Author Archives: Susan Napier-Sewell

TapRooT® Around the World: Equifactor® Equipment Troubleshooting in Bogota, Colombia

Posted: August 28th, 2018 in Career Development, Courses, Equipment/Equifactor®, Meet Our Staff, Performance Improvement, Pictures, TapRooT, TapRooT® Instructor, Training

Take a look into the recent 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course in Bogota, Colombia, taught by TapRooT® and Equifactor® Instructors Hernando Godoy Garzón and Piedad Colmenares.

Using Equifactor®, you can learn a more efficient, effective method to solve equipment failure and performance problems. Equifactor® integrates troubleshooting techniques and the TapRooT® Root Cause Analysis System to identify real root causes and implement lasting fixes faster and with more reliability. One single-user license of TapRooT® Root Cause Analysis software is included in this course.

The Equifactor® 3-day courses are designed for Maintenance, Reliability and Safety professionals who want a proven method of analyzing equipment problems and failures when conducting root cause failure analysis.

Many thanks to Hernando for sharing these pictures of action and insights into the great interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Monday Accidents & Lessons Learned: Simple Ship Repair Results in Fatal Fall

Posted: August 27th, 2018 in Accidents, Great Human Factors, Human Performance, Investigations

The accident
A crew member was making repairs to the surrounding handrails of the lowest of three intermediate platforms built into a cargo hold access ladder. The platform was designed as a landing to hold a single person while moving from one section of the cargo hold access ladder to the next. The ship was at sea, and the cargo hatch covers were closed. The handrails had been removed for repair, and the crew member was preparing to refit them to the platform. The lower platform was five meters above the tank top. There were no eyewitnesses to the accident. It was concluded that the crew member tripped or slipped from the platform and, as he was not wearing a safety harness, he fell to the tank top below. He died from multiple injuries.

Contributing factors
What caused the crew member to slip from the platform?

  1. The platform was cluttered with equipment that the crew member was using to effect the repairs and was not guarded by handrails, making the platform a congested and dangerous place to work.
  2. A single halogen light had been rigged about one meter above the platform. The light was another obstacle that the crew member had to work around.
  3. Although shipboard procedures required the crew member to use a safety harness for the task, he was not wearing one at the time. Wearing a safety harness and connecting it to a secure point would have arrested his fall.

Lessons learned
Working at any height without the protection of handrails creates a hazardous situation. It is crucial for seafarers to follow industry best practices—such as wearing a safety harness and connecting it to a secure point—whenever working from a height. Equally important, light should be abundantly sufficient to illuminate the immediate task and general working areas of workers and should cause no obstruction to workers. Finally, task areas should be clutter-free, prepped in advance for free unobstructed access.

This accident was reported by the Australian Transportation Safety Board.

Circumstances can crop up anywhere at any time if proper and safe sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: August 27th, 2018 in Career Development, Courses, Human Performance, Job Postings, Performance Improvement, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

HSE Manager

Health, Safety, & Environmental Manager

Health & Safety/CDM Director

HSE Officer

Environmental Health & Safety Manager

QHSE Manager

HSE Advisor 

HSE Manager

MWD Specialist

Health & Safety Advisor

Site Safety Coordinator

Safety Coordinator

Nurse

Specialist HSE

SHE Coordinator

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development and your career.

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Friday Joke

Posted: August 24th, 2018 in Jokes

Does Blame Make Sense in Incident Investigations?

Posted: August 23rd, 2018 in Career Development Tips, Great Human Factors, Human Performance, Meet Our Staff, Performance Improvement, Topic of the Week, Video

When we consider a recent accident—such as a pharmaceutical plant producing a bad batch of drugs and those drugs making their way past the QA process and, once distributed, ending up harming customers—one fact is indisputable: Human action broke down somewhere along the line. And the least productive next step is to begin a round of the blame game.

In this video, TapRooT® professionals Benna Dortch and Ken Reed highlight why blame is counterproductive—as well as an exercise in futility—in the workplace. While it may be human nature to default to finger-pointing, a blame-oriented organization can move beyond old habits. An organization that employs investigative methodology to accomplish a thorough review of the facts creates a culture where workers are not fearful to self-report missteps and mistakes.

