How do you know if your root cause analysis is adequate? Read the article on page 3 of the March Root Cause Network™ Newsletter and find out! Download your copy of the newsletter by clicking on this link: Mar14NL120.pdf
.What else can you learn in this edition?
- What’s Right and What’s Wrong with Human Performance Tools (Page 1)
- Why Do Supervisors Produce Bad Investigations? (Page 2)
- How Should You Target Your Investigations? (Page 2)
- What’s Wrong with Your Trending? (Page 2)
- Admiral Rickover’s Face-the-Facts Philosophy (Page 2)
- Proactive Use of TapRooT® (Page 3)
- Stop Slips, Trips, and Falls (Page 3)
- Risk Management Best Practices (Page 3)
- Upcoming TapRooT® Courses Around the World (Page 4)
- What Can You Learn at the 2014 Global TapRooT® Summit? (Page 5, 6, & 7)
Plus there’s more! An article you really should read and act upon. See the article on Page 3: “Are you Missing an Important Meeting?”
Why should you read that article among all the others? Here’s the first paragraph …
“What if you missed a meeting and it caused someone to die. Or maybe you lost your job if you weren’t there? Or your company lost millions of dollars because you simply didn’t attend a three-day meeting. Would you make sure that you were there?”
If those questions don’t grab your attention, what will?
Go to this link:
Print the March Root Cause Network™ Newsletter and read it from cover to cover!
You’ll be glad you did. (And you’ll find that there are several actions you will be compelled to take.)
If you are a TapRooT® User, you are already have improved your root cause analysis and incident investigation just by attending TapRooT® Training. But what can you do to get even better? To improve beyond your initial TapRooT® Training? To make your company’s incident investigations and root cause analysis world-class?
And choose the Incident Investigation & Root Cause Analysis Best Practices Track. What’s in the track?
- Advanced Causal Factor Development (Ken Turnbull)
- Interviewing: De-Coding Non-Verbal Behavior (Barb Phillips)
- Getting Your Root Cause Analysis PhD (Mark Paradies)
- Expert Facilitation of Investigations Using the TapRooT® Software (Brian Tink)
- Infamous Accident (Alan Smith, Alan Scot, & Harry Thorburn)
- Measure Your RC System: The Good, The Bad, and The Ugly (Ralph Blessing & Brian Dolin)
- Slips, Trips, & Falls: The Science Behind Walking (Robert Shaw)
- The Business End of Equipment Reliability (Heinz Bloch)
Plus you will hear great keynote speakers to give you practical improvement ideas and get you motivated to make change happen.
- Christine Cashen – Why Briansorm When You Can Brain El Niño?
- Carl Dixon – A Strange Way to Live
- Mark Paradies – World Class Performance Improvement
- Edward Foulke – Sweeping Workplace Safety Changes
- Rocky Bleier – Be the Best You Can Be
There’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility. And we know that you learn more when you are having fun so this won’t be a stuffy technical meeting that puts you to sleep. You will be involved and motivated.
Want to get even more out of your Summit experience? Then attend of the advanced pre-Summit Courses. I would recommend one of these if you are interested in making your TapRooT® implementation even better:
- Advanced Trending Techniques
- Advanced Causal Factor Development Course
- TapRooT® Evidence Collection Course
- Getting the Most from Your TapRooT® Software
- Reducing Serious Injuries and Fatalities Using TapRooT®
- Proactive Use of TapRooT®
- TapRooT® Analyzing and Fixing Safety Culture Issues
Here’s a link to the Federal Register request for comments:
Interestingly, OSHA says:
“While the PSM standard has been effective in improving process safety in the United States and protecting workers from many of the hazards associated with uncontrolled releases of highly hazardous chemicals, major incidents have continued to occur.“
It then goes on to list some of the many serious process safety accidents that have occurred after the regulation had plenty of time to be effective.
What does it mean when a regulation is put in place to stop accidents and the accidents continue? Either the regulation is ineffective or the enforcement is ineffective.
In my review of the regulation and comparing it to Admiral Rickover’s successful process (nuclear) safety program. I concluded that there are many gaping holes in the regulation that, even if enforcement was effective, would have allowed the accidents mentioned to occur.
However, I believe that it is doubtful that OSHA will adopt the tough stance that Rickover required to ensure safe operations of the Navy’s nuclear power plants.
To learn more about Admiral Rickover’s approach to process safety, see the links provided here:
Make sure that you scroll down because there are many interesting articles and videos.
Then return here to leave your comments about your concerns/recommendations about the revision of the OSHA Process Safety Management standard.
I was at a meeting last week and the topic came up about how people used their root cause analysis data. To my surprise, about half the companies represented didn’t have a way to produce any type of graphs. The other half could produce pie charts using Microsoft Excel. There were one or two other people who had other ways to look at their data that they manually put into a system of some sort.
That got me thinking:
How do readers of this e-Newsletter use their root cause analysis data?
So I established this poll so that people could respond.
Click on the comments link below (and then scroll down to the comments box) and just let me know what you do.
After a week or two I will compile the data and report it in another e-Newsletter post.
Pass this on to others you know and let’s see how many people we can get to comment.
- – - -
How do you use your root cause analysis data:
1) We don’t have a way to collect our data across the site/company so we don’t use it.
2) We collect the data but don’t have a way to present it graphically.
3) We collect the data and put it in Excel and produce pie charts.
4) We collect the data and put it in Excel and produce Pareto Charts and X mR Charts.
