Category: Investigations

5 Cognitive Biases that Influence Incident Investigations

September 20th, 2018 by

Whether we admit it or not, we are constantly under the influence of cognitive biases that distort our thinking, influence our beliefs, and sway the judgments we make as investigators.

Most of us are familiar with confirmation bias (looking for evidence to support a hypothesis, and rejecting any evidence that does not). However, did you know there are over 250 cognitive biases?

Here are five that may be affecting your investigations:

  1. Overconfidence. Yes, overconfidence is a bias even though it doesn’t sound like a fancy psychological term. This can really be a problem with experienced investigators because they know more, and may be more convinced that they are right.
  2. Stereotyping. Expecting a group or person to have certain qualities without having real information about the person. Again, a term that we are familiar with but may not realize we are doing to those involved in incidents. I’m not just referring to gender or racial stereotypes. You can stereotype a person many different ways. Here are some other examples: “She has an MBA. She must be smart.” “He has 20 years in the industry, he must be experienced.”
  3. Choice-supportive bias. When you decide something you tend to feel more attached to your decision, even if the decision has flaws.
  4. Bandwagon effect. Not sure of what to think of an investigation? Take the easy road . . . jump on the bandwagon. The probability of one investigator adopting a belief increases based on the number of team members who hold the same belief.
  5. Blind-spot bias. This simply means that we don’t accept that we could possibly be biased! We tend to notice biases in other people and not within us. We all fall into biases and need to be aware of that.

How do you avoid biases in an investigation? Use a system that doesn’t start with a hypothesis, TapRooT® Root Cause Analysis. Using the guided system, an investigator does not:

  • rely on his/her limited knowledge (no one can possibly know everything!).
  • fit workers into stereotypes that align with our hypothesis.
  • become married to his/her ideas.
  • become easily influenced by others.
  • have to fight his or her biases!

You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions. Once you understand what happened and identify the mistakes, errors or equipment failures, you will then be ready to analyze why the safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary. This system gets you to think beyond your current knowledge, and decreases investigator bias.

Learn the entire TapRooT® System in just two days. View the upcoming schedule here.

 

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

September 19th, 2018 by

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

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

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

When? Wednesday, September 19

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

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

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

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort. You don’t want to miss a minute of the TapRooT® Summit!

Monday Accident & Lessons Learned: Fatal Ammonia Accident

September 17th, 2018 by

What were the Causal Factors? 

Leave your comments here…

Investigative Interviewing Webinar: Tips for collecting better quality and quantity of evidence

September 14th, 2018 by

TapRooT® Instructor, Barb Carr, was a recent guest expert for Intelex, a global leader in EHSQ software. View the recorded webinar to learn how to become a more effective interviewer, and collect better quality and quantity of evidence.


Is It Better To Be Fast or Good?

September 12th, 2018 by

Imagine the old west. Two gunslingers standing 20 yards apart. It’s time to draw.

NewImage

Would it be better to be fast or good? As Wyatt Earp said:

Fast is fine. Accurate is final.

What does this have to do with root cause analysis?

I had someone ask me the other day:

How long should a simple root cause analysis take?

If you use Spin-A-Cause™, the answer is about 5 seconds.

Spin A Cause

But you have to answer the question …

Do you want FAST or GOOD?

But what if you could have BOTH?

That’s what the 2-Day TapRooT® Root Cause Analysis Training and the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about. Fast and Good simple investigations.

We selected the minimum number of powerful root cause analysis tools and built a simple process to perform simple investigations fast and accurately.

How long does it take to apply these techniques? Maybe 30 minutes to an hour once you have the information you need to answer the questions. Maybe slightly longer. Maybe longer yet if the incident turns out not to be “simple.”

The biggest variable is collecting the information (evidence). The second biggest variable is the requirements of your investigation system (presentations to management and approval red tape).

So if you are ready to be fast and good, sign up for one of our public 2-Day TapRooT® Root Cause Analysis Courses today. Here are the upcoming dates and locations:

http://www.taproot.com/store/2-Day-Courses/

Or have a course at your site. Contact us for a quote by clicking HERE.

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.

