Author Archives: Mark Paradies
Attending the 5-Day Advanced Root Cause Analysis Course in Hamburg, Germany will be a great experience because the training is exceptional. But you may also be interested in attending the Miniature Wonderland. Watch the following video for more info …
I was e-mailing with a TapRooT® User today and this is part of what they had to say about the Summit …
“… they are the best conferences that I have been to in the over 40 years of my career!!!”
See what he was talking about at:
One of the final steps in performing a TapRooT® Root Caquse Analysis is finding Generic Causes.
What is a Generic Cause? It is the reason that a root cause is widespread.
For example, a root cause for an error made while using a procedure might be that the procedure have more than one action per step.
4. Remove the drum lid and the polyethylene liner lid, place liner in prepared drum and place in loading position at the final packaging hut. Insert plastic bag in drum liner. Seal the plastic bag with tape to the inside of the drum loading insert.
The fix for this specific root cause might look something like this:
4. Remove the drum lid and the polyethylene liner lid. . . . . . ___
5. Place liner in prepared drum. . . . . . . . . . . . . ___
6. Place prepared drum in loading position at the final packaging hut. . ___
7. Insert plastic bag in drum liner. . . . . . . . . . . . ___
8. Seal the plastic bag with tape to the inside of the drum loading insert. ___
If the team then went to check other procedures and found that this problem was widespread, they would then have a generic problem. The question then becomes: “Why is the problem of ‘more than one action per step’ so widespread? What is the generic Cause that allows us to produce poor procedures?
The root cause analysis team may find that the people writing procedures have no guidance for writing procedures and no training on how to write procedures.
This should cause the team to look for other generic procedure problems.They might also find that procedure formats are confusing, the level of detail is inconsistent, there are excessive references,and the graphics need improvement.
The Corrective Action Helper® Guide provides guidance to fix these kinds of Generic Causes. But the widespread generic procedure problems probably indicate that the company or site doesn’t really know how to produce good procedures. Therefore, the Corrective Action Helper® Book recommendation to fix specific Generic Causes might not be enough guidance.
For example, the Corrective Action Helper® Guide says that for generic “greater than one action per step” problems, the investigators should consider:
“…a general procedure improvement program to remove multiple actions per step from the rest of the facilities procedures.”
However, if the procedures are in really bad shape, more must be done.
Of course, the Corrective Action Helper® Guide provides even more information – references. And if the investigators read the suggested reference, they may look for the additional problems and develop a plan to improve their procedures that is more comprehensive.
That would be great. But how many team read the references? My guess is … not that many. After all, in today’s downsized, super-efficient workplace, people just don’t have time.
That why System Improvements is here to provide assistance.
If you run into generic problems that you think may be important to fix, we can help.
At a minimum, we can coach your team on the development of generic corrective actions.
Beyond that, we can put an evaluation team together to evaluate the scope of the Generic Cause and develop a plan to improve performance by eliminating the Generic Cause and upgrading current systems.
Finally, if you really need help, we can put together a team to help implement the fix. In this cause, a team of experienced procedure writers to help your company fix their current procedures and coach your procedure writers how to write better procedures in the future.
We can even make rerun visits to audit the status of the corrective actions and the work of your procedure writers.
So when you find a Generic Cause that you know your company isn’t good at fixing (or doesn’t have the time to explore and fix), remember that System Improvements can help.
Don’t let problems repeat because Generic Causes are left un-fixed. Get help. Call us at 865-539-2139 or CLICK HERE to end us a message. We can help you improve!
Antoine de Saint-Exupery
Usually you think about goals when you are setting budgets or maybe at the start of the year. But now that we are well into the year (the first quarter is complete), I thought it might be time to review your goals and your progress on them for the year (and into next year).
I though I would start off by providing a list of the Top 10 Goals that would be applicable to most TapRooT® Users. You could review them, see if any of them are on your list, and reflect on how you are doing on achieving them.
Then, once you have contemplated your goals, I have a suggestion for for you to consider for each goal.
So let’s get started. Here are the Top 10 Goals.