5) We collect the data and put it in Excel and produce other types of charts (please list them).
6) We use TapRooT® Software but I haven’t thought about how to use our data.
7) We use TapRoot® Software and use the charting function in it to analyze our data.
8) We use other software and use it to trend our data using charts (please list software and chart types)
9) Other (tell us what you do)
- – - -
One more note:
a) Read Chapter 5 pf the TapRooT® Book.
b) Attend the 2-Day Advanced Trending Techniques Course on April 7-8 that is being held just before the 2014 Global TapRooT® Summit (just outside Austin, TX).
c) Attend the 2014 Global TapRooT® Summit and see the latest trending features being built into the TapRooT® Software.
We have started a new method of delivering the formerly “paper” Root Cause Network™ Newsletter. In the past you either received it by mail or as a PDF attachment to an e-mail. Now we will be including as one of the items in the TapRooT® Experts & Friends e-Newsletter.
So watch for the special edition of the e-Newsleller that includes a link to the Root Cause Network™ Newsletter every two months. We’ll include a list of the topics in the Root Cause Network™ Newsletter as part of the President’s Note (the first topic in the TapRooT® Experts & Friends e-Newsletter).
The topics in the January Root Cause Network™ Newsletter are:
- What Do You Need to Perfect Your 2014 Improvement Program? (Page 1)
- What Is Your Commitment to Safety? (Page 2)
- Benchmarking Improvement Programs (Page 2)
- Generate Improvement Team Spirit (Page 2)
- Dilbert Cartoon (Page 2)
- 2014 Global TapRooT® Summit Info (Page 3)
- Why Trend? (Page 3)
- Special Pre-Summit Courses (Page 3)
- Why Are Accident Causes the Same Around the World? (Page 4)
- International Networking (Page 4)
- Upcoming International TapRooT® Courses (Page 4)
- Pictures from TapRooT® Courses Around the World (Page 4)
- Upcoming North American TapRooT® Courses (Page 5)
- Pictures from Previous Global TapRooT® Summits (page 5)
Wow! That’s a lot of information. I would especially recommend the first article -
What Do You Need to Perfect Your 2014 Improvement Program?
But there are lot’s of other items that deserve a few minutes of your time.
If you didn’t receive your newsletter, you can download it by clicking on the link below or by going to THIS LINK.
The following is the text of a speech delivered in 1982 by Admiral Hyman G. Rickover – the father of the Nuclear Navy – at Columbia University. Rickover’s accomplishments as the head of the Nuclear Navy are legendary. From developing the first power producing submarine based nuclear reactor from scratch to operations in just three years to creating a program to guarantee process safety (nuclear safety) for over 60 years (zero nuclear accidents).
I am reprinting this speech here because I believe that many do not understand the management concepts needed to guarantee process safety. We teach these concepts in our “Reducing Serious Injuries and Fatalities Using TapRooT®” pre-Summit course. Since many won’t be able to attend this training, I wanted to give all an opportunity to learn these valuable lessons by posting this speech.
- – -
Human experience shows that people, not organizations or management systems, get things done. For this reason, subordinates must be given authority and responsibility early in their careers. In this way they develop quickly and can help the manager do his work. The manager, of course, remains ultimately responsible and must accept the blame if subordinates make mistakes.
As subordinates develop, work should be constantly added so that no one can finish his job. This serves as a prod and a challenge. It brings out their capabilities and frees the manager to assume added responsibilities. As members of the organization become capable of assuming new and more difficult duties, they develop pride in doing the job well. This attitude soon permeates the entire organization.
One must permit his people the freedom to seek added work and greater responsibility. In my organization, there are no formal job descriptions or organizational charts. Responsibilities are defined in a general way, so that people are not circumscribed. All are permitted to do as they think best and to go to anyone and anywhere for help. Each person then is limited only by his own ability.
Complex jobs cannot be accomplished effectively with transients. Therefore, a manager must make the work challenging and rewarding so that his people will remain with the organization for many years. This allows it to benefit fully from their knowledge, experience, and corporate memory.
The Defense Department does not recognize the need for continuity in important jobs. It rotates officer every few years both at headquarters and in the field. The same applies to their civilian superiors.
This system virtually ensures inexperience and nonaccountability. By the time an officer has begun to learn a job, it is time for him to rotate. Under this system, incumbents can blame their problems on predecessors. They are assigned to another job before the results of their work become evident. Subordinates cannot be expected to remain committed to a job and perform effectively when they are continuously adapting to a new job or to a new boss.
When doing a job—any job—one must feel that he owns it, and act as though he will remain in the job forever. He must look after his work just as conscientiously, as though it were his own business and his own money. If he feels he is only a temporary custodian, or that the job is just a stepping stone to a higher position, his actions will not take into account the long-term interests of the organization. His lack of commitment to the present job will be perceived by those who work for him, and they, likewise, will tend not to care. Too many spend their entire working lives looking for their next job. When one feels he owns his present job and acts that way, he need have no concern about his next job.
In accepting responsibility for a job, a person must get directly involved. Every manager has a personal responsibility not only to find problems but to correct them. This responsibility comes before all other obligations, before personal ambition or comfort.
A major flaw in our system of government, and even in industry, is the latitude allowed to do less than is necessary. Too often officials are willing to accept and adapt to situations they know to be wrong. The tendency is to downplay problems instead of actively trying to correct them. Recognizing this, many subordinates give up, contain their views within themselves, and wait for others to take action. When this happens, the manager is deprived of the experience and ideas of subordinates who generally are more knowledgeable than he in their particular areas.