TapRooT® Root Cause Analysis training can transform your investigations, moving beyond blame to clearly isolate systemic problems that can be fixed, and prevent (or greatly reduce) repeat accidents. Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change a blame culture into a culture of performance improvement.

f you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Join the Smart Conversation: If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST

Posted: August 22nd, 2018 in Career Development Tips, Human Performance, Meet Our Staff, Performance Improvement, Root Cause Analysis Tips, Summit, TapRooT, Topic of the Week, Video

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements to implement in your job and to include in other roles in your organization.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, August 22

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Bogota, Colombia

Posted: August 21st, 2018 in Career Development, Courses, Meet Our Staff, Performance Improvement, Pictures, Root Causes, TapRooT, TapRooT® Instructor, Training

Here’s a peek into the recent 2-Day TapRooT® Root Cause Analysis Training Course in Bogota, Colombia, taught by TapRooT® Instructor Piedad Colmenares. In a 2-Day TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Piedad for sharing these great pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Tune in tomorrow for TapRooT®’s Facebook Live, noon EST

Posted: August 21st, 2018 in Career Development Tips, Human Performance, Meet Our Staff, Performance Improvement, Presentations, Root Cause Analysis Tips, Summit, TapRooT, Topic of the Week, Video

Join our Facebook Live session tomorrow as TapRooT® professionals share insights designed to expand your knowledge base and sharpen your expertise and performance. We’ll be discussing Ken Reed’s recent post “Do LinkedIn Posts Encourage Poor Investigations?”

Connect with us tomorrow—and every Wednesday—for the TapRooT® discussion on Facebook Live. Make it a recurring event in your calendar—a good habit that will produce game-changing results. Put a reminder in your computer and smartphone to tune in on Wednesdays, noon EST. As always, feel free to comment on the discussion via our Facebook page.

Here’s how to join us tomorrow for the Facebook Live conversation:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, August 22, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

As you glean takeaways from the Facebook Live discussion, make plans to become immersed in best practices and learn state-of-the-art techniques at the 2019 Global TapRooT® Summit.

The Summit consistently earns the highest possible reviews from attendees. Using the TapRooT® System, attendees report documented constant improvement in workplace practices and reliability; dramatically improved statistics in problems, incidents and accidents, and losses; improvement efforts in process reliability that net significant financial savings, often hundreds of millions saved.

Save the date for the 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Do your own investigation into our courses and discover what TapRooT® can do for you. Contact us or call us at 865.539.2139 to pinpoint how we can best meet your needs.

Learn TapRooT® in Seattle

Posted: August 20th, 2018 in Career Development, Courses, Investigations, Local Attractions, Meet Our Staff, Performance Improvement, TapRooT, TapRooT® Instructor, Training

Register here for TapRooT® Training on October 24, 2018, in Seattle, Washington: 2-Day TapRooT® Root Cause Analysis Training.

Exposure to the 2-Day TapRooT® Root Cause Analysis Training in Seattle will equip you to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®.

A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply! Start your personal and professional growth in Seattle.  

While in the shadow of the iconic, 605-foot-tall Space Needle spire, you will want to get out and about. Below, to route you to points of interest and incredible edibles, we’ve included highlights of this seaport city. Dscover even more gems to explore on our Seattle Pinterest board.

A coastal walk, a satisfying seafood feast, and a connection with Seattle’s quirky culture and its walkable, breathtaking scenery—there’s something in Seattle that you will want to discover.

Experience Seattle

Lean into the beauty that is Puget Sound. Take a cruise or ferry across this immense Pacific Ocean inlet, along its forested shores, and delight in sailing smooth salt waters. Puget Sound has more than 170 islands, some connected by bridges, so there’s much to explore here. Kayaking and boating, hiking and biking, birding, whale-watching, diving and snorkeling, golfing—the Sound is rich in recreative adventures.