TOP 10 IMPROVEMENT GOALS
1. Improve safety to eliminate fatalities and serious injuries at our facilities. (If you are at a hospital, you might modify this goal to be: “Improve patient safety to eliminate sentinel events.” If you are responsible for equipment reliability you could say: “Improve equipment reliability to eliminate unexpected key equipment downtime.” If you are responsible for quality, you might say: “Improve quality before a major quality issue impacts a customer.”)
2. Improve management participation in improvement efforts.
3. Improve employee participation in improvement initiatives.
4. Motivate people to exhibit positive behaviors that result in success at work and at home.
5. Learn proven best practices from industry leaders that I can apply to our improvement initiatives to make them more effective.
6. Improve our corrective actions so that problems never repeat once they are effectively investigated and fixes are implemented.
7. Learn how to stop “normalization of deviance” to ensure our safety policies are effectively applied.
8. Develop proactive performance measures to better understand trends in safety, equipment reliability, and production performance.
9. Become a better TapRooT® User to continuously improve your root cause analysis initiatives.
10. Identify the gaps in our improvement initiatives and find ways to make those gaps into our strengths in the future.
These top ten goals are rather safety oriented, but if you are responsible for equipment reliability, quality, production, patient safety, you can modify the goals with your improvement efforts in mind and the “safety” list can be converted into a patient safety list, an equipment reliability list, or a production efficiency list.
Now, see how many of these goals match those goals on your top 10 list…
Do you have some goals that you need to add to your list?
How are you doing this year meeting your goals?
Have you made enough progress in the first quarter so that you feel confident
that by the end of the year you will have accomplished all of these goals?
TapRooT® Training and the 2015 Global TapRooT® Summit can help you achieve all 10 of these goals. How? Read on …
GOAL 1. Improve safety to eliminate fatalities and serious injuries at our facilities. (If you are at a hospital, you might modify this goal to be: “Improve patient safety to eliminate sentinel events.” If you are responsible for equipment reliability you could say: “Improve equipment reliability to eliminate unexpected key equipment downtime.” If you are responsible for quality, you might say: “Improve quality before a major quality issue impacts a customer.”)
Did you know that the best way to eliminate a problem is to become proactive in fixing problems? That means you must identify problems and fix them (using tapRooT® Root Cause Analysis) BEFORE an accident, sentinel event, equipment failure, quality issue, or production failure occurs.
How are you becoming more proactive? Here are several suggestions…
Proactive Improvement Suggestions
- SAFETY: Did you know that there is a “Proactive Use of TapRooT® Course”? It was developed to teach people how to become more proactive by using TapRooT® Root Cause Analysis to find and fix the causes of problems before major accidents happen. If you are trying to be more proactive, this just might be the course for you. WARNING: There is only one public Proactive Use of TapRooT® Course scheduled for this year. It is on June 1-2 in Las Vegas. If you want to become more proactive, register NOW by CLICKING HERE. Or get more information by clicking here. Also, consider attending the 2015 Global TapRooT® Summit where you will learn about developing proactive performance measures as part of the Safety Improvement Track. Register for both the Summit and the course by CLICKING HERE.
- EQUIPMENT RELIABILITY: If you are interested in improving equipment reliability by the use of effective troubleshooting and root cause analysis tools AND you would like to use those tools proactively, I have a suggestion. First, if you haven’t already attended an Equifactor® Course, sign up for the one on June 1-2 in Las Vegas. These techniques come highly recommend and are based on a combination of the work done by equipment reliability expert Heinz Bloch and root cause analysis expert Mark Paradies. Then you can stay for the Equipment Reliability Improvement and Troubleshooting Track at the 2015 Global TapRooT® Summit where you will meet Heinz Bloch and Mark Paradies and here the latest information about improving equipment performance. See the course description by clicking here. See the track schedule by clicking here. And register for both (and get a discount) by clicking here.
