Author Archives: Mark Paradies

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT, Video

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About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

Posted: January 17th, 2018 in Performance Improvement, Pictures, Summit, TapRooT

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The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

Come be INSPIRED by Inky at the 2018 Global TapRooT® Summit

Posted: January 16th, 2018 in Summit, Video

Het more information HERE.

Register HERE.

Time for some advanced root cause analysis?

Posted: January 15th, 2018 in Accidents, Current Events, Human Performance, Pictures, TapRooT

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What do you think? Does someone in the Hawaii government need to attend TapRooT® Training?

Which Summit Track Should You Attend?

Posted: January 15th, 2018 in Current Events, Pictures, Summit, Video

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There is so much to new information to learn and so many best practices being shared that the hardest question you have to answer is:

“What Best Practice Track should I attend at the 2018 Global TapRooT® Summit?”

 That’s a tough question to answer. Maybe you should bring enough folks so that some attends each track?

If you have to pick just one, watch these videos and read the information at the links below to help you select the right track that will help you improve performance at your company.

Quality

http://www.taproot.com/archives/61257

Patient Safety

http://www.taproot.com/archives/61721

Human Performance

http://www.taproot.com/archives/60950

Investigator

http://www.taproot.com/archives/61241

Asset Optimization

http://www.taproot.com/archives/61327

Safety

http://www.taproot.com/archives/60790

Software

http://www.taproot.com/archives/61000

Some info about the new software …

 

TapRooT® Certified Instructor

http://www.taproot.com/archives/61023

General Discussion and Keynote Speakers

Now REGISTER! 

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

Posted: January 12th, 2018 in Best Practice Presentations, Best Practice Presenters, Medical/Healthcare, Pictures, Summit

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Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.

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Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:

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Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.

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Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.

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Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

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Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.

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Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
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TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

Posted: January 10th, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooT, Video

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Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.

REASONS TO ATTEND THE SUMMIT

1. SAVE MONEY

You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.

2. GET A PROMOTION

What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.

3. GET FIRED UP!

Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.

4. HAVE FUN

What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.

ONE MORE IDEA…

Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.

GUARANTEE

We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

Why Should I get the New TapRooT® Books?

Posted: January 9th, 2018 in Courses, Performance Improvement, Root Cause Analysis Tips, TapRooT

When someone calls me for help with an investigation, I often ask them what color TapRooT® Book they have. Sometimes they want to know..

What difference does it make what color my book is?

The answer is that it let’s me know how long ago they took TapRooT® Training and what version of the TapRooT® System they are using.  It is always sad to see people struggling with an issue we solved by improving TapRoot® and they just don’t know about the improvement.

Over the almost three decades that we have been developing TapRooT®, we have made major improvements. If you are still using the system that came in three-ring binders, you are back in the 1996 version of the system.

You might think that NOBODY would be using that outdated a version of the system but someone sent me a review of TapRooT® that they read and … sure enough … the review was of the 1996 book. So to people still using the three-ring binders: Update your documentation to the newest version and you will be shocked.

If you have the green book, you are working from the 2000 revision. You are working from a system from the same millennia. Update to the new version and you will jump ahead 16 years.

If you have the thick black book, you are working from the 2008 version. You too will be pleasantly surprised by what we have learned in the last eight years and how we have improved the usefulness of the TapRooT® Books.

And what is the latest version? These books are also black but there are  smaller and there are eight of them (currently book five and eight are still in production).

What do these books look like and how are they an improvement over the older 2008 book?

BOOKS 3 & 4

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Above is the Investigation book set. It includes:

These are the books that cover using TapRooT® to find the root causes of everything from small/minor incidents to major accidents.

How are they an improvement over the older 2008 TapRooT® Book? Well … we took everything we have learned in the last eight years and used it to improve our documentation. And the first things we learned is … LESS IS MORE. That’s why we broke the books up into separate topics. You can just read what is applicable to what you are doing. But how specifically is the investigation set improved over the old book?

  • The set includes the latest Root Cause Tree® and Dictionary that make the system even better with improved definitions in the Dictionary and an new category (language) in the Communication Basic Cause Category.
  • The Essentials Book is a an easy read (only 100 pages long). It guides you through a new 5 step process that makes TapRooT® easy to use for simple investigations. This improves your simple investigations while saving time.
  • The Major Investigations Book explains the whole TapRooT® System and includes the traditional 7-Step Investigation Process. The book includes improved TapRooT® Techniques, detailed examples of each technique, and even better ideas to help you identify your Causal Factors before you start analyzing their root causes.
  • The set also references the latest TapRooT® Software (Version VI).