Soar over Seattle as Wings Over Washington transports you on a virtual aerial ride of the whole state—from Mount Ranier’s glacier-topped peaks to Olympic National Park’s seashore cliffs.

If you are up for a great view from the heights, overlook Elliott Bay from the Seattle Great Wheel (the West Coast’s tallest ferris wheel). Walk along Waterfront Park for inspiring views. Wander through masterworks along the zigzag path of the Olympic Sculpture Park. 

Take in aircraft and space vehicles plus historical exhibits at the Museum of Flight. Explore flight simulators, get a feel for what pilots experience, see the aviation pavilion and watch a 3D movie, and take a Boeing field tour.

For an artistic must-do in Seattle, visit Chihuly Garden and Glass, the international glass headquarters of Fulbright Fellowship recipient Dale Chihuly, and browse the Glasshouse. 

Taste Seattle

Can you say “pancake heaven”? Take a fork to breakfast at Portage Bay, its four locations serve up hefty portions and, yes, you might want to make a reservation.   

You may not be shopping for seafood, but duck into the very entertaining Pike Place Market that overlooks the Elliott Bay waterfront. It’s among the oldest continuously operated farmers market in America, serving patrons since August 17, 1907. Have dinner here, browse some of the independent shops, or taste-test excellent Northwestern adult beverages. For an eatery inside the market, sit down at Place Pigalle.

Chocoholics will want to investigate the free samples and perhaps a tour of Theo Chocolate Factory, a frontrunner in sustainable and organic cocoa bean practices that bills itself as “a company rooted in chocolate.”

Enjoy gazing over glistening waters of Elliott Bay while dining at Elliott’s Oyster House. Or, choose from among the eateries at Pier 57’s Miners Landing. Try the Salmon Cooker for fast, good, and relatively inexpensive fare. The Cooker serves up Alder-smoked salmon, halibut, and cod, classic fish and chips and clam chowder, as well as fresh oysters, Dungeness crab, shrimp and crab cocktails, and beer. Finish off with homemade ice cream. Try one of the other Miners Landing restaurants—the Crab Pot or Fisherman’s Restaurant & Bar. There’s also Alaskan Sourdough Bakery, which offers breakfast in addition to baked goods. Another eatery to try is AQUA by El Gaucho for both fresh seafood and custom-aged steaks.

For those fond of cider, check out the award-garnering Schilling Cider House. The cider shop offers more than 30 craft ciders and features tastings and classes. 

Of course, we can’t leave Seattle without a coffee encounter since it’s home to the following roasters and servers and then some.

If tea is more your taste, visit among these tea hotspots to find your best hot brew.

Register here for TapRooT® Training on October 24, 2018, in Seattle, Washington: 2-Day TapRooT® Root Cause Analysis Training.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out to discuss what we can do for you, or call us at 865.539.2139.

Monday Accidents & Lessons Learned: One Second Away from Major Tragedy

Posted: August 20th, 2018 in Accidents, Current Events, Great Human Factors, Human Performance, Investigations

Have you ever felt that you couldn’t challenge a company practice for fear of losing face or your position? It happens more often than you may imagine. Concerning recent findings from a 2017 Nottinghamshire incident investigation by the Rail Accident Investigation Branch (RAIB), Chief Inspector of Rail Accidents Simon French commented, “When the person in charge of a team is both a strong personality and an employee of the client, it can be particularly hard for contract workers to challenge unsafe behavior.” Inspector French further observed, “We have seen this sort of unsafe behavior before, where the wish to get the work done quickly overrides common sense and self-preservation. When we see narrowly avoided tragedies of this type, it is almost always the result of the adoption of an unsafe method of work and the absence of a challenge from others in the group.”

The incident
Around 11:22 am on October 5, 2017, a group of track workers narrowly avoided being struck by a train close to Egmanton level crossing, between Newark North Gate and Retford on the East Coast Main Line. A high-speed passenger train was approaching the level crossing on the Down Main line at the maximum permitted line speed of 125 mph (201 km/h) when the driver saw a group of track workers in the distance. He sounded the train’s warning horn but saw no response from the group. A few seconds later, the driver gave a series of short blasts on the train horn as it approached and passed the track workers.

