Author Archives: Mark Paradies

Remembering an Accident: 23 killed in Phillips Pasadena Explosion

Posted: October 23rd, 2017 in Accidents, Video

On October 23, 1989, the Phillips Chemical Plant exploded killing 23 people. Here’s a video about the accident that was one of the accidents that lead to the development of the OSHA Process Safety Management Standard.

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes reactively and significant issues that may lead to major problems proactively.

Register today: TapRooT® Advanced Root Cause Analysis Team Leader Training

How Many Industries and How Many Countries is Your Root Cause Analysis System Used In?

Posted: October 17th, 2017 in Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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I was talking to someone in the medical industry recently and they asked: “How many people in the medical industry use TapRooT®?”

I gave them several examples of major healthcare systems that use TapRooT® (including perhaps the world’s largest) but I thought … they asked the WRONG question.

The true value of a root cause analysis system is how many different places it is being used SUCCESSFULLY.

Note that this is not the same as if the system is used in a particular industry. It must be used successfully. And if it is used successfully in many other industries and many countries, that proves even more that the system is useful and will probably be useful when applied at your company.

Where is TapRooT® Root Cause Analysis applied successfully?

All over the world. On every continent but Antartica (we’ve never done a course there yet).

In what kind of industries? Try these:

  • Oil & Gas Exploration & Production
  • Refining
  • Chemical Manufacturing
  • Healthcare (Hospitals)
  • Pharmaceutical Manufacturing
  • Nuclear Power / Nuclear Fuels
  • Utilities
  • Auto Manufacturing
  • Aggregates
  • Mining (Iron, Gold, Diamonds, Copper, Coal, …)
  • Aluminum
  • Aviation (airlines and helicopters)
  • Shipping
  • Cosmetics
  • Construction
  • Data Security
  • Nuclear Weapons
  • Research Laboratories
  • Mass Transit
  • Regulatory Agencies
  • Prisons
  • Pulp & Paper
  • Engineering
  • Food & Drinks
  • Alchohol
  • Security
  • Recycling
  • Aerospace Manufacturing
  • Space Exploration
  • Pipelines
  • Agricultural Commodities
  • Steel
  • Forestry
  • City Government
  • General Manufacturing
  • Telecommunications
  • Airport Management

And that’s only a partial list.

Where can you read about the successful application of TapRooT® in some of these industries? Try these success stories:

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

You will see examples of companies that saved lives, save money, prevent injuries, improved service, made work more productive, and stopped the cycle of blame and punishment.

The reason that TapRooT® is used by industry leaders is that it works in such a wide variety of industries in such a wide variety of countries.

But don’t just believe the industry leaders. Attend one of our GUARANTEED courses. Guaranteed? That’s right. Here is our guarantee:

  • Attend the 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 and we will refund the entire course fee.

It’s that simple. Try to find a money-back guarantee like that anywhere else. We are so sure of your success that we guarantee it.

Don’t wait. Register for one of our root cause analysis courses today. For a list of upcoming public courses, see:

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

Why do people jump to conclusions?

Posted: October 10th, 2017 in Human Performance, Performance Improvement, Pictures, Root Cause Analysis Tips

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?

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And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Monday Accident & Lessons Learned: Mid-flight engine explosion forces landing

Posted: October 9th, 2017 in Accidents

“We looked out the window and saw half of the engine was missing.”

A rare emergency in which machinery and other parts broke away from a plane at high velocity occurred on an Airbus A380 with 500 passengers bound for Los Angeles.

The U.S. manufacturer of the engine, Connecticut-based Engine Alliance, said it was investigating the failure.

Read the article on NBC News.

Root Cause Tip: Courage

Posted: October 4th, 2017 in Root Cause Analysis Tips

Courage is not limited to the battlefield or the Indianapolis 500 or bravely catching a thief in your house.  The real tests of courage are much quieter.  They are inner tests, like remaining faithful when nobody’s looking, like enduring pain when the room is empty, like standing alone when you’re misunderstood. ~ Charles Swindoll

Investigating accidents, incidents, sentinel events, equipment failures, and quality issues requires courage.  Courage to challenge the way work is performed.  Courage to ask questions that people hope won’t be asked.  Courage to point out ways that management can improve the way the facility is managed.

