Category: Documents

NRC Issues "FINAL SAFETY CULTURE POLICY STATEMENT" ,,, Can You Show That You Are Compliant?

June 21st, 2011 by

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The NRC has issued what they are calling a “final safety culture policy statement.”  See:

I’m sure that it isn’t really final. (Aren’t we always learning and improving?) But I guess that they are saying they are done with the initial development and will now be starting to look at nuclear utilities to see that they have a positive safety culture.

What is a safety culture? The NRC says it is:

… an organization’s collective commitment, by leaders and individuals, to emphasize safety as an overriding priority to competing goals and other considerations to ensure protection of people and the environment.

The go on to define nine traits that nuclear plants should foster. They are:

1.Leadership Safety Values and Actions – Leaders demonstrate a commitment to safety in their decisions and behaviors;

2. Problem Identification and Resolution – Issues potentially impacting safety are promptly identified, fully evaluated, and promptly addressed and corrected commensurate with their significance;

3. Personal Accountability – All individuals take personal responsibility for safety;

4. Work Processes – The process of planning and controlling work activities is implemented so that safety is maintained;

5. Continuous Learning – Opportunities to learn about ways to ensure safety are sought out and implemented;

6. Environment for Raising Concerns – A safety-conscious work environment is maintained where personnel feel free to raise safety concerns without fear of retaliation, intimidation, harassment, or discrimination;

7. Effective Safety Communication – Communications maintain a focus on safety;

8. Respectful Work Environment – Trust and respect permeate the organization;

9. Questioning Attitude – Individuals avoid complacency and continuously challenge existing conditions and activities in order to identify discrepancies that might result in error or inappropriate action.

As I read more, I started thinking … As a utility, how do you measure your culture, diagnose opportunities for improvement, and demonstrate efforts to improve the safety culture at your plant?

Fortunately, we’ve been interested in safety culture for a long time and TapRooT® is able to help you diagnose safety culture issues.

But where to start? Safety culture is a tough subject. Many find it hard to be specific about culture issues. Even TapRooT® users sometimes don’t understand how TapRooT® can help them understand their safety culture and improve it.

So, we decided to build a course to help TapRooT® Users understand safety culture issues and then fix them.

This new course was built on a solid foundation of culture research and the bedrock of the TapRooT® System.

The FIRST public TapRooT® Analyzing and Fixing Safety Culture Issues will be held in Las Vegas on February 27-28, 2012. We will be putting out more information in future updates here on the Root Cause Analysis Blog, but, if you are interested in safety culture, you should plan to attend the course.

But the course isn’t all we are doing.

The TapRooT® Summit is also a great way for your company to demonstrate a commitment to improving your safety culture.

First, since problem identification and resolution is a major part of a positive safety culture, the Summit helps Summit participants by keeping them up-to-date on the latest incident investigation, troubleshooting, and root cause analysis technology. That way they can go back to their companies and make sure that issues really are fully evaluated and promptly addressed.

Second, another major trait that nuclear plants are suppose to foster is “continuous learning”. And continuous learning is what the Global TapRooT® Summit is all about. Learning best practices and new techniques from industry leaders from around the world. What better way to demonstrate your companies commitment to continuous learning than to send a team to the Summit and have them return to work with a custom plan to continuously improve performance.

Finally, the first trait mentioned by the NRC is that “Leaders demonstrate a commitment to safety in their decisions and behaviors.” But how can you demonstrate a leaders commitment? Participating in the Summit and making sure that your nuclear sites are well represented is an excellent way to demonstrate commitment. This is especially true because there is a best practice track for managers, the – “Leading Performance Improvement Track.”

The Leading Performance Improvement track includes these breakout sessions:

TapRooT® Implementation Success Stories (Leaders hear how others improved performance.)

What is Culture and How Do You Identify and Solve Culture Problems Using TapRooT® (Highlights from the 2-day course plus communication ideas to have effective safety communications.)

What Does Management Need to Know About Process Safety Improvement (Mark Paradies shares management lessons from Admiral Rickover and how missing elements of process safety management have contributed to major accidents.)

