Category: Current Events

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

September 27th, 2017 by

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

Here is a CNN report on the desperation:

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

Radiation Release – Time for Root Cause Analysis

September 27th, 2017 by

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

Time for root cause analysis?

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

See the article at THIS LINK.

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

September 26th, 2017 by

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

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

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

Generic Cause

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

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

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

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

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

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

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

GENERIC CAUSES

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

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

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

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

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

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

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

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

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

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

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

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

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

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

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

b. NAVIGATION

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

c. ROOT CAUSE ANALYSIS

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

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

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

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

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

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

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

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The world’s most modern Navy struggles with outdated culture

September 6th, 2017 by

To students of safety and accident prevention, the recent collisions involving the guided missile destroyers USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) seem strange. How can this happen with top shelf modern warships, equipped with state-of-the-art electronics, radar and GPS? Hint: look for human performance issues, and a culture of blame and punishment.

These are tragic accidents, with unnecessary loss of lives. The Navy’s immediate response was a 24-hour “safety stand down,” and a 60-day review of surface fleet operations, training, and certification. Perhaps more significantly, the Seventh Fleet commander Vice Admiral Aucoin was fired, due to a “loss of confidence in his ability to command.”

And this is where the problems start. To an outside observer, the Navy culture of “firing those responsible” seems very old fashioned. Not only do we waste money on repairing ship damage that should never have happened, we also voluntarily get rid of a large investment in recruiting and training with each officer let go.

A better answer is to analyze what happened in each case, find the root causes and put in place corrective actions to prevent the same accidents from happening again. The Navy investigation results are classified, but let me offer up two possible causes:

1. Guided missile destroyers are smaller, leaner and meaner than the conventional destroyers they replaced. They sail with a smaller crew and fewer officers. However, there is still the same amount of horizon to scan, so to say, so officers will have larger spans of responsibility and fewer opportunities to rest. Fatigue is a powerful influence on human performance.

2. The world is a dangerous place, and getting worse. A shrinking Navy is deployed on the same number of missions around the world, not allowing enough time in between for maintenance of ships and systems. Training and development of crews also suffers.

Our long experience in root cause analysis tells us that no matter how sophisticated systems or equipment are, they need maintenance to work properly. There is also always human factors involved. Human performance is fickle, and influenced by many factors such as fatigue, alertness, training, or layout of control panels. It is better to do a thorough RCA to identify causal factors and fix them, than to fire people up and down the chain of command and still have the same issues again later.

#TapRooT_RCA

Are you attending the NSC conference?

September 6th, 2017 by

If you are attending the conference, please come by the TapRooT® Booth (3536) and say hello. Barb and I will be there, so we hope to see you!

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

August 30th, 2017 by

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Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis:

As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

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

August 18th, 2017 by

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

August 16th, 2017 by

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

August 16th, 2017 by

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

August 11th, 2017 by

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

August 8th, 2017 by

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

Where is Mark Paradies this Week?

July 19th, 2017 by

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Where is Mark? In Los Angeles being interviewed by Kathy Ireland for an upcoming episode of Worldwide Business with Kathy Ireland®.

The topic? Root cause analysis.

When can you watch the show? We will post the times to watch when the release date is announced … stay tuned!

Should Helicopter Go Back in Service Before the Root Cause Analysis of a Crash is Finished?

July 12th, 2017 by

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Finishing a root cause analysis before returning the Super Puma to service in the North Sea is the issue that the Unite union is upset about.

The UK and Norwegian Civil Aviation Authorities have authorized the flights but several oil companies are reluctant to resume using the helicopters before the root cause analysis is complete.

For the whole story, see: http://www.bbc.com/news/uk-scotland-north-east-orkney-shetland-40567877

Can bad advice make improvements more likely?

July 12th, 2017 by

Here is what a consultant recently wrote in a blog article that was republished on LinkedIn:

“The 5 WHY analysis is a simple and very effective technique.”

What do I think about 5 Whys? It is simple but it is NOT effective. Proof of the lack of effectiveness is all over the place. See these articles to find out just some of what I’ve written about the effectiveness of 5 Whys in the past:

 An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

Under Scrutiny (page 32)

If your root cause analysis is having problems, don’t double down on 5 whys by asking more whys. The problem is the root cause analysis system (5 Whys) and not your ability to ask why effectively.

The problem is that the techniques wasn’t designed with human capabilities and limitations in mind.

What system was developed with a human factors perspective? The TapRooT® Root Cause Analysis System. Read more about how TapRooT® was designed here:

http://www.taproot.com/products-services/about-taproot

Or get the book that explains how TapRooT® can help your leadership improve performance:

TapRooT® Root Cause Analysis Leadership Lessons

Are you a member of the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends?

July 11th, 2017 by

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Sometimes people ask me what TapRooT® Users are doing about a particular issue. I recommend they ask the question on the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends.

There are over 3000 group members and it’ a great place to post a question or your opinions.

To join the group, see: https://www.linkedin.com/groups/2164007

 

“Human Error” by Maintenance Crew is “Cause” of NYC Subway Derailment. Two Supervisors Suspended Without Pay.

June 29th, 2017 by

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The New York Daily News says that a piece of track was left between the rails during repair of track on the NYC subway system. That loose track may have caused the derailment of an eight car train.

The rule is that any track less than 19.5 feet either be bolted down or removed. It seems that others say that the “practice” is somewhat different. This piece of track was only 13.5 feet long and was not bolted down.

But don’t worry. Two supervisors have been suspended without pay. And workers are riding the railed looking for other loose equipment between the rails. Problem solved. Human error root cause fixed…

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

Screen Shot 2017 05 31 at 1 20 19 PM

Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Are you attending Safety 2017 (otherwise known as ASSE)?

May 30th, 2017 by

If you are attending, please stop by the TapRooT® Booth (#508) and say hello. Barb Phillips and I will both be there.

Ask Barb about the new course and book for Interviewing and Evidence Collection that will be out soon.

Ask me about the new TapRooT® for Audits Course and book.

Free gift for the first 500 people!

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

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Authors

Angie ComerAngie Comer

Software

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

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 …

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