Category: Performance Improvement

Monday Accident & Lessons Learned: The Cost of an Accident – BP Pays Out $56 Billion So Far

May 23rd, 2016 by

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

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.

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:

http://www.taproot.com/taproot-summit/register-for-summit

Root Cause Analysis Tip: Save Time and Effort

May 4th, 2016 by

The Nuclear Energy Institute published a white paper titled:

Reduce Cumulative Impact From the Corrective Action Program

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:

Using the Essential TapRooT® Techniquesto Investigate Low-to-Medium Risk Incidents

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 Just published this year, this book is now the basis for our 2-Day TapRooT® Root Cause Analysis Course and starting on Thursday will be the standard book in our public 2-Day TapRooT® Courses.

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?

 That’s easy.

 

  • 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.

 

 

 

A Quote from Admiral Rickover…

April 28th, 2016 by

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“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.” 

Nudging Human Behavior in the Rail Industry

April 20th, 2016 by

rail

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.

Managing Risk the Matrix Way

April 16th, 2016 by

Our partners in Scotland are sponsoring a charity event. Here’s a video that explains a little about it…

 Mhorven Sherret Promo.mp4

And below is a flier to tell you more…

Alan Smith Flyer copy

For more information, see:

http://www.stillincontrol.co.uk

 

COMPLETE SERIES – Admiral Rickover: Stopping the Normalization of Deviation with the Normalization of Excellence

April 14th, 2016 by

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You may have dropped in on this series of articles somewhere in the middle. Here are links to each article with a quick summary…

1. There is No Such Thing and the Normalization of Deviation

Point of this article is that deviation IS NORMAL. Management must do something SPECIAL to make deviation abnormal.

2. Stop Normalization of Deviation with Normalization of Excellence

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.

3. Normalization of Excellence – The Rickover Legacy – Technical Competency

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.

4. Normalization of Excellence – The Rickover Legacy – Responsibility

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.

5. Normalization of Excellence – The Rickover Legacy – Facing the Facts

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.

6. Normalization of Excellence – The Rickover Legacy – 18 Other Elements of Rickover’s Approach to Process Safety

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.

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

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?

3 Things that Separate the “Best of the Best” from the Rest

April 14th, 2016 by

Are you getting the results you are looking for?

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 Safety

March 31st, 2016 by

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The previous three articles discusses Rickover’s “key elements” to achieving safety in the Navy’s nuclear program. They are:

  1. Technical Competence
  2. Total Responsibility
  3. Facing the Facts

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:

  1. Conservatism of Design
  2. Robust Systems (design to avoid accidents and emergency system activation)
  3. Redundancy of Equipment (to avoid shutdowns and emergency actions)
  4. Inherently Stable Plant
  5. Full Testing of Plant (prior to operation)
  6. Detailed Prevent/Predictive Maintenance Schedules Strictly Adhered To
  7. Detailed Operating Procedures Developed by Operators, Improved with Experience, and Approved by Technical Experts
  8. Formal Design Documentation and Management of Change
  9. Strict Control of Vendor Provided Equipment (QA Inspections)
  10. Formal Reporting of Incidents and Sharing of Operational Experience
  11. Frequent Detailed Audits/Inspections by Independent, Highly Trained/Experienced Personnel that Report to Top Management
  12. Independent Safety Review by Government Authorities
  13. Personal Selection of Leaders (looking for exceptional technical knowledge and good judgment)
  14. One Year of Specialized Technical Training/Hands-On Experience Prior to 1st Assignment
  15. Advanced Training for Higher Leadership Positions
  16. Extensive Continuing Training and Requalification for All Personnel 
  17. Strict Enforcement of Standards & Disqualification for Violations
  18. Frequent Internal Self-Assessments

Would like to review what Rickover had to say about them? See his testimony here:

Rickover Testimony

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:

  1. Blame Orientation (Lack of Praise)
  2. Fatigue
  3. Needed for Advanced Root Cause Analysis

Let me talk about each briefly.