Monday Accidents & Lessons Learned: Ensure Safety Behind the Wheel

September 10th, 2018 by

In June 2018, a Queensland owner/operator truck driver was reversing his single-deck truck up to a ramp to load cattle used in a rodeo. It appears he placed the truck in reverse and began to idle backwards. The gearing of the truck in reverse was sufficiently low that it did not require the driver to have his foot on the accelerator. He then opened the door and stood on the running board of the truck holding onto the steering wheel to maneuver the truck while looking backward to where he was going. He fell from the running board of the truck and was fatally crushed under the front wheel as the truck continued to reverse itself.

Also, in June 2018, a courier van driver sustained serious fractures when he was dragged under his vehicle. He had returned to the parked van to retrieve an item through the front window when it rolled backward. It appears he was dragged under the vehicle while trying to stop it.

Both investigations are continuing.

Contributing factors
Some contributing factors to these incidents include:

  • Workers being under a heavy vehicle or trailer, or in its path
  • Unsafe systems of work being applied, such as poor separation of traffic from pedestrian areas
  • Failing to immobilize:
    -the handbrake of the vehicle not applied
    -the wheels of the heavy vehicle or trailer not immobilized
    -components of the heavy vehicle or trailer not restrained or adequately supported
    -brakes malfunctioning
  • Not conducting a risk assessment before working on the vehicle

Action required in immobilizing heavy vehicles
If an employee needs to work near a heavy vehicle, or between a heavy vehicle and another object, first make sure the vehicle is immobilized by:

  • Switching off the motor and removing the key from the ignition to render it inoperable
  • Applying the handbrake
  • Using wheel chocks, if warranted and required

Establish a safe operating procedure and ensure workers follow it to eliminate the risk of anyone failing to immobilize their vehicle.

Consider installing a handbrake warning system to alert drivers when the handbrake has not been applied (these can be easily retrofitted).

Working under heavy vehicles and trailers
For work under heavy vehicles and trailers, ensure an appropriate load support is used (e.g. stands or lifting devices).

Risk assessments before commencing work
Before commencing work, identify hazards and assess risks associated with working under and around heavy vehicles or trailers. Where appropriate:

  1. Establish an exclusion zone that is clearly marked and enforced.
  2. Use safe work procedures for maintenance and repair tasks, and ensure that workers are trained in these procedures.
  3. Ensure worker training, experience, and competency is consistent with the nature and complexity of the task.

Similar risks exist for light and smaller vehicles, and a risk assessment should be conducted before commencing work.

Preventing similar incidents
There have been incidents where vehicle drivers and others have been killed or seriously injured after being hit, pinned, or crushed by the uncontrolled movement of vehicles. The risk of a vehicle moving in an uncontrolled or unexpected manner must be managed by ensuring appropriate control measures are in place. Controls may include, but are not limited to, the following:

  • Before leaving a vehicle, ensure it is stationary and out of gear with the emergency brake applied.
  • Do not climb into a moving vehicle.
  • Do not allow any movement of the truck or vehicle unless there is someone in the driver’s seat who is able to receive oral or visual warnings and can immediately act to prevent harm (e.g. apply brakes or steer the truck).
  • When reversing, ensure the area around the vehicle is clear.
  • Always employ reverse with the aid of mirrors or a spotter.

The person conducting a business or undertaking should conduct a risk assessment of work practices, develop appropriate safe work systems, conduct appropriate training, and ensure the system is enforced at the workplace.

Statistics
Since 2012, there have been 47 incidents involving workers or others being crushed, struck or run over by a truck moving in an uncontrolled method. Eleven were fatal, and 27 involved a serious injury. In the same period, 49 improvement notices and 25 prohibition notices were issued for uncontrolled movement or rolling of trucks, semitrailers, and more.

Since 2012, there have been 10 work-related deaths involving a person being run over by a vehicle or some other type of machinery. In the same period, 10 prohibition notices and eight improvement notices have been issued in relation to a person being run over by a vehicle or other type of machinery.

Each year, there are around 130 accepted worker compensation claims involving a worker being struck or crushed by a truck. Of these claims, more than a third involve a serious injury, and two are fatal.

Annually, there are around 600 accepted workers compensation claims involving a worker injured by mobile plant*. Of these claims, about 40 percent involve a serious injury requiring five or more days off work, and two are fatal.

