Author Archives: Mark Paradies

What would your management do to avoid scenes like these?

Posted: September 18th, 2017 in Accidents, Pictures

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Are they ready to improve their company’s root cause analysis?

Root Cause Analysis for the FDA

Posted: September 13th, 2017 in Investigations, Performance Improvement, Pictures, Quality, Root Cause Analysis Tips, TapRooT

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

Monday Accident and Lesson Learned: Eyes-only inspection didn’t see Ohio fair ride’s corrosion

Posted: September 11th, 2017 in Accidents

An 18-year-old man lost his life and seven others were injured when an amusement park ride ripped apart. Hidden corrosion may be what caused the malfunction. States set their own rules on ride testing and many do not have the resources to conduct nondestructive testing on their own.

Read:

Eyes-only inspection didn’t see Ohio fair ride’s corrosion

on USA Today.

Corrective Action Advice

Posted: September 6th, 2017 in Pictures, Root Cause Analysis Tips

If you use TapRooT® to find the root causes of incidents, quality issues, hospital sentinel events, equipment failures, production issues, and cost overruns, you are way ahead of your competition that is just asking “Why” five times. But what should you do to stop repeat incidents when you fix the causes of your problems?

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1. Remove the Hazard and/or the Target.

If you have been to TapRooT® Training you know what a Hazard and a Target are. Did you realize that the most effective fix is to get rid of them (if you can).

If you can get rid of them, you still may want to fix the causes of the root causes you identify. However, is there is no Hazard, you can be pretty sure you won’t have that accident happen again.

2. Install a more reliable Safeguard.

Once again, if you have been to TapRooT® Training, you know what a Safeguard is.

To have your previous incident, all the Safeguards for that incident had to fail. These failed Safeguards were your Causal Factors.

Strengthening your failed Safeguards is what root cause analysis is all about. But how much stronger can you make a weak Safeguard?

Perhaps a better idea is to implement a strong Safeguard?

An example would be to replace several weak Human Action Safeguards with a strong Engineered Safeguard.

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3. Fix the root causes of the failed Safeguards.

Use your Corrective Action Helper® Guide/Software Module to develop effective fixes for the root causes of the failed Safeguards that you identified. The Corrective Action Helper® Guide is a great way to get new ideas to fix problems that you previously just couldn’t seem to fix.

4. Get your fixes implemented.

It is no use to develop fixes and put them in a database (the backlog) and never get them implemented. make sure that corrective actions get done!

Monday Accident and Lesson Learned: Have we learned anything from famous downtime fiascos?

Posted: September 4th, 2017 in Accidents

 

Finding root causes is important not only to keep our workplaces safer but also to avoid costly incidents. IT systems downtime can cost companies millions of dollars in lost production.

This article examines the massive power outage in Silicon Valley last April as well as the August outage at Delta Airlines and asks the important question: What have we learned.

Read:

Have We Learned Anything from Famous Downtime Fiascos?

on Inc.

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

Posted: August 30th, 2017 in Accidents, Current Events, Human Performance, Investigations, Pictures, Root Causes

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Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis:

As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

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Should you use TapRooT® to find the root causes of “simple” problems?

Posted: August 30th, 2017 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT, Training

Everybody knows that TapRooT® Root Cause Analysis is a great tool for a team to use when investigating a major accident. But can you (and should you) use the same techniques for a seemingly simple incident?

Lots of people have asked us this question. Instead of just saying “Yes!” (as we did for many years), we have gone a step further. We have created guidance for someone using TapRooT® when investigating low-to-moderate risk incidents.

Can you get this guidance? YES! Where? In our new book:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

TapRooT Essentials Book

For “simple” incidents, we just apply the essential TapRooT® Techniques. This makes the investigation as easy as possible while still getting great results. Also, because you perform a good investigation, you can add your results to a database to find trends and then address the Generic Causes as you collect sufficient data.