BLAME ORIENTATION

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.

FATIGUE

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. 

If you would like to learn more about advanced root cause analysis, see our course offerings:

COURSES 

And sign up for our weekly newsletter:

NEWSLETTER

The EPA’s Revision to the Risk Management Plan Regulation is Open for Comments

March 30th, 2016 by

The modifications have been published in the Federal Register. See:

https://www.federalregister.gov/articles/2016/03/14/2016-05191/accidental-release-prevention-requirements-risk-management-programs-under-the-clean-air-act

To see the previous article about the modifications and their impact on root cause analysis, see:

http://www.taproot.com/archives/53634

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:

https://www.regulations.gov/#!documentDetail;D=EPA-HQ-OEM-2015-0725-0001

To add your comment, see:

https://www.regulations.gov/#!submitComment;D=EPA-HQ-OEM-2015-0725-0001

Normalization of Excellence – The Rickover Legacy – Facing the Facts

March 24th, 2016 by

In the past two weeks we’ve discussed two of the “essential” (Rickover’s word) elements for process safety excellence …

Technical Competence

Responsibility

This week we will discuss the third, and perhaps most important, essential element – FACING THE FACTS.

What is facing the facts? Here are some excerpts of how Rickover described it:

“… To resist the human inclination to hope that things will work out,
despite evidence or suspicions to the contrary.

If conditions require it, you must face the facts and brutally make needed changes
despite significant costs and schedule delays. … The person in charge must
personally set the example in this area and require his subordinates to do likewise.

Let me give two examples from Rickover’s days of leading the Navy Nuclear Power Program that illustrate what he meant (and how he lived out this essential element).

Many people reading this probably do not remember the Cold War or the Space Race with the USSR. But there was a heated competition with national importance in the area of technology during Cold War. This technology race extended to the development of nuclear power to power ships and submarines.

Rickover in 1947, Rickover proposed to the Chief of Naval Operations that he would develop nuclear power for submarine propulsion. The technical hurdles were impressive. Developing the first nuclear powered ship was probably more difficult than the moon shot that happened two decades later. Remember, there were no computers. Slide rules were used for calculations. New metals had to be created. And new physics and radiation protection had to be created. None the less, Rickover decided that before he built the first nuclear powered submarine, he would build a working prototype of the submarine exactly like the actual submarine that was proposed. It would be built inside a hull and surrounded by a water tank to absorb radiation from the reactor. 

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This first submarine reactor was built near Idaho Falls, Idaho, and went critical for the first time in March of 1953. Just imagine trying to do something like that today. From concept to critical operations in just 6 years!

The prototype was then operated to get experience with the new technology and to train the initial crew of the first submarine, the USS Nautilus. The construction of the ship started in 1952 before the prototype was completed. Therefore, much of the construction of the Nautilus was complete before appreciable experience could be gained with the prototype. Part of the reason for this was that the lessons learned from the construction of the prototype allowed the Nautilus construction to progress much faster than was possible for the prototype.

However, during the operation of the prototype it was found that some of the piping used for the non-reactor part of the steam plant was improper. It was eroding much faster than expected. This could eventually lead to a hazardous release of non-radioative steam into the engineering space – a serious personnel hazard. 

This news was bad enough, but the problem also had an impact on the Nautilus. There was no non-destructive test that could be performed to determine if the right quality piping had been used in the construction of the submarine. Some said, go ahead with construction. We can change out the piping of the Nautilus after the first period underway and still beat the Russians to sea on nuclear power.

Rickover wouldn’t hear of it. He insisted that the right way to do it was to replace the piping even though it meant a significant schedule delay. Accepting the possibility of poor quality steel would be sending the wrong message … the message that taking shortcuts with safety was OK. Therefore, he insisted that all the steam piping be replaced with steel of known quality before the initial criticality of the reactor. He set the standard for facing the facts. (By the way, they still beat the Russians to sea and won the race.)

