Category: Performance Improvement
I just went through the attendance list for the 2016 Global TapRooT® Summit and I was impressed. What a great bunch of people we are having come together in San Antonio!
For me, as President of System Improvements and one of the creators of the TapRooT® Root Cause Analysis System, the Summit always seems like old home week or a high school reunion. I get to see some of our clients that have been working hard to save lives, improve quality, and keep their companies from getting a black eye.
We’ve been doing these Summits since 1994 and you might not believe it but, I’ve been learning new and valuable stuff at the Summit every year.
So for all of you coming to the 2016 Global Summit,
I CAN’T WAIT TO SAY “HOWDY!”
And get caught up on what you have been doing to make the world a better place.
And for those who haven’t signed up yet,
What? You don’t know why you should attend? You need the knowledge shared at the Summit to …
SAVE YOUR COMPANY $$$
Those are business critical topics that you need to make your company best in class.
See the Summit brochure at:
See the Summit agenda at:
If you need more convincing, let me plead with you to attend. Watch this video…
Can command and control improve safety?
According to this ABC article, Chinese government has “ordered” improvements in safety. Yet 11 people died in an accident at an Aluminum Corp. of China aluminum plant when equipment they were dismantling fell on them. The article also mentions the chemical explosion that killed 173 people in the port city of Tianjin last year.
What are you doing to improve safety?
Can you or your management “order” improvements?
Perhaps you need to learn root cause analysis and best practices and skills to make your safety program world class?
If you want next year to be better than this year, sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
Pick the advanced course that will help you learn the skills you need to to improve your company’s performance.
Then pick the best practice sharing sessions at the Summit that will help you meet the biggest challenges that face your company.
Learn from your peers from around the world (see the LIST here).
Learn from people in your industry and other industries (see the LIST here).
And don’t forget our Summit GUARANTEE:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
Have you ever had an accident and someone in management says …
“That looks like a bad trend to me.“
And you didn’t think it was but you couldn’t prove him wrong?
Have you ever had a regulator tell you that you have problems that look like an adverse trend and you didn’t know how to respond?
Have you ever wondered if a slight improvement in safety statistics is really significant?
Have you ever wondered how long it will take without a significant accident until you can say that performance really has improved?
Have you ever presented trend data and hoped that nobody asked any real questions because you were just making stuff up?
IF YOU DON’T LIKE YOUR ANSWERS TO ANY OF THESE QUESTIONS, you need to attend the TapRooT® Advanced Trending Techniques Pre-Summit Course in San Antonio, TX, on August 1-2.
We only offer this course once a year and anyone interested in learning how to trend safety statistics should attend.
Electrical energy helps us in many ways, but when it is misused and an arc flash occurs … perhaps this video will help people get the message that arc flash precautions are important!
WARNING – GRAPHIC CONTENT AT VARIOUS POINTS – DON’T WATCH IF YOU WILL BE UPSET
Want to learn more about arc flash safety? We have a session about it at the 2016 Global TapRooT® Summit. The session titled “Arc Flash Prevention” is from 1:40-2:50 on Thursday in the Safety Best Practices Track.
Scott King and Terry Butler will present Employee and contractor protection utilizing general electrical principles as referenced by OSHA and NFPA 70E 2015 guidelines and qualified low voltage safety training.
Learning Objectives for this session include:
- Provide an overview of the importance of Arc Flash Safety
- Understanding Electrical Hazards
- Safe Work Practices
- Incident Energy Exposure Levels
- Risk Assessment Analysis
- Personal Protective Equipment (PPE)
- Safety Training
See the complete 2106 Global TapRooT® Summit schedule at:
And register for the Summit at:
Here is a video with lessons learned about a fatal accident involving equipment (a scissor lift).
But there is an additional lesson that we can learn.
Every worksite should have a supervisor perform a quick Safeguard Analysis before people start work.
In this case, power lines were an obvious hazard (high voltage). And getting equipment with booms or lifts near them would cause the natural Safeguard (distance) to fail. If this Safeguard Analysis had been performed proactively, the worker could have been warned OR the actions (visually warnings and signage) could have been implemented to prevent the fatality.
Don’t wait for a fatality. Use TapRooT® to proactively prevent fatalities.
Would you like to learn to use TapRooT® to look for problems before accident, quality problems, and other failures happen? Then you should attend the upcoming TapRooT® for Audits Course on August 1-2 in San Antonio, Texas (just before the 2016 Global TapRooT® Summit on August 3-5). Register here:
The Wall Street Journal announced that BP incurred $56 Billion in expenses from the Deepwater Horizon explosion and spill. And the end is still not in sight.
BP’s CFO said “It’s impossible to come up with an estimate [of future costs].”
Of course, those costs don’t include the lives lost and the negative PR that the company has received.
How much is a best in class process safety program worth? As BP’s CFO says …
It’s impossible to come up with an estimate.
If you would like to learn best practices to improve your safety performance and make your programs “best in class,” the at ten the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
What? You say YOUR COMPANY CAN’T AFFORT IT? Can it afford $56 Billion? The investment in your safety program is a pittance compared with the costs of a major accident. Your company should put spending on safety improvement BEFORE other investments … especially in difficult times.