The ideas we have for improving low-to-medium risk investigations alone are worth buying the new set.

Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is included in the 2-Day TapRooT® Root Cause Analysis Training. The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training include Book 4: Using TapRooT® Root Cause Analysis for Major Investigations, and Book 3.

But that’s just two (Books 3 & 4) of the new books. What else is there and what new information is in the other six books? Read on…

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BOOK 1

Until Book 1: TapRooT® Root Cause Analysis Leadership Lessons was written, we really didn’t have a book that explained the concepts of TapRooT® Root Cause Analysis to management. Now we have produced a concept book that is just 70 pages long (think of it as a bedtime story for management). When management asks what they need to know about TapRooT®, Book 1 is the place to start.

Of course, we would like leaders to learn much more about a tool that should be in their leadership tool kit but Book 1 is a starting point to get management to understand the basis for TapRooT® and how it will help them improve safety, quality, productivity, and environmental compliance.

To learn more about this book, CLICK HERE, or order your copy at: http://www.taproot.com/store/TapRooT-R-Philosophy.html.

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BOOK 2

Book 2: TapRooT® Root Cause Analysis Implementation, is for those in charge of an improvement program. It explains how TapRooT® can be used to improve an already existing program or part of a completely new improvement effort.

Making this a separate book (89 pages long) helps the right people get the right information to make their improvement program much more effective.

What’s in the book?

  • The “Just Do It!” method of getting started.
  • How to add TapRooT® Root Cause analysis to an existing 6 Sigma, Lean, 8-D, Process Safety, Behavior-Based Safety, or other improvement initiative.
  • Building a best-in-class improvement initiative.
  • A checklist to evaluate your improvement efforts.

If you are serious about improvement and in charge of a program to make improvement happen … this book is for you. Order it HERE.

Book 5

This book is close enough to finished that I can explain what you will find in it when it comes out. If you are interested in equipment troubleshooting and root cause analysis, this is the book for you.

Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability, explains how to use TapRooT® and Equifactor® to solve equipment problems. The new book explains the techniques and includes a paper version of the equipment troubleshooting tables from the TapRooT® VI Software all in one book. That makes this a much handier reference.

We expect this book to be available in the 1st half of 2018. Watch our newsletter for more information.

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Book 6

Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, explains how to build TapRooT® root cause analysis into your audits and proactive improvement efforts. It’s only 57 pages long and is a great compliment to books 3 and 4.

It describes the 7-step process for using TapRoot® in an audit and how to build TapRooT® techniques into your proactive improvement efforts.

When you order the book HERE, you will also get the latest:

  • TapRooT® Root Cause Tree®
  • TapRooT® Root Cause Tree® Dictionary
  • TapRooT® Corrective Action Helper® Guide

What’ new about book 6? It is the latest information about using TapRooT® to audit performance. It can be used for safety or quality audits. It’s a very fast read.

This book is included in the course materials for the pre-Summit TapRooT® for Audits Course.

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Book 7

Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills, is all about information collection. We’ve never had a book specifically about this topic. In the past you had to find some of the information provided here buried in the steps of the old 2008 TapRooT® Book.

But this book is more than just a rehash of the information about interviewing and evidence collection. In  addition to information about planning your evidence collection, emergency response and scene management, and the TapRooT® investigation process, it includes:

  • The 3 P’s and an R of evidence collection. (People, Paper, Physical, and Recordings)
  • The TapRooT® 12-Step Interview Process (Cognitive Interviewing)
  • Decoding non verbal behavior
  • Building your investigation kit
  • An initial observation form
  • An interview preparation form
  • An evidence log
  • How to use Change Analysis and CHAP as part of an interview/evidence collection process

That’s a lot to pack into a 93 page book! Buy this book by CLICKING HERE.

Book 8

This book is also still in production but is also expected in the first half of 2018. Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management, explains the state-of-the-art in performance measurement and trending.

If you have ever wondered how you can prove that you have improved or if a “negative” trend is actually significant, this is the book for you.