Prosecutions and compliance
In May 2017, a company was fined $60,000 and an individual $3,000 following the death of a worker who was run over by a truck and trailer. The worker was lying under the back of the trailer to check on bouncing that had occurred while driving. Moments later, the truck and trailer began moving backward. The trailer wheels rolled over the worker, followed by the truck wheels.

In February 2017, a regional council was fined $170,000 following the death of a worker. The worker was killed after he was struck and run over by a reversing truck on a civil construction site.

In December 2016, a road freight transport company was fined $60,000 and a court ordered undertaking for two years with recognizance of $60,000 following the death of a worker who was run over by a trailer. The prime mover and trailer appeared to have trouble releasing its trailer brakes. The worker went to the rear of the trailer and attempted to release a trailer brake. When the vehicle began rolling backward, he tried to reengage the spring brake but was struck by the trailer wheels.

In June 2016, a company was fined $120,000, after a worker was killed operating a six-ton mobile yard crane to perform shifting the load of steel product. The worker was seen running alongside the crane which was traveling down a slope, uncontrolled, with no one in the operator’s seat. He was either struck by the crane, or it tipped, then run over and killed. The driver was not licensed to operate this type of crane.

*Powered mobile plant is defined by the Work Health and Safety Regulation 2011 (WHS Regulation) to mean any plant that is provided with some form of self-propulsion that is ordinarily under the direct control of an operator, and includes: earthmoving machinery (e.g. rollers, graders, scrapers, bobcats) excavators.

Thanks to WorkCover Queensland for this information highlighting the risks associated with workers being crushed or hit by heavy vehicles or trailers.

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.

TapRooT® Around the World: 3-Day Equifactor® in Bogota, Colombia

September 5th, 2018 by

Here’s a glimpse into a recent 3-Day Equifactor® course in Bogota, Colombia, taught by TapRooT® Instructors Hernando Godoy and Piedad Colmenares. We really appreciate Diana Munevar for sharing these pictures that show teamwork, the TapRooT® learning experience, and a great time in the process!

The 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course is designed to help investigators troubleshoot equipment problems to get the information they need to find and fix the root causes of equipment-related failures. These tools can be used by equipment troubleshooting experts, maintenance and equipment reliability specialists, or other investigators who don’t have an extensive understanding of equipment engineering.

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 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:

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.

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.

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.

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.

Do LinkedIn Posts Encourage Poor Investigations?

August 21st, 2018 by

Lifting Incident Video

 

I find a lot of good information on LinkedIn.  However, I’ve noticed a disturbing trend in the types of posts that have been appearing in my feed.

LinkedIn tailors my feeds toward the types of things they think I’m interested in, and in general, they do a pretty good job. Therefore, they are throwing a lot of accident videos my way. Some of these have the opportunity to show some serious issues.  However, it is the comments that are disappointing.

Here is an example of a crane accident saw today.  LINK

There is merit in watching the video.  However, the premise of the post is for everyone to watch the video and list the “root causes” and the “reasons, in your opinion.”  These types of posts just encourage poor incident investigations!

It is easy to watch a video and list the mistakes that were made.  In this video, people listed their opinions on what went wrong:

“Cost cutting”

“Crane overloaded”

“Poor training”

“No lift plan”

“Poor risk assessment”

“Inadequate MoC”

“Poor planning”

But are any of these correct?  It’s possible NONE of these problems were actually present.  For example, what if there had been a mechanical failure on one of the cranes?  I can think of half a dozen possible scenarios that would involve none of the problems listed above.  Most of the listed issues are just easy ways to blame someone.  That’s just lazy.  In these posts, you can watch people preach about their favorite errors and point out how the operators / management / supervisors were at fault, and how “I wouldn’t have let this happen.”  And yet, these types of problems happen every day, to good people with good intentions.

I do think there are some really good outcomes from posts like this.  The first step in any good root cause analysis is to gather unbiased information.  Instead of encouraging people to point out problems, opinions, and solutions, why don’t we change the original question to, “If you were going to perform this investigation, what questions would you be asking?”  I think this is a much more useful type of post.  It encourages the viewers to engage their critical thinking skills and figure out what types of problems might have contributed to the issue.  Are there Management System issues?  Mechanical failure or maintenance problems?  Supervision issues?  Human engineering deficiencies which confused the operators?