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The second example is perhaps even more astounding. Since no civilian or Navy power plants existed, there were no standards for how much occupational exposure a nuclear technician could receive. In addition, submarines were made for war and some proposed that any civilian radiation allowance should be relaxed for military men because they were sailors who must take additional risks. (Remember, we were doing above ground nuclear weapons testing in the US and marching troops to ground zero after the blast during this period.)

Rickover’s staff argued that a standard slightly higher than the one being developed for civilian workers would be OK for sailors. This higher standard would save considerable shielding weight and would result in a faster, more capable submarine. Rickover would hear nothing of it. He insisted that the shielding be built so that the projected radiation dose received by any sailor from the reactor during operation be no higher than that experienced by the general public. (Everyone receives a certain amount of exposure from solar radiation, dental and medical X-rays, and background radiation from naturally occurring radionuclides.) That was the design standard he set.

Many years later, it was noticed that Russian submarine crews were given time off after their deployments to relax in Black Sea resorts. Some thought this was just a reward for the highly skilled sailors. However, it was later discovered that this time off was required to allow the sailors time for their bone marrow to regenerate after damage due to high levels of radiation. The Russians had not used extra shielding and hence their sailors got significant radiation doses. Perhaps that why Russian nuclear submarine duty got the nickname of “babyless duty.”

There was no similar problem for US Nuclear Power Program personnel. Rickover made sure that the facts were faced early in the design process and no adverse health effects were experienced by US submarine sailors.

Let’s compare Rickover’s facing the facts to industrial practices. What happens when a refinery experiences problems and faces a shutdown? Does management “face the facts” and accept the downtime to make sure that everything is safe? Or do they try to apply bandages while the process is kept running to avoid losing valuable production? What would be the right answer to “face the facts” and achieve process safety excellence? Have we seen major accidents caused by just this kind of failure to face the facts? You betcha!

That’s it, the first three (and most important) of Rickover’s essential elements for process safety excellence. But that isn’t all. In his testimony to Congress he outlined additional specific elements that completed his reactor safety management system. I’ll outline the remaining elements in next week’s article.

Normalization of Excellence – The Rickover Legacy – Responsibility

March 17th, 2016 by

For the previous article, see:

https://www.taproot.com/archives/53085

The second of the “essential” elements for excellence described by Rickover is RESPONSIBILITY.

You probably think you know what this means. You probably think that this is something your company already emphasizes. But read on and you will discover that it may be a missing element of your process safety program, and one reason that your company is not achieving excellence.

In the Nuclear Navy, Admiral Rickover was totally responsible. He was in charge of the design, construction, operations, and maintenance of all the Navy’s nuclear reactors (prototypes, subs, and ships). This single point of responsibility was unique in the Navy and is unique in the civilian world.

And responsibility for safety was (and is) passed down the chain of command to each Commanding Officer, Engineer, Engineering Watch Officer, and Reactor Operator. If you see something unsafe, you are fully authorized and expected to act.

If a Reactor Operator saw some safety parameter go out of spec, s/he was fully authorized and expected to SCRAM (emergency shut down) the reactor. There was no asking permission or waiting for approval.

If a reactor accident (a meltdown) had occurred, Rickover would take full responsibility. And the rest of the chain of command would likewise take responsibility for their actions.

Do you remember the hearings in front of congress after the Deepwater Horizon accident? Each of the executives from BP, Transocean, and Halliburton pointed fingers at the other executives. None would take responsibility for the accident.

An Associated Press Story said:

Executives of the three companies, all scheduled to testify before the Senate
Energy and Natural Resources Committee, are trying to shift responsibility for the
environmental crisis to each other, according to prepared testimony
.”

The Washington Post had to say about the testimony:

“Three major oil industry executives agreed on one thing in a pair of
Senate hearings Tuesday: Someone else was to blame for the drilling rig accident
that triggered the massive oil spill in the Gulf of Mexico.”

