Category: Performance Improvement
In 2008 we wrote the book TapRooT® – Changing the Way the World Solves Problems. In one book we stuffed in all the information we thought was needed for anyone from a beginner to an expert trying to improve their root cause analysis program. It was a great book – very complete.
As the years went on, I realized that everybody didn’t need everything. In fact, everything might even seem confusing to those who were just getting started. They just wanted to be able to apply the proven essential TapRooT® Techniques too investigate low-to-moderate risk incidents.
Finally I understood. For a majority of users, the big book was overkill. They wanted something simpler. Something that was easy to understand and as easy as possible to use and get consistent, high-quality results. They wanted to use TapRooT® but didn’t care about trending, investigating fatalities, advanced interviewing techniques, or optional techniques that they would not be applying.
Therefore, I spent months deciding was were the bare essentials and how they could be applied as simply as possible while still being effective. Then Linda Unger and I spent more months writing an easy to read 50 page book that explained it all. (Yes … it takes more work to write something simply.)
Chapter 1: When is a Basic Investigation Good Enough?
Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System
- Find Out What Happened & Draw a SnapCharT®
- Decision: Stop or More to Learn?
- Find Causal Factors Using Safeguard Analysis
- Find Root Causes Using the Root Cause Tree® Diagram
- Develop Fixes Using the Corrective Action Helper Module
- Optional Step: Find and Fix Generic Causes
- What is Left Out of a Basic Investigation to Make it Easy?
Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation
Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation
By April, the new book and philosophy will be incorporated into our 2-Day TapRooT® Root Cause Analysis Course. But you can buy the new book (that comes with the latest Dictionary, Root Cause Tree®, and TapRooT® Corrective Action Helper® Guide) from our web site NOW. See:
I think you will find the book invaluable because it has just what you need to get everything you need for root cause analysis of low-to-medium risk incidents in just 10% of the old book’s pages.
Eventually, we are developing another eight books and the whole set will take the place of the old 2008 TapRooT® Book. You will be able to buy the books separately or in a boxed set. Watch for us to release each of them as they are finished and the final box set when everything is complete.
Many industries have dropped into a recession or a downright depression.
Oil, coal, iron ore, gas, and many other commodity prices are at near term (or all time) lows.
When the economy goes bad, the natural tendency is for companies to cut costs (and lay people off). Of course, we’ve seen this in many industries and the repercussion have been felt around the world.
Since many of our clients are in the effected industries, we think about how we could help.
If you could use some help … read on!
I think the first way we can help is to remind TapRooT® Users and management at companies that use TapRooT® that in hard times, it is easy for employees to hear they wrong message.
What is the wrong message?
Workers and supervisors think that because of the tough economic times, they need to cut corners to save money. Therefore, they shortcut safety requirements.
- A mechanic might save time by not locking out a piece of equipment while making an adjustment.
- An operator might take shortcuts when using a procedure to save time.
- Pre-job hazard analyses or pre-job brief might be skipped to save time.
- Facility management might cut operating staff or maintenance personnel below the level needed to operate and maintain a facility safely.
- Supervisors may have to use excessive overtime to make up for short staffing after layoffs.
- Maintenance may be delayed way past the point of being safe because funds weren’t available.
These changes might seem OK at first. When shortcuts are taken and no immediate problems are seen, the decision to take the shortcut seems justified. This starts a culture shift. More shortcuts are deemed acceptable.
In facilities that have multiple Safeguards (often true in the oil, mining, and other industries that ascribe to process safety management), the failure of a single Safeguard or even multiple Safeguards may go unnoticed because there is still one Safeguard left that is preventing a disaster. But every Safeguard has weaknesses and when the final Safeguard fails … BOOM!
This phenomenon of shortcuts becoming normal has a PhD term … Normalization of Deviation.
The result of normalization of deviation? Usually a major accident that causes extensive damage, kills multiple people, and ruins a company’s reputation.
