Category: Investigations

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

 

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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.

Ever have trouble with root cause analysis during batch production with impurities?

July 6th, 2018 by

We received the question below in our TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn, please join the discussion with your experiences and best practices.

How would one do a SnapCharT® for intermittent product quality issues that span weeks/months?

The only way to detect the product impurity is to use the product. Even so, the impurity seems random in the same batch or lot, at different weeks or months, with different upstream raw material suppliers, with different personnel. Past root cause analysis was not systematic enough to find the rc. Fixes did not solve.

Investigative Interviewing Series, (Part 3 of 3): Extension Techniques

June 28th, 2018 by

Ever wondered how to get more than one word or one sentence answers from the witnesses you interview? Here’s your answer!

What are extension techniques and why are they so important from TapRooT® Root Cause Analysis on Vimeo.

Join TapRooT® tomorrow at noon EST for Facebook Live

June 26th, 2018 by

Join us tomorrow when TapRooT® professionals Barb Carr and Benna Dortch discuss the topic, “What are extension techniques and why are they so important?” This is the third part of the investigative interviewing series. In the first installment, Barb discussed a powerful but underutilized technique: building rapport. Last week’s tip presented another powerful interviewing technique: effective listening.

Take a read through Barb’s recent articles for more context: Evidence Collection: Top 3 Tips for Improving your Investigative Interviewing Skills Series and Investigative Interviewing Series, (Part 2 of 3): Effective Listening. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to join in for tomorrow’s Facebook Live:

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

When? Tomorrow, Wednesday, June 27

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

Last week on TapRooT®’s Facebook Live in the Effective Listening session, we learned that only through effective listening will you learn to pick up on the “right” questions to ask. Barb 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 to review your skills:

Investigative Interviewing Series, (Part 2 of 3): Effective Listening

June 21st, 2018 by

Last week, we started our 3-part investigative interviewing series. In the first installment, I discussed a powerful but underutilized technique: building rapport. This week’s tip presents another powerful interviewing technique: effective listening.

Most interviewers approach interviews with the idea that they need to know the right questions to ask. We challenge you to examine how you can possibly know the right questions to ask going into the interview when you haven’t even heard what the interviewee saw or knows.

Only through effective listening will you be able to know the “right” questions to ask. 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.”

Then, sit back, listen and identify which follow-up questions need to be asked.

How are your effective listening skills? No one is born with them, but you can develop them with practice. Take our listening inventory quiz below and become a better investigative interviewer.

Watch here via video.

So, how do you encourage interviewees to keep talking and give you the whole story? Join us next Wednesday as we discuss extension techniques.

Monday Accident & Lessons Learned: Why is Right of Way Maintenance Important?

June 18th, 2018 by

Here is another example of why right of way maintenance is important for utility transmission and distribution departments …

Wildfires

An article on hazardex reported that the California Department of Forestry and Fire Protection (Cal Fire) said in a press release that 12 of the wildfires that raged across California’s wine country were due to tree branches touching PG&E power lines.

Eight of the 12 fires have been referred to county District Attorney’s offices for potential criminal prosecution for alleged violations of California laws.

The fires last October killed 44 people, burned more than 245,000 acres, and cost at least $9.4 billion dollars of insured losses. PG&E has informed it’s shareholders that it could be liable costs in excess of the $800 million in insurance coverage that it has for wildfires.

PG&E is lobbying state legislators for relief because they are attributing the fires to climate change and say they should not be held liable for the damage.

What lessons can you learn from this?

Sometimes the cost of delayed maintenance is much higher than the cost of performing the maintenance.

Can you tell which maintenance is safety critical?

Do you know the risks associated with your deferred maintenance?

Things to think about.

Investigative Interviewing Series (Part 1 of 3): The Power of Rapport

June 14th, 2018 by

Gather more quantity and quality of information from interviews conducted during incident investigations. In this 3-week series, we will examine 3 top tips to improve your interviewing skills. Today’s segment highlights the power of rapport.

The Power Of Rapport For Investigative Interviewing from TapRooT® Root Cause Analysis on Vimeo.

View the session on video here:

We are global to meet your needs. 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 or 865.357.0080.

2018 Global TapRooT® Summit Best Practices: Engineers Have Freedom To Investigate Low Level Incidents

June 13th, 2018 by

2018 Global TapRooT® Summit Best Practices – Engineers Have Freedom To Investigate Low Level Incidents from TapRooT® Root Cause Analysis on Vimeo.