Deepwater Horizon: A Dramatic Portrayal (A dramatic presentation that can capture management’s attention and help them see the management roots of a major accident.)

Criminal Prosecution of Accidents (What happens to those involved when accidents become crimes. Two reports from people who experienced post-accident criminal investigations.)

Investigation & Root Cause Analysis Insights (Insights into root cause analysis from two perspectives – Mark Paradies, creator of TapRooT®, and a government regulator.)

Designing Your Continuous Improvement Program (Kevin McManus – the Systems Guy – shares practical lessons he has learned from industrial experience and his experience as a Malcolm Baldridge Award Senior Examiner.)

How Pfizer Achieves Operational Excellence (Hear Pfizer’s operational excellence story.)

In addition to these breakout sessions, all Summit participants hear from the excellent Keynote Speakers. Two of particular interest to senior management are:

A16 Ken Mattingly

Ken Mattingly speaking about “Lessons Learned from Apollo 13 and Space Shuttle Operations.”


Dr. Beverly Chiodo speaking about “Character Driven Success.”

So start planning for your management and all your improvement team members to be at the Global TapRooT® Summit in Las Vegas from February 27 – March 2, 2012, and attending a special 2-day course and the 3-day Summit to help you achieve – and demonstrate – a positive safety culture.

Checklist for Checklists

June 21st, 2011 by

Dr. Atul Gawande at Brigham and Women’s Hospital and several associates developed this “Checklist for Checklists” for use at hospitals…

Checklist For Checklists Group Draft 5

Great stuff. Check out his web site at:

Root Cause Analysis Tip: Improving the Use of TapRooT® through Knowledge

June 15th, 2011 by

If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.

To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:

  • Specifically designed on-site training for gaps identified as additional needs in your trending and proactive assessments.
  • Feedback for our investigators through our Advisory Board and one-on-one.
  • A Summit for system experts, which include our clients, to share best practices from multiple industries.

The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:

1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)

Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.

Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:

Task Performance Levels

1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
3. Can do all parts of the task. Needs only a spot check of completed work.
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)

Task Knowledge Levels

a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)

Subject Knowledge Levels

A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
D. Can evaluate conditions and make proper decisions about the subject.

By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).

Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:

1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.

2-Day TapRooT® Incident Investigation and Root Cause Analysis
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis

2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.

3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.

4. Develop in-house group sessions to discuss lessons learned.

5. Schedule refresher training to give competency levels high.

Good luck on your quest for knowledge!

Second Fatality this Year at Henley Street Bridge Construction Site

May 24th, 2011 by

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This job is in Knoxville – the home of System Improvements and TapRooT®. But just because it is down the road from our offices doesn’t mean that they learn from their incidents to prevent major accidents. Here’s the story that we know so far from the web:

Some construction companies run extremely safe sites. At others, the fatalities persist. Perhaps the “bad” companies should read the article below from a 2003 Root Cause Network™ Newsletter (click on the document below to open the PDF):


What Management Needs to Know About Process Safety Improvement (or Why We Continue To Have Process Safety Accidents)

May 16th, 2011 by

I’m giving this talk in Bruges, Belgium for Total today and posted a PDF of the talk here so people who attended could get copies of the slides.

Click on the object below to download it…


As usual, the slides don’t tell the whole story. So if you would rather hear this talk, plan to attend the TapRooT® Summit on February 29 – March 2, 2012, in Las Vegas.

Monday Accident & Lessons Learned: Worker drowns in sump; what is in a “good” work plan?

May 9th, 2011 by

Read the Investigation Report published by here Work Safe Alberta:


1. While replacing a sump pump, an experienced work dropped the assembly parts into a sump (pictured below) that was filling continuously with water.

2. In an effort to retrieve the parts that could not be reached within arms length, the worker fall into the sump getting his head and upper body stuck.

3. Workers once finding him in that condition were unable to remove the jammed worker (suction most likely an issue) and had to call rescue.

4. The worker was pronounced dead at the scene.


Findings and Actions from the Report:

7.1 Direct Cause

7.1.1 Worker 1 got stuck head first in the sump and drowned while trying to retrieve a check valve and a rubber hose adapter that had fallen into the sump.