So, the first thing that we at System Improvements can do to help you through tough times is to say …
This could be happening to your operators, your mechanics, or your local management and supervision.
When times are bad you MUST double up on safety audits and management walk arounds to make sure that supervisors and workers know that bad times are not the time to take shortcuts. Certain costs can’t be cut. There are requirements that can’t be eliminated because times are tough and the economy is bad.
When times are tough you need the very BEST performance just to get by.
When times are tough, you need to make sure that your incident investigation programs and trending are catching problems and keeping performance at the highest levels to assure that major accidents don’t happen.
Your incident investigation system and your audit programs should produce KPI’s (key performance indicators) that help management see if the problems mentioned above are happening (or are being prevented).
If you aren’t positive if your systems are working 100%, give us a call (865-539-2139) and we would be happy to discuss your concerns and provide ideas to get your site back on the right track. For industries that are in tough times, we will even provide a free assessment to help you decide if you need to request additional resources before something bad happens.
Believe me, you don’t want a major accident to be your wake up call that your cost cutting gone too far.
How would you like to save time and effort and still have effective root cause analysis of small problems (to prevent big problems from happening)?
For years I’ve had users request “TapRooT®-Lite” for less severe incidents and near-misses. I’ve tried to help people by explaining what needed to be done but we didn’t have explicit instructions.
Last summer I started working on a new book about using TapRooT® to find the root causes of low-to-medium risk incidents. And the book is now finished and back from the printers.
- The book is only 50 pages long.
- It makes using TapRooT® easy.
- It provides the tools needed to produce excellent quality investigations with the minimum effort.
- It will become the basis for our 2-Day TapRooT® Root Cause Analysis Course.
When can you get the book? NOW! Our IT guys have a NEW LINK to the new book on our store.
By April, we should have our 2-Day TapRooT® Course modified and everything should be interlinked with our new TapRooT® Version VI Software.
In hard economic times, getting a boost in productivity and effectiveness in a mission critical activity (like root cause analysis) is a great helping hand for our clients.
The new book is the first of eight new books that we will be publishing this year. Watch for our new releases and take advantage of the latest improvements in root cause analysis to help your facility improve safety, quality, and efficiency even when your industry is in tough economic times. For more information on the first of the new books, see:
If you need help, give us a call. (865-539-2139)
Are you having a backlog of investigations because of staff cuts? We can get you someone to help perform investigations on a short term basis.
Need to get people trained to investigate low-to-medium risk incidents effectively (and quickly)? We can quote a new 2-Day TapRooT® Root Cause Analysis Course t to be held at your site.
Need a job because of downsizing at your company? Watch the postings at the Root Cause Analysis Blog. We pass along job notices that require TapRooT® Root Cause Analysis skills.
This isn’t the first time that commodity prices have plummeted. Do you remember the bad times in the oil patch back in 1998? We helped our clients then and we stand by to help you today! We can’t afford to stop improvement efforts! Nobody wants to see people die to maintain a profit margin or a stock’s price. Let’s keep things going and avoid major accidents while we wait for the next economic boom.
Did you make your New Year’s resolutions? Your ideas to improve your performance next year?
In many companies, you are expected to have plans to improve performance Better production performance, quality, equipment reliability, safety, process safety, and financial performance are all expected parts of the normal year to year improvement process. If you are leading any of these improvement efforts, you better have a plan.
What if you could do something to both improve your personal performance and your company’s performance? Would that be interesting?
The first idea I have for people who have never attended a TapRooT® Root Cause Analysis Course is to ATTEND a COURSE!
What are you waiting for? TapRooT® Root Cause Analysis is proven by leading companies around the world to help them find and fix the root causes of performance problems. And the TapRooT® System can be used proactively to stop problems before major incidents happen. This can lead to improved financial performance in addition to improved safety, quality, equipment reliability, and production performance.