In addition, the book explains what management should know about trends. This information can keep them from being misled by false trends and how to use trends to manage improvement initiative.

The math involved isn’t complicated, but it is beyond some of the common “trending” graphs that you may be using now.

This book is included in the pre-Summit Advanced Trending Techniques Course. Watch our newsletter for more information on when the book will be available.

KEEP UP TO DATE! If you don’t have the latest TapRooT® Books that apply to your work, order them today!

4 Steps to Playing like a Champion in 2018

Posted: January 8th, 2018 in Career Development, Summit


Ever wonder what your life would feel like if you had the knowledge to live life at the top of your game? Champions know how to compete, but they are not born that way. Every champion has to first learn how to qualify for the game before they even get a chance to compete for the win.

So, how do you qualify to play?

First

Begin today by forming a mental picture of where you want to be. If you can form a strong mental picture and rehearse it, your brain will find a way to get you there. Write it down.  Read it daily.

Second

Expect setbacks and move past them. Let them be lessons learned that propel you forward not anchors that weigh you down. A champion is an ordinary individual who persists through obstacles. Are expectations causing you stress? Don’t put the high expectations of others in a negative light.  Expectations are really support… a belief that you can accomplish a goal.

Third

Stay focused on your mental picture of success and support yourself with positive affirmations. If you are not telling yourself that you are capable of success every single day, there is no way you are going to experience it. If you are waiting for someone else to believe in you, they are probably waiting for you to believe in yourself. Stay positive.

Fourth

Strive for improvement. You will experience wins practicing these steps but regardless of your achievements, operate under the goal of self-improvement. So, practice these steps to qualify to play, and then join us at the 2018 Global TapRooT® Summit to continue improving! Boaz Rauchwerger is our special keynote speaker on Wednesday, February 28 at 12:30 p.m., presenting “Play Like a Champion Every Day.” After his keynote, he will be presenting “Improve People Skills and Become More Productive” in a best practice session from 1:30 pm to 2:30 pm on the Alternative Sessions Track.

Boaz Rauchwerger is Speaker of the Year for Vistage International, the world’s largest organization of CEO’s. He is the founder and president of Boaz Power Corp., a Los Angeles-based high performance consulting firm. He is also an internationally-known professional business speaker for major corporations such as American Airlines, Xerox, and Toyota.

Previously, Boaz was a newspaper publisher, owned his own advertising agency and has produced corporate films as well as a network television show. He is the author of “How to Create Exceptional Outcomes – Become the CEO of a Very Successful Life.” Boaz holds a degree in journalism, public relations and advertising from the University of Tulsa.

Join us for his game-changing presentations and live your life like a champion in 2018!

Register today!

Learn more.

Resolve to Improve!

Posted: January 2nd, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooT

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On New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:

  1. Get healthy.
  2. Get organized.
  3. Live life to the fullest.
  4. Learn new hobbies.
  5. Spend less/save more.
  6. Travel.
  7. Read more.

Are you surprised by any of the above? Nothing earth shattering there.  Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.

Here are some work-related resolutions to consider…

  • Eliminate the blame environment when someone makes a mistake.
  • Stop problems from happening over and over again.
  • Save time and get better results when you perform an incident investigation.
  • Learn best practices to make your workplace safer and more productive.
  • Become better at your job by applying state-of-the-art root cause analysis.

How do you do these things?

TapRooT®

Start by attending TapRooT® Training. See our upcoming courses here:

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

Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:

http://www.taproot.com/taproot-summit/summit-schedule

And register here:

http://www.taproot.com/taproot-summit/register-for-summit

The knowledge you will gain will help you make 2018 the best year ever.

Take some time off!

Posted: December 26th, 2017 in Pictures

Each week I try to write something engaging about root cause analysis, incident investigation, or performance improvement.

This week I’m taking some time off to be with the family.

I suggest you do the same.

  • Stop responding to electronics.
  • Stop reading e-mails.
  • Put your cell phone on do not disturb.

Live in the minute and enjoy those around you for one week.

Then you can get back to the grind of making your company excellent.

Best Regards!

MarkwithBaby

Merry Christmas!