- PATIENT SAFETY: Improving patient safety has been a focus of the Global TapRooT® Summit since the late 1990s. This year we;ve combined a pre-Summit 2-Day TapRooT® Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement Course with the Improving Healthcare Quality and Patient Safety Track at the Summit so that those who aren’t familiar with TapRooT® can learn the techniques and discover how to apply them proactively to improve patient safety. See the course details by clicking here. See the 2015 Global TapRooT® Summit Healthcare Quality and Patient Safety Track schedule by clicking on the track button at this link: http://www.taproot.com/taproot-summit/summit-schedule. Register for both the course and the tracy by CLICKING HERE.
- QUALITY/OPERATIONS: If you would like to apply TapRooT® to improve quality or add it to your Lean/Six Sigma Program, then you should attend the pre-Summit TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training. Then attend the Process Quality and Corrective Action Program Track at the 2015 Global TapRooT® Summit. Lean/Six Sigma improvement efforts can be made even more effective (and more proactive) when effective root cause analysis (TapRooT®) is embedded into the program. CLICK HERE to register for both the course and the track.
GOAL 2: Improve management participation in improvement efforts.
Is your management involved in your improvement efforts as much as they should be? Many say that a lack of management support is one of they major problems that have when trying to improve performance.
One thing that improvement managers must realize is that it IS NOT management’s job to stay excited about an improvement program. It is the improvement program manager’s job to keep management excited and to let them know if they fail to show support for the improvement effort.
This is especially true because of the recent downturns in the oil and mining industries. Several people have told me that travel and training bans enacted because of budget cutting efforts are devastating their efforts to benchmark improvements with others and learn new best practices to keep their program moving forward. When these “global bans” get in the way of making improvement progress happen, improvement managers have to point the problem out to management and let them know that this is sending a clear message that the improvement effort is clearly NOT a top priority and clearly falls behind profitability on the list of things management cares about.
Remind your managers that cutting back on improvement is actually expensive because of the costs of poor quality, accidents, equipment failures, and production upsets.
GOAL 3: Improve employee participation in improvement initiatives.
If your employees don’t seem to be involved in improvement efforts, maybe it is because you haven’t provided the opportunity?
Have you trained your employees to use advanced root cause analysis to solve problems and to use the same tools proactively?
If you need to get your employees fully committed to improving, give them the tools they need. Have an on-site TapRooT® Root Cause Analysis Course. Call us at 865-539-2139 or CLICK HERE to request more information about an on-site course.
GOAL 4: Motivate people to exhibit positive behaviors that result in success at work and at home.
Motivating people is a difficult topic. Perhaps the best advice I’ve ever heard about motivation employees was a talk I heard from Dr. Beverly Chiodo. That’s why for the last decade I’ve had her to speak at the Global TapRooT® Summit. And she is speaking again this year in two sessions. The first is the opening keynote talk on Thursday. Her talk is titled “Character Driven Success” and it will have an impact on your life.
She will speak again on Thursday afternoon in a breakout session. Her talk for this session – Praising the 49 Character Traits – will give you practical ideas for changing behavior by properly praising your employees.
If behavior is important to your improvement efforts, don’t miss these two talks. Register for the 2015 Global TapRooT® Summit today.
GOAL 5: Learn proven best practices from industry leaders that I can apply to our improvement initiatives to make them more effective.
How do you learn about new best practices from inside and outside your industry? Inside and outside your profession?
Two standard methods are:
- Industry/professional trade magazines.
- Industry/professional conferences.
There are some excellent conferences to consider in any industry/profession.
What I’ve found is that even at the best of these conferences, there tend to be industry or professional silos. For example:
- Oil industry folks tend to learn best practices from the oil industry,
- Nuclear industry folks learn from the nuclear industry
- Aviation … aviation
- Heathcare … healthcare
- Manufacturing … manufacturing
- Quality folks tend to meet and share best practices with quality folks,
- Equipment reliability … equipment reliability
- Safety … safety
And to make matters worse, we then tend to look inside out own geographic area/culture/language. US people attend conferences in North America. Europeans … Europe. Australians … Australia.
That’s why when we created the TapRooT® Summit we wanted to do something very different. We wanted to cross geographic, industrial, and professional boundaries.
And we wanted to create an environment where benchmarking and sharing experience is fun.