Here’s another way to watch the Best Practices session via video:

Learn more about investigating low-level incidents in the TapRooT® book Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents and through our courses. Discover what TapRooT® can do for you; Contact or call us: 865.539.2139.

Our Best Practices speaker for this session is Will Canda, representing Nutrien Ltd. The Saskatchewan agriculture industry leader, Nutrien, has more than 1,500 farm retail centers and employs more than 20,000 people across operations in 14 Canadian countries. Nutrien is the biggest global fertilizer producer by capacity, and has the largest U.S. network of farm retail stores.

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

 

 

We have a sneak peek for you on today’s Facebook Live!

June 13th, 2018 by

TapRooT® professional Barb Carr will be featured on today’s Facebook Live session. To get a sense of the subject, look at Barb’s recent article.

As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

We look forward to being with you on Wednesdays! Here’s how to join us today:

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

When? Today, Wednesday, June 13

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

If you missed last week’s Facebook Live discussion with Mark Paradies and Benna Dortch, catch it below on Vimeo or here on video.

Why do we still have major process safety accidents from TapRooT® Root Cause Analysis on Vimeo.

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.

Get a sneak peek tomorrow on TapRooT®’s Facebook Live!

June 12th, 2018 by

Not to give too much away here but you have the unique opportunity to gather very useful information tomorrow during TapRooT’s Facebook Live session.

We can announce that TapRooT® professionals Barb Carr and Benna Dortch will be the facilitators for the session. To get a glimmer of the subject, take a look at Barb’s recent article. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to get your sneak peek for tomorrow’s Facebook Live:

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

When? Tomorrow, Wednesday, June 13

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

 

2018 Global TapRooT® Summit Best Practices: Instilling Competencies Around Employees

June 12th, 2018 by

2018 Global TapRooT® Summit Best Practices – Instilling Competencies Around Employees from TapRooT® Root Cause Analysis on Vimeo.

You can view the Best Practices discussion on video here.

In this session, Steven Sandlin, Oceaneering International Inc., discusses investigations in his company’s incident management process, and the vetting and roles of the individuals responsible for the investigations.

Is your team trained to handle a catastrophic event?

Major accidents happen when precursors are missed. Precursors are indicators that a potential crisis is brewing; however, they can be proactively analyzed to stop that crisis from occurring as well as reactively analyzed so they never happen again.

Our 5-day TapRooT® Advanced Root Cause Analysis Team Leader Training equips your team to recognize critical precursors. Find and fix the root causes of a major accident using all of the essential TapRooT® techniques plus advanced tools to analyze problems, and find root causes that you previously would have overlooked before they become a major crisis. Onsite training is available for 10 or more.

View course outline.

Inquire about hosting an onsite course for 10 or more at your company.

Register one or more for a public course near you.

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

New Study Suggests Poor Officer Seamanship Training Across the Navy – Is This a Generic Cause of 2017 Fatal Navy Ship Collisions?

June 7th, 2018 by

BLAME IS NOT A ROOT CAUSE

It is hard to do a root cause analysis from afar with only newspaper stories as your source of facts … but a recent The Washington Times article shed some light on a potential generic cause for the fatal collisions last year.

The Navy conducted an assessment of seamanship skills of 164 first-tour junior officers. The results were as follows

  • 16% (27 of 164) – no concerns
  • 66% (108 of 164) – some concerns
  • 18% (29 of 164) – significant concerns

With almost 1 out of 5 having significant concerns, and two thirds having some concerns, it made me wonder about the blame being placed on the ship’s Commanding Officers and crew. Were they set up for failure by a training program that sent officers to sea who didn’t have the skills needed to perform their jobs as Officer of the Deck and Junior Offiicer of the Deck?

The blame heavy initial investigations certainly didn’t highlight this generic training problem that now seems to be being addressed by the Navy.

Navy officers who cooperated with the Navy’s investigations faced court martials after cooperating.

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According to and article in The Maritime Executive Lt j.g. Sarah Coppock, Officer of the Deck during the USS Fitzgerald collision, pled guilt to charges to avoid facing a court martial. Was she properly trained or would have the Navy’s evaluators had “concerns” with her abilities if she was evaluated BEFORE the collision? Was this accident due to the abbreviated training that the Navy instituted to save money?