Posted: December 25th, 2017 in Current Events

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The Georgia State Public Services Commission Demands Root Cause Analysis of Atlanta Airport Blackout

Posted: December 21st, 2017 in Accidents, Current Events, Equipment/Equifactor®, Investigations, Pictures

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Read about the story in The Atlanta Journal-Constitution: http://www.ajc.com/news/georgia-regulators-demand-answers-about-atlanta-airport-blackout/nDwICT5QFrUyXOvFnZbroM/

It’s hard to believe there wasn’t a redundant transmission line and transformers to such a vital resource.

Are you interested in improving human performance? Try this four step plan!

Posted: December 19th, 2017 in Courses, Great Human Factors, Human Performance, Performance Improvement, Pictures, Summit

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Is discipline the main way you “fix” human error problems?

Are you frustrated because people make the same kind of mistakes over and over again?

Have you tried “standard” techniques for improving human performance and found that they just don’t get the job done long term (they have an impact short term but not long term)?

Is management grasping for solutions to human error issues?

Would you like to learn best practices from industry human performance experts?

Try this four step plan:

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1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Course.

The TapRoot® System is made to reactively and proactively help you solve human performance issues. It has built in human factors expert systems that guide you to the root causes of human errors and help you develop effective fixes. The 5-Day TapRooT® Course is the best way to learn the system and get started fixing human performance issues.

See the upcoming course schedule here: http://www.taproot.com/store/5-Day-Courses/

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2. Attend the Understanding and Stopping Human Error Course

At this two day class, Dr. Joel Haight, a human factors and safety improvement expert and industrial engineering professor at the University of Pittsburg (where he is the Director of the Safety Engineering Program) shares the reasons why people make mistakes and what you can do to understand the problems and fix them.

Joel is an expert TapRooT® User having extensive experience apply TapRooT® to fix human factors problems at a Chevron refinery and in the oil field in Kazakhstan. He is also an expert in applying other human performance analysis and improvement techniques. He brings this knowledge to the 2-Day Understanding and Stopping Human Error Course.

It is best if you have already attended at least a 2-Day TapRooT® Course prior to attending this course. See the course description here: http://www.taproot.com/taproot-summit/pre-summit-courses#HumanError

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3. Attend the Human Factors Track at the 2018 Global TapRooT® Summit

Once a year we put together a track at the Global TapRooT® Summit that is designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s what you get at the Human Factor Track at the Summit. What are the sessions at the 2018 Global TapRooT® Summit?

  • TapRooT® Users Share Best Practices – This is a workshop designed to promote the sharing of investigation, root cause analysis, and human performance best practices from TapRooT® Users from around the world. Every year I attend this session and get new ideas that I share with others to help improve performance. Many say this is the best session at the Summit because they get such great ideas and develop new, helpful contacts from many different industries.
  • Top 5 Reasons for Human Error and How to Stop Them – Mark Paradies, President of System Improvements and a human factors expert, shares his deep knowledge of the top five reasons that he see’s for people making “human errors.” For each of these he shares his best ideas to stop the problems in their tracks.
  • Stop Daily Goofs for Good – Kevin McManus, a TapRooT® Instructor and performance improvement expert, shares systematic improvement ideas s to prevent human error and improve cognitive ergonomics on the job.
  • Using Wearables to Minimize Daily Human Errors – Using “wearables” is a technological approach to error prevention. Find out more about how it is being used and may be applied even more effectively in the future.
  • Alarm Management, Signal Detection Theory, and Decision Making – Are people at your facility overwhelmed by alarms? Do the become complacent because of nuisance alarms? Dr. Joel Haight, Director of the University of Pittsburg Safety Engineering Program will discuss control system decisions, decision execution, alarm management, signal detection theory, and decision making theory and how it could be critical in an emergency situation.
  • The Psychology of Failing Fixes – Why do your fixes fail to prevent human error? That’s what this session is all about!
  • What is a Trend and How Can You Find Trends in the TapRooT® Data? – looking for trends in human error data is an important activity to identify generic human factors problems and take the first step to major human performance improvements. Now for the bad news. Most people really don’t understand trending. Find out what you need to know and how to put trending to work in your improvement program.
  • Performance Improvement Gap Analysis – This is the session where you put everything together. Where does your program have holes? How can you apply what you have learned to fill those holes? What are others doing to solve similar problems? Put your plan together so you are ready to hit the ground running and make improvements happen when you get back to work.

And the Best Practice Sessions outlined above are only a start. You will also see five great Keynote Speakers:

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Mike Williams will share his experience surviving the Deepwater Horizon explosion.