But beyond that, you will be adding an advanced skill to your toolbox that you can use for the rest of your career. Think of it as a magic problem solving wand that you can use to astound others by the improvement initiatives you will lead. This can lead to promotions and personal financial gain. Sounds like a great personal improvement program.
If you already have attended a 2-Day TapRooT® Root Cause Analysis Course, you can take the next step to improving your performance improvement skills. Attend a 5-Day TapRooT® Course and make improvements happen even faster.
What else can you do? Attend the Global TapRooT® Summit in San Antonio on August 1-5. What will attending the Summit do for you and your company?
First, you will meet industry leaders from around the world. This networking may be the key to your next job or the next great hire for your company.
Second, the knowledge shared across disciplines and across industries is second to none. If you need new ideas to improve your company’s performance, The Global TapRooT® Summit and we guarantee you will take home ideas that will save your company much more money than the cost of your attendance.
Third, the knowledge you share will help others and make the world a better place. What goes around comes around. Surely your efforts to help others will bring good luck to your efforts to improve personally and professionally.
Finally, you will have a great time. In addition to being invaluable place to learn new improvement skills, the Global TapRooT® Summit is fun. Why? Because every year we learn new ways to make the Summit more fun. And we’ve been improving the experience since 1993.
Now is the time to make your plans for 2016. Get your courses and your Summit attendance scheduled. Get ready too make your skills better and your company a better place to work.
The last paragraph of the article was:
“Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.“
So here is what the Aiken Standard wrote about the SRNS root cause analysis:
“Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”
What do you think? Did they look into Management System causes?
If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident?
In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures.
I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes.
This is how a culture of expediency exists alongside a culture of blame.
What can you learn from this incident?
One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame.
Had an interesting discussion today about cross industry / cross discipline performance improvement benchmarking.
It seems that many people benchmark inside their industry. Oil industry people benchmark with oil industry people. Heathcare with Healthcare. Nuclear with Nuclear. The list goes on and on.
Also, safety people go to safety conferences. Quality people go to quality conferences. Maintenance and reliability people go to maintenance and reliability conference.
So, I had someone ask me where they could do cross industry/cross discipline benchmarking. Nuclear safety people with Pharmaceutical Quality folks. Aviation safety folks with healthcare quality people. Refining process safety folks with Aviation safety people.
The answer? Plan on attending the 2016 Global TapRooT® Summit on August 1-5 in San Antonio.
We don’t have the final schedule out yet but it will be out soon. But I can guarantee that there will be sessions from all sorts of experts and people attending from all sorts of industries and disciplines. That’s what is so special about the TapRooT® Summit. We make a special effort to get people from different industries and different disciplines together to meet, make friends, and benchmark their improvement initiatives.
So start planning to attend.
There will be people there from all over the world.
And consider bringing a team from your company that includes people from safety, process safety, quality, operations, and maintenance. Contact us by clicking HERE for information about group discounts.
Hope to see someone from every TapRooT® User company (and some folks who are only thinking about using TapRooT®) there!
An article in the Aiken Standard got me thinking again about the topic of safety stand-downs (this time called a “safety pause”).
These temporary “stop work” activities where safe work practices are suppose to be reviewed, and where new emphasis is suppose to be applied to ensure safety, are common in government operations (this time a DOE site) and the nuclear industry. I’ve written about them before:
- Monday Accident & Lessons Learned: When is a “Safety Standdown” a “Standdown”
- Monday Accident & Lessons Learned: Mistakes at TVA Reactors Results in Safety Stand Down
- Nuclear Plant “Near-Miss” in Canada Leads to Safety Stand Down
- 22 Near-Fatal Accidents in 12 Months at a UK Steel Mill – Is a Safety Standdown Adequate?
The safety pause at Savannah River Nuclear Solutions is a really long pause. It started on September 11 after a September 3 incident in the H Canyon – HB Line portion of their operations where Plutonium was being handled.