Here is some coverage of the testimony that talks about “divided responsibility” …

Watch what it takes to get Tony Hayward to say he was the ultimately in command of safety at BP.

Without Rickover’s unique concept of total accountability/responsibility, people can sidestep responsibility. Without full accountability/responsibility, decisions to:

  • cut budgets,
  • reduce staffing,
  • defer maintenance,
  • opt for cheaper designs,
  • or shortcut company requirements

are easy to make because no one person is responsible. As Philippe Paquet wrote:

When everyone is responsible, no one is responsible.”

Therefore, as Rickover points out, you must have one person at the top clearly responsible for process safety or no one is responsible and you will NOT be able to achieve excellence.

That’s it for this week’s discussion of excellence. Next week’s topic is perhaps the most important concept in excellence and process safety … “Facing the Facts.”

Grading Your Investigations

March 10th, 2016 by

How do you grade an incident investigation? Here’s an Excel spreadsheet to use…

RateRootCauseAnalysis03082016.xlsx

How do you use the spreadsheet? Here’s a video from last year’s Summit …

Grading Your Investigation from TapRooT® Root Cause Analysis on Vimeo.

Would you like to learn this and hear about someone who has been using it to improve their company’s investigations? Go to the Grading Your Investigations Breakout Session (Wednesday – 1:30-2:30) at the 2016 Global TapRooT® Summit.

Normalization of Excellence – The Rickover Legacy – Technical Competency

March 10th, 2016 by

If you read last week’s article about stopping the normalization of deviation with the normalization of excellence, you are ready to start learning to apply Rickover’s philosophies of excellence to achieve amazing performance.

In his testimony to Congress, he starts out explaining the nuclear program and the success that has been achieved to that point. He then explains that there is no simple formula to achieve this success. Rather, what we now recognize as a management system is a “integrated whole of many factors.” He emphasizes that these factors cannot be used individually, but rather, must all be used together. He says, “Each element depends on all the other elements.”

So before I start explaining the individual elements, heed Rickover’s advice:

“The problems you face cannot be solved by specifying compliance with one or two simple procedures.
Reactor safety requires adherence to a total concept wherein all elements are recognized
as important and each is constantly reinforced.” 

 If you aren’t in the nuclear industry, you can replace the words “reactor safety” with “process safety” or maybe even “patient safety” to apply Rickover’s philosophies to your industry.

The first three elements that Rickover explains are:

  • Technical Competence
  • Responsibility
  • Facing the Facts

This really is the core of Rickover’s management philosophy and I will explain each in detail.

Technical Competancy

Rickover believed that to manage a high risk enterprise (nuclear power plant, refinery, offshore drilling platform, or other high risk ventures) you have to fundamentally understand the technical aspects of the job. This was NOT an overview of how things worked. It was a detailed understanding of the science, chemistry, physics, and engineering behind the processes.

The requirement for technical knowledge didn’t stop with the operations manager or plant manager. The technical knowledge requirement went all the way up to the CEO/President level. The higher on the org chart you were – the better your technical knowledge was suppose to be.

Rickover said:

“At Naval Reactors, I take individuals who are good engineers and make them into managers.
They do not manage by gimmicks but rather by knowledge, logic, common sense, and hard work.” 

All the managers (officers) in the Naval Nuclear Power Program went through a rigorous screening process. First, they were selected from the top portions of good engineering programs from universities across the US. Non-engineer majors were also considered if they had excellent grades in physics, calculus, and chemistry. All people selected then went to Naval Reactors headquarters where they took a technical test to evaluate their technical abilities. Tough engineering, math, chemistry, and physics questions were asked on a non-multiple choice test where the work to achieve the answer had to be shown.

The next day the candidates were put through several technical interviews by high level Department Heads at Naval Reactors.  The candidates were asked to solve tough real-life scenarios and apply their technical skills to real-world problems.

