Category: Human Performance

TapRooT® Around the World: Cork, Ireland

September 18th, 2018 by

Look into the Two-Day TapRooT® Techniques course in Cork, Ireland, where students and TapRooT® Instructors Thomas Di Giacomo and Chris Vallee gathered at the Imperial Hotel Cork on South Mall. Attendees enjoyed a bit of history along with the TapRooT® course, as guests such as Sir Walter Scott, William Thackeray, Franz Liszt, and Charles Dickens have stayed at the hotel.

In the span of the two-day course, students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Upon course completion, attendees received a certificate and a 90-day subscription to TapRooT® VI, the online software service.

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

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

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

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

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

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

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

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

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

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

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

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

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

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

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

TapRooT® Around the World: Johannesburg, South Africa

September 13th, 2018 by

Take a look into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, taught by TapRooT® Instructor Sanjay Gandhi. We are grateful to Sanjay for sharing these pictures that show teamwork, the TapRooT® learning experience, and a great time in the process!

Through TapRooT® Training with our exceptional instructors, students learn to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to identify the root cause of any issue and/or incident.

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

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

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

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

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

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

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

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

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

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

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

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

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

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

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

The UK General Medical Council Shows a Lack of Understanding of Root Cause Analysis

September 11th, 2018 by

Screen Shot 2018 09 07 at 6 10 40 PM

Here is a quote from an article in gponline.com:

“The GMC says human factors refers to the ‘environmental, organisational and job factors –
and human and individual characteristics – which influence behaviour at work in a way
that can affect health and safety,’ while root cause analysis is a systematic process for identifying
‘root causes’ of problems or events and an approach for responding to them.

Responding to the review, the GMC said: ‘Focusing on root cause analysis may not always be
the best way of dealing with all investigations and we understand that exploration of a
human factors approach is underway at several NHS Trusts in England.'”

To use an “English” term …

“What rubbish!”

Who gave this team of senior managers the idea that human factors is not a part of a root cause analysis?

If they aren’t including human factors, behavior, organizational factors (Management Systems), procedures, training, communications, work direction, and quality processes in their root cause analysis … THEY AREN’T DOING ROOT CAUSE ANALYSIS THE RIGHT WAY.

Instead of trying “human factors,” they should try a root cause analysis system that automatically includes “human factors,” the TapRooT® Root Cause Analysis System.

Find out more about how TapRooT® includes human factors at:

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

Why did they decide they needed to change? Because their system exhibits a blame culture and abysmal root cause analysis. A particle case involving Dr. Bawa-Garba finally got senior leadership to admit that they need to improve. But instead of finding out what is wrong with their practices, they decided they needed a new buzz-word … human factors.

We have written several articles about root cause analysis practices in the UK and the need for improvement (see Dr. Death, Healthcare Scandal, Bias & Blame, House of Commons Calls for RCA Training, Highest Number of Serious Incidents. and Not Preventable), but even though a decade has passed, little improvement has occurred.

Will a new focus on human factors solve the problems of the UK National Health System? Doubtful. Good root cause analysis (that includes human factors among other things), and implementation of appropriate corrective actions could have solved these problems years ago. I would guess that:

  • poor root cause analysis,
  • unwillingness to change,
  • understaffing and budgeting,
  • poor Management Systems, and
  • bureaucracy,

will continue to haunt NHS patients no matter how many human factors courses are given to hospital staff members.

NHS senior leadership must understand what is wrong (through advanced root cause analysis) and be willing to make change happen BEFORE real improvement will occur.

Contact us (CLICK HERE) if you are committed to making root cause analysis (that includes human factors) work at your facility or company.

Career Opportunities for Candidates with TapRooT® Skills

September 10th, 2018 by

You’re telling everyone that you’re an effective problem-solver when you have the expertise of TapRooT® training on your resume. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to everyone you meet, especially prospective employers. If you have TapRooT® training and skills, explore your professional advancement through these global opportunities.