An SRNS spokesperson is quoted by the paper as saying that: “SRNS is a stronger, healthier company as a result of these actions and we are working for sustained improvement.”
Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the “pause” to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.
In 2011 the mining recession started. The price of commodities (iron ore, copper, and other metals) suffered when demand from China dropped. This recession was somewhat independent from the housing crash of 2008.
What is the natural tendency of an industry faced with falling prices and falling demand? To cut costs. And that happened across the mining industry.
The Wall Street Journal is now pointing to the increased number of fatalities at large mining companies “when most are enacting heavy cost cuts as they battle to remain profitable amid a downturn in world commodity prices.” (See articles here and here.)
This negative press coverage by the WSJ resulted from the recent dam failure at a mine co-owned by BHP and Vale (the mine operator is named Samarco) (see article here).
Has cost cutting led to increased mining accidents? Will falling oil prices result in more oil industry fatalities? It is difficult to prove a cause and effect link but statistics point to negative trends.
The Wall Street Journal story above raises a great question. How effective is a federal prosecution in improving corporate and employee behavior?
Of course, the article was written by Kurt Mix, the accused, but it seems to raise very valid points that government investigations can go out of control, and that individuals have a very hard time fighting back against “the system.”
Why is the advice of any good attorney to “say nothing” to a criminal investigator before you have an attorney advising you? Because you may not know what serious laws you are breaking by what you see as non-criminal behavior.
Can this “don’t talk” advice make it harder for investigators to find the root causes of an accident? You bet!
So the next time you think that a criminal investigation is the answer to improve safety performance, maybe you should think again.
The new EPA emission regulation (not yet published in the Federal Register, but available here), requires a root cause analysis and corrective actions for upset emission releases including flare events.
Not only is a root cause analysis with corrective actions required, but a second event from the same equipment for the same root cause would trigger a diviation of the standard (read “fine”). In addition, the same device with more than 3 events per 3 years or the combination of 3 releases becomes a deviation.
This means it is time for effective, advanced root cause analysis of emission events. Time to send your folks to TapRooT® Root Cause Analysis Training!
What methods do you use to trend your accident data?
Is a decrease in lost time injuries seen as a success?
Is in an increase in injuries a failure and time for drastic action?
Are you using bar graphs or a simple line graph to look for trends?
How much change in the stats is enough for you to tell management that significant change has occurred?
That’s what I learned about 20 years ago and have been perfecting ever since.
How can you learn them too?
First, you can read Chapter 5 of the TapRooT® Book.
Second, you can study advanced trending and learn to use XmR Charts to trend accident data (both frequently occurring data and infrequently occurring data).
Third, you can attend SI’s TapRooT® Advanced Trending Techniques Course. You can hold one on your site for your people or the public course we hold each year just before the TapRooT® Summit.
When is the next public course?
On August 1-2, 2016 in San Antonio, TX. That’s a long time but it is the first public course. Mark your calendar to save the dates.
What will you learn at the TapRooT® Advanced Trending Techniques Course?
See the course outline here: http://www.taproot.com/courses#2-day-adv-trending
Also, read this article about picking targets for improvement to learn a little more before you attend a course:
And if you are interested in learning more about advanced trending, ask us about having a course at your site. Contact us by CLICKING HERE.
I saw an article about a hospital error that injured a patient. The article said they were going to perform a root cause analysis. It’s strange how a simple line in an article can get me WORKED UP.
Why am I WORKED UP? I know that many root cause analyses are BAD. What defines bad root cause analysis?
- The look to place blame.
- They look to cover up mistakes.
- They look for easy answers.
- They jump to conclusions.
- They pick their favorite root causes.
- They don’t improve performance.
That’s a BAD list. But I see it all the time.
In fact, that’s why I started to work inventing TapRooT®. I wanted to solve those problems. And for many TapRooT® Users, we have.
But there still is a long way to go.
There are still people who think that 5-Whys is a good system (some would even say an advanced system) for finding root causes.