The feedback that we get after every Global TapRooT® Summit is that we’ve done a very good job of that.
For example, a process safety person from a chemical plant learns best practices from a licensing engineer in the nuclear industry. A healthcare quality improvement professional learns best practices from a flight safety professional. And a nuclear safety engineer learns things from an equipment reliability specialist from a foundry.
Not only do they learn, but they have a good time doing it!
That’s why I’ve had many TapRooT® Summit participants tell me that it is the BEST networking experience that they have ever experienced. Better than any industry conference that they go to.
Thus if you haven’t yet met your goal of learning valuable best practices that you can implement to keep your improvement program fresh and progressing, you should consider attending the 2015 Global TapRooT® Summit. See all the track schedules at THIS LINK.
GOAL 6: Improve our corrective actions so that problems never repeat once they are effectively investigated and fixes are implemented.
How is your CAPA program doing in preventing repeat incidents? If your goal is to improve, there are several ideas that I could suggest.
- Perform better root cause analysis. If you haven’t taken a TapRooT® Root Cause Analysis Course, take one SOON! See the course schedule by clicking on your continent at THIS LINK.
- If you already use TapRooT® and want to improve your use of the technique. Attend an 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course. See the course details (which should convince you to attend) at this LINK.
- TapRooT® Users should also consider attending the 2015 Global TapRooT® Summit where there are several track that may be of interest including the Incident Investigation and Root Cause Analysis Best Practice Track, the Process Quality and Corrective Action Program Track, the Safety Improvement Track, and the Improving Healthcare Quality and Patient Safety Track.
- There is actually a pre-Summit course – Creative Corrective Actions Course – that is targeted toward people that want to develop better, more effective, corrective actions. See the details by CLICKING HERE.
At least one of those four ideas should help you jumpstart efforts to reach your goals in 2015/2016.
GOAL 7: Learn how to stop “normalization of deviance” to ensure our safety policies are effectively applied.
Mark Paradies is presenting a session about “How to STOP the normalization of deviation” at the 2015 Global TapRooT® Summit in Las Vegas the Human Error Reduction & Behavior Change Track. The talks is in Session 5. Be sure that you are there if you are interested in this topic and want to STOP the normalization of deviation.
GOAL 8: Develop proactive performance measures to better understand trends in safety, equipment reliability, and production performance.
This is another topic being covered at the 2015 Global TapRooT® Summit. Finals details of this session are not yet posted on the Summit site because the talks are still being developed. But you can be sure that new, interesting, useful information on proactive performance indicators will be presented and that you will develop indicators for your facility.
GOAL 9: Become a better TapRooT® User to continuously improve your root cause analysis initiatives.
You can start your journey to performance improvement by simply attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. But all TapRooT® Users know, this is just the start. Practice, coaching, and advanced training are part of the journey to becoming an expert root cause analysis investigator.
The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training is designed to help you become a root cause analysis expert.
But what do you do to improve your skills after you have attended a 2-Day and 5-Day Course? There are several options.
The 2015 Global TapRooT® Summit includes the following nine tracks:
- Safety Improvement
- Equipment Reliability & Troubleshooting
- Human Error Reduction & Behavior Change
- Improving Healthcare Quality & Patient Safety
- Incident Investigation & Root Cause Analysis
- Process Quality & Corrective Action Programs
- TapRooT® Software
- TapRooT® Certified Instructor
- Special Topics
This is an excellent source of knowledge to improve your performance improvement skills. But beyond the knowledge you learn, you will also make great contacts – friends – across many industries and professional disciplines that can also help you expand your performance improvement network.
Second, before the Summit we hold special advanced training for performance improvement experts to help them refresh and broaden their skills. Before the 2015 Summit, the following advanced courses will be offered that you can use to become a better root cause analysis expert:
- Creative Corrective Actions
- Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement
- Understanding and Stopping Human Error
- Combatting Fatigue
- Interviewing & Investigation Basics
- Proactive TapRooT® Use
- Hazard Recognition
- Getting the Most from Your TapRooT® Software
- TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis
- Risk Assessment and Management Best Practices
- TapRooT® Analyzing and Fixing Safety Culture Issues
- TapRooT® Advanced Trending Techniques
- Advanced Causal Factor Development
- Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course
That’s a great list of courses full of advanced knowledge to help you improve.
