Category: Career Development Tips

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

September 19th, 2018 by

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Chris Vallee discussing, Do you perform incident investigations like you watch the news?

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

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

When? Wednesday, September 19

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

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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. You don’t want to miss a minute of the TapRooT® Summit!

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

September 18th, 2018 by

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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

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

When? Wednesday, September 19

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.

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

September 12th, 2018 by

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professional Michelle Wishoun who will discuss TapRooT® Certified Instructors. You’ll also learn more about our upcoming Global TapRooT® Summit during today’s session.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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

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

When? Wednesday, September 12

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. You don’t want to miss a minute of the TapRooT® Summit!

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

September 11th, 2018 by

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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

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

When? Wednesday, September 12

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.

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

September 5th, 2018 by

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Mark Paradies who will offer insights and improvements to implement in your job and to include in situations throughout your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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

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

When? Wednesday, September 5

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.

Join the Smart Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

September 4th, 2018 by

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals Benna Dortch and Mark Paradies presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

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

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

When? Wednesday, September 5

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.

Join TapRooT® Today at Noon EST on Facebook Live

August 29th, 2018 by

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 29

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.

Does Social Media Encourage Poor Root Cause Analysis?

August 29th, 2018 by

Who doesn’t love a good online video? Videos can encourage interaction and make you think, but are they leading us down poor thought paths or compelling us to jump to conclusions? Asking ourselves this question caused us to ponder, Does social media encourage poor root cause analysis?

Listen as TapRooT® professionals Benna Dortch and Ken Reed explore this topic. You will want to glean further insights from Ken’s article, Do LinkedIn Posts Encourage Poor Investigations? (For the Vimeo version of this video, click here.)

TapRooT® Root Cause Analysis training can transform your investigations, 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 your workplace into a culture of performance improvement.

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.

Does Blame Make Sense in Incident Investigations?

August 23rd, 2018 by

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. (For the Vimeo version of this video, click here.)

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

August 22nd, 2018 by

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.

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

August 21st, 2018 by

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.

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

August 15th, 2018 by

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.

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

August 8th, 2018 by

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.

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

August 7th, 2018 by

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

August 6th, 2018 by

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.

It’s TapRooT® Time! Join Us Today at Noon EST

August 1st, 2018 by

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 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 1

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.

Join TapRooT® Tomorrow for Facebook Live at Noon EST

July 31st, 2018 by

Make plans now to join our knowledgeable TapRooT® professionals tomorrow for the weekly Facebook Live discussion that brings you insights and improvements for your workplace 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 1

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: Zooming to “Too Low Terrain”

July 30th, 2018 by

When the Electronic Flight Bag (EFB) platform—frequently a tablet device—was introduced as a human-machine interface into the aviation industry and the cockpit, the platform proved to  facilitate improvements for both pilots and the aviation community, but the human-machine interface has encountered operational threats in the early years of EFB utilization.

NASA’s Aviation Safety Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One routine problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, and unknowingly “slides” important information off the screen, making it no longer visible. A second type of problem manifests itself in difficulty operating the EFB in specific flight or lighting conditions. Yet a third wrinkle relates to EFB operation in a particular flight phase.

Let’s look at what happened in an A319 when “zoom” went awry:

Prior to departure, an A319 crew had to manage multiple distractions. An oversight, a technique, and a subtle EFB characteristic all subsequently combined to produce a unrecognized controlled flight toward terrain.

“We received clearance from Billings Ground, ‘Cleared … via the Billings 4 Departure, climb via the SID.’ During takeoff on Runway 10L from Billings, we entered IMC. The Pilot Flying (PF) leveled off at approximately 4,600 feet MSL, heading 098 [degrees]. We received clearance for a turn to the southeast … to join J136. We initiated the turn and then requested a climb from ATC. ATC cleared us up to 15,000 feet. As I was inputting the altitude, we received the GPWS alert, ‘TOO LOW TERRAIN.’ Immediately, the PF went to Take Off/Go Around (TO/GA) Thrust and pitched the nose up. The Pilot Monitoring (PM) confirmed TO/GA Thrust and hit the Speed Brake handle … to ensure the Speed Brakes were stowed. Passing 7,000 feet MSL, the PM announced that the Minimum Sector Altitude (MSA) was 6,500 feet within 10 nautical miles of the Billings VOR. The PF reduced the pitch, then the power, and we began an open climb up to 15,000 feet MSL. The rest of the flight was uneventful.