A manager must instill in his people an attitude of personal responsibility for seeing a job properly accomplished. Unfortunately, this seems to be declining, particularly in large organizations where responsibility is broadly distributed. To complaints of a job poorly done, one often hears the excuse, “I am not responsible.” I believe that is literally correct. The man who takes such a stand in fact is not responsible; he is irresponsible. While he may not be legally liable, or the work may not have been specifically assigned to him, no one involved in a job can divest himself of responsibility for its successful completion.
Unless the individual truly responsible can be identified when something goes wrong, no one has really been responsible. With the advent of modern management theories it is becoming common for organizations to deal with problems in a collective manner, by dividing programs into subprograms, with no one left responsible for the entire effort. There is also the tendency to establish more and more levels of management, on the theory that this gives better control. These are but different forms of shared responsibility, which easily lead to no one being responsible—a problems that often inheres in large corporations as well as in the Defense Department.
When I came to Washington before World War II to head the electrical section of the Bureau of Ships, I found that one man was in charge of design, another of production, a third handled maintenance, while a fourth dealt with fiscal matters. The entire bureau operated that way. It didn’t make sense to me. Design problems showed up in production, production errors showed up in maintenance, and financial matters reached into all areas. I changed the system. I made one man responsible for his entire area of equipment—for design, production, maintenance, and contracting. If anything went wrong, I knew exactly at whom to point. I run my present organization on the same principle.
A good manager must have unshakeable determination and tenacity. Deciding what needs to be done is easy, getting it done is more difficult. Good ideas are not adopted automatically. They must be driven into practice with courageous impatience. Once implemented they can be easily overturned or subverted through apathy or lack of follow-up, so a continuous effort is required. Too often, important problems are recognized but no one is willing to sustain the effort needed to solve them.
Nothing worthwhile can be accomplished without determination. In the early days of nuclear power, for example, getting approval to build the first nuclear submarine—the Nautilus—was almost as difficult as designing and building it. Many in the Navy opposed building a nuclear submarine.
In the same way, the Navy once viewed nuclear-powered aircraft carriers and cruisers as too expensive, despite their obvious advantages of unlimited cruising range and ability to remain at sea without vulnerable support ships. Yet today our nuclear submarine fleet is widely recognized as our nation’s most effective deterrent to nuclear war. Our nuclear-powered aircraft carriers and cruisers have proven their worth by defending our interests all over the world—even in remote trouble spots such as the Indian Ocean, where the capability of oil-fired ships would be severely limited by their dependence on fuel supplies.
The man in charge must concern himself with details. If he does not consider them important, neither will his subordinates. Yet “the devil is in the details.” It is hard and monotonous to pay attention to seemingly minor matters. In my work, I probably spend about ninety-nine percent of my time on what others may call petty details. Most managers would rather focus on lofty policy matters. But when the details are ignored, the project fails. No infusion of policy or lofty ideals can then correct the situation.
To maintain proper control one must have simple and direct means to find out what is going on. There are many ways of doing this; all involve constant drudgery. For this reason those in charge often create “management information systems” designed to extract from the operation the details a busy executive needs to know. Often the process is carried too far. The top official then loses touch with his people and with the work that is actually going on.
Attention to detail does not require a manager to do everything himself. No one can work more than twenty-four hours each day. Therefore to multiply his efforts, he must create an environment where his subordinates can work to their maximum ability. Some management experts advocate strict limits to the number of people reporting to a common superior—generally five to seven. But if one has capable people who require but a few moments of his time during the day, there is no reason to set such arbitrary constraints. Some forty key people report frequently and directly to me. This enables me to keep up with what is going on and makes it possible for them to get fast action. The latter aspect is particularly important. Capable people will not work for long where they cannot get prompt decisions and actions from their superior.
I require frequent reports, both oral and written, from many key people in the nuclear program. These include the commanding officers of our nuclear ships, those in charge of our schools and laboratories, and representatives at manufacturers’ plants and commercial shipyards. I insist they report the problems they have found directly to me—and in plain English. This provides them unlimited flexibility in subject matter—something that often is not accommodated in highly structured management systems—and a way to communicate their problems and recommendations to me without having them filtered through others. The Defense Department, with its excessive layers of management, suffers because those at the top who make decisions are generally isolated from their subordinates, who have the first-hand knowledge.
To do a job effectively, one must set priorities. Too many people let their “in” basket set the priorities. On any given day, unimportant but interesting trivia pass through an office; one must not permit these to monopolize his time. The human tendency is to while away time with unimportant matters that do not require mental effort or energy. Since they can be easily resolved, they give a false sense of accomplishment. The manager must exert self-discipline to ensure that his energy is focused where it is truly needed.
All work should be checked through an independent and impartial review. In engineering and manufacturing, industry spends large sums on quality control. But the concept of impartial reviews and oversight is important in other areas also. Even the most dedicated individual makes mistakes—and many workers are less than dedicated. I have seen much poor work and sheer nonsense generated in government and in industry because it was not checked properly.
One must create the ability in his staff to generate clear, forceful arguments for opposing viewpoints as well as for their own. Open discussions and disagreements must be encouraged, so that all sides of an issue will be fully explored. Further, important issues should be presented in writing. Nothing so sharpens the thought process as writing down one’s arguments. Weaknesses overlooked in oral discussion become painfully obvious on the written page.