Regional HES Advisor

Quality Inspector

PSM Safety Advisor 

Safety Technician

Lab Quality Technician

Environmental Safety & Health Manager 

Quality Inspector

Program Manager HSE

Quality, Health, Safety, & Environmental Manager

Field Service Representative

Project Manager

Health & Facilities Manager

Process Safety Advisor

HSE Manager

HSE Associate Coordinator

Wireline Field Service Manager

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

September 5th, 2018 by

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

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

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

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

When? Wednesday, September 5

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

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

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

Monday Accidents & Lessons Learned: “Brute Force” Compromises Assets

September 3rd, 2018 by

Fighting today’s cybercrime has become a scenario in which businesses continually strive to stay ahead of the most recent evolution. Technology has forever changed the way we work, and the company culture that stays cybersecurity-alert is less likely to spend worklife looking over its collective shoulder.

The very real situation that follows is a Lesson Learned, the Risk of Internet Accessible Cyber Assets, from Western Electric Coordinating Council and NERC (North American Electric Reliability Corporation).

The Problem 
An electronic access point connected to the internet from a low-impact facility for remotely accessing a capacitor bank was compromised by unauthorized internet users for seven months prior to discovery.

Details
A registered entity discovered a compromised electronic access point connected to the internet from a low-impact facility. The access point was originally intended to be temporary and was installed by a SCADA (supervisory control and data acquisition) Manager who subsequently left the entity without providing adequate documentation and turnover to the next SCADA Manager. The access point was misidentified as a remote terminal unit (RTU) with an end-of-life (EOL) operating system and left in place. Unauthorized personnel accessed the cyber asset for seven months before the registered entity became aware of the compromise. Because the device was identified as an EOL system, the compromised system was not maintained (patched, monitored, etc.) by the registered entity and was thus more susceptible to exploitable vulnerabilities.

The initial compromise resulted from an unauthorized internet user guessing via a “brute force”1 method the weak password for the administrators’ account, which permitted remote access. The compromised cyber asset was used over a seven-month period as a mail relaying (SMTP) and remote desktop (RDP) scanner.2 Additionally, the IP address and credentials for the cyber asset were posted on a Russian-based media site, and the cyber asset was subsequently infected with ransomware. The compromise was discovered after support staff could not remotely access the cyber asset. The purpose of the internet-connected access point was to remotely access and operate the capacitor banks to ensure the reliability of the system. Upon looking into the matter further, personnel discovered that the cyber asset was compromised with ransomware, so the registered entity immediately powered off the cyber asset.

Forensic analysis on the compromised system identified several different scanning tools designed to locate remotely accessible RDP or SMTP servers along with text files containing IP addresses for the scanners to target. Although the attackers likely conducted reconnaissance on the local network to identify other vulnerable devices, the primary focus of their activity appears to identify other remote systems to target for attacks.

Corrective Actions
The registered entity removed the compromised device from service and performed forensic analysis to identify all malware on the affected device and determine agent(s) of the compromise, time lines, and reveal (to the most possible extent) the underlying activities and motives of the compromise. A virus scan was also performed on all devices at the same site as well as a review of logs on all of the devices to look for anomalous activity. Other locations were also scanned to determine whether they had similar installations or issues.

Lesson Learned
Cyber assets at low-impact facilities capable of remote internet connectivity are susceptible to unauthorized access from the internet or unsecured networks if not properly secured. These remote access points are typically used to provide communication paths for monitoring and control purposes to maintain BES (Bulk Electric System) reliability. Remote connectivity that can provide unauthorized and potentially malicious access to systems that supply auxiliary power, power quality, voltage support, fault monitoring, and breaker control is of particular concern.

Failure to develop and follow appropriate policies and procedures to control the installation and maintenance of cyber assets may create exploitable vulnerabilities that could negatively impact BES reliability. In this case, installation of, inaccurate identification of, and failing to provide adequate security protections for a device connected to a registered entity’s network led to the compromise of the device. There may be several practical lessons learned that can be derived from this event that apply to low-impact cyber assets and constitute good cybersecurity practices in general.