Finally, each candidate had the now famous Admiral Rickover interview. Rickover reviewed the candidates academic performance, test results, and interview performance and then asked some of his famous style of questions to evaluate how the candidate reacted under pressure.

My test and interviews went well enough until my Rickover interview. Before the interview, you sat in a room listening to a continuous lecture on what you should and should not do when in the presence of the Admiral. You were informed that you would be accompanied into the room by a senior officer who would sit directly behind you. That you should not address the Admiral until he spoke to you (he was a busy man who didn’t need to be interrupted). That you should take your seat in the chair in front of his desk and wait for him to address you. That when he asked you questions, you should answer directly and that “No excuse sir!” was not an answer. If he asked you a question he wanted to know the answer … not an excuse. That a direct answer was “Yes Sir! or No Sir!” If he asked you if you were married, “Yes Sir” would be a good answer but that didn’t mean that he wanted to hear about your sex life.

Before too long, my name was called and I departed with my escort for the Admiral’s office. When I entered his office I was shocked. Spartan would be a generous description of the accommodations. Old furniture was probably WWII surplus. Rickover’s desk was piled full of neatly stacked folders full of paper, and he was working on something with his head down.

He was a tiny, wiry looking old man, (He was probably in his late seventies, and I was in my senior year of college so too me he looked ancient).

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There was an old looking wooden chair directly in from of his desk. I sat down and immediately noticed that one of the legs was shorter than the rest. The chair naturally tipped back and forth. You could either lean forward and have the chair sit still forward or lean back and hold the chair back. I leaned back trying to maintain a straight posture.

I watched Rickover as he worked. He was busy reviewing paperwork and occasionally signing something as he moved files from one stack to another. Finally he stopped and took a file from a different stack and started looking at it. I thought, “That’s my file.”

A minute or two later he looked up at me and said.

“Midshipman Paradies, I see here you got a lot of Cs in your studies at the University of Illinois,
can you tell me why you did so poorly?”

My first thought was … “I’m sure glad he didn’t ask me about that D or E.” I certainly didn’t want to mention drinking beer and playing football and basketball, so I responded:

Well Admiral, Electrical Engineering at the University of Illinois is a difficult curriculum and that’s all the better I could do.

I didn’t know that this was one of his standard questions, and he was looking for you to make excuses. I also didn’t know that Rickover had a MS in Electrical Engineering and that he thought it was a tough curriculum.

He said, “OK.”

He closed the file and looked me in the eyes and asked:

“ Midshipman Paradies, are you married?”

That was one of the questions that they warned us to answer directly. I said, “No Sir.”

He asked, “Are you engaged?”  I said, “Yes Sir.”

He continued to look me directly in the eyes (a very penetrating stare) and asked:

 “Has your fiancé every told you that you are good looking?”

That question caught me totally off guard, Here is this shrunken, bent over old admiral asking me about being good looking … where was he going with this?

I answered, “Yes Sir.”

He asked,

 “ What do you think she meant?”

 I was at a total loss. What did she mean? Who knows. I certainly didn’t want to say that I didn’t know. So I said,

Well, I guess Admiral that she liked the way I looked.”

He said, “No Midshipman Paradies, you are wrong.”

I then gave my best answer of the day. I said, “Yes Sir.”

He said,

What she meant was that she wanted to marry you.
When you go back, will you ask your fiancé what she meant and
send me a letter and tell me what she says
?”

I said, “Yes Sir.”

He said, “Get out of my office,” and pointed toward the door.

That was the end of my interview. I had passed. And I did go back and ask my fiancé what she meant and wrote the Admiral and told him what she said.

You might think that writing the letter wan’t important. But it was. The Admirals staff kept track of every letter that he was owed. When I returned for my Engineers Exam, when I checked in with my orders, the woman behind the desk asked, “Do you have any outstanding correspondence with the Admiral?” I said, “No.” She looked in a folder and said, “That’s correct, you sent the letter that you owed the Admiral in 1978.”