7.2 Contributing Factors

7.2.1 Worker 1 got stuck in the narrow opening of the sump housing.

7.2.2 Worker 1 was unable to safely retrieve the check valve and rubber hose adapter by hand.

7.2.3 At the time of the investigation, water was continually draining into the sump.  The depth of the water in the sump was approximately 76.2 centimeters.

8.2.3 GSS conducted a hazard assessment for sump pump work, developed a “Safe Work Practice for Repair/Replacement” of sump pumps and provided a copy to Occupational Health and Safety.  GSS trained all affected workers in the safe work practice.

8.2.4 GSS complied with all orders issued by Occupational Health and Safety.

So if you were reviewing this report, what should the new Work Plan have included?

… one issue not identified is not blocking the sump access area to prevent assembly parts from being dropped in.

If this were a TapRooT® investigation we would start with a SnapCharT® (a  sequence of events) and then look for the missing best practices that were related to the Causal Factors by using the Root Cause Tree®. These missing best practices would be the foundations of an adequate Work Plan.

Did You Get Your Root Cause Network™ Newsletter Today? Read About Six Common Safety Culture Problems.

April 28th, 2011 by

Just checking to see if TapRooT® Users got their Root Cause Network™ Newsletter today. I think you will find the Six Common Culture Problems story on page one both interesting and helpful when assessing culture issues.

Here’s a copy for download if you didn’t get yours by e-mail:

May 11 Nl

Just click on the document above to download it.

Friday Joke: Here's Thinking of You

April 15th, 2011 by

On tax day you may feel depressed, overburdened, unloved. You don’t have to feel that way. Just watch this PowerPoint sent to me by a TaprooT® User …


Monday Accident & Lessons Learned: UK RAIB Has 8 Recommendations for Track Maintenance Issue

April 4th, 2011 by

The report from the UK Rail Accident Investigation Branch is titled:

Derailment of an engineering train between Gloucester Road and Earl’s Court stations on London Underground 12 May 2010

To read the report that includes eight recommendations, see:

Potential Human Factors Root Cause of the Deepwater Horizon Accident

March 31st, 2011 by

One of the interesting avenues of questioning that TapRooT® would lead investigators to is the human factors involved in detecting that a blowout was starting while the well displacement was in progress.

Two people had indications that could have detected the blowout starting and could have helped those in control of the well maintain control of the well or shut the well in before a blowout occurred.

Therefore, investigators should be looking at the human factors of the detection of a well blowout.

I was reviewing information on the Deepwater Horizon Joint Investigation site and found these pictures …




Screen Shot 2011-03-31 At 12.02.44 Pm

The first three graphs are fairly easy to interpret. Especially with the clearly marked notes with arrows pointing to the applicable trends. The last one is a typical multiple pen strip chart that is difficult to interpret.

So my question would be … “What do the real indicators look like?”

The displays and alarms are a big deal for this accident. This could be a major reason why the crew didn’t detect the blow out starting when they could have taken action.

Does anyone have actual pictures of the type of indicators they would be using? I’d love to have a look at them. If you have them, contact me by clicking here.

Deepwater Horizon – Macondo Well Blowout – Chief Counsel's Report

February 22nd, 2011 by

The Chief Counsel has released a more detailed report about the Deepwater Horizon blowout. See it at:

So far I can’t get the whole report to download, but I can download the separate chapters. Once again, a massive report … This time over 350 pages with animation of certain key technical issues.

A Note in Portuguese from our Brazilian Instructor Boris Risnic

February 2nd, 2011 by

Here’s a note about the upcoming course in Brazil from Boris Risnic …

Taproot Visao Geral 2D

Mark’s Initial Comments on the President’s Commission Report on the BP Deepwater Horizon Accident

January 18th, 2011 by

I didn’t make it very far into the report before the political tone became apparent.

In the second paragraph of the first section (the Forward), the report says:

A treasured American landscape, already battered and degraded from years of mismanagement, faced yet another blow as the oil spread and washed ashore.