The first step in a good root cause analysis is to gather the right information.  By changing the tone on these types of posts, we might be able to work in the direction of a good root cause analysis, instead of just assuming everyone is stupid.

 

 

Learn TapRooT® in Seattle

August 20th, 2018 by

Register here for TapRooT® Training on October 24, 2018, in Seattle, Washington: 2-Day TapRooT® Root Cause Analysis Training.

Exposure to the 2-Day TapRooT® Root Cause Analysis Training in Seattle will equip you to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®.

A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply! Start your personal and professional growth in Seattle.  

While in the shadow of the iconic, 605-foot-tall Space Needle spire, you will want to get out and about. Below, to route you to points of interest and incredible edibles, we’ve included highlights of this seaport city. Dscover even more gems to explore on our Seattle Pinterest board.

A coastal walk, a satisfying seafood feast, and a connection with Seattle’s quirky culture and its walkable, breathtaking scenery—there’s something in Seattle that you will want to discover.

Experience Seattle

Lean into the beauty that is Puget Sound. Take a cruise or ferry across this immense Pacific Ocean inlet, along its forested shores, and delight in sailing smooth salt waters. Puget Sound has more than 170 islands, some connected by bridges, so there’s much to explore here. Kayaking and boating, hiking and biking, birding, whale-watching, diving and snorkeling, golfing—the Sound is rich in recreative adventures.

Soar over Seattle as Wings Over Washington transports you on a virtual aerial ride of the whole state—from Mount Ranier’s glacier-topped peaks to Olympic National Park’s seashore cliffs.

If you are up for a great view from the heights, overlook Elliott Bay from the Seattle Great Wheel (the West Coast’s tallest ferris wheel). Walk along Waterfront Park for inspiring views. Wander through masterworks along the zigzag path of the Olympic Sculpture Park. 

Take in aircraft and space vehicles plus historical exhibits at the Museum of Flight. Explore flight simulators, get a feel for what pilots experience, see the aviation pavilion and watch a 3D movie, and take a Boeing field tour.

For an artistic must-do in Seattle, visit Chihuly Garden and Glass, the international glass headquarters of Fulbright Fellowship recipient Dale Chihuly, and browse the Glasshouse. 

Taste Seattle

Can you say “pancake heaven”? Take a fork to breakfast at Portage Bay, its four locations serve up hefty portions and, yes, you might want to make a reservation.   

You may not be shopping for seafood, but duck into the very entertaining Pike Place Market that overlooks the Elliott Bay waterfront. It’s among the oldest continuously operated farmers market in America, serving patrons since August 17, 1907. Have dinner here, browse some of the independent shops, or taste-test excellent Northwestern adult beverages. For an eatery inside the market, sit down at Place Pigalle.

Chocoholics will want to investigate the free samples and perhaps a tour of Theo Chocolate Factory, a frontrunner in sustainable and organic cocoa bean practices that bills itself as “a company rooted in chocolate.”

Enjoy gazing over glistening waters of Elliott Bay while dining at Elliott’s Oyster House. Or, choose from among the eateries at Pier 57’s Miners Landing. Try the Salmon Cooker for fast, good, and relatively inexpensive fare. The Cooker serves up Alder-smoked salmon, halibut, and cod, classic fish and chips and clam chowder, as well as fresh oysters, Dungeness crab, shrimp and crab cocktails, and beer. Finish off with homemade ice cream. Try one of the other Miners Landing restaurants—the Crab Pot or Fisherman’s Restaurant & Bar. There’s also Alaskan Sourdough Bakery, which offers breakfast in addition to baked goods. Another eatery to try is AQUA by El Gaucho for both fresh seafood and custom-aged steaks.

For those fond of cider, check out the award-garnering Schilling Cider House. The cider shop offers more than 30 craft ciders and features tastings and classes. 

Of course, we can’t leave Seattle without a coffee encounter since it’s home to the following roasters and servers and then some.

If tea is more your taste, visit among these tea hotspots to find your best hot brew.