Also, this “simple” process is what we teach in the 2-Day TapRooT® Training. See our upcoming public 2-Day TapRooT® Courses here:

http://www.taproot.com/store/2-Day-Courses/

Now … WHY should you use TapRooT® to analyze “simple” problems rather than something “simple” like 5-Whys?

Because:

  1. Even though the incident may seem simple, you want to find and fix the real root causes and not just focus on a single causal factor and end up with “human error” as a root cause (as happens many times when using 5-Whys).
  2. When you use TapRooT® for simple incidents, you get more practice using TapRooT® and your investigators will be ready for a bigger incident (if you have one).
  3. You want to solve small problems to avoid big problems. TapRooT® helps you find and fix the real root causes and will help you get the great results you need.
  4. The root causes you find can be trended and this allows analysis of performance to spot Generic Causes.
  5. Your management and investigators only learn one system, cutting training requirements.
  6. You save effort and avoid needless recommendations by applying the evaluation tool step built into the simple TapRooT® Process. This stops the investigation of problems that aren’t worth investigating.

That’s six good reasons to start using TapRooT® for your “simple” investigation. Get the book or attend the course and get started today!

Interesting Story – Was Quarry Employee Responsible for His Own Death?

Posted: August 24th, 2017 in Accidents, Investigations, Pictures, Root Causes

Jim Whiting, one of our TapRooT® Instructors in Australia, set me this article:

MCG Quarries blames Sean Scovell, 21, for his own death in 2012

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Read the article. What do you think? Where does self responsibility end and management responsibility start? What would your root cause analysis say?

Second Navy Ship Collides – What is going on?

Posted: August 23rd, 2017 in Accidents, Investigations, Pictures, TapRooT, Video

First, god bless the missing and dead sailors and their families and shipmates who experienced this, the second crash in the past two months.

I’ve waited a couple of days to comment on this second Navy collision with fatalities because I was hoping more information would be released about what happened to cause this collision at sea. Unfortunately, it seems the Navy has clamped down on the flow of information and, therefore, no intelligent comments can be made to compare the collision of the USS John S. McCain with the earlier collision of the USS Fitzgerald.

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What do we know?

  • They are both similar Navy DDG’s with the same staffing levels (only 23 officers).
  • They were both in a shipping channel.
  • They both hit (or were hit by) a merchant ship.
  • The crew was trained to the same Navy standards.

That’s about it.

Of course, we know what they did to those involved in the previous accident (see my previous article HERE).

Was the timing of this second collision just bad luck?

We could use the Navy’s collision statistics to answer that question. Of course, you would have to agree about what is a collision. Would a grounding count? Would there have to be injuries or a fatality?

We would then use the advanced trending techniques that we teach in our pre-Summit trending course to see if the second collision was so close in time to the first that it indicated a significant increase in the collision frequency. To learn about these techniques, see:

http://www.taproot.com/taproot-summit/pre-summit-courses#AdvancedTrendingTrending

Since we don’t have facts (and will probably never get them), what is my guess? The things I would consider for this accident are the same as for the last. Look into what happened including:

  1. Fatigue
  2. Where was the CO?
  3. What did the CIC watch team do?
  4. Experience/training of the bridge and CIC team.

What should the Navy do? A complete, detailed TapRooT® Investigation.

Admiral Richardson (formerly the head of the Navsea 07 – the Nuclear Navy) has the right words about the analysis the Navy is performing. What is missing? A systematic guide for the investigators and prevent them from jumping to conclusions.

In a TapRooT® Investigation, we would start collecting facts and developing a SnapCharT® to truly understand what happened. Next we would identify all the causal Factors before we started analyzing their root causes using the Root Cause Tree® Diagram. Next, we would consider the generic causes and then develop effective (SMARTER) corrective actions. Unfortunately, this will be hard to do because of the Navy’s tradition of blame.