“On the inbound leg [to Billings], the aircraft had experienced three APU auto shutdowns. This drove the Captain to start working with Maintenance Control. During the turn, after completion of the walkaround, I started referencing multiple checklists … to prepare for the non-normal, first deicing of the year. I then started looking at the standard items. It was during this time that I looked at the BILLINGS 4 Departure, [pages] 10-3 and 10-3-1. There are no altitudes on … page [10-3], so I referenced [page] 10-3-1. On [page] 10-3-1 for the BILLINGS 4 Departure at the bottom, I saw RWY 10L, so I zoomed in to read this line. When I did the zoom, it cut off the bottom of the page, which is the ROUTING. Here it clearly states, ‘Maintain 15,000 or assigned lower.’ I never saw this line. When we briefed prior to push, the departure was briefed as, ‘Heading 098, climb to 4,600 feet MSL’; so neither the PF nor the PM saw the number 15,000 feet MSL. The 45-minute turn was busy with multiple nonstandard events. The weather was not great. However, that is no excuse for missing the 15,000-foot altitude on the SID.”

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.

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, 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.

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

July 25th, 2018 by

Join our Facebook Live session today as TapRooT® professional Ken Reed discusses, How to Use TapRooT® to Analyze a Single, Small Problem. As Ken observes, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

There is a full spectrum of possible uses of TapRooT® in your improvement programs. Use TapRooT® for:

  • Really large, complex, high-risk incidents (Major Investigations)
  • Smaller, less complex problems (Low-to-Medium Risk Incidents)
  • A very simple problem found, for example, during an audit (single Causal Factor)

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, July 25

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.

2018 Global TapRooT® Summit Best Practices: TapRooT® Safety Alerts

July 24th, 2018 by

The 2018 Global TapRooT® Summit, in Knoxville, Tennessee, brought many valuable insights from Best Practices guest speakers to our attendees, and we want to share these with you.

Our Best Practices speaker for this session is Erick Pike, from Ontario, Canada. Here, Erick brings great insights regarding the universality of hazards and a process for sharing safety alerts and lessons learned. Watch the Best Practices session via the video below or here in Vimeo.

Learn more about investigating low-level incidents in the TapRooT® book Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents and through our courses. Discover what TapRooT® can do for you; Contact 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.

Learn with TapRooT® Tomorrow at Noon EST on Facebook Live: How to Use TapRooT® to Analyze a Single, Small-Sized Problem

July 24th, 2018 by

Make plans now to join TapRooT® professional Ken Reed tomorrow for our Facebook Live discussion: How to Use TapRooT® to Analyze a Single, Small Problem. Ken observes that, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

To put this into the big-picture TapRooT® perspective, Ken explains, “You can use TapRooT® for:

  1. Really large, complex, high-risk incidents (Major Investigation)
  2. Smaller, less complex problems (Low-to-Medium Risk Incidents)
  3. A very simple problem found, for example, during an audit (single Causal Factor)

So, this gives you a full spectrum of possible uses of TapRooT® in your improvement programs.”

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, July 25

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.

What Are SnapCharT®s and Why Are They Important?

July 23rd, 2018 by

TapRooT®’s systematic process for finding the root causes of problems is used around the world to investigate and fix all categories of mission-critical issues, problems, and potential incidents. The first steps of the TapRooT® process are planning the investigation, collecting information, and understanding what happened. The investigator draws a SnapCharT® to understand what happened and to organize the information about what happened. In this Facebook Live session, you will learn more about the value and vital importance of SnapCharT®s from TapRooT® professionals Benna Dortch and Dave Janney.

Watch the session here in Vimeo.

TapRooT® has special tools—such as the Root Cause Tree® and TapRooT® Root Cause Tree Dictionary—to help investigators find root causes of Causal Factors. Our books and training through our custom courses, software and webinars, and TapRooT® professionals will educate, facilitate, and guide you through investigations into the root causes of human performance problems. Let us know how we may help you. Contact or call us: 865.539.2139.