Some don’t recognize the drawback of using cause and effect to analyze problems. That there is a tendency to find the answer that you want to find (rather than looking at the evidence objectively).
Some think that just filling out a form is good enough. Somehow this will prevent mistakes and save lives.
WELL I HAVE NEWS FOR THEM … It hasn’t worked for years and it won’t start working tomorrow!
The definition of insanity is to keep doing things the same way and to expect a different result.
Don’t be insane!
It is time to try TapRooT® and see how it can help guide you to the real, fixable causes of problems.
We guarantee our courses.
Here is the guarantee:
Attend the course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.
If you are investigating serious problems, then attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Here’s more information about the course: http://www.taproot.com/courses#5-day-root
Here are our upcoming public courses being held around the world:
Found an interesting old (2000) report from the UK HSE about incident/accident investigations. They had a contractor perform surveys about accident/incident investigation tools and results.
TYPE OF INVESTIGATION SYSTEM
It seems that homegrown investigation systems or no system were the most frequently used to investigate accidents/incidents.
With that type of investigation system, it should be no surprise that the three top corrective actions were:
- Tell them to be more careful/aware.
- Training/refresher training
- Reinforce safe behavior (Is that discipline?)
That’s what we found back in the early 1990’s.
Think it has changed any today?
HOW MUCH TIME SPENT INVESTIGATING?
Another interesting fact. How long did people typically spend doing investigations?
- 42% took 5 hours or less
- 35% took 5 to 20 hours
- 18% took over 20 hours
One third of those polled had NO accident/incident investigation training. Most of the rest just had general health and safety training as part of IOSH or NEBOSH courses. Also, most people performing investigations were not dedicated health and safety professionals.
What do you think? Is this similar to your experience at your company?
The report then provided a review of example investigations that the researchers had reviewed. As an expert in root cause analysis, these were awful but typical. many just filled out a form. Others grilled people and decided what they thought were the causes and the corrective actions.
HOW ARE YOU DOING?
Are you 15 years behind with no system, no training, and bad results?
Then you need to attend a TapRooT® Course. See: http://www.taproot.com/courses
Have you started to improve but still have a long way to go? You might want to attend one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See: http://www.taproot.com/store/5-Day-Courses/
Are you good to great but you want to be even better? The plan to attend the 2016 Global TapRooT® Summit in San Antonio, TX, on August 1-5. We’ll be posting more details about the Summit soon.
What is the easiest way to tell a good root cause analysis program from a bad one?
The involvement of senior management.
How do you know if a root cause analysis program is about to fail?
Senior management changes and the new management shows no interest in the root cause analysis program.
What level of senior management is involved in the best root cause analysis programs?
All the way to the corporate board.
The answers to the three questions above show that senior management involvement is extremely important to the success of any root cause analysis program. The better the root cause analysis program, the more senior management involvement counts. That’s why I thought I’d take this time to explain how senior management should be involved in a root cause analysis program.
I’ve seen a few leading companies where the Corporate Board was knowledgeable of the safety/process safety/quality improvement programs. The best had a senior manager who was responsible for reporting key reactive and proactive statistics to a special board committee with primary responsibility for safety and other improvement efforts. The committee, that included the CEO, also was provided with overviews of the most serious incident investigations and summaries of improvement efforts.
This board’s interest ensured that people paid attention to the programs and that budgets weren’t slashed for key improvement initiatives (because they were supported by the board).
Of course, VPs or Division Managers were interested in their division’s reactive and proactive improvement performance. What VP or Division Manager wouldn’t be if the Corporate Board was going to see their statistics. They wanted to be able to manage performance so they became involved in improvement efforts. The held divisional meetings to review progress and presentation of root cause analyses of their biggest problems. They held Plant Managers and Unit Leaders responsible for their performance making improvement programs succeed.