Some of my friends have been asking if I thought that some type of sabotage was involved. Some sort of hacking of the combat systems. In my experience, unless it was extremely foggy, you should be able to use your eyes and the simple bridge radar to navigate. You don’t need fancy technology to keep you from colliding. Simple “constant bearing decreasing range” tells you a collision is coming. To prevent it you turn or slow down (or perhaps speed up) to get a bearing rate of change to bring the other ship down whichever side is appropriate (use the rules of the road).

The trick comes when there are multiple contacts and restricted channels. That’s when it is nice to have someone senior (the Commanding Officer) on hand to second check your judgment and give you some coaching if needed.

Most of the time you spend of the bridge is boring. But when you are steaming in formation or in a shipping channel with lots of traffic, it quickly goes from boring to nerve-racking. And if you are fatigued when it happens … watch out! Add to that an inexperience navigation team (even the Commanding Officer may be inexperienced) and you have an accident waiting to happen.

Is that what happened to the USS John S. McCain? We don’t know.

What we do know is that the Navy’s typical blame and shame response with a safety stand down thrown in won’t address the root causes – whatever they may be – of these accidents.

The Navy seldom releases the results of their investigations without heavily redacting them. What we do know is that previous  investigations of previous collisions were heavy on blame and included little in the way of changes to prevent fatigue or or inexperienced watch standers. The fact is that the corrective actions from previous collisions didn’t prevent this string of collisions.

What can you do? Advise anyone you know in a position of responsibility in the Navy that they need advanced root cause analysis to improve performance. The young men and women that we send to sea deserve nothing less. Navy brass needs to end the blame game and coverup and implement truly effective corrective actions.

Why is getting the best root cause analysis training possible a great investment?

Posted: August 23rd, 2017 in Courses, Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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Why do you train employees to investigate accidents, incidents, quality problems, equipment failures, and process upsets? Because those events:

  • Cost Lives
  • Cause Injuries
  • Ruin the Reputation of Your Product and Company
  • Cause Regulatory Issues (and Big Fines)
  • Cause Expensive Downtime
  • Cause Missed Schedules and Delayed Shipments

You want to learn from past problems to prevent future issues. Its even better if you can learn from small problems to prevent big accidents.

Therefore, you invest in your employees education because you expect a return on your investment. That return is:

  • No Fatalities
  • Reduced Injuries (Better LTI Stats)
  • A Reputation for Excellent Product Quality
  • Good Relations with Your Regulators and Community
  • Excellent Equipment Reliability and Reduced Corrective Maintenance Costs
  • Work Completed on Schedule
  • Shipments Go Out On Time and On Budget

When you think about your investment in root cause analysis training, think about the results you want. Review the diagram below (you’ve probably seen something like it before). Many managers want something for nothing. They want fast, free, and great root cause analysis training. But what does the diagram say? Forget about it! You can’t even have fast-great-cheap (impossible utopia). They usually end up with something dipped in ugly sauce and created with haste and carelessness! (Does 5-Why training ring a bell?)

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What should you choose? TapRooT® Training. What does it do for you? Gives you guaranteed return on your investment.

What? A guarantee? That’s right. Here is our TRAINING GUARANTEE:

Attend a course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

How can we make such an iron-clad guarantee? Because we have spent almost 30 years developing the world’s best root cause analysis system that has been tested and reviewed by experts and used by industry leaders. Over 10,000 people each year are trained to use TapRooT® to find and fix the root causes of accidents, quality problems, and other issues. Because of this extensive worldwide user base, we know that TapRooT® will help you achieve operational excellence. Thus, we know your investment will be worthwhile.

Plus, we think you will be happy with the investment you need to make when you see the results that you will get. What kind of results? That depends on the risk you have to mitigate and the way you apply what you learn, but CLICK HERE to see success stories submitted by TapRooT® Users.

Don’t think that the return on investment has to be a long term waiting game (although long term investments are sometimes worthwhile). Read this story of a FAST ROI example:

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s about a 40000% instant ROI.