My interview was rather straightforward compared to the stories I’ve heard about other Midshipmen. Perhaps the favorite one I heard was from a friend of mine we’ll call Midshipman F.

Midshipman F was a History major. He had taken calculus, chemistry, physics, and other technical subjects and had done quite well. Rickover asked him if he wanted to be in the Naval Nuclear Program, why didn’t he get a technical degree. He responded that to understand the world, history was important.

Rickover then started to tell him that he had wasted his time with history classes. Rickover bet that Midshipman F didn’t know anything about history and ask him questions about history (which were “current events” to Rickover). After listening to Midshipman F answer some history questions, Rickover told him that he was “stupid” and didn’t know anything about history, and to go stand in the closet.

Midshipman F went over to the closet and opened the door, but there was already someone in the closet who looked like a senior officer. He stepped in, shut the door, and they both stood there in the dark and didn’t say a word.

After what Midshipman F said seemed like forever, his escort came over and opened the door and told Midshipman F that the Admiral would like to talk to him again. They went back to arguing over history and Midshipman F was kicked out of the Adsmirals Office twice to go sit in the “penalty box” (another very small room with a chair where you would be sent when the Admiral wanted to make you cool your heels). Midshipman F never gave up his argument about the importance of History and was eventually allowed into the Admiral’s program.

But whenever F would tell the story, he ended it with:

I’ve always wondered whatever happened to the other guy who was in the closet.

When you were accepted into the Nuclear Navy, you had to complete a year of extremely difficult technical training before you reported to your first ship. The competition was tough. In the 100 people in my class, many had Masters Degrees in Engineering. One guy had a “photographic memory.” He could remember everything that was written on the board and everything the instructor said verbatim. Not only could he do that, but he did it while doing the homework from the previous lecture. I had the third lowest GPA of anyone in the class and was immediately assigned to “remedial study.”

We had 7 hours of class a day with an hour off for lunch. I used my lunch time to study and usual put in an additional 5 hours each night and another 12 hours on the weekend. I had to keep study logs with how I applied my time in 5 minute intervals. I did well, graduating in the top 10 students in the class. Others did less well … 10 students failed out in the first 6 months. After 6 months, you were assigned to a nuclear prototype plant (and actual naval reactor that had been built ashore to test the design) and went through advanced classes and qualification to be a engineering officer of the watch (EOOW). For this qualification, you worked shift work with mandatory 12 hour days of watch standing, studying, and “check outs” from qualified personnel. Again, I did well and was the second officer to qualify in my class at the prototype 5 weeks before the end of the six month tour. One individual failed out of our prototype training (failed to qualify in the six month time span).

Why is it important to know about this pre-ship education? Because it gives someone who did not go through the program some idea of the technical knowledge that Rickover expected before anyone was allowed to go to sea and qualify to run one of “his” reactors.

And this was just the start of Technical Competency.

Once at sea there was never ending qualifications and continuing training. Drills. And annual “ORSE Board” inspections with level of knowledge exams and interviews.

An officer had to pass another level of Technical Competency call the Engineer’s Exam. To prepare for this exam, the officer was suppose to study in his “spare time” and learn everything there was to know about the design and technical specifications of the reactor plant and systems on his ship. Any topic from the start of Nuclear Power School to current operating problems to any potential equipment failure to system on his ship were fair game for the 8 hour test (with 30 minutes off for lunch) and three technical interviews. You couldn’t get less than a 3.0 score (of 4.0 total) on any section of the exam and couldn’t get less than a 3.2 of 4.0 total on the test. All the questions were essays or engineering calculations. And you had to write fast to complete the exam. During the inter portion of the exam on the next day, any of the interviewers could flunk you if they didn’t like the answers to their questions. Once again, at the end of the process, you had an interview with the Admiral. If you passed, you were then allowed to be assigned as the Engineering Officer for one of Rickover’s ships. People did fail and their career in the Nuclear Navy was over.