Involved Plant Managers demand good root cause analysis and schedule reviews of detailed root cause analyses of significant problem investigations. They make sure that their key improvement programs are staffed with well trained, insightful leaders and that they have plentiful staff and budget to perform investigations, review reactive and proactive statistics, sponsor training throughout the plant, and look outside the company for improvement ideas. They are the site sponsors of the improvement programs. They are trained in the root cause analysis tools being applied at the plant. Because they are trained, they offer insightful critiques of the investigation presentations. They reward employees for their participation in root cause analyses and the improvement programs.
WHAT DOES YOUR COMPANY DO?
Is your senior management involved in performance improvement?
Do you have best practices for management involvement that I’ve missed and should be included here?
What do you need to do to improve your management involvement?
If you have support, are you ready for management turnover?
Rome wasn’t built in a day. Don’t worry if your program doesn’t have all the management support that it needs. But don’t ignore your program’s shortcomings. Work on getting more management support all the way up to the corporate board.
When safety/improvement performance is seen as equally important, you know you have achieved a level of support that most improvement managers can only dream about.
Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness? How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post. But the real question is, do you want MORE than all of the useful information we provide on this blog? That’s okay – we’ll allow you to be greedy!
A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more. Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”
We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses. If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”
Thank you for being part of the global TapRooT® community!
Over a decade ago, I wrote this article to make a point about stopping construction fatalities. I’ve reposted it because it is missing from the archives. Does it still apply today? Perhaps it applies in many other industries as well. Let me know by leaving a comment.
StopSacrifices.pdf (click to open the pdf)
Is your company making money, losing money, or breaking even? How do you go from being a money-losing or break-even operation to a money-making good example?
Here’s a quick answer:
1. Send at team to TapRooT® Root Cause Analysis Training.
2. When they get back to work, put them to work solving your most expensive problems.
Don’t think this will work? Then see this success story…
Want more proof? See the rest of the success stories at:
If you need to improve your sites profitability, learn to use TapRooT® Root Cause Analysis to solve operational and maintenance problems. See our public course schedule for courses being held around the world at:
You have established a good performance improvement program, supported by performing solid incident investigations. Your teams are finding good root causes, and your corrective action program is tracking through to completion. But you still seem to be seeing more repeat issues than you expect. What could be the problem?
We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations. But many companies are skipping over the Generic Cause Analysis portion of the investigation process. While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.
6 Reasons to Look for Generic Root Causes
Here are 6 reasons to conduct a generic cause analysis on your investigation results:
1. The same incident occurs again at another facility.
2. Your annual review shows the same root cause from several incident investigations.
3. Your audits show recurrence of the same behavior issues.
4. You apply the same corrective action over and over.
5. Similar incidents occur in different departments.
6. The same Causal Factor keeps showing up.
These indicators point to the need to look deeper for generic causes. These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents. When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present. Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.
Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis. There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.
I overheard a senior executive talking about the problems his company was facing:
- Prices for their commodity were down, yet costs for production were up.
- Cost overruns and schedule slippages were too common.
- HSE performance was stagnant despite improvement goals.
- They had several recent quality issues that had caused customer complaints.
- They were cutting “unnecessary” spending like training and travel to make up for revenue shortfalls.
I thought to myself …
“How many times have I heard this story?”
I felt like interrupting him and explaining how he could stop at least some of his PAIN.
I can’t do anything about low commodity prices. The price of oil, copper, gold, coal, or iron ore is beyond my control. And he can’t control these either.
But he was doing things that were making his problems (pain) worse.
For example, if you want to stop cost overruns, you need to analyze and fix the root causes of cost overruns.
How do you do that? With TapRooT®.
And how would people learn about TapRooT®? By going to training.
And what had he eliminated? The training budget!
How about the stagnant HSE performance?
To improve performance his company needs to do something different. They need to learn best practices from other industry leaders from their industry AND from other industries.
Where could his folks learn this stuff? At the TapRooT® Summit.