Register here for TapRooT® Training on October 24, 2018, in Seattle, Washington: 2-Day TapRooT® Root Cause Analysis Training.

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

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.

Chris Watts Interview: Decoding His Nonverbal Behavior

August 17th, 2018 by

During an investigative interview, an interviewee’s nonverbal behavior will give clues as to whether or not he or she is confident in what he or she is saying. We can’t determine whether someone is lying by his/her body language, but lack of confidence may indicate that the interviewee:

  1. doesn’t remember.
  2. is not sure of what he/she remembers.
  3. is hiding the true story.

These are moments where we, as investigators, want to question and probe further for answers.

 

The recent news about Shannan Watts and her children is tragic and incomprehensible. After watching the Chris Watts interview (which occurred shortly after his wife and daughters went missing but before their bodies were recovered), I noted these red flags.

  1. Just 34 seconds into the interview, his mouth becomes very dry. We know this because he licks his lips. This occurs again at 1:22. There are some things we can control about body language; other things, like things we do when dry mouth occurs when we are extremely nervous, are controlled by the oldest human brain system, the reptilian brain. We can’t cover it up. Investigators, when you notice someone licking his/her lips or swallowing hard during an interview, the question should be, “What could the interviewee be nervous about?” It’s not necessarily an indication of lying (you can’t prove a lie with body language); however, it is a flag that the interviewee is unusually nervous. This is early in the interview; note whether he becomes more uncomfortable or more comfortable. Typically, in an investigative interview, an interviewee will show some cues of discomfort in the beginning, and then show more relaxed, less guarded nonverbal cues as the interview progresses.
  2. At around 1:26 minutes, as he spells the name of his daughter Celeste, he closes his eyes. This is a blocking behavior. It may indicate, “I can’t look at this.” It may be a response that comes from him truly knowing what happened to his daughter and not wanting to “see” it. After spelling her name, he swallows hard. Investigators: When an interviewee closes his/her eyes, note the words he/she is saying. Ask, “What does this person not want to see?” We commonly see this behavior when an employee witnesses a traumatic event, such as a serious injury or death on the job, and is retelling it. Also, note when nonverbal communication signals are thrown off in rapid succession. That is a reliable sign that you need to do follow-up questions on that part of the interview.
  3. After he says “Bella is four; Celeste is three,” we see that he compresses his lips. (He draws them inward and they seem to disappear.) This is sometimes a sign that an interviewee is holding something back. Investigators, when you note this behavior, gently probe for more information. The interviewee may be keeping information he/she is unsure about providing. Assure the interviewee that no detail is too small to report.
  4. At 1:52 minutes, he touches the side (the bulb) of his nose. Touching or covering the nose is sometimes a body language sign that the interviewee is not certain of what he is saying and is nervous about how it will be received. There are many nerve endings in the nose, so the nose tingles under stress. We may touch it without thinking about what we are doing or why we are doing it. Investigators, this may occur because the interviewee doesn’t remember, is not sure about what he/she remembers, or he/she does remember and is attempting to cover something up. Always note when an interviewee brings his/her hands to his/her face, listen carefully to the words that are being spoken at that moment. Gently probe for more information.
  5. At around 2:20 minutes, when he is telling the interviewer he hopes his wife is somewhere safe, it is interesting to note his facial expression doesn’t match what he is saying. If your loved one is missing and you are hoping he/she is safe, would you have a pleasant, almost smiling, expression? Investigators, when evaluating an interviewee’s statement, does his/her facial expression match what his/her words are saying? If it doesn’t match, what is the interviewee trying to hide by masking his/her expression? He goes on to talk about how he misses his children, with the same pleasant expression, and when he says, “It was tearing me apart,” he closes his eyes again, displaying blocking behavior.
  6. 3:53 Again, licking his lips due to dry mouth at, “I just want everybody to come home,” after talking about missing his wife and children.
  7. 3:55 – 4:03 Extended lip compression at “Wherever they are at, come home. That’s what I want.”
  8. The camera pans off him for a few seconds and, when it returns, we see he is crossing his arms. The way he is crossing his arms makes me feel he is not defending himself, but comforting himself. He looks like he is cradling himself. Occasionally, he will move his left arm, but immediately returns it to cradling. Investigators, self-comforting is a nonverbal behavior to note. Why does the interviewee need to self-comfort?
  9. 5:00 He states, “I just want them back,” and laughs. Again, laughter is not an emotion you would expect from a worried husband and father. Investigators, note when an interviewee’s laughter or facial expression doesn’t match his/her words.
  10. At around six minutes, when the interviewer asks about what the police are saying, he licks his lips again and swallows hard, indicating continued discomfort.
  11. At 6:48, there is extended lip compression, and he licks his lips again as he describes how police looked for surveillance cameras in the neighborhood but found nothing. This may indicate that he is concerned about the police looking for evidence.
  12. At around seven minutes, when the interviewer asks him what he would say to his wife if he could, he closes his eyes after he says his wife’s name (blocking behavior). He is also shaking his head “no” even though the words he is saying would align with a “yes” nod. This may indicate that he knows they are not coming back. Investigators, note when an interviewee shakes his/her head “yes” or “no.” Do the words match “yes” or “no”? These clues appear in rapid succession and should be analyzed.