How much value can you achieve from your investment in great root cause analysis? Consider these issues:

  • How much is human error costing your company?
  • If the EPA fines you $100,000 per day for an environmental permit violation, how much could it cost?
  • What is your reputation for product quality worth?
  • How much is just one day of downtime worth to your factory?
  • How much would a major accident cost?

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I’m not asking you to take my word for how much great root cause analysis training (TapRooT® Training) will help your company. I’m just asking you to give it a try to see how much it can help your company.

Just send one person to one of our 2-Day or 5-Day TapRooT® Courses. Then see how they can help solve problems using the TapRooT® Techniques. I know that you will be pleased and I’ll feel good about the lives you will save, the improvements in quality that you will make, and the improved bottom line that your company will achieve when you get more people trained.

See the list of upcoming public TapRooT® Training being held around the world:

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

 Or contact us for a quote for a course at your site:

http://www.taproot.com/contact-us

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

Posted: August 18th, 2017 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

Posted: August 16th, 2017 in Accidents, Current Events, TapRooT, Video

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

Posted: August 16th, 2017 in Current Events, Pictures, Quality, TapRooT

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

ACE – How do you find the root causes?

Posted: August 16th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Ace clipart four aces playing cards 0071 1002 1001 1624 SMU

First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

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

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

Posted: August 11th, 2017 in Accidents, Current Events, Investigations, Pictures

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

Posted: August 8th, 2017 in Accidents, Current Events, Investigations, Pictures, Video

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

How Much Do You Believe?

Posted: August 1st, 2017 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT, Training

I was talking to my kids about things they read (or YouTube videos) on the internet and asked them …

How much of what you see online do you believe?

I told them that less than half of what I see or read online is believable (maybe way less than half).

But the next question I asked was more difficult …

How do you know if something is believable? How would you prove it?

This made them think …

I said that I have a lifetime of experience that I can use to judge if something sounds believable or not. Of course, that isn’t proof … but it does make me suspicious when something sounds too good to be true.

They didn’t have much life experience and therefore find it harder to judge when things are too good to be true.

However, we all need to step back and think … How can I prove something?

What does that have to do about accident and incident investigations?

Do you have a built-in lie detector that helps you judge when someone is making up a story?

I think I’ve seen that experienced investigators develop a sense of when someone is making up a story.

We all need to think about how we collect and VERIFY facts. Do we just accept stories that we are told or can we verify them with physical evidence.

The 1-Day TapRooT® Effective Interviewing & Evidence Collection Course that will be held in Houston on November 8th will help you think about your interviews and evidence collection to make your SnapCharT® fact based. In addition to the 1-Day Interviewing Course you can also sign up for the 2-Day TapRooT® Root Cause Analysis Course being held in Houston on November 6-8 by CLICKING HERE.

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Barb Phillips will be the instructor for the Effective Interviewing & Evidence Collection Course. Don’t miss it!

Is There Just One Root Cause for a Major Accident?

Posted: July 26th, 2017 in Accidents, Courses, Investigations, Pictures, Root Cause Analysis Tips, Root Causes, TapRooT

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Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

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

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

Get Both Books and Save

Posted: July 25th, 2017 in Pictures, TapRooT

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There are two new books that explain how to perform TapRooT® root cause analyses.

One is used to investigate low to medium risk incidents. It is titled:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

It is used for fast, simple investigations.

The second is used for major investigations, big fires, oil spills, fatalities, and the such. It is titled:

Using TapRooT® Root Cause Analysis for Major Investigations

It includes all the TapRooT® optional techniques.

Did you know that you can buy both books at the same time and save? To order, CLICK HERE.

Mark Paradies and Kathy Ireland on Worldwide Business – It’s a wrap!

Posted: July 21st, 2017 in TapRooT, Video

Here’s a live Facebook cut from the end of shooting. We’ll post the show dates here.

System Improvements,Inc. is now LIVE on the set of Worldwide Business with kathy ireland!

Posted by Worldwide Business with kathy ireland on Wednesday, July 19, 2017

 

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