If you are a senior manager, don’t wait for your safety folks to ask to attend the Summit. Send them an e-mail. Tell them you are putting a team together to attend the Summit with you to learn best practices to prevent major accidents. Ask them who would be the best people to include on this team. Then get them all registered fot the Summit.
Remember, the Summit is GUARANTEED.
Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.
Wow! A guaranteed ROI. How can we be so sure that you will return to work with valuable ideas to implement? Because we’ve been hosting these Summits for over 20 years and we know the “best of the best” attend the Summit and we know the value of the ideas they share each year. We’ve heard about the improvements that Summit attendees have implemented. Being proactive is the key to avoiding $56 Billion dollar mistakes.
So don’t wait. Get your folks registered today at:
The Nuclear Energy Institute published a white paper titled:
To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated.
How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.
For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.
Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).
We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:
Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations.
What’s in the new book? Here’s the Table of Contents:
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
The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.
If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.
If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.
If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.
One more question that you might have for us ,,,
How does TapRooT® stay one (or more) steps ahead of the industry?
- We work across almost every industry in every continent around the world.
- We spend time thinking about all the problems (opportunities for improvement) that we see.
- We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board.
- We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.
We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.
If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.
“Responsibility is a unique concept,
it can only reside and inhere in a single individual.
You may share it with others, but your portion is not diminished.
You may delegate it, but it is still with you.
You may disclaim it, but you cannot divest yourself of it.
Even if you do not recognize it or admit is presence, you cannot escape it.
If responsibility is rightfully yours, no evasion, or ignorance,
or passing the blame cna shift the burden to someone else.
Unless you can point your finger at the man who is responsible when something goes wrong,
then you never had anyone really responsible.”
A colleague at a recent Rail Safety conference pointed me to this article on how to change people’s behavior on rail lines in London. How do we influence people to:
– put trash in trash bins
– be courteous while playing music
– keep feet off the train seats
They’ve tried signs and warnings. I think we can all agree those have limited effect. There are audible reminders. The escalators in Atlanta Airport talk to you continuously on the way down to the trains.
Here are some other (gentler) ways the London Underground is trying to influence passengers to do what is required.
COMPLETE SERIES – Admiral Rickover: Stopping the Normalization of Deviation with the Normalization of ExcellenceApril 14th, 2016 by Mark Paradies
You may have dropped in on this series of articles somewhere in the middle. Here are links to each article with a quick summary…
Point of this article is that deviation IS NORMAL. Management must do something SPECIAL to make deviation abnormal.
A brief history of how Admiral Rickover created the first high performance organization. The Nuclear navy has a history of over 50 years of operating hundreds of reactors with ZERO process safety (nuclear safety) accidents. He stopped the normalization of deviation with the NORMALIZATION OF EXCELLENCE. Excellence was the only standard that he would tolerate.
This article describes the first of Rickover’s three keys to process safety: TECHNICAL COMPETENCE. The big difference here is this isn’t just competence for operators or supervisors. Rickover required technical competence all the way to the CEO.
The second key to process safety excellence (the normalization of excellence) – RESPONSIBILITY.
Do you think you know what responsibility means? See what Rickover expected from himself, his staff, and everyone responsible for nuclear safety.
FACING THE FACTS is probably the most important of Rickover’s keys to achieving excellence.
Read examples from the Nuclear Navy and think about what your management does when their is a difficult decision to make.
Here is the other 18 elements that Rickover said were essential (as well as the first three keys).
That’s right, the keys are the start but you must do all of these 18 well.
Here is Rickover’s own writing on what makes the Nuclear Navy special. What to this day (over 35 years after Rickover was retired) keeps the reactor safety record spotless.
That’s it. The whole series. I’m thinking about writing about some recent process safety related accidents and showing how management failed to follow Rickover’s guidance and how this lead to poor process safety performance. Would you be interested in reading about bad examples?
There are some companies out there who “get it.” We see it all the time at our courses. Some companies just seem to be able to understand what it takes to not just have an incident investigation program, but actually have an EFFECTIVE program that can demonstrate consistent results. As a comparison, some companies write great policies, say all the right things, and seem to have a drive to make their businesses better, and yet don’t seem to be able to get the results they are looking over. By contrast, great companies are able to translate this drive into results. They have fewer injuries, less downtime, fewer repeat incidents, and happier employees. What is the difference?
We often see three common threads in these successful world-class companies:
1. Their investigation teams are given the resources they need to actually perform excellent investigations. The team members are given time to participate in the process. This doesn’t mean that they have time during the day, and then (after work) it is time to catch up on everything they missed. They are truly given dedicated time (without penalty) to perform quality investigations. They are also given authority to speak to who they need and gather the evidence they need. Finally, they are given management support throughout the process. These items allow the team members to focus on the actual investigation process, instead of fighting hurdles and being distracted by outside interference.
