Author Archives: Mark Paradies
We have been working hard to make TapRooT® even better. Therefore, we have NEW things to share.
We have three new books that are available and three more that will be coming out in the first quarter. They are part of the new nine book set that will all be out by the end of 2017.
To see what is available now, CLICK HERE.
We’ve been updating our TapRooT® Training. Every course has had major improvements. Of course, the new courses include the new books, but there is much more that’s been improved to make TapRooT® easier to use and more effective. To find out more about our TapRooT® Courses, CLICK HERE.
Have you had a look at our new Version VI TapRooT® Software? It’s cloud-based and is device independent. Use it on your PC, Mac, or any tablet. CLICK HERE for more info.
IMPROVE YOUR ROOT CAUSE ANALYSIS BY USING THE LATEST TECHNOLOGY
The old TapRooT® Books, training, and software were good. The NEW TapRooT® Books, Training, and Software are even better. Don’t miss out in the advances in TapRooT® Technology. Get the latest by clicking on the links above and updating your technology.
Also, as more new books, courses, and software improvements are released as the year progresses, we will let you know by posting information here. Keep watch and keep up with the latest in advanced root cause analysis.
Are you sending people to our Public TapRooT® Training?
Or are you having a TapRooT® Course at your site?
And arranging TapRooT® Training at one or more of your facilities around the world?
If you want to choose your dates, now is the time to get your onsite courses scheduled.
And if you want to choose a particular public course, now is the time to get your folks registered!
Did you make your New Year’s resolutions? Your ideas to improve your performance next year?
In many companies, you are expected to have plans to improve performance. Better production performance, quality, equipment reliability, safety, process safety, and financial performance are all expected parts of the normal year-to-year improvement process. If you are leading any of these improvement efforts, you better have a plan.
What if you could do something to both improve your personal performance and your company’s performance? Would that be interesting?
Plan to attend a TapRooT® Root Cause Analysis Course!
What are you waiting for? TapRooT® Root Cause Analysis is proven by leading companies around the world to help them find and fix the root causes of performance problems. And the TapRooT® System can be used proactively to stop problems before major incidents happen. This can lead to improved financial performance in addition to improved safety, quality, equipment reliability, and production performance.
But beyond that, you will be adding an advanced skill to your toolbox that you can use for the rest of your career. Think of it as a magic problem-solving wand that you can use to astound others by the improvement initiatives you will lead. This can lead to promotions and personal financial gain. Sounds like a great personal improvement program.
Now is the time to make your plans for 2017. Get your courses scheduled. Get ready to make your skills better and your company a better place to work.
Read this story about a recent BP internal audit:
You can see why many managers don’t want written reports critical of any safety or environmental performance.
Does your company have any practices to mitigate bad press from internal audits?
A Report from the UK Rail Accident Investigation Branch:
Structural failure caused by scour at Lamington viaduct, South Lanarkshire, 31 December 2015
At 08:40 hrs on Thursday 31 December 2015, subsidence of Lamington viaduct resulted in serious deformation of the track as the 05:57 hrs Crewe to Glasgow passenger service passed over at a speed of about 110 mph (177 km/h). The viaduct spans the River Clyde between Lockerbie and Carstairs. Subsequent investigation showed that the viaduct’s central river pier had been partially undermined by scour following high river flow velocity the previous day. The line was closed for over seven weeks until Monday 22 February 2016 while emergency stabilisation works were completed.
The driver of an earlier train had reported a track defect on the viaduct at 07:28 hrs on the same morning, and following trains crossed the viaduct at low speed while a Network Rail track maintenance team was deployed to the site. The team found no significant track defects and normal running was resumed with the 05:57 hrs service being the first train to pass on the down line. Immediately after this occurred at 08:40 hrs, large track movements were noticed by the team, who immediately imposed an emergency speed restriction before closing the line after finding that the central pier was damaged.
The viaduct spans a river bend which causes water to wash against the sides of the piers. It was also known to have shallow foundations. These were among the factors that resulted in it being identified as being at high risk of scour in 2005. A scheme to provide permanent scour protection to the piers and abutments was due to be constructed during 2015, but this project was deferred until mid-2016 because a necessary environmental approval had not been obtained.
To mitigate the risk of scour, the viaduct was included on a list of vulnerable bridges for which special precautions were required during flood conditions. These precautions included monitoring of river levels and closing the line if a pre determined water level was exceeded. However, this process was no longer in use and there was no effective scour risk mitigation for over 100 of the most vulnerable structures across Scotland. This had occurred, in part, because organisational changes within Network Rail had led to the loss of knowledge and ownership of some structures issues.
Although unrelated to the incident, the RAIB found that defects in the central river pier had not been fully addressed by planned maintenance work. There was also no datum level marked on the structure which meant that survey information from different sources could not easily be compared to identify change.
As a result of this investigation, RAIB has made three recommendations to Network Rail relating to:
- the management of scour risk
- the response to defect reports affecting structures over water
- the management of control centre procedures.
Five learning points are also noted relating to effective management of scour risk.
For more information, see:
SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.
Are you using advanced root cause analysis to investigate near-misses and stop major accidents? Major accidents can be avoided. That’s a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:
TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.
For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.
Don’t wait! If you have attended TapRooT® Training, get signed up today!
Teenagers seem to have no concept of how far away from death that they are. Very few over 25 would do this…
When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.
The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.
This modern definition of a root cause leads to this definition of root cause analysis:
Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring.
Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.
Even though a decade had passed since proposing this new definition, I still have people ask:
“Why did you change the definition? I liked it like it was!“
Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.
The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!
The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.
This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.
The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.
One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.
That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.
Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.
For a report from the UK Rail Accident Investigation Branch, see:
Here is my Thanksgiving posting. I post it every year, lest we forget…
In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!
One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.
During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.
The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.
With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.
Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.
The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.
Is this the root cause of Thanksgiving?
This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:
“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”
William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.
If you don’t understand what happened, you will never understand why it happened.
You would think this is just common sense. But if it is, why would an industry allow a culture to exist that promotes blame and makes finding and fixing the root causes of accidents/incidents almost impossible?
I see the blame culture in many industries around the world. Here is an example from a hospital in the UK. This is an extreme example but I’ve seen the blame culture make root cause analysis difficult in many hospitals in many countries.
Dr. David Sellu (let’s just call him Dr. Death as they did in the UK tabloids), was prosecuted for errors and delays that killed a patient. He ended up serving 16 months in high security prisons because the prosecution alleged that his “laid back attitude” had caused delays in treatment that led to the patient’s death. However, the hospital had done a “secret” root cause analysis that showed that systemic problems (not the doctor) had led to the delays. A press investigation by the Daily Mail eventually unearthed the report that had been kept hidden. This press reports eventually led to the doctor’s release but not until he had served prison time and had his reputation completely trashed.
If you were a doctor or a nurse in England, would you freely cooperate with an investigation of a patient death? When you know that any perceived mistake might lead to jail? When problems that are identified with the system might be hidden (to avoid blame to the institution)? When your whole life and career is in jeopardy? When your freedom is on the line because you may be under criminal investigation?
This is an extreme example. But there are other examples of nurses, doctors, and pharmacists being prosecuted for simple errors that were caused by systemic problems that were beyond their control and were not thoroughly investigated. I know of some in the USA.
The blame culture causes performance improvement to grind to a halt when people don’t fully cooperate with initiatives to learn from mistakes.
TapRooT® Root Cause Analysis can help investigations move beyond blame by clearly showing the systemic problems that can be fixed and prevent (or at least greatly reduce) future repeat accidents.Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.
Foe course information and course dates, see:
Found this TV show about the crash and thought it was interesting … What can you learn?