Remember, when you think you face the challenge of confronting people and influencing them to change … courageously look for a different path.

Instead of forcing your views, find a way to make yourself an ally of those you think must change.  Your objective is to create an environment where you have an opportunity to share your vision and create enthusiasm for it.  As an ally, you learn how they view the problem in greater detail.  You may even discover some of your assumptions were wrong.  As an ally, they are more open to receive your ideas.  When you are work as a team – rather than adversaries – the chances of success are much higher.

Why is Root Cause Analysis Applied Reactively More Than Proactively?

Posted: October 3rd, 2017 in Accidents, Human Performance, Performance Improvement, Pictures, TapRooT, Training

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

Monday Accidents & Lessons Learned: Fatal Collision between Tram and Pedestrian

Posted: October 2nd, 2017 in Accidents

 

A tram driver did not see a pedestrian approach a crossing. There were many contributing factors. Read the RAIB report and the lessons learned here.

Puerto Rico is in trouble, Does anyone know how we can help?

Posted: September 27th, 2017 in Current Events

They are in terrible shape. If I could, I would load up a trailer with supplies and head out. I feel so helpless. What can we do?

Here is a CNN report on the desperation:

http://www.cnn.com/2017/09/27/us/puerto-rico-hurricane-maria/index.html

Radiation Release – Time for Root Cause Analysis

Posted: September 27th, 2017 in Accidents, Current Events, Investigations

A National Institute of Standards and Technology employee was exposed to radiation when a glass ampule broke.

Time for root cause analysis?

The US Nuclear Regulatory Commission has sent a team to investigate.

See the article at THIS LINK.

Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

Posted: September 26th, 2017 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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First, let me state that the reason I seem to be carried away by the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much. Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

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What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet. And if you know me, you know that I think they should be using TapRooT® to do this.

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In TapRooT®, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® and see if there is a generic causes using a three step process. The three steps are:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?
  3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these question.

TapRooT® Users know about the Root Cause Tree® and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions. If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

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Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information we can get a hint at the generic causes for these accidents.

Before I list the generic causes we are guessing at and discuss potential fixes, here is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

GENERIC CAUSES

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade if there is the will to invest in a capable fleet. All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

  • Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
  • Conduct the training for all ships on a prioritized basis.
  • Integrate the training into junior officer training courses and department head and perspective XO and CO training.
  • Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staffs.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

  • Develop a standard watch rotation schedule to minimize fatigue.
  • Review underway requirements and prioritize to allow for adequate rest.
  • Allow daytime sleeping to reduce fatigue.
  • Minimize noise during daytime sleeping hours to allow for rest.
  • Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
  • Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
  • Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for CO’s when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

This corrective action is difficult because a through training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented that are not listed above.

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class I learned that it was a 2nd or 3rd order control problem and these types of problems are very difficult for humans to solve. Thus ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

  • A seamanship training program be developed based on best human factors and training practices including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
  • Develop ship handing course for junior officers to complete before they arrive at their first ship to learn and practice common ship handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking and avoidance in restricted waters.
  • Develop an advanced ship handing corse for department heads that refreshes/tests their ship handling skills and teaches them how to coach junior officers to develop their ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance.
  • Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters including when to take control if the ship is in extremis (and practice of this skill).
  • Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship handing and supervisory skills to be passed before reporting to a ship.
  • Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

  • Perform a task analysis of required navigation shipboard duties including new technology duties and duties if technology fails (without shipboard computerized aids).
  • Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

  • Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
  • Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
  • Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

  • Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, number of days at sea under certain levels of high operating tempo, number of days at sea without a port call, staffing levels in key jobs, …
  • Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

  • Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current operating tempo.
  • Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
  • Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
  • Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support current operating tempo and create a better nuclear surface fleet carrier path.
  • Establish a new ship building program to support a modern 400 ship Navy by 2030.
  • Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to adopt and apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources needed to keep our young men and women safe at sea.