When and where are the pre-Summit Courses and the 2015 Global TapRooT® Summit? The courses and Summit will be held in Las Vegas on June 1-5, 2015. Register now to make sure that you get your first choice for training.
GOAL 10. Identify the gaps in our improvement initiatives and find ways to make those gaps into our strengths in the future.
Every TapRooT® Session Track at the 2015 Global TapRooT® Summit includes a session focussed on identifying the gaps in your performance improvement program and developing ideas to improve your improvement efforts to eliminate the gaps. So if you are interested in eliminating the holes in your improvement program, attend the 2015 Global TapRooT® Summit and make your improvement efforts sizzle with new best practices, new ideas, and lessons learned from industry leaders.
That’s it. Ten goals and the ways that TapRooT® Training and the TapRooT® Summit can help you meet those goals.
Don’t waste 2015 and 2016 standing still. Get your performance improvement program moving at the speed of light by getting the training and networking that you need to accelerate your program and your career.
Good thing he has his safety vest on!
Watch this video and see if you think they learned all the lessons they should have learned …
I’ll just be under it for a minute …
See the article by Heinz Bloch at:
And then attend the Equipment Reliability and Troubleshooting Track at the 2015 Global TapRooT® Summit and hear Heinz speak about the business end of equipment reliability and the foundations of Equifactor®. See the complete Summit schedule at:
If you are a ship’s captain, it looks like this…
1. Where was the first TapRooT® Summit (then called the TapRooT® Conference) held?
c) San Antonio
2. How many TapRooT® Summits have been held since the first Summit?
3. In what year was the first TapRooT® Summit Held?
4. Who was presented with the “Most Beloved Speaker” Award?
a) Ed Skompski
b) Mark Paradies
c) Beverly Chiodo
d) ED Hill
5. Counting this year, how many times has the Global TapRooT® Summit been held in Las Vegas?
6. Where was the largest (by attendance) Global TapRooT® Summit ever held?
d) Las Vegas
7. How was JR Ewing connected to the Global TapRooT® Summit?
a) He invented it.
b) People from his oil company always attend.
c) He was involved in a TapRooT® investigation.
d) A JR look alike attended the TapRooT® Summit reception in 1998 at the Southfork Ranch.
8. How many Summit Best Practice Tracks are there at this year’s Global TapRoot® Summit?
9. You can customize your Summit schedule by picking topics from different Best Practice Tracks.
10. Last years Global TapRooT® Summit was held in?
a) Las Vegas
Check the comments field below for the answers!
And don’t miss the 2015 Global TapRoot® Summit. For more information see:
A press release from the UK RAIB:
RAIB is investigating an incident that occurred at 17:25 hrs on Saturday 7 March 2015, in which train reporting number 1Z67, the 16:35 hrs service from Bristol Temple Meads to Southend, passed a signal at danger on the approach to Wootton Bassett junction, Wiltshire. The train subsequently came to a stand across the junction. The signal was being maintained at danger in order to protect the movement of a previous train. However, at the time that the SPAD occurred, this previous train had already passed through the junction and was continuing on its journey. No injuries, damage or derailment occurred as a result of the SPAD.
Wootton Bassett junction is situated between Chippenham and Swindon stations on the Great Western main line and is the point at which the line from Bristol, via Bath, converges with the line from South Wales. It is a double track high speed junction which also features low speed crossovers between the up and down main lines (see figure below for detail).
Wootton Bassett junction in 2012 – the lines shown from left to right are the Up Goods,
Up Badminton, Down Badminton, Up Main and Down Main (image courtesy of Network Rail)
The junction is protected from trains approaching on the up main from Chippenham by signal number SN45, which is equipped with both the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS). This signal is preceded on the up main by signal SN43, which is also equipped with AWS and TPWS. The maximum permitted line speed for trains approaching the junction from this direction is normally 125 mph. However, on 7 March, a temporary speed restriction (TSR) of 85 mph was in place on the approach to signal SN45. A temporary AWS magnet had been placed on the approach to signal SN43 to warn drivers of this TSR.