After watching this short interview once, I identified these nonverbal behaviors that made me question the validity of his story. Never rely solely on the words an interviewee says. Evaluate whether his/her mood matches the words, and carefully note each body language signal that indicates what he/she just stated may need to be probed further.

If you investigate accidents and incidents, and would like to learn more about interviewing techniques to solve problems at your facility, contact us at editor@taproot.com. We offer onsite and public courses.

What’s Wrong with Pharmaceutical Root Cause Analysis?

August 8th, 2018 by

Pharma

I was forwarded a copy of an interesting letter about American and Canadian Standards Boards with certifying bodies rejecting pharmaceutical quality incident reports because of poor root cause analysis. It stated that 90% of the rejections of reports were due to three types of root causes that were unacceptable (and I quote):

  1. Employee Error / Human Error / Operator Error OR anyone else who made an error is not an acceptable root cause – Was the training ineffective?  Was the procedure too vague?
  2. Misunderstood the requirement / Did not know it was a requirement / Our consultant told us this was ok OR any other misunderstandings is not an acceptable root cause.  Was the training effective?
  3. We had a layoff / Mona was on maternity leave / we moved locations / we scaled back production / we are still closing out Wayne’s 40 deviations from the last audit OR most other employee or business conditions are not acceptable root causes  They are DIRECT CAUSES.

The letter proposed four rules to follow with all future submissions:

  1. RULE #1:  The root cause can not be a re-statement of the deviation.  Example:  Deviation – Company XYZ did not document Preventive Actions as required by procedure.  Root Cause – We did not document Preventive Actions as required by the procedure.
  2. RULE #2:  There can not be an obvious “Why” that can be easily answered to the provided root cause – in this case they have not gone deep enough.  Example: Root Cause – The purchasing coordinator made a mistake and did not check to see if the supplier was approved.  Obvious “WHY” Was the training effective?  Did the procedure provide enough detail in this area?
  3. RULE #3:  The root cause can not be a direct cause.  Example:  Deviation – There were a number of internal audits scheduled for 2008 that were not completed.  Root Cause – We had a layoff and we did not have enough Internal Auditors to conduct the audits.
  4. RULE #4:  The root cause is a brief description of the cause of the problem.  We do not want any long stories regarding direct causes or what they are doing well even though this happened or who said what.  This is un-necessary detail and only adds confusion.

Wow! I would have thought this guidance would not be necessary. Are responses to quality incidents really this poor? Or is this letter a fake?

No wonder TapRooT® Users have no problem getting approvals for their root cause analysis. None of these problems would happen with any investigation using TapRooT®.

Why would TapRooT® Users never stop at the three causes listed above? Because they would understand that some are Causal Factors (the start of the root cause analysis) and they would have guidance provided by the Root Cause Tree® Diagram to help them find the real, fixable root causes of human performance and equipment failure related problems. This includes analyzing things like “internal audits not completed”; “human error”; and “misunderstood requirements.”

In addition, the TapRooT® Software helps investigators develop concise custom reports that only includes the details needed to understand what happened, how it happened, the root causes, and the effective corrective actions needed to prevent recurrence.