Note that in the press release, information came out that hadn’t previously been released that the Fitzgerald’s main navigation radar was known to be malfunctioning and that Lt. j.g. Coppock thought she had done calculations that showed that the merchant ship would pass safely astern.

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In other blame related news, the Chief Boatswains Mate on the USS McCain plead guilty to dereliction of duty for the training of personnel to use the Integrated Bridge Navigation System, newly installed on the McCain four months before he arrived. His total training on the system was 30 minutes of instruction by a “master helmsman.” He had never used the system on a previous ships and requested additional training and documentation on the system, but had not received any help prior to the collision.

He thought that the three sailors on duty from the USS Antietam, a similar cruiser, were familiar with the steering system. However, after the crash he discovered that the USS McCain was the only cruiser in the 7th fleet with this system and that the transferred sailors were not familiar with the system.

On his previous ship Chief Butler took action to avoid a collision at sea when a steering system failed during an underway replenishment and won the 2014 Sailor of the Year award. Yet the Navy would have us believe that he was a “bad sailor” (derelict in his duties) aboard the USS McCain.

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Also blamed was the CO of the USS McCain, Commander Alfredo J. Sanchez. He pleaded guilty to dereliction of duty in a pretrial agreement. Commander Sanchez was originally charged with negligent homicide and hazarding a vessel  but both other charges were dropped as part of the pretrial agreement.

Maybe I’m seeing a pattern here. Pretrial agreements and guilty pleas to reduced charges to avoid putting the Navy on trial for systemic deficiencies (perhaps the real root causes of the collisions).

Would your root cause analysis system tend to place blame or would it find the true root and generic causes of your most significant safety, quality, and equipment reliability problems?

The TapRooT® Root Cause Analysis System is designed to look for the real root and generic causes of issues without placing unnecessary blame. Find out more at one of our courses:

http://www.taproot.com/courses

Decisions that get people killed

May 30th, 2018 by

When you read “decisions that get people killed” do you think about decisions that workers make? These are not the decisions we are referring to!

What are we referring to? Come and learn at the 2019 Global TapRooT® Summit. We are pleased to announce our first confirmed keynote speaker, Mark Paradies, President of System Improvements, Inc.

He will be discussing decisions that set up major accidents. These types of decisions are usually made by senior management, and they can have very serious consequences. Management needs to know about them, and what they need to do to prevent major accidents.

 

Mark your calendar to join us for the 2019 Global TapRooT® Summit, March 11 – 15, 2019 at La Toretta Lake Resort & Spa, Montgomery, Texas.

Avoid Big Problems By Paying Attention To The Small Stuff

May 24th, 2018 by

If you didn’t catch the Facebook Live discussion yesterday, join in now to hear TapRooT® professionals Mark Paradies and Benna Dortch discuss this week’s topic: Avoid Big Problems by Paying Attention to the Small Stuff. After you’ve listened to the discussion via the Vimeo below, go to Mark’s article here for further exploration of the precursor mindset.

Avoid Big Problems By Paying Attention To The Small Stuff from TapRooT® Root Cause Analysis on Vimeo

The 2-Day TapRooT® Root Cause Analysis Course is a good choice to send folks to for learning how to investigate precursor incidents. Your best problem-solvers need to learn more to gain the necessary skills for coaching others, and to investigate significant incidents and major accidents; they would attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. And, we can always come to your workplace to teach your team, just let us know or call us: 865.539.2139.

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

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

When? Every Wednesday

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

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

May 22nd, 2018 by

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Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

May 21st, 2018 by

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years. 

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing. 

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB.  The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

  • Captain’s actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Company’s safety management system
  • Inadequate company oversight
  • Need for damage control plan
  • Flooding in cargo holds
  • Loss of propulsion
  • Downflooding through ventilation closures
  • Need for damage control plan
  • Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

Root Cause Tip: Repeat-Back Strengthens Positive Communication

May 17th, 2018 by

Misunderstood verbal communication can lead to a serious incident.

Risk Engineer and HSE expert, Jim Whiting, shared this report with us recently highlighting four incidents where breakdowns in positive communications were factors. In each circumstance, an operator proceeded into shared areas without making positive communication with another operator.

Read: Positive communication failures result in collisions.

Repeat-back (sometimes referred to as 3-way communication) can reinforce positive communication. This technique may be required by policy or procedure and reinforced during training on a task for better compliance.