2. The investigation teams are rewarded for their results. This doesn’t mean they are offered monetary rewards. However, it is not considered a “bad deal” to have to perform the investigation. Final reports are reviewed by management and good questions are asked. However, the team does not feel like they are in front of a firing squad each time they present their results. Periodic performance reviews recognize their participation on investigation teams, and good performance (both by the teams and by those implementing corrective actions) are recognized in a variety of ways. Team members should never dread getting a call to perform an investigation. They should be made to feel that this is an opportunity to make their workplace better, and it’s management’s job to foster that attitude.
3. Great companies don’t wait for an incident to come along before they apply root cause analysis techniques. They are proactive, looking for small problems in their businesses. I often hear people tell me, “Luckily, I only have to do a couple investigations each year because we don’t have many incidents.” That just means they aren’t looking hard enough. Any company that thinks that everything is going great is sticking their head in the sand. World-class companies actively seek problems, before they become major incidents. Why wait until someone gets hurt? Go find those small, everyday issues that are just waiting to cause a major problem. Fixing them early is much easier, and this is recognized by the Best of the Best.
Oh, and actually, there is a #4:
4. The Best of the Best use TapRooT®!!!
REGISTER for a course and build an effective program with consistent results!
Normalization of Excellence – The Rickover Legacy – 18 Other Elements of Rickover’s Approach to Process SafetyMarch 31st, 2016 by Mark Paradies
The previous three articles discusses Rickover’s “key elements” to achieving safety in the Navy’s nuclear program. They are:
In addition to these three keys that Rickover testified to Congress about, he had 18 other elements that he said were also indispensable. I won’t describe them in detail, but I will list them here:
- Conservatism of Design
- Robust Systems (design to avoid accidents and emergency system activation)
- Redundancy of Equipment (to avoid shutdowns and emergency actions)
- Inherently Stable Plant
- Full Testing of Plant (prior to operation)
- Detailed Prevent/Predictive Maintenance Schedules Strictly Adhered To
- Detailed Operating Procedures Developed by Operators, Improved with Experience, and Approved by Technical Experts
- Formal Design Documentation and Management of Change
- Strict Control of Vendor Provided Equipment (QA Inspections)
- Formal Reporting of Incidents and Sharing of Operational Experience
- Frequent Detailed Audits/Inspections by Independent, Highly Trained/Experienced Personnel that Report to Top Management
- Independent Safety Review by Government Authorities
- Personal Selection of Leaders (looking for exceptional technical knowledge and good judgment)
- One Year of Specialized Technical Training/Hands-On Experience Prior to 1st Assignment
- Advanced Training for Higher Leadership Positions
- Extensive Continuing Training and Requalification for All Personnel
- Strict Enforcement of Standards & Disqualification for Violations
- Frequent Internal Self-Assessments
Would like to review what Rickover had to say about them? See his testimony here:
Now after the description of the excellence of Rickover’s program, you might think there was nothing to be improved. However, I think the program had three key weaknesses. They are:
- Blame Orientation (Lack of Praise)
- Needed for Advanced Root Cause Analysis
Let me talk about each briefly.
The dark side of a high degree of responsibility was a tendency to blame the individual when something went wrong. Also, success wasn’t celebrated, it was expected. The result was burnout and attitude problems. This led to fairly high turnover rate among the junior leaders and enlisted sailors.
Want to work long hours? Join the Nuclear Navy! Eighteen hour days, seven days a week, were normal when at sea. In port, three section duty (a 24 hour day every third day) was normal. This meant that you NEVER got a full weekend. Many errors were made due to fatigue. I remember a sailor was almost killed performing electrical work because of actions that just didn’t make sense. He had no explanation for his errors (they were multiple) and he knew better because he was the person that trained everyone else. But he had been working over 45 days straight with a minimum of 12 hours per day. Was he fatigued? It never showed up in the incident investigation.
ADVANCED ROOT CAUSE ANALYSIS
Root Cause Analysis in the Nuclear Navy is basic. Assign smart people and they will find good “permanent fixes” to problems. And this works … sometimes. The problem? The Nuke Navy doesn’t train sailors and officers how to investigate human errors. That’s where advanced root cause analysis comes in. TapRooT® has an expert system that helps people find the root causes of human error and produce fixes that stop the problems. Whenever I hire a Navy Nuke to work at System Improvements, they always tell me they already know about root cause analysis because they did that “on the boat.” But when they take one of our courses, they realize that they really had so much to learn.
Read Part 7: Statement of Admiral Rickover in front of the Subcommittee on Energy Research and Production of the Committee on Science and Technology of the US House of Representatives – May 24, 1979
If you would like to learn more about advanced root cause analysis, see our course offerings:
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The modifications have been published in the Federal Register. See:
To see the previous article about the modifications and their impact on root cause analysis, see:
Hurry if you want to submit comments. The register says:
“Comments: Comments and additional material must be received on or before May 13, 2016. Under the Paperwork Reduction Act (PRA), comments on the information collection provisions are best assured of consideration if the Office of Management and Budget (OMB) receives a copy of your comments on or before April 13, 2016.Public Hearing. The EPA will hold a public hearing on this proposed rule on March 29, 2016 in Washington, DC.”
April 13, 2016, isn’t far away!
For comment information, see:
To add your comment, see: