Author Archives: Mark Paradies
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? That 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?
I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:
“If people would just try harder, be more careful, or be more alert, the problems would go away.”
This implies bad people (careless, lazy, and/or dullards) are the issues.
Have you ever met one of these people? Do you work in an organization that thinks this way?
I once had a safety manager at a refinery tell me:
“At our refinery, 5% of the people account for 95% of the lost time injuries.”
He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.
Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.
TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.
Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.
And don’t worry about trying something new. Our courses are guaranteed!
Attend our training, 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.
That’s a strong guarantee because we know that TapRooT® will work for your company.
For more information about TapRooT®, watch the video at:
As a TapRooT® User, you probably know that Mark is one of the co-creator’s of the TapRooT® Root Cause Analysis System and a co-author of the TapRooT® Book series. You have probably heard that he has all sorts of experience with root cause analysis and incident investigation. But did you know that …
Mark is a Certified Professional Ergonomist (CPE).
He was the 85th person to be certified in ergonomics and human factors by the Board of Certified Professional Ergonomists. Mark has worked extensively on projects to improve human performance and reduce human errors.
His Masters Degree research at the University of Illinois was focused on the proper roles of operators and automation for the next generation of nuclear power plants (human factors function allocation).
Before starting System Improvements, he worked on projects to improve aspects of human performance including procedures usability and usage, and operator, maintenance, and technical training.
He also developed systems for managing performance improvement in a resource limited environment.
He used his human factors knowledge and experience to build into the TapRooT® System the ability to analyze and fix human performance/human behavior issues.
Mark was in Admiral Rickover’s Nuclear Navy (a High Reliability Organization).
Mark has studied high reliability organizations. But Mark has one major advantage over most of those who do academic research and speak about high reliability organizations … He has worked in a high reliability organization – the Nuclear Navy (the original high reliability organization). Therefore, he knows what works, why it works, and what doesn’t work BECAUSE HE HAS BEEN THERE. He understands Admiral Rickover’s management systems and practical methods to guard against normalization of deviation.
Mark has a unique understanding of process safety.
Marks has two engineering degrees (BSEE and MS Nuc E), human factors training, and experience working in Admiral Rickover’s Nuclear Navy (where he achieved his Engineer Certification). This gives him a unique understanding of process/nuclear safety. He has written about this experience (see this LINK) and provided talks for companies interested in improving their process safety systems and senior management understanding of process safety. (See part of his Summit talk in 2012 HERE.)
Mark has developed trending techniques for infrequently occurring safety and quality data.
Mark used the work of statistical experts Dr. Donald Wheeler, Dr. Walter Shewhart, and W. Edwards Deming to develop techniques to find statistically valid trends of infrequently occurring accident data. Mark is working on a new book about performance measurement and trending that will be published in 2017. Watch for the next trending course based on his work being held prior to the 2018 Global TapRooT® Summit.
Mark has practical experience.
In his spare time between working for high reliability organizations (the Nuclear Navy and Du Pont) and leading System Improvements, Mark designed and built roads (driving a bulldozer, track loader, excavator, and dump trucks), produced hardwood lumber from trees, and helped design two houses. While working in college getting his BS in Electrical Engineering, he was a field supervisor (in actual agricultural fields) and a cable TV installation and repair man. While still in high school, Mark worked in agricultural jobs, construction, retail, and ran his own lawn mowing and landscape business.
That’s a little more about the lessor known facts about Mark’s experience and expertise. If you have questions for Mark or would like him to consult with you about your improvement efforts, contact him at this LINK, or call 865-539-2139.
The Navy still likes to blame folks as a root cause. At least that’s what I see in this report about a “pilot error” keeping a F/A-18 Hornet making it back to the carrier USS Theodore Roosevelt.
Seems there were lot’s of Causal Factors that contributed to the loss of an $86 million dollar aircraft that are described in this article on Military.com:
I haven’t found the report of the video on line.
What do you think of the report of the investigation?
We are making a major move forward in 2017. There will be a whole NEW basis for TapRooT® when we are done writing the nine new books that will document the TapRooT® System.
Some of the new TapRooT® Books are out and are available on the TapRooT® Web Site.
What is out so far?
- Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents
- Book 4: TapRooT® Root Cause Analysis for Major Investigations
- Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement
If you would like to get the TapRooT® Essentials Book and The Major Investigation Book at the same time, you can get them for a discount by CLICKING HERE.
These new book sets will include the latest Root Cause Tree® (2015), Root Cause Tree® Dictionary (2016) and Corrective Action Helper® Guide (2016).
By the end of the year we are hoping to also have available:
- Book 1: The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
- Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
- Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
Also, watch for our translations of these books in Spanish, Portuguese, German, and French. (Not out yet but we are working on it.)
We are excited about the advances we have made and how usable the new books are.
FAST SIMPLE INVESTIGATIONS
If you want great root cause analysis for a fast, simple investigation, you need to read:
We have made major strides in making TapRooT® easy to use. We even have a new five step process for doing a low-to-medium risk incident investigation.
Not all investigations are simple. We knew we needed to write a book that explained the whole TapRooT® process and tools for investigating high potential and high risk incidents. Therefore we wrote:
There is excellent new materials that completely document the entire 7-step TapRooT® System and all the TapRooT® Tools.
Do you want to get ahead of accidents, incidents, and quality issues? Then you need:
This book details the way you can apply the TapRooT® Tools to your proactive improvement efforts – especially audits.
Each of these books are tied to new courses.
The TapRooT® Essentials Book is tied to our 2-Day TapRooT® Root Cause Analysis Training.
The TapRooT® Major Investigations Book is tied to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. The course reviews a copy of the TapRooT® Essentials Book.
And finally, the Using TapRooT® for Audits Book is linked to our 2-Day TapRooT® four Audits Course.
We hope you will find these books (and courses) as helpful as others have.
Lessons learned from six trains passing through an emergency speed restriction at excessive speed. For the complete story. see this post from the UK Rail Accident Investigation Branch: