meet and exceed the regulation being developed.

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