Repeat-back is used to ensure the information shared during a work process is clear and complete. In the repeat back process, the sender initiates the communication using the receiver’s name, the receiver repeats the information back, and the sender acknowledges the accuracy of the repeat back or repeats the communication if it is not accurate.

There are many reasons why communications are misunderstood. Workers make assumptions about an unclear message based on their experiences or expectations. A sender may choose poor words for communication or deliver messages that are too long to remember. The message may not be delivered by the sender in the receiver’s primary language. A message delivered in the same language but by a worker from a different geographical region may be confusing because the words do not sound the same across regions.

Can you think of other reasons a repeat-back technique can be helpful? Please comment below.

“It was such a simple mistake!”

May 14th, 2018 by

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When you have a major incident (fire, environmental release, etc.), your investigation will most likely identify several causal factors (CF) that, if they had not occurred, we probably would not have had the incident.  They are often relatively straight forward, and TapRooT® does a great job identifying those CFs and subsequent root causes.

Sometimes, the simplest problems can be the most frustrating to analyze and fix.  We think to ourselves, “How could the employee have made such a simple mistake?  He just needs to be more careful!”  Luckily, TapRooT® can help even with these “simple” mistakes.

Let’s look at an example.  Let’s say you are out on a ship at sea.  The vessel takes a bit of a roll, and a door goes shut on one of your employees.  His finger is caught in the door as it shuts, causing an injury.  Simple problem, right?  Maybe the employee should just be more aware of where he is putting his hands!  We will probably need more effective fixes if we really want to prevent this in the future.

How can we use TapRooT® to figure this out?  First of all, it is important to fully document the accident using a SnapCharT®.  Don’t skip this just because you think that the problem is simple.  The SnapCharT® forces you to ask good questions and makes sure you aren’t missing anything.  The simple problem may have aspects that you would have missed without fully using this technique.  In this example, maybe you find that this door is different than other doors, which have latches to hold them open, or handles to make it easier to open the door.  Imagine that this door might have been a bathroom stall door.  It would probably be set up differently than doors / hatches in other parts of the ship.

So, what are your Causal Factors?  First, I probably would not consider the sudden movement of the ship as a CF.  Remember, the definition of a CF states that it is a mistake or an error that directly leads to the incident. In this case, I think that it is expected that a ship will pitch or roll while underway; therefore, this would not be a CF. It is just a fact. This would be similar to the case where, in Alaska, someone slipped on a snow-covered sidewalk. I would not list that “it was snowing” as a CF.  This is an expected event in Alaska. It would not be under Natural Disaster / Sabotage, either, since snow is something I should be able to reasonably protect against by design.

In this case, I would consider the pitch / roll of the vessel as a normal occurrence.  There is really nothing wrong with the vessel rolling. The only time this would be a problem is if we made some mistake that caused an excessive roll of the vessel, causing the door to unexpectedly slam shut in spite of our normal precautions. If that were the case, I might consider the rolling of the ship to be a CF.  That isn’t the case in this example.

You would probably want to look at 2 other items that come to mind:

1.  Why did the door go shut, in spite of the vessel operating normally?
If we are on a vessel that is expected to move, our doors should probably not be allowed to swing open and shut on their own. There should be latches / shock absorbers / catches that hold the door in position when not being operated. Also, while the door is actually being operated, there should be a mechanism that does not depend on the operator to hold it steady while using the door. I remember on my Navy vessel all of our large hatches had catches and mechanisms that held the doors in place, EXCEPT FOR ONE HEAVY HATCH. We used to tell everyone to “be careful with that hatch, because it could crush you if we take a roll.” We had several injuries to people going through that hatch in rough seas. Looking back on that, telling people to “be careful” was probably not a very strong safeguard.

Depending on what you find here, the root causes for this could possibly be found under Human Engineering, maybe “arrangement/placement”, “tools/instruments NI”, excessive lifting/force”, “controls NI”, etc.

2. Why did the employee have his hand in a place that could cause the door to catch his hand?
We should also take a look to understand why the employee had his hand on the door frame, allowing the door to catch his finger.  I am not advocating, “Tell the employee to be careful and do not put your hand in possible pinch points.” That will not work too well. However, you should take a look and see if we have sufficient ways of holding the door (does it have a conventional door knob? Is it like a conventional toilet stall, with no handle or method of holding the door, except on the edge?). We might also want to check to see if we had a slippery floor, causing the employee to hold on to the edge of the door / frame for support. Lots of possibilities here.

