Category: Current Events

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

Screen Shot 2017 07 17 at 10 44 23 AM

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

Screen Shot 2017 07 06 at 5 15 37 PM

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

NewImage

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!

Freeze on New RMP Rule linked to the ATF announcement about the West, TX, Fertilizer Explosion

May 5th, 2017 by

The new EPA RMP rule which had an effective date March 14, 2017, has been “frozen” under the Trump administration regulatory freeze until February 19, 2019.

The main reason for the freeze in the case of the RMP rule is that the rule modifications were largely based on the West, TX fertilizer explosion. However, two days before the comment period ended, the ATF announced that they suspected that the West, TX, fertilizer explosion was NOT an accident, but rather was an intentional act.

Now the whole rule is being reconsidered.

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

Should We Continue to Fund the CSB?

April 17th, 2017 by

The Trump Administration has cut funding for several independent agencies in their 2017 budget request. One is the US Chemical Safety Board.

The CSB has produced this video and a report to justify their continued funding.

REPORT LINK

The question taxpayers need to ask and answer is, what are the returns on the investment in the CSB?

The CSB produces investigation reports, videos, and a wish list of improvements.  In 2016 the agency published seven reports and two videos  (it has six investigations that are currently open). That makes it a cost of $1.2 million per report/video produced when you divide their $11 million 2016 budget by their key products.

The 2017 budget request from the CSB was $12,436,000 (a 13% increase from their 2016 budget).

Should the government spend about $12 million per year on this independent agency? Or are these types of improvements better developed by industry, other regulatory agencies (EPA and OSHA), and not-for-profit organizations (like the Center for Chemical Process Safety)?

Leave your comments here (click on the comments link below) to share your ideas. I’d be interested in what you think. Or write your representatives to provide your thoughts.

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

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To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

Avoid the Danger of New Hires

March 1st, 2017 by

 

Is your safety program ready?

Is your safety program ready?

There is a feeling of cautious optimism in the oil sector, as the price of oil seems to have stabilized above $50/barrel. Rig count in the Permian has more than doubled since last spring. US EIA and JPMorgan are forecasting US production at near record levels of over 9.5 million barrels per day by the end of next year. US exports are up, with China ramping up oil purchases from the US, while OPEC production cuts are holding.

This all sounds good for the US oil sector. It is expected that hiring will start picking up, and in fact Jeff Bush, president of oil and gas recruiting firm CSI Recruiting, has said, “When things come back online, there’s going to be an enormous talent shortage of epic proportions.”

So, once you start hiring, who will you hire? Unfortunately, much of the 170,000 oil workers laid off over the past couple of years are no longer available. That experience gap is going to be keenly felt as you try to bring on new people. In fact, you’re probably going to be hiring many people with little to no experience in safe operation of your systems.

Are you prepared for this? How will you ensure your HSE, Quality, and Equipment Reliability programs are set up to handle this young, eager, inexperienced workforce? What you certainly do NOT want to see are your new hires getting hurt, breaking equipment, or causing environmental releases. Here are some things you should think about:

– Review old incidents and look for recurring mistakes (Causal Factors). Analyze for generic root causes. Conduct a TapRooT® analysis of any recurring issues to help eliminate those root causes.
– Update on-boarding processes to ensure your new hires are receiving the proper training.
– Ensure your HSE staff are prepared to perform more frequent audits and subsequent root cause analysis.
– Ensure your HSE staff are fully trained to investigate problems as they arise.
– Train your supervisors to conduct audits and detailed RCA.
– Conduct human factors audits of your processes. You can use the TapRooT® Root Cause Tree® to help you look for potential issues.
– Take a look at your corrective action program. Are you closing out actions? Are you satisfied with the types of actions that are in there?
– Your HSE team may also be new. Make sure they’ve attended a recent TapRooT® course to make sure they are proficient in using TapRooT®.

Don’t wait until you have these new hires on board before you start thinking about these items. Your team is going to be excited and enthusiastic, trying to do their best to meet your goals. You need to be ready to give them the support and tools they need to be successful for themselves and for your company.

TapRooT® training may be part of your preparation.  You can see a list of upcoming courses HERE.

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