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Dr. Carol Gunn will share the story of the her sisters unnecessary death in a hospital and patient safety improvement.

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Inky Johnson will share his experience with a debilitating football injury and how it changed his life and helps him inspire excellence in others.

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Mark Paradies will help you get the most out of your application of TapRooT®.

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Vincent Ivan Phipps will teach yo to amplify your leadership skills and communication ability.

We know that the Summit will provide you with new ideas and the inspiration to implement them.

Start

4. Get started! Analyze your human performance issues and make improvements happen!

Just Do It! get back to work and implement what you have learned. Need more help? We can provide training at your site to get more people trained in using TapRooT® so that you have help making change happen.

Don’t wait! Get your four step plan started! Register for the courses and Summit today!

Hack of safety system causes plant shutdown …

Posted: December 18th, 2017 in Accidents, Current Events, Investigations, Uncategorized

Jim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.

There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.

Old incident (2014) but is the sub fleet still overworked?

Posted: December 15th, 2017 in Current Events, Pictures

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Can it be true that a Nuclear Navy submarine has sat in port in Guam for six months awaiting repairs while it was suppose to be deployed? Read: “Bizarre Deployment” in Navy Times.

Secretary of the Navy Strategic Readiness Review – Management System Problems Broke the US Navy

Posted: December 14th, 2017 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement, Pictures

Yes, “Management System Problems Broke the US Navy” is my headline.

 

The report to the Secretary of the Navy is much worse than I thought. The report outlines how budget restrictions and congressional leadership made the Navy conform to the structures of the Army and the Air Force and de-emphasized the role of providing seapower. That’s how the US Navy was broken. And it will be difficult to fix. (“All the King’s horses and all the King’s men couldn’t put Humpty Dumpty together again!” was a lesson learned in 1648 during the English civil war.)

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Many of the problems are Management System problems as outlined in a Navy Times article about the Strategic Review report to the Secretary of the Navy. The good news is … the authors of the Strategic Review get the Management System root causes pretty much right! The bad news is that it is less clear that the Navy has the ability to fix the issues because they are a result of Congressional action (funding, ship procurement, the Defense Officer Personnel Management Act, the Goldwater-Nichols Act of 1986, and National Defense Authorization Act provisions) and the Navy’s response to congressional cutbacks (Optimum Manning, the SWOS-in-a-box, modifications to the surface warfare officer sea-shore rotations and assignments, and the 2001 Revolution in Training for enlisted personnel).

The review says that the Navy must cut back their commitments to operational requirements in “peacetime.” But that is unlikely in the near wartime footing that they Navy faces in their forward deployments.

One of the recommendations made by the Strategic Review is for the Type Commanders to implement the “Rickover Letters” that are part of the Nuclear Navy Commanding Officer reporting structure. This will only work if the Type Commanders maintain strict requirements that Admiral Rickover established in the Nuclear Navy. This has not been the culture in the conventional surface Navy – EVER. Thus this would be a dramatic cultural shift.

Navy brass in the 1980’s and 1990’s wished that sailors at sea could do more with less and that “technology” would make that possible. Unfortunately the cuts were made (Optimal Manning and Continuous Maintenance Plan) without proof of concept testing. Now, over two decades later, the chickens have come home to roost.

The USA is an island nation. We can’t exist in our modern economy without sea trade. Thus, the USA must be the premier sea power. This requirement is independent of the “War on Terror,” the “War on Drugs,” or other missions to support land forces. Somehow past Presidents and Congressional leaders have not funded the seapower mission. Thus, we find ourselves in a bind that will be hard to fix.

The people in senior Navy leadership positions have grown up in a broken system. We must now ask them to fix (restore) the system when they have never seen it work properly. The CNO in a Navy Nuke from the submarine fleet that has faced budget reductions but has not faced the same personnel and training issues. He grew up in a different culture.

By making the US Navy the “same” as the Air Force and the Army, the unique requirements of the Navy were overlooked and the Navy was broken. Can it be fixed? The recommendations of the Strategic Review could start the repair process. But it is only a start. Many uniquely “Navy” cultural and readiness issues are not addressed in the report. Plus, this report probably will not get the attention it deserves until a failure of our war-fighting ability at sea produces a major foreign policy fiasco or, even worse, economic collapse at home because our island nation is cut off from overseas supplies.