The track workers became aware of the train about three seconds before it reached them. One of the group shouted a warning to three others who were between the running rails of the Down Main line. These three workers cleared the track about one second before the train passed them. During this time, thinking his train might strike one or more of them, the driver continued to sound the horn and made an emergency brake application before the train passed the point where the group had been working. The train subsequently came to a stop around 0.75 miles (1.2 km) after passing the site of work.

The immediate cause of the near-miss was that the track workers did not move to a position of safety as the train approached. The group had been working under an unsafe and unofficial system of work, set up by the Person in Charge (PiC). Instead of adhering to the correct method of using the Train Operated Warning System (TOWS) by moving his team to, and remaining in, a position of safety while TOWS was warning of an approaching train, the PiC used the audible warning as a cue for the lookout to start watching for approaching trains in order to maximize the working time of the group on the track. This unsafe system of work broke down when both the lookout and the PiC became distracted and forgot about the TOWS warning them of the approaching train.

Although the PiC was qualified, experienced, and deemed competent by his employer, neither his training nor reassessments had instilled in him an adequate regard for safety along with the importance of following the rules and procedures. Additionally, none of the team involved challenged the unsafe system of work that was in place at the time. Even though some were uncomfortable with it, they feared they might lose the work as contractors if they challenged the PiC.

Recommendations
As a result of its investigation the RAIB has made three recommendations. These relate to:

    1. Strengthening safety leadership behaviour on site and reducing the occurrences of potentially dangerous rule breaking by those responsible for setting up and maintaining safe systems of work;
    2. Mitigating the potentially adverse effect that client-contractor relationships can have on the integrity of the Worksafe procedure such that contractors’ staff feel unable to challenge unsafe systems of work for fear of losing work;
    3. Clarifying to staff how the Train Operated Warning System (TOWS) should be used.

Lessons learned
The findings of this investigation also reinforced the importance of railway staff understanding their safety briefings and challenging any system of work that they believe to be unsafe.

Inspector French added this comment to the findings, “We are therefore recommending that Network Rail looks again at how it monitors and manages the safety leadership exercised by its staff, and how they interact with contractors. There have been too many near-misses in recent years.”

Circumstances can crop up anywhere at any time if proper and safe sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: August 20th, 2018 in Career Development, Courses, Human Performance, Job Postings, Performance Improvement, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Environmental Health & Safety Manager

QHSE Manager

HSE Advisor 

HSE Inspector

MWD Specialist

HSE Manager

Specialist HES Operations

HSE Technical & Administrative Assistant 

Patient Safety Analyst

Health & Safety Advisor

Safety Specialist/Safety Officer 

Site Safety Coordinator

Safety Coordinator

Nurse

Specialist HSE

SHE Coordinator

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development and your career.

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, August 31, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Friday Joke

Posted: August 17th, 2018 in Jokes

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

Posted: August 15th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, TapRooT, Topic of the Week, Video

Join our Facebook Live session today as TapRooT® professionals Ken Reed and Benna Dortch discuss human factors. As you listen and glean takeaways from this discussion, start making plans to learn even more from the Human Factor Track at the 2019 Global TapRooT® Summit, designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s only part of what you’ll get through attending the Human Factor Track at the 2019 Summit.

Plan ahead to tune in for next week’s Wednesday with FB Live. Put a reminder on your calendar, in your phone, or a post-it on your forehead to tune in for TapRooT®’s FB Live. Dig in with us as we explore a workplace-relevant topic with takeaways. And, as always, feel free to join the discussion via comments on our Facebook page.