Finally, before you were allowed to become a Commanding Officer on one of Rickover’s ships, you had to qualify for command at sea and then go through “Charm School.” Charm School was an assignment to Rickover’s staff where you studied advanced topics and went through a series of brutal interviews with Rickover and his staff members. It was probably someone going though Charm School who was standing in Rickover’s closet when Midshipman F opened the door. Successfully completing Charm School (in some number of months to a year) got you your ticket to your very own “boat” (submarine) or nuclear powered surface ship as the Commanding Officer. Again, there were people who did not get Rickover’s blessing to command a nuclear powered ship. And despite over a decade of service, there was no appeal. If you didn’t have what it takes … you were out.

Most officers also managed to get an advanced degree somewhere along their career.

That’s Technical Competency.

I’ve worked at Du Pont. As a consultant, I’ve visited many refineries, chemical plants, and oil companies. The only thing that comes close to the technical competency required in the Nuclear Navy is the qualification in the commercial nuclear industry and the training program for astronauts at NASA. However, neither program has the advanced technical training requirements for senior level executives.

I’ll discuss Responsibility and Facing the Facts in the next article in this series.

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

book_graphic_1511

If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Stop Normalization of Deviation with Normalization of Excellence

March 3rd, 2016 by

There is no Normalization of Deviation. Deviation IS NORMAL!

If you don’t think that is true, read this previous article:

There is no such thing as “Normalization of Deviation”

In 1946, Admiral Rickover was one of a small group of naval officers that visited the Manhattan Project in Oak Ridge, Tennessee, to learn about nuclear power and to see if there were ways to apply it in the US Navy. He had the foresight to see that it could be applied as a propulsion for submarines – freeing subs from the risky proposition of having to surface to recharge their batteries. 

Rickover

But even more amazing than his ability to see how nuclear power could be used, to form a team with exceptional technical skills, and to research and develop the complex technologies that made this possible … he saw that the normal ways that the Navy and industrial contractors did things (their management systems) were not robust enough to handle the risk of nuclear technology.

Rickover set out to develop the technology to power a ship with the atom and to develop the management systems that would assure excellence. In PhD research circles these new ways of managing are often called a “high performance organization.”

Rickover’s pursuit of excellence was not without cost. It made him the pariah in naval leadership. Despite his accomplishments, Rickover would have been forced out of the Navy if it had not been for strident support from key members of Congress.

Why was Rickover an outcast? Because he would not compromise over nuclear safety and his management philosophies were directly opposed to the standard techniques used throughout the Navy (and most industrial companies).

What is the proof that his high performance management systems work? Over 60 years of operating hundreds of naval nuclear reactors ashore and at sea without a single process safety accident (reactor meltdown). And his legacy continues even after he left as head of the Nuclear Navy. The culture he established is so strong that it has endured for 30 years!

Compare that record to the civilian nuclear power industry, refinery process safety incidents, or off shore drilling major accidents. You will see that Rickover developed a truly different high performance organization that many with PhD’s still don’t understand. 

In his organization, deviation truly was abnormal.

What are the secrets that Rickover applied to achieve excellence? They aren’t secret. He testified to his methods in front of Congress and his testimony is available at this link:

http://www.taproot.com/content/wp-content/uploads/2010/09/RickoverCongressionalTestimony.pdf

What keeps other industries from adopting the Rickover’s management systems to achieve equally outstanding performance in their industries? The systems Rickover used to achieve excellence are outside the experience of most senior executives and applying the management systems REQUIRES focussed persistence from the highest levels of management.

To STOP the normalization of deviation, the CEO and Presidents of major corporations would have to insist and promote the Normalization of Excellence that is outlined in Rickover’s testimony to Congress.