These type of political statements and adjectives that can easily agitate public opinion are common throughout the first three chapters that I read this weekend. My opinion is that an accident report should stand on the facts. Perhaps Chapter 4 will present them – I’m still reading.

However, the Editors of The Wall Street Journal were not convinced. In an article in the “Review & Outlook” of the editorial page titled: “Gulf Political Spill”, they said:

Unable to name what difinitively caused the well failure, the commission resorts to a hodgepodge of speculation.”

It also says:

Its [the report’s] section ‘The Root Causes: Failures in Industry and Government’ uses questionable decisions made by the Macondo players to suggest, with no evidence, that such behavior is the industry norm.”

Toward the end of the editorial, it says:

The unbalanced, tendentious nature of the commission report vindicates those who suspected from the start that this was all a political exercise.

They conclude the WSJ editorial with:

The BP spill was a tragedy that should be diagnosed with a goal of preventing a repeat, not in order to all but shut down an industry that is vital to U.S. energy supplies and the livelihood of millions on the Gulf Coast.”

What I’d suggest is that you read the 398 page report for yourself and leave your comments here based on your own observations. Let me know what you think.

To download the report, go to:

President's Commission Releases Report on BP Deepwater Horizon Oil Spill

January 18th, 2011 by

Here are the important links to download the report …
First, download the report at:

Full Report Download Page

Staff Working Papers Page

But the report cites another report still to be written – The Chief Counsel’s Report. The final report references this report for more about the facts of the investigation. There is a place to request notification when the Chief Counsel’s Report is completed on the full report download page.

Friday Joke: The Blame Oriented Alternative to TapRooT®

January 14th, 2011 by

Sometimes people ask me what the most popular problem solving system (besides TapRooT®) is. That easy! Blame.

Here’s a self-executing PowerPoint to help you understand the concept …


Screen Shot 2011-01-07 At 3.23.24 Pm

Is this the way  your employees view your root cause analysis?

Environmental Groups Blast Louisiana Refineries for “Accidents” Reported to the LA Dept of Environmental Quality

December 14th, 2010 by

Here’s the story from the New Orleans Times-Picayune:

While the groups complain about under-reporting, they then turn around to say that the numbers reported show that a BP Texas City type accident could threaten workers and local residents.

What do you think? A fair use of data or a political hit job?

Safe Holiday Wish PowerPoint

December 2nd, 2010 by

I post several Holiday Safety PowerPoints that were given to me by TapRooT® Users. They are yours for toolbox holiday safety meetings.

Here is the first:


Monday Accident & Lessons Learned: Technical Investigation Report concerning the Fire on Eurotunnel Freight Shuttle 7412 on 11 September 2008

November 22nd, 2010 by

See the joint report by the French Bureau d’enquêtes sur les Accidents de transport terrestre and the UK Rail Accident Investigation Branch at:

Taking Improvement to the Next Level

October 27th, 2010 by

You really need to be at this talk to hear what I have to say. This PowerPoint is for the attendees to remind them of what they heard…


Lessons Learned from Rickover About Process Safety/Nuclear Safety

October 22nd, 2010 by

Rickover’s ideas are still applicable and controversial today. Here’s the slides from the talk I’m giving at the Summit…


Prioritizing Improvements

October 21st, 2010 by

Here’s the “kick off” slides from a discussion we will be having at the Summit…


Welcome to the TapRooT® Summit

October 21st, 2010 by

The Summit starts next Wednesday, but I’ll be posting some of the talks so that people attending the Sumnmit can print them to take notes and preview what they will hear.

Caution: A PowerPoint of a talk isn’t the same as a talk. I know in my talks, there are things that are said that make the slides “come alive.” Also, some of the bullets on the slides are “for discussion.” They aren’t meant as a final conclusion, but rather as a starting point. Therefore, these talks should be observed and participated in at the Summit rather than being read as a final statement.

here is the Summit intro talk that will be delivered by Mark Paradies, Linda Unger, Ed Skompski, Ken Reed, Chris Vallee, and David Janney.


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