His folks didn’t attend because they didn’t have a training or travel budget!
And the quality issues? He could have his people use the same advanced root cause analysis tools (TapRooT®) to attack them that they were already using for cost, schedule, and HSE incidents. Oh, wait. His people don’t know about TapRooT®. They didn’t attend training.
This reminds me of a VP at a company that at the end of a presentation about a major accident that cost his company big $$$$ and could have caused multiple fatalities (but they were lucky that day). The accident had causes that were directly linked to a cost cutting/downsizing initiative that the VP had initiated for his division. The cost cutting initiative had been suggested by consultants to make the company more competitive in a down economy with low commodity prices. At the end of the presentation he said:
“If anybody would have told me the impacts of these cuts, I wouldn’t have made them!”
Yup. Imaging that. Those bad people didn’t tell him he was causing bad performance by cutting the people and budget they needed to make the place work.
That accident and quote occurred almost 20 years ago.
Yes, this isn’t the first time we have faced a poor economy, dropping commodity prices, or performance issues. The more things change, the more they stay the same!
But what can you do?
Share this story!
And let your management know how TapRooT® Root Cause Analysis can help them alleviate their PAIN!
Once they understand how TapRooT®’s systematic problem solving can help them improve performance even in a down economy, they will realize that the small investment required is well worth it compared to the headaches they will avoid and the performance improvement they can achieve.
Because in bad times it is especially true that:
“You can stop spending bad money
or start spending good money
The Associated Press reported that the US Department of Justice is warning food companies that they could face civil and criminal charges if they poison their customers.
POISON THEIR CUSTOMERS!
Yes, you read it right.
We are again testing the fine line between accidents and criminal behavior.
How does a company know that they have gone over the line? The FDA stops showing up and the FBI puts boundary tape around your facilities.
Are you in the food business? Think it is time to start taking root cause analysis of food safety incidents seriously? You betcha!
Your company can’t afford a Blue Bell Ice Cream incident. You need to effectively analyze and learn from smaller incidents to stop the big accidents from happening.
What tool should you use for effective root cause analysis? The TapRooT® Root Cause Analysis System.
Why choose TapRooT® Root Cause Analysis?
Because it has proven itself effective in a wide number of industries around the world. That’s why industry leaders use it and recommend it to their suppliers.
Find out more about the TapRooT® System at:
And then attend one of our public courses held around the world.
You can attend at no risk because of our iron-clad guarantee:
Attend a TapRooT® Course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.
Get started NOW because you can’t afford to wait for the FBI to knock on your door with a warrant in their hand.
United grounds all of their flights for two hours due to “computer problems” (see the CNBC story).
The NYSE stops trading for over three hours due to an “internal technical issue” (see the CNBC story).
Computer issues can cost companies big bucks and cause public relations headaches. Do you think they should be applying state of the art root cause analysis tools both reactively and proactively to prevent and avoid future problems?
TapRooT® has been used to improve computer reliability and security by performing root cause analysis of computer/IT related events and developing effective corrective actions. The first TapRooT® uses for computer/high reliability network problems where banking and communication service providers that started using TapRooT® in the late 1990’s. The first computer security application of TapRooT® that we knew about was in the early 2000s.
Need to improve your root cause analysis of computer and IT issues? Attend one of our TapRooT® Root Cause Analysis Courses. See the upcoming course schedule at:
The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.
A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.
Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?
“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.
No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions. On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.
You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:
1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)
2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)
3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!
4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.
Simple… yes? Maybe? Feel free to post your examples and thoughts.
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
What do you think of this accident investigation and lessons learned?
John Lehman, the youngest Secretary of the Navy who fired the oldest admiral ever, says that Obama’s decision to promote the head of the Nuclear Navy after just two years will put the best safety record in the world at risk.
Here’s a link to the article: http://www.wsj.com/articles/obama-torpedoes-the-nuclear-navy-1432591747
What do you think?