Here’s the scoop for tuning in:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, August 15, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Intelex and TapRooT® Partner to Offer In-Depth Root Cause Analysis

Posted: August 14th, 2018 in Current Events, Media Room, Meet Our Staff, Performance Improvement, Presentations, Quality, TapRooT® Instructor, Topic of the Week, Video

In this video, hear about TapRooT®’s recent partnership with Intelex Technologies, a leading global provider of cloud-based Environmental, Health, Safety and Quality (EHSQ) management software. The integration of Intelex Technologies with TapRooT® allows customers to enter an injury in Intelex, perform a detailed root cause analysis using TapRooT®, and capture the result of the root cause analysis within Intelex. Customers are able to leverage Intelex’s powerful reporting and analytics foresight on injury and root cause data, ultimately producing better decisions and reducing the risk of repeat incidents, injuries and illnesses. The integration will also remove the administrative and record keeping hassle of managing two disparate incident and root cause analysis tools.

About the partnership, TapRooT®’s Vice President and Chief Technology Officer Dan Verlinde said, “We’re excited to establish a partnership with Intelex. TapRooT® and Intelex both create safer work places and help companies achieve operational excellence—that’s why this was an obvious opportunity to collaborate. This partnership will allow our joint customers to realize an integrated Environmental Health and Safety and Root Cause Analysis solution, while reducing duplicate effort.” And, Kristen Duda, Vice President, Strategic Alliances and Partnerships at Intelex, observed of the new integration, “This partnership provides customers with an industry-leading, integrated solution for taking their injury and root cause analysis data to the next level. By leveraging Intelex and TapRooT®, customers can drive impactful proactive safety decisions.”

Connect with us on Wednesdays for TapRooT®’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Monday Accidents & Lessons Learned: An Assumption Can Lead You to Being All Wet

Posted: August 13th, 2018 in Accidents, Great Human Factors, Human Performance

IOGP Well Control Incident Lesson Sharing

The International Association of Oil & Gas Producers (IOGP) is the voice of the global upstream oil and gas industry. The industry of oil and gas provides a significant proportion of the world’s energy to meet growing demands for heat, light, and transport. IOGP members produce 40 percent of the world’s oil and gas, operating in the Americas, Africa, Europe, the Middle East, the Caspian, Asia, and Australia.

IOGP shares a Well Control Incident Lesson Sharing report recounting a breakdown in communication, preparation and monitoring, and process control. Importantly, through the findings, we identify that the overarching project plan was erroneously based on the expectation, albeit assumption, that the reservoir was depleted. Let’s track this incident:

What happened?
In a field subjected to water flooding, when drilling through shales and expecting to enter a depleted reservoir, gas readings suddenly increased. Subsequently, the mud weight was increased, the well was shut-in, and the drill string became stuck when the hole collapsed during kill operations. Water-flood break-through risks were not communicated to the drill crew, and the drill crew failed to adequately monitor the well during connections. The loss of well control, hole, and drill string was due to poor communication and well-monitoring.

  • Drilling 8″1/2 x 9″1/2 hole with 1.30SG mud weight (MW) at 2248m – this mud density is used to drill the top section shales for borehole stability purpose
  • Crossed an identified sands layer which was expected to be sub-hydrostatic (0.5SG)
  • Observed a connection gas reading up to 60% + pack off tendency.
  • Increased mud weight by step to 1.35SG but gas readings were still high
  • Decided to shut the well in and observed pressure in the well SIDP 400 psi – SICP 510 psi
  • A Gain of +/- 10m3 was estimated later (by postmortem analysis of the previous pipe connection and pump-off logs)
  • Performed Driller’s Method and killed the well by displacing 1.51 SG kill mud
  • Open hole collapsed during circulation with the consequence of string getting stuck and kick zone isolated

What went wrong? 
The reservoir was expected to be depleted. This part of the field was artificially over-pressurized by a water injector well. This was not identified during the well preparation phase. and the risk was not transmitted to the drilling teams. Lack of crew vigilance. Poor well monitoring during DP connections. The high connection gas observed at surface were the result of a crude contamination in the mud system. Significant gain volumes were taken during the previous pipe connections without being detected.

Corrective actions and recommendations 
-The incident was shared with drilling personnel and used for training purposes.

-Shared the experience and emphasized to reinforce the well preparation process with a rigorous risk identification: the hazard related to a continuous injection in a mature field to be emphasized.

-Reinforce well monitoring. Specifically, during pipe connections.