Another suggestion: Whenever I have what I consider a “simple” mistake that I just can’t seem to understand (“How did the worker just fall down the stairs!?”), I find that performing a Critical Human Action Profile (CHAP) can be helpful.  This tool helps me fully understand EXACTLY what was going on when the employee made a very simple yet significant mistake.

TapRooT® works really well when you are trying to understand “simple” mistakes.  It gets you beyond telling the employee to be more careful next time, and allows you to focus on more human performance-based root causes and corrective actions that are much more likely to prevent problems in the future.

Evidence Collection: Two things every investigator should know about scene management

April 17th, 2018 by

You may not be part of scene management when an incident occurs at your facility but there are two things every investigator should know:

  1. Hazards that are present in the work area and how to handle them. It’s impossible to anticipate every accident that could happen but we can evaluate hazards that are present at our facilities that could affect employees and the community at large to structure a scene management plan.
  2. Priorities for evidence collection. The opportunity to collect evidence decreases over time. Here are a few things to keep in mind during, and immediately following, scene management.
    • Fragile evidence goes away.
    • Witnesses forget what they saw.
    • Environmental conditions change making it hard to understand why an incident occurred.
    • Clean-up and restart begins; thus, changing the scene from its original state.

Learn more by holding our 1-Day Effective Interviewing & Evidence Collection Training at your facility. It is a standalone course but also fits well with our 2-Day TapRooT® Root Cause Analysis Training. Contact me for details: carr@taproot.com.

 

You’re invited to Facebook Live for Wednesday lunch

April 16th, 2018 by

We invite you to tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a contemporary, workplace-relevant topic. Put a reminder on your calendar, in your phone, or stick a post-it on your forehead to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s how to connect with us for Wednesday’s Facebook Live:

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

When? Wednesday, April 18, 2018

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

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Be sure to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

How many investigations are enough?

April 16th, 2018 by

 

I’d like you to think about this scenario at work.  You’ve just sent your team to Defensive Driving School, and made sure they were trained and practiced on good driving skills.  They were trained on how to respond when the vehicle is sliding, safe following distances, how to respond to inclement weather conditions, etc.

Now that they’re back at work, how many managers would tell their recently-trained employees, “I’m glad we’ve provided you with additional skills to keep yourself safe on those dangerous roads.  Now, I only want you to apply that training when you’re in bad weather conditions.  On sunny days, please don’t worry about it.”  Would you expect them to ONLY use those skills when the roads are snow-covered?  Or ONLY at rush hour?  I think we would all agree that this would be a pretty odd thing to tell your team!

Yet, that’s what I often hear!

I teach TapRooT® courses all over the world. We normally start off the class by asking the students why they’re at the course and what they are expecting to get from the class. I often hear something that goes like this:

“I’m here to get a more structured and accurate root cause analysis process that is easy for my staff to use and gets repeatable results.  I don’t expect to use TapRooT® very often because we don’t have that many incidents,  but when we do, we want to be using a great process.”

Now, don’t get me wrong, I appreciate the sentiment (we don’t expect to have many serious incidents at our company), and we can definitely meet all of the other criteria.  However, it does get a little frustrating to hear that some companies are going to reserve using this fantastic product to only a few incidents each year.  Doesn’t that seem to be a waste of terrific training?  Why would we only want our employees to use their training on the big stuff, but not worry about using that same great training on the smaller stuff?

There are a couple of reasons that I can think of that we have this misconception on when to use TapRooT®:

  • Some managers honestly believe that they don’t have many incidents.  Trust me, they are not looking very hard! Our people (including ourselves) are making mistakes every day.  Wouldn’t it be nice if we went out there, found those small mistakes, and applied TapRooT® to find solid root causes and corrective actions to fix those small issues before they became large incidents?
  • Some people think that it takes too long to do a good RCA.  Instead, they spend time using an inferior investigation technique on smaller problems that doesn’t fix anything anyway.  If you’re going to take time to perform some type of RCA, why waste any time at all on a system that gives you poor results?
  • Some people don’t realize that all training is perishable.  Remember those defensive driving skills?  If you never practice them, do you ever get good at them?

I recognize that you can’t do an RCA on every paper cut that occurs at your facility.  Nobody has the resources for that.  So there must be some level of “incident” at which makes sense to perform a good analysis.  So, how do we figure out this trip point?