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Monday Accidents & Lessons Learned: ExxonMobil Baton Rouge Refinery Isobutane Release and Fire

Posted: September 25th, 2017 in Accidents

On November 22, 2016, an isobutane release and fire seriously injured four workers in the sulfuric acid alkylation unit at the ExxonMobil Refinery in Baton Rouge, Louisiana (“Baton Rouge refinery”). During removal of an inoperable gearbox on a plug valve, the operator performing this activity removed critical
bolts securing the pressure-retaining component of the valve known as the top-cap. When the operator then attempted to open the plug valve with a pipe wrench, the valve came apart and released isobutane into the unit, forming a flammable vapor cloud. The isobutane reached an ignition source within 30 seconds of the release, causing a fire and severely burning four workers who were unable to exit the vapor cloud before it ignited.

Read key lessons learned from this incident here.

Is punishment the best way to improve performance in the Navy?

Posted: September 20th, 2017 in Human Performance, Performance Improvement, Pictures

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In my decades of root cause analysis, less than 2% of incidents are caused by some sort of willful action that does not have a system cause. However, in many incident responses, companies discipline people for mistakes that were caused by system problem. This unwarranted punishment leads to:

  • Covering up problems.
  • Lying about what people did.
  • Morale issues when people are punished for things that were not their fault.
  • Mystery incidents that no one seems to know anything about (no one will talk).
  • Poor performance because the root causes of the problems are not being addressed.

Thus, I was disappointed when I saw the US Navy resort to discipline before the root cause analysis was completed after the collision of the USS Fitzgerald. Then again more discipline was used (this time against an Admiral) after the collision of the USS John S. McCain.

I wrote several articles about the collisions:

What is the Root Cause of the USS Fitzgerald Collision?

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

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

Several senior naval officers and others that discipline was needed for Navy personnel when a mission fails or a ship collides with another.

This brought to mind two sayings that I learned in the Navy. The first is:

The beatings will continue until morale improves.

The second is:

Why be fair when you can be arbitrary.

Do people in the Navy really respond to random discipline? The kind of discipline that’s been proven not to work in the civilian world?

I spent 7 years in the US Navy and have had close contacts with many people in the Navy since I left to start my civilian career. What I can tell you is this:

  1. Being at sea is different than working in a civilian job
  2. The Navy generally has a stricter set of operating rules than a civilian workforce does.
  3. There is a wider range of disciplinary actions that are available in the Navy than in the civilian word. (Although flogging and keel-hauling have been eliminated.)
  4. You can’t quit in the Navy if you have a bad boss.
  5. It’s difficult to fire someone that works for you if they are incompetent (you are stuck with those who you are assigned to lead).
  6. People ARE NOT different. They don’t become some sort of robot just because they joined the Navy.

Why did I include point #6 above? Because I’m often told that discipline is needed in the Navy to improve performance (One Admiral told me that it “sharpens the Commanding Officers game”).

It seems that some believe that senior naval officers (people commanding Navy ships – the Commanding Officers or COs) would try less hard, be less alert, and have worse performance if they didn’t have the threat of being relieved of command if they run into another ship or run aground.

Yes – the CO is ultimately responsible. Therefore, how could it NOT be the CO’s fault? They have ultimate authority on their ship … don’t they?

Let’s look at a an example. What if:

  • A ship was assigned a rigorous operational schedule of demanding technical missions.
  • The ship had several key pieces of equipment that that had been reported as broken (because of lack of time, parts, and money to perform maintenance).
  • The ship had many junior, barely qualified personnel serving in key positions because of the Navy’s planned rotation of officers and enlisted personnel and planned reduction of ashore training before new personnel arrived for their tour of duty.
  • The ship was undermanned because new ships were designed with new, smaller, crews but still had the same work to be performed as on older ships with 20-30% more people. This saved the Navy budget money – especially in the time of sequester.
  • The ship had several key personnel left ashore – with no replacement – because they were pregnant.
  • The CO was new to the ship and had little experience with this type of ship because he was assigned wartime duties ashore in Iraq during the Gulf Wars and missed an Executive Officer and a Department Head tours that would have provided more applicable experience and knowledge for this assignment.
  • People were fatigued after several tough evolutions but still had to drive the ship through a narrow, busy straight to get to their next assigned mission.

Is any of this under the CO’s control? Don’t these circumstances contribute to a mission failure if one occurs (like a collision). Would discipline make any of these factors change?

Does telling the CO that you are going to punish him (or her) if he or his crew makes a mistake make ANY difference?

Please leave me your comments. I’d be interested in what you have to say.

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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

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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.

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