Policy and Procedures

  1. Train employees and contractors on cybersecurity awareness, policy, and practices
  2. Catalog cyber assets at low-impact facilities to determine use and facilitate accurate records
  3. Consult with and obtain authorization from responsible IT departments as well as compliance and risk management groups to evaluate potential risks and impacts of internet-facing and internet-worked cyber assets at low-impact facilities
  4. Have personnel (e.g., operations, maintenance) who perform periodic onsite visits conduct cyber-device inventory checks as part of routine safety and maintenance inspections
  5. Consider using a checklist
  6. Periodically reevaluate risks and potential impacts of the inventoried cyber assets as new threats and vulnerabilities are revealed or vendor support is discontinued
  7. An entity’s IT department could use tools such as Shodan3 and nmap4 on the entity’s own public IP space on a regular basis to verify only authorized ports are open to the internet
  8. When an employee or contractor leaves the company or is terminated, ensure appropriate turnover and knowledge transfer processes occur

Cybersecurity practices to consider for low-impact facilities

  • Identify and secure cyber assets at low-impact facilities capable of remote connectivity
  • Where possible, implement network access controls within the system to prevent the installation of unauthorized hardware
  • Implement network segmentation into trust zones
  • Change default passwords with strong passwords on user accounts and administrative accounts and restrict operational use of administrative accounts
  • Implement MFA (multi-factor authentication) for all internet-facing resources that support these technologies
  • Provide for a patch management plan for evaluating security patching for cyber assets at low-impact facilities
  • Whenever practical, monitor the network for anomalous behavior

1“Brute forcing” is an automated method of attempting authentication with many different passwords until the attacker is able to successfully login to the system.

2A network scanner performs a scan on a network and collects an electronic inventory of the systems and the services for each device on the network. In this case, the server was used to scan for open SMTP (Simple Mail Transfer Protocol) servers and RDP (Remote Desktop Protocol) servers for potential compromise.

3Shodan is an internet site used to discover devices that are connected to the internet, where they are located and who is using them.

4Nmap (“Network Mapper”) is a free and open source (license) utility for network discovery and security auditing.

TapRooT® recommends the following modifications to your online behavior to reduce the possibility of cybercrime:

  • Change passwords regularly; be the sole owner of your passwords; avoid using personal information in passwords; create passwords with random keyboard patterns, numbers, and special characters.
  • Don’t respond to emails or messages requesting personal or financial information.
  • Sending your password in an email is a definite no-no.
  • Never give unauthorized persons access to business computers—at the workplace or at home.
  • Don’t interact with money-sending instructions in emails.
  • Always call clients and vendors to verify any financial/billing changes.
  • Choose automatic software updates.
  • Back up data to reduce the likelihood of ransomware attacks, and ensure that your backup management is secure. (Often, a company’s most valuable asset is its intellectual property, so a loss in this area can be disastrous.)
  • Install/maintain antivirus and anti-spyware software and a firewall on all business computers.
  • Secure all WiFi networks and passwords.
  • Educate all employees what comprises business information, and the risks in sharing this with anyone.
  • Grant administrative privileges only to trusted staff and limit employee access to data systems that are workload-critical.
  • Require administrative approval and assistance in any and all downloads by employees.

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

Career Opportunities for Candidates with TapRooT® Skills

September 3rd, 2018 by

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

Safety & Health Manager

Patient Safety Analyst

EMT Safety Technician

Safety Officer

HSE Manager

MWD Specialist

Health & Safety Advisor

HSE Manager

Health, Safety, & Environmental Manager

Health & Safety/CDM Director

HSE Officer

Environmental Health & Safety Manager

QHSE Manager

HSE Manager

Site Safety Coordinator

Safety Coordinator

Nurse

Specialist HSE

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

TapRooT® Around the World: Onsite at TransCanada in Mexico

August 31st, 2018 by

Here’s a glimpse into recent TapRooT® Root Cause Analysis Training courses, held onsite in Mexico at TransCanada. The courses were taught by TapRooT® Instructors Marco Flores, Jesus Alonso, and Piedad Colmenares. We appreciate Piedad passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Join TapRooT® Today at Noon EST on Facebook Live

August 29th, 2018 by

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

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

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

When? Today, Wednesday, August 29

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

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

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

Does Social Media Encourage Poor Root Cause Analysis?