-Review mapping of injection on the field.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: August 13th, 2018 in Career Development, Courses, Job Postings, Performance Improvement, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Specialist HES Operations

Senior Process Engineer

HSE Technical & Administrative Assistant 

Patient Safety Analyst

HES Drilling Specialist

Safety Specialist/Safety Officer 

Service Specialist

HSE Associate Coordinator

Service Operator 

Associate- Senior Engineer Nuclear

Site Safety Coordinator

Safety Coordinator

Nurse

Senior Safety Advisor

Specialist HSE

SHE Coordinator

Project Operations Manager 

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development and your career.

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, August 31, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Friday joke

Posted: August 10th, 2018 in Jokes

No matter how it’s spelled, you heard him.

Tune in Today: TapRooT® Has News You Can Use, Noon EST

Posted: August 8th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, Topic of the Week, Video

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

We ‘re excited to be with you on Wednesdays! Feel free to add comments on TapRoot®’s Facebook page during the discussion. Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, August 8

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Onsite, Topaz Marine, Baku, Azerbaijan

Posted: August 7th, 2018 in Career Development, Courses, Human Performance, Investigations, Meet Our Staff, Performance Improvement, Pictures, TapRooT® Instructor, Training

Enjoy a glimpse into a recent 2-Day TapRooT® Root Cause Analysis Training, held onsite at Topaz Marine, in Baku, Azerbaijan, taught by TapRooT® instructor Per Ohstrom. We appreciate Per passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Adealaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Tune in Tomorrow for TapRooT®’s Facebook Live, Noon EST

Posted: August 7th, 2018 in Career Development Tips, Human Performance, Meet Our Staff, Performance Improvement, Topic of the Week, Video

It’s TapRooT® time! Join us tomorrow at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, August 8

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Monday Accidents & Lessons Learned: Dumping the Electronic Flight Bag En Route

Posted: August 6th, 2018 in Accidents, Career Development Tips, Great Human Factors, Human Performance, Performance Improvement

The electronic flight bag (EFB) has demonstrated improved capability to display aviation information such as airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance. This portable electronic hardware has proven facilitative for flight crews in efficiently performing management tasks. While the EFB provides many advantages and extensive improvements for the aviation community in general and for pilots specifically, some unexpected operational threats have surfaced.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. Today’s particular instance relates to EFB operation in a particular phase of flight:

An ERJ175 pilot attempted to expand the EFB display during light turbulence. Difficulties stemming from the turbulence and marginal EFB location rendered the EFB unusable, so the pilot chose to disregard the EFB entirely.

“We were on short final, perhaps 2,000 feet above field elevation. [It had been a] short and busy flight. I attempted to zoom in to the Jepp Chart, currently displayed on my EFB, to reference some information. The EFB would not respond to my zooming gestures. After multiple attempts, the device swapped pages to a different chart. I was able to get back to the approach page but could not read it without zooming. I attempted to zoom again but, with the light turbulence, I could not hold my arm steady enough to zoom. [There is] no place to rest your arm to steady your hand because of the poor mounting location on the ERJ175.

“After several seconds of getting distracted by…this EFB device, I realized that I was … heads-down for way too long and not paying enough attention to the more important things (e.g., acting as PM). I did not have the information I needed from the EFB. I had inadvertently gotten the EFB onto a company information page, which is bright white rather than the dark nighttime pages, so I turned off my EFB and continued the landing in VMC without the use of my EFB. I asked the PF to go extra slowly clearing the runway to allow me some time to get the taxi chart up after landing.

“… I understand that the EFB is new and there are bugs. This goes way beyond the growing pains. The basic usability is unreliable and distracting. In the cockpit, the device is nearly three feet away from the pilot’s face, mounted almost vertically, at a height level with your knees. All [EFB] gestures in the airplane must be made from the shoulder, not the wrist. Add some turbulence to that, and you have a significant heads-down distraction in the cockpit.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes of some common problems that pilots have experienced. In this issue, we learned about precursor events that have occurred during the EFB’s adolescence.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend situations and find and fix problems. Attend one of our courses. Among our offerings are a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

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Success Stories

If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

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