A diagram of the layout of Wootton Bassett junction – note that some features have been omitted for clarity (not to scale)
The train which passed signal SN45 at danger consisted of steam locomotive number 34067 ‘Tangmere’, and its tender, coupled to 13 coaches. The locomotive is equipped with AWS and TPWS equipment.
The RAIB’s preliminary examination has shown that, at around 17:24 hrs, train 1Z67 was approaching signal SN43 at 59 mph, when it passed over the temporary AWS magnet associated with the TSR. This created both an audible and visual warning in the locomotive’s cab. However, as the driver did not acknowledge this warning within 2.7 seconds, the AWS system on the locomotive automatically applied the train’s brakes. This brake application should have resulted in the train being brought to a stand. In these circumstances, the railway rule book requires that the driver immediately contact the signaller.
The RAIB has found evidence that the driver of 1Z67 did not bring the train to a stand and contact the signaller after experiencing this brake application. Evidence shows that the driver and fireman instead took an action which cancelled the effect of the AWS braking demand after a short period and a reduction in train speed of only around 8 mph. The action taken also had the effect of making subsequent AWS or TPWS brake demands ineffective.
Shortly after passing the AWS magnet for the TSR, the train passed signal SN43, which was at caution. Although the AWS warning associated with this signal was acknowledged by the driver, the speed of the train was not then reduced appropriately on the approach to the next signal, SN45, which was at danger. Because of the earlier actions of the driver and fireman, the TPWS equipment associated with signal SN45 was unable to control the speed of the train on approach to this signal.
As train 1Z67 approached signal SN45, the driver saw that it was at danger and fully applied the train’s brakes. However, by this point there was insufficient distance remaining to bring the train to a stand before it reached the junction beyond SN45. The train subsequently stopped, standing on both the crossovers and the up and down Badminton lines, at around 17:26 hrs. The signalling system had already set the points at the junction in anticipation of the later movement of 1Z67 across it; this meant that no damage was sustained to either the train or the infrastructure as a result of the SPAD.
The RAIB has found no evidence of any malfunction of the signalling, AWS or TPWS equipment involved in the incident.
The RAIB’s investigation will consider the factors that contributed to signal SN45 being passed at danger, including the position of the temporary AWS magnet associated with the TSR. The investigation will also examine the factors that influenced the actions of the train crew, the adequacy of the safety systems installed on the locomotive and the safety management arrangements.
RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.
We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation.
These findings will be available on the our website.
The Houston Chronicle published an article by Rafael Moure-Eraso of the Chemical Safety Board that was titled: “Hazardous work takes toll on Latinos”.
In the article, Rafael Moure-Eraso claims that among Latinos “… fatality and injury rates are disproportionately high.” He provides statistics on Latino fatalities and injuries in various industries. He references a report that states the obvious (as many Latinos are recent immigrants, they tend to get lower paying and more dangerous jobs). He also states that Latinos are more likely to be at risk as residents near chemical plants (once again, obviously rich people usually don’t sit their mansions next to chemical plants and the poor are more likely to buy cheap housing in a less desirable locations – like next door to an industrial site).
The article seems to be a mix of environmental justice political speech and a call for new federal regulations to improve chemical plant safety.
He ends the article with:
“You can’t put a price on someone’s life. Latinos help drive the country’s economy working hard for companies big and small, often in dangerous occupations. They have a right to safer workplaces and communities.”
That made me think …
- Are new rights (the right to safety … whatever that is) and new federal programs really the way to improve safety in the workplace?
- Do accidents really target specific races?
- Would a federally run workplace be safer than those run by commercial companies?
- Would safety improve faster with more federal direction?
- Does the government know better than those in commercial industry how to improve safety?
- What does management at major companies need to do if they want to avoid a whole new level of “one size fits all” government regulation of process safety and industrial safety?
These are all very interesting questions that take considerable thought. I’d be interested in your opinions. Leave a comment here.