When important decisions are not documented, one becomes dependent on individual memory, which is quickly lost as people leave or move to other jobs. In my work, it is important to be able to go back a number of years to determine the facts that were considered in arriving at a decision. This makes it easier to resolve new problems by putting them into proper perspective. It also minimizes the risk of repeating past mistakes. Moreover if important communications and actions are not documented clearly, one can never be sure they were understood or even executed.
It is a human inclination to hope things will work out, despite evidence or doubt to the contrary. A successful manager must resist this temptation. This is particularly hard if one has invested much time and energy on a project and thus has come to feel possessive about it. Although it is not easy to admit what a person once thought correct now appears to be wrong, one must discipline himself to face the facts objectively and make the necessary changes—regardless of the consequences to himself. The man in charge must personally set the example in this respect. He must be able, in effect, to “kill his own child” if necessary and must require his subordinates to do likewise. I have had to go to Congress and, because of technical problems, recommended terminating a project that had been funded largely on my say-so. It is not a pleasant task, but one must be brutally objective in his work.
No management system can substitute for hard work. A manager who does not work hard or devote extra effort cannot expect his people to do so. He must set the example. The manager may not be the smartest or the most knowledgeable person, but if he dedicates himself to the job and devotes the required effort, his people will follow his lead.
The ideas I have mentioned are not new—previous generations recognized the value of hard work, attention to detail, personal responsibility, and determination. And these, rather than the highly-touted modern management techniques, are still the most important in doing a job. Together they embody a common-sense approach to management, one that cannot be taught by professors of management in a classroom.
I am not against business education. A knowledge of accounting, finance, business law, and the like can be of value in a business environment. What I do believe is harmful is the impression often created by those who teach management that one will be able to manage any job by applying certain management techniques together with some simple academic rules of how to manage people and situations.
Why Are the Major, Steady Declines in Minor and Recordable Injuries Not Seen to the Same Extent in Major Accident (Fatality) Statistics?Posted: December 26th, 2013 in Courses, Human Performance, Performance Improvement
Why are the major, steady declines in minor and recordable injuries not seen to the same extent in major accident (fatality) statistics? Mark Paradies has new insight into the phenomenon and has used it to develop systematic methods to stop major accidents by using TapRooT® both reactively and proactively.
Register for Reducing Serious Injuries & Fatalities Using TapRooT®, a 2-Day Pre-Summit Course scheduled for April 7-8, 2014 in Horseshoe Bay, Texas.
The course highlights three major sources of major accidents:
* industrial hazards
* process safety and
* driving safety.
Learn new ideas to revolutionize your fatality/major accident prevention programs and start you down the road to eliminating major accidents.
Learn more about the Summit: http://www.taproot.com/taproot-summit
Register for this 2-day course and the Summit and save $200!
According to the U.S. Department of Labor, slips, trips and falls make up the majority of general industry accidents. Here are some eye-opening statistics:
- 95 million workdays per year are lost due to slip-and-fall injuries
- 9 million people go to the hospital each year due to slips, trips, and falls.
- Slips, trips, and falls are the number one cause of workers’ compensation claims costing, on average, $20,000 per claim.
- The average time off due to a fall accident is 38 days.
- Occupations with the most slips, trips, and falls are food servive workers, nurses, janitors, and police officers.
- Slips, trips, and falls account for 65% of all work days lost due to injury.
(Source of statistics: EHS Today)
Isn’t it time you did something about slips, trips, and falls at your company? Start planning now to attend the 2014 pre-Summit courses titled “Preventing Slips, Trips, and Falls” (April 7-8, 2014, Horseshoe Bay Texas).
Rob Shaw, expert in preventing slips, trips, and falls from the UK Health & Safety Laboratory, is coming to the US to share the results of his research. This includes practical exercises to reduce the likelihood of slips, trips, and falls at your facility.
For more information, CLICK HERE.
Also, sign up for the 2014 Global TapRooT® Summit. You can learn best practices to improve safety from industry leaders and experts from around the world.
Learn more about the Summit or
Learn more about this course.
The UK Rail Accident Investigation Branch has released their annual report for 2012. CLICK HERE to download the report.
Carolyn Griffiths, the Chief Inspector at the RAIB, starts the report with an interesting observation … that they see some accidents types happen over an over again from one year to the next. She says that this is evidence that the industry needs to do more.
That brings up two important questions …
1) Are you reviewing your accident history on a periodic basis and have you looked for recurring events?
2) If you have noticed recurring events, why are they happening? Why haven’t you be successful in preventing recurrence?
Some serious thought is needed to learn from our past experience and to make sure that we don’t relive history.
We offer advanced trending courses that can help you really understand performance at your facility.
See information about the course here:
Trending is NOT too hard. Watch what these kids are doing…
© Copyright 2013 By System Improvements Inc. Used by Permission.
WHAT IS YOUR PURPOSE?
Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.
For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.
Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.
The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.
This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…
WAITING FOR BIG ACCIDENTS
Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?
I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:
Near-Misses Not Reported
If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.
Hazards Not Recognized
Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).
Shortcuts Become a Way of Life (standards not enforced)
This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.
Process Safety Not Understood
We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.
Ineffective Root Cause Analysis
If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.
Inadequate Corrective Actions
I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?
Corrective Actions Not Implemented
Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.
Trends Not Identified
If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.
INVESTIGATING PAPER CUTS
Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.
Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.
WHAT SHOULD YOU DO?
You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.
“An ounce of prevention is worth a pound of cure.”
If you can’t see yourself ending up in jail because of an accident, how about your attorney’s office?