Here are some guidelines and tips you can follow to help you figure out what level of problem should be investigated using TapRooT®:

  • First of all, we highly recommend that your investigators perform one TapRooT® investigation at least every month.  Any longer than that, and your investigation skills start becoming dull.  Think about any skill you’ve learned.  “Use it, or lose it.”
    • Keep in mind that this guideline is for each investigator.  If you have 10 investigators, each one should be involved in using TapRooT® at least monthly.  This doesn’t have to be a full investigation, but they should use some of the tools or be involved in an investigation at least every month.
  • Once you figure out how many investigations you should perform each year to keep your team proficient, you can then figure out what level of problem requires a TapRooT® investigation.  Here is an example.
    • Let’s say you have 3 investigators at your company.  You would want them to perform at least one investigation each month.  That would be about 36 investigations each year.  If you have about 20 first aid cases each year, that sounds like a good level to initiate a TapRooT® investigation.  You would update your company policy to say that any first aid case (or more serious) would require a TapRooT® investigation.
    • You should
      also do the same with other issues at the company.  You might find that your trigger points would be:

      • Any first aid report or above
      • Any reportable environmental release
      • Any equipment damage worth more than $100,000
    • When you add them all up, they might be about 36 investigations each year.  You would adjust these levels to match your minimum number to maintain proficiency.
  • At the end of each year, you should do an evaluation of your investigations.  Did we meet our goals?  Did each investigator only do 4 investigations this year?  Then we wasted some opportunities.  Maybe we need to lower our trip points a bit.  Or maybe we need to do more audits and observations, with a quick root cause analysis of those audit results.  Remember, your goal is to have each investigator use TapRooT® in some capacity at least once each month.
  • Note that all of this should be specified in your company’s investigation policy.  Write it down so that it doesn’t get lost.

Performing TapRooT® investigations only on large problems will give you great results.  However, you are missing the opportunity to fix smaller problems early, before they become major issues.

TapRooT®: It’s not just for major issues anymore!

The Scientific Method In Relation To Root Cause Analysis

April 13th, 2018 by

Did you miss last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation? Here’s an opportunity to catch up on the discussion, as Mark and Barb distill the disciplines and factors that historically have been involved in solving complex problems. Also, peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

Tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a workplace-relevant topic. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s the info you need to connect with us for our next Facebook Live:

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

When? Wednesday, April 18, 2018

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

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Monday Accidents & Lessons Learned: When Retrofitting Does Not Evaluate Risks

April 9th, 2018 by

Bound for London Waterloo, the 2G44 train was about to depart platform 2 at Guildford station. Suddenly, at 2:37 pm, July 7, 2017, an explosion occurred in the train’s underframe equipment case, ejecting debris onto station platforms and into a nearby parking lot. Fortunately, there were no injuries to passengers or staff; damage was contained to the train and station furnishings. It could have been much worse.

The cause of the explosion was an accumulation of flammable gases within the traction equipment case underneath one of the train’s coaches. The gases were generated after the failure of a large electrical capacitor inside the equipment case; the capacitor failure was due to a manufacturing defect.

Recently retrofitted with a modern version of the traction equipment, the train’s replacement equipment also included the failed capacitor. The project team overseeing the design and installation of the new equipment did not consider the risk of an explosion due to a manufacturer’s defect within the capacitor. As a result, there were no preventative engineering safeguards.

The Rail Accident Investigation Branch (RAIB) has recommended a review of the design of UK trains’ electric traction systems to ensure adequate safeguards are in place to offset any identified anomalies and to prevent similar explosions. Learn about the six learning points recommended by the RAIB for this investigation.

Use the TapRooT® System to solve 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.

Scientific Method and Root Cause Analysis

April 4th, 2018 by

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I had someone tell me that the ONLY way to do root cause analysis was to use the scientific method. After all, this is the way that all real science is performed.

Being an engineer (rather than a scientist), I had a problem with this statement. After all, I had done or reviewed hundreds (maybe thousands?) of root cause analyses and I had never used the scientific method. Was I wrong? Is the scientific method really the only or best answer?

First, to answer this question, you have to define the scientific method. And that’s the first problem. Some say the scientific method was invented in the 17th century and was the reason that we progressed beyond the dark ages. Others claim that the terminology “scientific method” is a 20th-century invention. But, no matter when you think the scientific method was invented, there are a great variety of methods that call themselves “the scientific method.” (Google “scientific method” and see how many different models you can find. The one presented above is an example.)