August 29th, 2018 by

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

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

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

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

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

August 27th, 2018 by

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

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

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

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

This accident was reported by the Australian Transportation Safety Board.

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

Career Opportunities for Candidates with TapRooT® Skills

August 27th, 2018 by

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

HSE Manager

Health, Safety, & Environmental Manager

Health & Safety/CDM Director

HSE Officer

Environmental Health & Safety Manager

QHSE Manager

HSE Advisor 

HSE Manager

MWD Specialist

Health & Safety Advisor

Site Safety Coordinator

Safety Coordinator

Nurse

Specialist HSE

SHE Coordinator

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Does Blame Make Sense in Incident Investigations?

August 23rd, 2018 by

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

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

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

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

Dunning-Kruger Effect – Another Reason You Need TapRooT® Root Cause Analysis

August 22nd, 2018 by

Watch this Ted-Ed talk about the Dunning-Kruger Effect.  The Dunning-Krger Effect is a cognitive bias whereby people who are incompetent at something are unable to recognize their own incompetence.  Not only do they fail to recognize it, they’re also likely to feel confident that they are competent.

Investigators can fall into this trap. Often when people use cause-and-effect (5-Whys, Fault Trees, Why Trees, …), they think they know the root cause of the problem. All they have to do is build the tree that proves their answers. How does cause and effect analysis fall short?

The #1 reason it falls short is because gaps in an investigator’s knowledge (that he/she underestimate) block the other possibilities, and the investigator doesn’t realize that he/she is jumping to conclusions.

“When you don’t know that you don’t know, it’s a lot different than when you do know that you don’t know.” – Bill Parcells

If you do know that you don’t know every possibility, how do you bridge that gap? The TapRooT® Root Cause Analysis System guides you. TapRooT® root cause analysis helps investigators “fill in the gaps” in their knowledge to keep them from making the mistake of thinking that they know more than they do. TapRooT® offers an investigation and improvement process that includes built-in human factors, root cause analysis and troubleshooting tools. It takes investigators far beyond their own knowledge. TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.

TapRooT® encourages investigators to identify all the mistakes, errors or equipment failures, and find the root cause of each one. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each mistake, error or equipment failure that contributed to an accident.

The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. This is how an investigator can know what he/she doesn’t know.

Attend a public TapRooT® Root Cause Analysis Course and find out how TapRoot® can help you improve your ability to find and fix the real root causes of incidents, accidents, quality problems, patient safety events, process safety incidents, quality problems, and equipment failures.  See our upcoming courses here:

 http://www.taproot.com/store/Courses/

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

August 22nd, 2018 by

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

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

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

When? Today, Wednesday, August 22

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

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

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

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

August 21st, 2018 by

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

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

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

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

When? Tomorrow, Wednesday, August 22, 2018

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

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

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

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

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

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

August 20th, 2018 by

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

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

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

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

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

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

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

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

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

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

Career Opportunities for Candidates with TapRooT® Skills

August 20th, 2018 by

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

Environmental Health & Safety Manager

QHSE Manager

HSE Advisor 

HSE Inspector

MWD Specialist

HSE Manager

Specialist HES Operations

HSE Technical & Administrative Assistant 

Patient Safety Analyst

Health & Safety Advisor

Safety Specialist/Safety Officer 

Site Safety Coordinator

Safety Coordinator

Nurse

Specialist HSE

SHE Coordinator

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Can Your Management Learn?