What’s the point of the headline?
You have a choice. You can either be proactive and prevent accidents or reactive and fight fires after the accidents occur.
What is better … hiring good lawyers to keep you out of jail after a fatal accident or spending time and effort being proactive to prevent the accident from happening?
In both cases, TapRooT® is a great tool for finding and fixing the root causes of problems. But we believe being proactive is much better than being reactive.
Would you like to be proactive in preventing fatalities? Then attend the Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT®.
Whatever you do, DON’T sit by idly waiting for a major accident to occur. Develop you plan to improve performance and prevent fatalities and serious injuries from happening.
Do it today or you may have plenty of time to contemplate your plan while sitting in a jail cell!
New Report: Hospital Errors are the Third Leading Cause of Death in the US and Improvement is Too SlowPosted: October 31st, 2013 in Medical/Healthcare, Performance Improvement
The Leapfrog Group issued a press release about hospital safety scores that once again showed that errors in hospitals are deadly and that improvement of patient safety is occurring too slowly. See the press release at:
Here is more discussion about the most recent rating results:
And here is a site where you can look up the ratings of the hospitals near you:
What can you do to start improving performance at your hospital? Advanced root cause analysis – TapRooT® – can tell you what needs to be fixed.
Learn how TapRooT® can help your hospital improve patient safety by attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Here’s our upcoming worldwide course schedule:
Just click on your continent to see courses closer to you.
And if you are already TapRooT® Trained, attend the Improving Healthcare Quality and Patient Safety Track at the 2014 Global TapRooT® Summit near Austin, Texas. See the track topics by clicking on the fourth button in the left column at:
You will learn best practices from other hospitals and from other industries from around the world.
Found two calculators for the cost of accidents on MSHA’s web site.
The first estimates the annual accident costs at your site when you plug in your annual number of fatalities, your annual number of lost work day cases, and your annual number of reportable cases without a lost workday.
The second calculator estimates the impact of accidents on profits/sales at your company.
Both bof these calculators are generic (not just for mining injuries) based on National Safety Council data.
See both calculators at:
His article in Metals Engineering Quarterly starts with …
“Progress — like freedom — is desired by nearly all men, but not all understand that both come at a cost. Whenever society advances — be it in culture and education or science and technology — there is a rise in the requirements man must meet to function successfully. The price of progress is acceptance of these more exacting standards of performance and relinquishment of familiar habits and conventions rendered obsolete because they no longer meet the new standards.”
Read and consider the entire article here …
If you answered a hornet’s nest, you are correct!
It’s the first one I’ve ever seen in person in the wild (with real, live hornets buzzing in and out).
What does this have to do with root cause analysis?
Practice the skills you learn in a TapRooT® class by analyzing everyday situations. In this example, let’s look at Energy – Safeguard – Target.
What is the ENERGY?
I guess I would call it a biological source of Energy – HORNETS!
What is the TARGET?
Anything that disturbs the nest. It could have been me if I moved any closer.
What are the SAFEGUARDS that protected me from the hornets?
In this case, the only safeguard was my own awareness when walking through the woods.
That’s a pretty weak human performance safeguard. But this time it worked!
Should I have removed the hazard? No way! That’s much more risk that just leaving the area and remembering where the nest is.
How many “awareness” safeguards do you depend on at work? Is that really good enough? Should you be removing the hazards?
That’s your root cause analysis tip to think about for today!
Want to learn more about TapRooT®, advanced root cause analysis, and Energy – Safeguard – Target Analysis (we call it Safeguard Analysis)? Then attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the upcoming worldwide public course schedule at:
I remember this song from when I was a kid. Watch Johnny Cash sing it here:
Here’s the lyrics:
They gave him his orders down at Monroe, Virginia,
Saying, “Steve, you’re way behind time;
This is not 38, but it’s Old 97,
You must set her into Spencer on time.”
He turned around, saying to his black, greasy fireman,
“Just heave in a little more coal,
And when we reach that White Oak Mountain,
You just watch Old 97 roll.”
It’s a mighty rough road from Lynchburg to Danville,
And Lima’s on a three-mile grade;
It was on that grade that he lost his air brakes,
You can see what a jump he made.
He was going down grade, doing ninety miles an hour,
When his whistle began to scream;
They found him in the wreck, with his hand on the throttle.
He was scalded to death by the steam.
A message arrived at Washington Station,
And this is what it read:
Those two brave men who pulled Old 97
Are lying in Danville, dead.”
Oh, ladies, you must take warning,
From this time on and learn:
Never speak harsh words to your true loving husband,
He may leave you and never return.
Here’s another version that might be easier to hear…
What’s the lesson learned from this accident/song?
The original lesson was …
So now all you ladies … you’d better take a warning
From this time on and learn
Dont you speak hard words to your true lovin’ husband
He may leave you and never return – poor boy!
But our perspective on safety has changed. Now everyone has the right to return home in one piece.
Accident should be prevented. Especially fatalities.
How can you prevent fatalities? If you would like to learn the latest strategies, attend the 2014 pre-Summit Course:
Don’t miss this chance to learn to stop the train wrecks before they happen!
Here’s another version of the song from The Beverly Hillbillies Show!
No sad lesson learned with this version … Let’s make sure there are no sad lessons learned at your facility!
When I started reading this article by Karl Stephan, I thought … “Oh no. Here we go again.” What made me think that? This statement:
“Home to a large number of refining and petrochemical plants and other high-tech industries, Texas has had more than its share of explosions, fires, leaks of toxic and polluting chemicals, and other chemical-related accidents.”