If you are in the pharmaceutical industry and you want to stop having problems with root cause analysis and want to start having effective investigations, root cause analysis, and fixes for problems, attend our TapRooT® Training and learn how simple advanced root cause analysis is.

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.

Remembering An Accident: Sayano-Shushenskaya Hydroelectric Dam

August 2nd, 2018 by

One of the world’s largest hydroelectric plants, Sayano-Shushenskaya Hydroelectric Dam, suffered a catastrophic failure On August 17, 2009, that lead to the death of 75 people, and the pollution of the Yenisei River with 40 tons of oil spilling into it. So how did a major incident like this happen?

On the day of the accident the dam was undergoing major repairs and upgrades. Nine of the ten turbines were operating at full capacity, even the troublesome  #2 turbine. This turbine had previously been offline because of persistent vibrations and maintenance issues, but it was brought back online the previous night. A fire at the Bratsk Power Station caused a drop in electricity production and the decision was made to run Turbine #2 to help with the electrical shortage.

Just before 8:13 am large vibrations were felt by a technician worker on the roof, and according to his recount of the the incident the vibrations gradually grew into a load raw. Shortly after two massive explosion occurred and turbine #2 shoot through the floor 50 feet into the air, and then it came crashing back down. The water that was spinning the turbine was now gushing out at a rate of 67,600 gallons a second. The gushing water produced massive amounts of pressure that ripped the room apart leading to the roofs collapse.

Eventually the gushing water flooded the lower levels and submerged the other turbines. Unfortunately, the plant’s automatic safety system failed to turn off turbines #7 and #9, which were operating at full capacity. This triggered short circuits that left the plant in total darkness adding to the confusion and mayhem.

Several employees struggled to manually close the pen-stock intake gates, and finally succeed at 9:30 am putting an end to the disastrous incident. Because of communication failures and system failures 75 people lost their lives, many were injured, and 40 tons of oil polluted the Yenisei River. Restoring the damage caused by the explosion took years and it cost US$89.3 million to complete.

(Before & After Photo)

To learn more about the Sayano-Shushenskaya Hydroelectric Dam incident click here.

 

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

Investigating Even the Smallest Problems using TapRooT®

July 31st, 2018 by

 

Many companies think about using TapRooT® only when something really significant occurs. Things like major environmental releases, or serious injuries, or expensive quality control issues. These are considered Major Investigations in TapRooT®.

Some companies are also using TapRooT® on less complex, lower risk problems. Problems such as a dropped object, a small spill from a container, or a minor first aid case might be investigated using the Simple Investigation process in TapRooT®.

However, what about REALLY simple problems? Does it make sense to perform entire TapRooT® investigations for just a simple problem that you spot on the job site? Actually, TapRooT® is EXCELLENT at helping you quickly find root causes for even small issues, before they become incidents or near misses. Think about the benefits of finding, analyzing, and fixing these tiny problems:

  • They are pretty easy to find
  • They are pretty easy to fix
  • They are pretty inexpensive to fix
  • They have the opportunity to prevent major issues in the future

Chris Vallee and I talked a bit about this on our last TapRooT® Live session.  Take a look here and let us know what you think.

Why Does Blame “Make Sense”?

July 25th, 2018 by

Think about a recent accident …

  • a ship runs aground
  • a refinery has a major fire
  • an oil well has a blowout and explosion
  • a pharmaceutical plant makes a bad batch of drugs and it gets by the QA process and customers are harmed

One thing that you can be sure of in ALL of the accidents above is that:

someone screwed up!

You never have a major accident if all the Safeguards function as designed. And guess what … we depend on human actions, in many cases, as a significant or sometimes as the ONLY Safeguard.

Therefore, when an accident happens, there is usually at least one human action Safeguard that failed.

If you are in a blame oriented organization, the obvious answer is to BLAME the individual (or team) that failed to prevent the accident. If you can find who is to blame and punish them, you can get back to work.

It MAKES SENSE because “if only they had done their job …” the accident would not have happened. Punishing the individual will set an example for everyone else and they will try harder not to make mistakes.