So let’s just say the scientific method that the person was insisting was the ONLY way to perform a root cause analysis required the investigator to develop a hypothesis and then gather evidence to either prove or disprove the hypothesis. That’s commonly part of most methods that call themselves the scientific method.

What’s the problem with this hypothesis testing model? People don’t do it very well. There’s even a scientific term the problem that people have disproving their hypothesis. It’s called CONFIRMATION BIAS. You can Google the term and read for hours. But the short description of the problem is that when people develop a hypothesis that they believe in, they tend to gather evidence to prove what they believe and disregard evidence that is contrary to their hypothesis. This is a natural human tendency – think of it like breathing. You can tell someone not to breath, but they will breath anyway.

What did my friend say about this problem with the scientific method? That it could be overcome by teaching people that they had to disprove all other theories and also look for evidence to disproves their theory.

The second part of this answer is like telling people not to breath. But what about the first part of the solution? Could people develop competing theories and then disprove them to prove that there was only one way the accident could have occurred? Probably not.

The problem with developing all possible theories is that your knowledge is limited. And, of course, how long would it take if you did have unlimited knowledge to develop all possible theories and prove or disprove them?

The biggest problem that accident investigators face is limited knowledge.

We used to take a poll at the start of each root cause analysis class that we taught. We asked:

“How many of you have had any type of formal training
in human factors or why people make human errors?”

The answer was always less than 5%.

Then we asked:

“How many of you have been asked to investigate
incidents that included human errors?”

The answer was always close to 100%.

So how many of these investigators could hypothesize all the potential causes for a human error and how would they prove or disprove them?

That’s one simple reason why the scientific method is not the only way, or even a good way, to investigate incidents and accidents.

Need more persuading? Read these articles on the problems with the scientific method:

The End of Theory: The Data Deluge Makes The Scientific Method Obsolete

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

That’s just a small handful of the articles out there.

Let me assume that you didn’t read any of the articles. Therefore, I will provide one convincing example of what’s wrong with the scientific method.

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Supposedly he did this using the scientific method. And it worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Einstein was wrong!

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were wrong but that most everyone believed … what chance do you and I have to develop the right answer during our next incident investigation?

Now for the good news.

Being an engineer, I didn’t start with the scientific method when developing the TapRooT® Root Cause Analysis System. Instead, I took an engineering approach. But you don’t have to be an engineer (or a human factors expert) to use it to understand what caused an accident and what you can do to stop a future similar accident from happening.

Being an engineer, I had my fair share of classes in science. Physics, math, and chemistry are all part of an engineer’s basic training. But engineers learn to go beyond science to solve problems (and design things) using models that have limitations. A useful model can be properly applied by an engineer to design a building, an electrical transmission network, a smartphone, or a 747 without understanding the limitations of quantum mechanics.

Also, being an engineer I found that the best college course I ever had that helped me understand accidents wasn’t an engineering course. It was a course on basic human factors. A course that very few engineers take.

By combining the knowledge of high reliability systems that I gained in the Nuclear Navy with my knowledge of engineering and human factors, I developed a model that could be used by people without engineering and human factors training to understand what happened during an incident, how it happened, why it happened, and how it could be prevented from happening again. We have been refining this model (the TapRooT® System) for about thirty years – making it better and more usable – using the feedback from tens of thousands of users around the world. We have seen it applied in a wide variety of industries to effectively solve equipment and human performance issues to improve safety, quality, production, and equipment reliability. These are real world tests with real world success (see the Success Stories at this link).

So, the next time someone tells you that the ONLY way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there is a better way to do it today.

If you don’t know how to use the TapRooT® System to solve problems, perhaps you should attend one of our courses. There is a basic 2-Day Course and an advanced 5-Day Course. See the schedule for public courses HERE. Or CONTACT US about having a course at your site.

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Using TapRooT® to Improve Investigations, Stop Fault Finding, Reduce Injuries, & Cut Workers’ Compensation Costs Submitted by Dave Hales, Safety & Compliance Supervisor, Skyline Mines, Canyon Fuel Company, LLC   Challenge Skyline Mines is an underground coal mining operation with over 350 employees. Our challenge is to go from a company with a better than …

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