After all, I thought, how could he know that Texas had more than their fair share of chemical accidents? Fair share by what standards? Amounts of chemicals produced? Employment? After all, should accidents be allotted equally to all states no matter what there industrial mix is?
But I my first impression was wrong. The article turned into a discussion of a real problem. You can’t find accurate statistics about chemical accidents. Even worse, you can’t get agreement on what chemical incidents should be reported and who they should be reported to.
The article doesn’t propose any wonderful solution, but it is worth reading. So see:
Before you can analyze root causes, you need to decide what you are looking for. The first definition of a “root cause” used by TapRooT® was:
“The most basic cause (or causes) that can reasonably be identified
that management has control to fix and, when fixed,
will prevent (or significantly reduce the likelihood of) the problem’s recurrence.”
But in 2008, we published a new definition for a root cause:
“A Root Cause is the absence of a best practice or the failure to apply knowledge
that would have prevented the problem.“
Therefore, root cause analysis is:
“The process of looking for the problems that can be fixed
when best practices and knowledge are applied.”
That may seem like a simple definition, but in finding root causes, the devil is in the details.
In the more than 30 years we have spent developing TapRooT® and improving it until is is an international best practice for root cause analysis, we have found several steps to finding root causes that just can’t be overlooked.
First, you have to understand the sequence of events that lead to an accident or incident BEFORE you can understand why it happened. This understanding comes from careful investigation and collection of facts and organizing those facts into a timeline.
In TapRooT® Courses, we teach investigators to start each investigation by drawing a SnapCharT® – a graphic “picture” of what happened and the facts around each step in the sequence of events.
Second, once the sequence of events and facts surrounding them are understood, investigators are taught to organize the events and facts and identify Causal Factors that, if eliminated, would have prevent the incident or made it less severe. Causal Factors are NOT root causes. Instead, the are the problems that are caused by the root causes. They are usually failed safeguards that were suppose to prevent the accident. These failed safeguards are often related to human errors and equipment failures that need to be prevented in the future to keep the accident from recurring.
Once the Causal Factors have been identified, the investigator is taught to look for each Causal Factor’s root causes.
That’s right. We aren’t looking for the root causes of the accident. Instead, we are looking for the root causes of the Causal Factors that came together on that particular day in that particular sequence to cause the accident. The root causes have often been around for years waiting for just the right sequence of events with the right Causal Factors to cause the accident.
In TapRooT®, we teach a technique called the Root Cause Tree® to help an investigator find the root causes of the Causal Factor. In most other root cause tools, the investigator is limited by their knowledge when analyzing root causes. In other words, that can’t find root causes that they aren’t aware of.
The Root Cause Tree® provides guidance to investigators to get them to consider potential causes beyond their preexisting knowledge by using a set of question and definitions to expand the potential causes that an investigator considers. This set of questions is an eye opener to both new investigators and experienced professionals because of the depth and breadth of the root causes that they are encouraged to consider.
In addition, once investigators get practiced using TapRooT®, they find they do a much better job collecting evidence earlier in an investigation because their eyes have been opened to new lines of inquiry that they previously would not have considered.
Once the specific root causes of the Causal Factors of an accident have been found, TapRooT® Courses teach investigators to look for generic causes.
Generic cause analysis takes the investigator from a root cause to the systemic reasons that the root cause was allowed to exist. For example, if a problem was caused by a valve not being labeled, generic cause analysis would check to see if other valves were also not labeled and, if they weren’t, why labels weren’t being applied (or were being lost) throughout the facility.
Once the root causes and generic causes are identified, the investigators are taught to use two tools – Corrective Action Helper® and SMARTER – to develop effective corrective actions that address the root and generic causes.
Finally in TapRooT® Courses, investigators are taught to present their finding to management so that management can understand what happened and the actions they need to promote to prevent recurrence of the accident.
That’s it! Using TapRooT®, root cause analysis is a systematic, repeatable, auditable process that is focused on finding and fixing the real root causes of problems so that future accidents and incidents can be prevented.
Want more information about TapRooT®? See:
For the various types of TapRooT® Root Cause Analysis Courses, see:
And if you are interested in TapRooT® Training, see our public TapRooT® Root Cause Analysis Courses that we hold around the world at:
Or to arrange a TapRooT® Root Cause Analysis Course at you site, CLICK HERE.
by Mark Paradies
Someone recently asked me:
“How is TapRooT® different from other root cause analysis tools?“
While answering the question, I concluded that it was the wrong question. The question should have been:
“Why is it that so many industry leaders have chosen TapRooT®
to be their standard for finding and fixing the root causes of problems?“
It’s not what makes TapRooT® different … It’s what makes TapTooT® clearly superior that should be the focus of the question and my answer.
Some people just don’t get this line of questioning. They say things like:
“Every techniques has its advantages and disadvantages.“
They just don’t understand that people can’t be trained in every technique.
Companies can’t afford to train everyone to be a guru problem solver.
Companies need a “best answer.” A root cause system that has been intelligently designed to meet the needs of the people in the field. People doing real investigations. A system they can adopt as a standard.
The techniques in this standard system need to be “human factored” – designed with the limitations and capabilities of the users in mind.
When designing TapRooT®, Mark Paradies and Linda Unger not only used the human factors expertise that Mark brought to the development, but also worked with outstanding human factors experts (including Dr. Charles O. Hopkins and Smoke Price).