 

Monday Accidents & Lessons Learned: A Taxiway by Any Other Name

July 23rd, 2018 by

An EFB, or electronic flight bag, is portable electronic hardware, increasingly utilized for flight deck or cabin use to facilitate flight crews perform flight management tasks easier and more efficiently. At a basic level, EFBs can perform flight-planning calculations and offer a variety of digital documentation, such as navigational charts, operations manuals, and aircraft checklists.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. This report illustrates how complications between EFBs and human operators develop into precursor events:

“A B737 Captain encountered frustration while using his moving map. Although the specific incident is not cited, the Captain clearly identifies an EFB operational problem and offers a practical solution for the threat.

‘In [our] new version of [our EFB chart manager App], … a setting under Airport Moving Map (AMM) … says, “Set as default on landing,” [and I cannot] … turn it off. If [I] turn it off, it turns itself back on. This is bad.… It should be the pilot’s choice whether or not to display it at certain times—particularly after landing. Here’s the problem with the AMM: When you zoom out, the taxiway names disappear.

‘Consider this scenario: As you turn off the runway at a large airport, you look down at the map (which is the AMM, not the standard taxi chart, because the AMM comes on automatically, and [I] cannot turn that feature off). You get some complicated taxi instructions and then zoom out the AMM [to] get a general, big-picture idea of where you’re supposed to go. But when [I] zoom out the AMM, taxiway names disappear.… [I] have to switch back to the standard taxi chart and zoom and position that chart to get the needed information. That’s a lot of heads-down [tablet] manipulation immediately after exiting the runway, and it’s not safe.

‘[Pilots should have] control over whether or not to automatically display the AMM after landing. The AMM may work fine at a small airport, but at a large airport when given taxi instructions that are multiple miles long, the AMM is useless for big-picture situational awareness.'”

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.

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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July 18th, 2018 by

 

For news you can use, join TapRooT® professionals Dave Janney and Michelle Wishoun in our Facebook Live discussion. Our topic today is: Why Is SnapChart® So Important? As always, feel free to ask questions or comment on our Facebook page during the session.

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/

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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.

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.

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: When One Good Turn Definitely Doesn’t Deserve Another

July 16th, 2018 by

The electronic flight bag (EFB) is rapidly replacing pilots’ conventional papers in the cockpit. While the EFB has demonstrated improved capability to display aviation information—airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance—NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies, such as this one:

“This B757 Captain received holding instructions during heavy traffic. While manipulating his EFB for clarification, he inadvertently contributed to an incorrect holding entry.

‘[We were] asked to hold at SHAFF intersection due to unexpected traffic saturation. While setting up the FMC and consulting the arrival chart, I expanded the view on my [tablet] to find any depicted hold along the airway at SHAFF intersection. In doing so, I inadvertently moved the actual hold depiction…out of view and [off] the screen.

‘The First Officer and I only recall holding instructions that said to hold northeast of SHAFF, 10-mile legs. I asked the First Officer if he saw any depicted hold, and he said, “No.” We don’t recall instructions to hold as depicted, so not seeing a depicted hold along the airway at SHAFF, we entered a right-hand turn. I had intended to clarify the holding side with ATC, however there was extreme radio congestion and we were very close to SHAFF, so the hold was entered in a right-hand turn.

‘After completing our first 180-degree turn, the controller informed us that the hold at SHAFF was left turns. We said that we would correct our holding side on the next turn. Before we got back to SHAFF for the next turn, we were cleared to [the airport].'”

Volpe National Transportation Systems Center, U.S. Department of Transportation, weighs in on EFBs: “While the promise of EFBs is great, government regulators, potential customers, and industry developers all agree that EFBs raise many human factors considerations that must be handled appropriately in order to realize this promise without adverse effects.”

CALLBACK is the award-winning publication and monthly safety newsletter from NASA’s Aviation Safety Reporting System (ASRS). CALLBACK shares reports, such as the one above, that reveal current issues, incidents, and episodes.

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.

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