August 15th, 2018 by

Challenger

Long ago, my boss was tasked with reviewing the Challenger space shuttle accident for lessons learned for a major chemical company. I assisted him, and his conclusion was that all the same management system causes were present at our company.

He had a dilemma. How should he present this to senior management? He would be presenting to the company President and all the Senior Vice Presidents. He knew they were NOT expecting to hear that they had problems. This might severely hurt his career.

He decided to just present the “facts,” and that they would reach the same conclusions that he did.

He made the presentation. I was there. At the end, the President of the company thanked him for his hard work, and said to everyone else that it was good that there was no similarities between NASA’s management and our company’s management. In other words, no lessons for us.

So much for just presenting the facts.

Why didn’t senior management reach the same conclusions that my boss did when presented with the same facts? The problem was that our management couldn’t critically review their own management systems. They thought that they were doing great, and any other feedback was outside their paradigm. They were not being self-critical. They could not face the facts. And no one else was willing to tell them that they needed to improve (lots of “yes men” around them).

Of course, NASA’s management didn’t learn their lesson. They went on to have the Colombia shuttle accident because they didn’t learn from their experience and could not face the facts.

Another example of management not being able to learn was the BP’s management after the BP Texas City Refinery explosion.

First, they had a hard time getting past blaming the operators and supervisors (five were fired). There was an internal BP group (the Bonse report – see Bonse Main Report.pdf) that recommended management discipline (blaming the lower levels of senior management). However, no immediate disciplinary action was taken. Within two years, all the senior line management from the Refinery General Manager to the CEO were gone (none were fired immediately as part of the incident response). So the ability of that management to learn didn’t make any difference – they were gone!

However, managers on the upstream (exploration and production) side of the organization, didn’t seem to learn from the the accident on the downstream side of the organization. The result? The BP Deepwater Horizon accident happened because of failure to apply process safety lessons learned to the management of exploration operations.

These examples of failures to learn are the reasons why I ask the question in the title of this article:

Can your management learn?

That brings up the question:

What should managers do to learn?

Here are some ideas…

First, management has to be self-critical. Instead of blaming people at the pointy end of the stick (operators, maintenance people, and supervisors), they should say…

What did we do to cause this incident?
What should we do differently to prevent future incidents?

Being self-critical also means understanding Rickover’s “Facing the Facts” concept. See more about that concept at:

http://www.taproot.com/archives/53656

Second, senior management needs to understand root cause analysis. This may be more common today than it was thirty plus years ago because more senior managers have had some experience with advanced root cause systems (TapRooT®). They need to understand their (management’s) impact on management systems and their impact on investigations and implementation of corrective actions.

Management may also need to understand advanced trending concepts (we are publishing a book later this year about this) to be able to learn from their company’s statistics (or at least be critical of presentations about statistics).

What ideas do you have? Leave them as comments to share with others.

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

August 13th, 2018 by

IOGP Well Control Incident Lesson Sharing

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

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

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

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

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

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

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

-Reinforce well monitoring. Specifically, during pipe connections.

-Review mapping of injection on the field.

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

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

August 7th, 2018 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

August 7th, 2018 by

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

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

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

When? Wednesday, August 8

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

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

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

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

August 6th, 2018 by

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

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

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

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

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

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

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

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

TapRooT® Around the World: Sao Paulo, Brazil

August 3rd, 2018 by

Here’s a peek into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil, taught by TapRooT® instructors Boris Risnic and Marcelo Marquez. Many thanks to Marcelo for passing along these insightful images!

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Join TapRooT® Tomorrow for Facebook Live at Noon EST

July 31st, 2018 by

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

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

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

When? Wednesday, August 1

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

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

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

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Success Stories

Saving Time, Resources & Effort using TapRooT® Sofware Submitted by: Shelley Hassen, HSE Assurance & Compliance Manager Company: WILLBROS Canada Challenge Our company was utilizing the Web Based version of the TapRooT® Software globally to perform and record all RCAs but our work is very project-based and often in remote locations with internet connectivity issues. …

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

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