They human factored the TapRooT® System to make it usable. That makes it superior.
But the development efforts didn’t stop there.
Mark got reviews and comments from safety and reliability experts from a number of industries including aviation (Jerry Lederer, father of aviation safety), nuclear power and nuclear weapons (Larry Minnick, nuclear plant safety expert, and Paul Haas, DOE human factors & safety expert), and the oil/petrochemical business (Heinz Bloch, equipment reliability guru).
Those named are just a sample … not an exhaustive list. There were many more TapRooT® Users who helped in the early TapRooT® development efforts.
This made TapRooT® grow beyond one philosophy – beyond a single industry perspective.
Investigation + Root Cause Analysis
All this knowledge helped us develop not just a root cause analysis system, but something more … an investigation and improvement process that includes built-in human factored root cause analysis and troubleshooting tools.
When people tack root cause analysis on to an already completed investigation, they are missing the power of the techniques to help the investigator collect and evaluate investigative information.
That’s why TapRooT® is not just root cause analysis. TapRooT® is root cause analysis meshed with troubleshooting, an investigation process, and performance improvement processes (both reactive and proactive).
The whole system is made to work together seamlessly.
That’s different and superior!
Don’t Start Off Looking for “Why?”
I don’t want to give away all the secrets that make TapRooT® superior, but I will share a few more that should help people trying to decide if they should attend TapRooT® Training.
First, unlike many root cause analysis tools (think 5-Why’s or any cause-and-effect based system), TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.
That’s a key difference.
One of the big drawbacks of many systems is that people using them jump to conclusions about why something happened before they understand what happened. It’s a natural human tendency. In fact, the more knowledge about a problem someone is, the more likely they are to think they automatically know the answer.
In TapRooT®, an investigator’s first goal is to build a complete SnapCharrT®.
A SnapCharT® visually shows what happened and as much information as can be gathered about the factors that surrounded what happened before one starts looking for root causes.
Users find this initial focus a major advantage because it helps them avoid the “blame trap” and the trap of jumping to conclusions.
Expert System Helps Investigators See Beyond Their Current Knowledge
The next major advantages of TapRooT® is the way TapRooT® looks at root causes and the tool used to guide investigators to the root causes of the problems causal factors.
In TapRooT®, we realized that accidents aren’t quite like falling dominoes. In fact, most accidents have multiple causes that existed prior to the accident and just never came together in the exactly wrong fashion at one point in time to cause the accident. Sometimes people call this coincidence “bad luck.” Engineers and statisticians may think of using Monte Carlo methods to simulate the seemingly randomness of real life.
Because of this, TapRooT® encourages investigators to identify all the causal factors and to find each causal factor’s root causes. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each causal factor that contributed to an accident.
Think about this as multiple opportunities to improve performance by improving multiple defenses to keep accidents from happening.
The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. Nobody has anything close to our tree.
Most of the development effort of the Root Cause Tree® was focussed on helping people in the field find the causes of human performance (including behavioral) problems.
The Root Cause Tree® is unique in the guidance it gives investigators in analyzing human performance issues including an expert system to start the troubleshooting of human errors, the categorization of best practices that is embedded in the tree, and the guidance for each category built into the Root Cause Tree® Dictionary.
Some say that the goal we set out for the Root Cause Tree® is impossible to achieve. We wanted to capture 90 – 98% of the root causes of human error in the categories on the tree. They say that it is impossible to include ALL the causes of human error in a model. Instead, they say that one should start out with an open mind and analyze each problem from scratch.
There are two problems with this argument.
First, the human brain thinks categorically. For example, the language we use to describe an accident is based on words (categories). So even if you try to start with an open mind, your brain is already categorizing.
We have found that the vast majority of investigators have not had specialized training in human factors. Therefore, they don’t know what they should be looking for (they don’t have the categories in their brain). This makes it almost impossible for them to identify the causes of human errors and develop effective corrective actions.
That’s why they revert to the standard answers of blame (counseling and discipline solutions), training, and, when all else fails, writing a procedure. It’s not that these answers are always wrong. It is that these answers are just a small fraction of what needs to be done to improve human performance. And the Root Cause Tree® provides a much more complete answer.
Second, we never said the Root Cause Tree® has all the answers.
The Root Cause Tree® is just the best list we’ve ever seen. We think it is closer to the 98% end of the scale than to the 90% end. And we know it is much more complete than the answers in the models carried in the heads of the people who come to our training. Thousands of users that we train each year tell us that TapRooT®’s Root Cause Tree® expands the universe of problems they can find and solve …. It does not restrict their problem solving efforts.
Having designed TapRooT® and spent over 20 years improving it, I could go on with other major and minor advantages that we’ve worked so hard to incorporate into the TapRooT® System. But I’ll stop here with one more reason that TapRooT® is superior…
We started with a great design but we didn’t stop.
We search for and implement ideas that make TapRooT® ever better, including ideas from international experts and our TapRooT® Advisory Board (60+ people from industry leading companies).
Better training, better software, and better techniques.
Continuous improvement keeps TapRooT® the state-of-the-art in root cause analysis and makes it superior.
TapRooT® as Your Root Cause Analysis Standard
Of course, there are more advantages to using TapRooT® – reasons that industry leaders around the world have standardized on just one method of root cause analysis. But by now you are probably thinking…
“Why haven’t we standardized on TapRooT® yet?”
Seems like a great idea.
Get started by attending one of our public TapRooT® Courses.