Sure enough, when the same accident doesn’t happen again right away, management believes they fixed the problem with blame and punishment.

I was thinking of this the other day when someone was talking to me about an investigation they had done using TapRooT®. They had recently adopted TapRooT® and, in the past, had frequently blamed people for accidents.

In this case, a worker had made a mistake when starting up a process. The mistake cost the facility over $200,000. The operator thought that she probably was going to be fired. Her apprehension wasn’t reduced when someone told her she was going to be “taprooted.”

She participated in the investigation and was pleasantly surprised. The investigation identified a number of Causal Factors including her “screw up.” But, to her surprise, they didn’t just stop there and blame her. They looked at the reasons for her mistake. They found there were three “root causes” that could be fixed (improvements that could be made) that would stop the mistake from being made in the future.

She came away realizing that anybody doing the same job could have made the same mistake. She saw how the investigation had improved the process to prevent future similar mistakes. She became a true believer in the TapRooT® System.

When you discover the real fixable root causes of human performance related Causal Factors, BLAME DOES NOT MAKE SENSE. In fact, blame is counter productive.

If people see that the outcome of an investigation is usually blame and discipline, it won’t take long until most incidents, if at all possible, become mystery incidents.

What is a mystery incident?

A refinery plant manager told me this story:

Back early in his career, he had been an engineer involved in the construction and startup of a major facility. One day when they were doing testing, the electrical power to some vital equipment was lost and then came back on “by itself.” This caused damage to some of the equipment and a delay in the startup of the plant. An investigation was performed and no reason for the power failure or the reason for the power coming back on could be found. No one admitted to being in the vicinity of the breaker and the breaker was closed when it was checked after the incident.

Thirty years later they held an unofficial reunion of people who had worked on the project. At dinner, people shared funny stories about others and events that had happened. An electrician shared his story about accidentally opening the wrong breaker (they weren’t labeled) and then, when he heard alarms going off, re-shutting the breaker and leaving the area. He said “Well, I’m retired and they can’t punish me for it now.”

That electrician’s actions had been the cause of the incident. The refinery manager telling the story added that the electrician probably would have been fired if he had admitted what he had done at the time. The refinery manager then added that, “It is a good thing that we use TapRooT® and know better than to react to incidents that way. Now we look for and find root causes that improve our processes.”

Are you looking for the root causes of incidents and improving processes?

Or are you still back in the “bad old days” blaming people when a mistake happens?

If you haven’t been to a TapRooT® Course, maybe you should go now and see how to go beyond blame to find the real, fixable root causes of human error.

See our upcoming TapRooT® Courses by clicking on THIS LINK.

Or contact us to get a quote for a course at your site by CLICKING HERE.

And if your management still thinks that blame and punish is a good idea, maybe you should find a way to pass this article along (without being identified and blamed).

What Are SnapCharT®s and Why Are They Important?

July 23rd, 2018 by

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

Watch the session here in Vimeo.

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

 

The Best Incident Investigation Performance Indicator

July 18th, 2018 by

NewImage

If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:

  • Was the root cause analysis inadequate?
  • Were the corrective actions ineffective?
  • Why didn’t management or peer review catch the problem with the previous investigation?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).

Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.

Here are two examples:

  • Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
  • Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?

Cancel your lunch plans! Join TapRooT® today at noon EST!

July 11th, 2018 by

Join TapRooT® professionals Benna Dortch and Ken Reed today at noon EST for TapRooT®’s Facebook Live discussion.

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

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

When? Today, Wednesday, July 11

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

Recently, on TapRooT®’s Facebook Live, we learned that only through effective listening will you learn to pick up on the “right” questions to ask in your investigations. TapRooT® Instructor Barb Carr gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below, featuring TapRooT® professionals Benna Dortch and Barb Carr, to review your skills:


Do your own investigation into our courses and discover what TapRooT® can do for you.

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

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

Winners and Losers in Healthcare’s Shift to Value-Based Payments

July 9th, 2018 by

 

Image result for scale budget

The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Our Acrylates Area Oxidation Reactor was experiencing frequent unplanned shutdowns (trips) that…

Rohm & Haas

At our phosphate mining and chemical plants located in White…

PCS Phosphate, White Springs, Florida
Contact Us