One last comment.

The Strategic Review calls for the establishment of a “learning culture.” The authors of the Strategic Review call for proactive learning instead of the current culture of punishment based reactive learning. They frequently mention the “normalization-of-deviation” as if it a relatively recent US Navy cultural problem rather than being the state of the conventional surface navy for decades (or centuries?). They should read the article about Admiral Rickover and the normalization-of-excellence to better understand the changes that are needed. Also, establishing a proactive, learning culture isn’t possible until the US Navy understands advanced root cause analysis (which current investigations and corrective actions prove that the Navy does not understand).

The recommendations of section 6.3 of the Strategic Review are putting the “cart in front of the horse.” The FIRST step in correcting the Navy’s culture is for all naval officers (senior commanders through junior officers) to understand advanced root cause analysis. Without this understanding, learning – either proactive or reactive – is impossible. We have worked with industry leaders and we know of what we speak.

I certainly hope the US Navy makes significant progress in correcting the glaring shortcomings outlined in the Strategic Review. The lives of sailors at sea depend on it. But even worse, a failure to fix the root causes of the Management System problems and the poor understanding of advanced root cause analysis will certainly lead to failures of our seapower and serious foreign policy issues that may cause tremendous economic troubles for the US. I’m old and may not see the day when we discover that under-investment in seapower was a gigantic mistake. But if this problem isn’t fixed rapidly and effectively, certainly my children and grandchildren will face an uncertain, dark future.

I would be happy to discuss the improvements in root cause analysis that are needed with any Navy leader concerned that a more effective approach is needed.

What are the favorite blog posts from this year and from all time?

Posted: December 12th, 2017 in Current Events, Pictures, TapRooT

The end of the year is coming and sometimes it is good to look back and see whats been trending for people who read this blog. Let’s look at the articles posted in 2017 and see what’s been trending …

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5. How Far Away is Death? (October – above)

4. Friday Joke: An Old Nuke Navy Joke… (October)

3. US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald (August)

2. What happens when root cause analysis becomes too simple? Six problems I’ve observed. (July)

1. What is the Root Cause of the USS Fitzgerald Collision? (July)

And then let’s look back to the past to see the top five most popular articles of all time:

5. Root Cause Tip: What’s a Causal Factor? (2012)

4. 7 Secretos / secretos del análisis de Causa raíz (2011)

3. Live Your Core Values: 10 Minute Exercise to Increase Your Success (2013)

2. 7 Secrets of Root Cause Analysis (2011)

1. An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts… (2007)

Santa Accidents 2

Posted: December 11th, 2017 in Current Events

Dennis Osmer – RIP

Posted: December 8th, 2017 in Current Events, Meet Our Staff, Pictures

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Dennis Osmer, 70, TapRooT® User/Instructor and safety and ergonomics expert died on December 1, 2017 from bladder cancer.

Dennis started using TapRooT® at Novartis and became the worldwide head of occupational health, safety, environment, and emergency management at CIBA Vision.

After he retired from CIBA Vision in 2008, he became a TapRooT® Instructor and for five years helped students learn to apply TapRooT® to improve safety and quality. In addition, he helped clients by facilitating difficult investigations to stop future safety issues.

Dennis was one of our first clients to show how TapRooT® could be used to investigate and prevent ergonomics issues while working for CIBA Vision. Here is a link to the success story that he presented at the Global TapRooT® Summit: http://www.taproot.com/archives/18992. This work saved many workers the pain and suffering from ergonomic injuries in the facilities customer support and distribution departments and saved the company over $6 million dollars in workers compensation costs in the six years after the program was implemented.

Some people just have an ability to make positive change happen and Dennis was one of those people. Everyone here at System Improvements and all of his students and co-workers, as well as his family, will miss him.

See this link: http://www.legacy.com/obituaries/atlanta/obituary.aspx?pid=187407009, for his obituary and memorial.

Friday Joke: Nuclear Winter Wonderland

Posted: December 8th, 2017 in Documents, Jokes, Video

Winter wonderland

Click on the links below for a Nuclear Winter Wonderland (either a Quicktime movie or a PowerPoint)

Nuclear Winter Wonderland Movie.mov

Nuclear_Winter_Wonderland.pptx

The PPTX is the best quality.

Or try this YouTube video…

 

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