See the complete schedule at:
These courses come with a money-back guarantee:
Attend a TapRooT® Course. Go back to work and apply what you have learned. If you don’t find root causes that you previously would have overlooked and if you and your boss don’t agree that you develop better corrective actions that are more effective, just return the course materials and any software supplied and we will refund the entire course fee.
That’s how confident we are that you will feel the difference.
TapRooT® isn’t just different, it’s superior.
Already Using TapRooT®? Get Better!
How do those that already use TapRooT® keep up with the newest TapRooT® improvements to sustain their programs and build on their success?
They attend the TapRooT® Summit.
That’s the best way to learn even more.
For information, see:
and get registered!
Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.
Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.
Often FDA findings are found by an external audit. To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction? Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?
I suggest Enforcement needs improvement is not the only problem. To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators. Here is our upcoming courses link: http://www.taproot.com/store/Courses/
To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit. http://www.taproot.com/content/wp-content/uploads/2012/02/RileyandGorman.pdf
Then check out the quality track in the upcoming 2014 Summit in April. http://www.taproot.com/products-services/summit
With all our knowledge, why do we continue to have deadly process safety accidents?
Process safety accidents are accidents that kill people not by standard industrial safety hazards like falls from height or contact with electrical lines. Rather, process safety accidents happen when a potentially hazardous process fails.
OSHA and the EPA have written regulations to attempt to control these accidents – fires and explosions – in the chemical industry. But process safety accidents happen in more industries than chemical manufacturing plants and refineries. Examples include the Deepwater Horizon oil drilling accident, the fertilizer explosion in West, Texas, (a distribution site), airline crashes, nuclear plant accidents, grain elevator dust explosions, etc. The list goes on and on. You might even include patient safety accidents at hospitals.
Why, when we know how to make these processes work reliably, do accidents continue? I believe management doesn’t understand the keys to running a high reliability operation at a high hazard facility. These lessons go beyond OSHA/EPA regulations and require a commitment and understanding by senior management of the technology being managed and of the processes to ensure safety. And I spoke about these concepts at the 2010, 2012, and 2013 TapRooT® Summits. If you missed these talks, you can see them by CLICKING HERE.
That will get you started. But you should also plan to attend one of our Best Practices for Reducing Serious Injuries and Fatalities Course on October 24-25 in Knoxville, TN. CLICK HERE for more information.
People usually have a reason they attend TapRooT® Training. They are trying to improve an aspect of their business performance. But they don’t usually have any idea of ALL the ways TapRooT® can help their company improve. This list provides ideas for you to think about:
• Better accident/incident investigation to improve safety.
• Improve lean/six sigma programs by applying advanced root cause analysis.
• Find the root causes of equipment failures and improve equipment reliability.
• Proactive analysis of business processes to eliminate human error.
• Proactive analysis of potentially fatal tasks to prevent fatalities and serious injuries.
• Improved root cause analysis of near-miss accidents with potential for fatal injuries.
• Analysis of cost overruns/schedule delays.
• Analysis of customer complaints.
• Improved pre-job safety analysis to prevent injuries.
• Analysis of production outages.
• Analysis of environmental permit violations to improve permit compliance.
• Improve behavior-based safety by analyzing observations that have potential for serious injuries.
• Human resources analysis of disciplinary cases using root cause analysis.
• Improved audits/assessments using root cause analysis for audit planning and corrective action development.
• Pre-startup proactive equipment reliability analysis.
• Provide accurate statistics for analysis of programmatic issues.
• Development of human performance improvement audit checklists.
Anything in the list catch your eye?
If you haven’t already attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, maybe you should.
Also, consider attending our 2014 Global TapRooT® Summit near Austin, Texas, on April 7-11.
What Happens When a Root Cause Analysis Conflicts with Management Expectations … What do you do to manage sensitive investigations?Posted: July 9th, 2013 in Accidents, Current Events, Investigations, Performance Improvement
One of the most difficult root cause analyses is one that deals with safety culture and management systems.
Although I have no first hand knowledge of this case described in the link below, I would guess this is a good example of how a division can grow between managers and analysts when a root cause analysis becomes sensitive. Read this Associate Press article to get some background material:
Once a root cause analyst decides they have to go to the press to “restore the focus on safety,” you know that the analyst thought that the root cause analysis report/presentation didn’t get the attention that the analyst thought was deserved. I would say that this desperate move is both a failure for the analyst and for management – nobody is a winner and everybody loses.
How can a company avoid this difficult situation? I think there are three things needed:
1) A root cause analysis system that is based on facts and guidance in the areas of management systems/culture.
2) Selecting knowledgable analysts that have the ability to work with management and help them see where improvements are needed and constantly upgrading the analyst’s skills.
3) Management that is involved in the root cause analysis process and willing to address findings with actions that make change happen.
One more thing that can help the process succeed is a rewards system for good investigations that thoroughly look for and address management system root causes.
What have you done at your facility to improve root cause analysis and prevent missed expectations on sensitive root cause analyses?
Have you had your investigation facilitators/team leaders attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?
Have people who will investigate culture issues taken the Analyzing and Fixing Safety Culture Issues Course that we offer prior to the TapRooT® Summit?
Has management been trained to participate in root cause analyses and do they understand their role in making root cause analysis successful?
Does your management team understand the difference between managing industrial safety and process safety?
Are you learning best practices on improving root cause analysis and process improvement by having your program manager attend the TapRooT® Summit every year?
Things to think about (and a small price to pay) to keep your career on track and your company out of the papers.
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