Sometimes Rickover’s testimony to Congress may not be clear to someone who has not experience life in the Nuclear Navy. Therefore, I will explain (translate from Nuclear navy terminology) what Rickover meant and provide readers with examples from my Nuclear Navy career and from industry.

However, I won’t do it here. You will have to wait until next week for another article.

How Can the Summit Help Your Company and Your Career?

March 2nd, 2016 by
San Antonio, Texas

San Antonio, Texas

Should you attend the Global TapRooT® Summit in San Antonio, Texas, August 1 – 5, 2016?  How can it help your company and your career?

Ask yourself these questions:

1. Does your facility/company need to improve in any of these areas:

  • Asset Optimization
  • Human Factors
  • Investigations
  • Reducing Medical Error
  • Quality
  • Safety
  • TapRooT® Software

2. Are you a Certified TapRooT® Instructor that needs to maintain their certification?

3. Do you want to be more motivated to improve performance?

4. Would you like to get a team of people from your facility excited about performance improvement?

5. Do you need knew ideas to take your improvement program to the next level?

6. Do you need to refresh your TapRooT® knowledge?

7. Would you like to visit the world-famous San Antonio River Walk?

8. Would you like to meet a bunch of new valuable contacts that can help you improve performance at your facility and advance your career?

9. Are you interested in benchmarking your improvement efforts against other industry leaders?

10. Are you interested in best practices from other industries that can be applied to improve performance in your industry?

If you said “yes” to any of these questions, that’s how it will help your company and your career!

To register, click here.

For more information, click here.

For the Summit schedule, click here.

Would Ronald Reagan Endorse the New TapRooT® Book for Low-to-Moderate Incident Investigations?

February 25th, 2016 by

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Ronald Reagan said:

They say the world has become too complex for simple answers. They are wrong.”

That’s why I think Reagan would like the new TapRooT® Book …

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It makes using TapRooT® simple for analyzing simple incidents.

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

Where can you get the new book? CLICK HERE!

 

When is a “Trend” a “Trend”?

February 25th, 2016 by

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Here’s an article that claims that the number of “reactor incidents” on British nuclear subs doubled in one year…

http://sundodgers.com/2016/02/22/reactor-incidents-on-new-nuclear-subs-double-in-one-year/

Is this a trend? As the anti-nuke spokesperson says, it is “…only a matter of time before these incidents result in a serious nuclear accident.”

Or is it as the spokesperson for the Ministry of Defense said:

In line with our high safety standards, we record all incidents regardless of how minor they are, to ensure lessons are learnt. There are no issues with the safety of the submarines and the MoD has safely operated over 80 nuclear reactor cores since 1963.

Do you know how to mathematically determine if a change in performance is a trend?

Unfortunately, the article does not give us the data that we need to make an informed calculation.

The good news is that we know how to make the calculation and use trends to manage performance.

Where can you learn advanced trending and how to apply it to manage your facility?

At the 2-Day TapRooT® Advanced Trending Techniques Course just prior to the 2016 Global TapRooT® Summit.

The course and Summit are being held in SanAntonio, Texas. The course is on August 1-2. The Global Summit is on August 3-5.

You can attend both and save $200 off the combined course/Summit price.

Register at: http://www.taproot.com/taproot-summit/register-for-summit

Are You Being Held Back Because You Think You Know Everything???

February 16th, 2016 by

Those who are humble learn from others.

This saves the humble learner the difficulty of experiencing the pain of learning by trial and error (or in other words, the pain of mistakes).

As Sam Levenson said:

You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.

But have you met folks who are so sure of themselves that they must believe that they know it all?

Just imagine the smartest person in history. Then imagine how little of the total knowledge of the universe that that person actually knew. How can anyone think that they know it all?

I was thinking about this because I run into people that can’t learn from others because when they walk into a room, they think they are the smartest person in the room. They pontificate. They expect everyone to listen to their stories and learn. But they don’t  listen to others and learn.

I hope I’m not talking about you … or your boss. Learning from others is really important.

Where can you learn from others?

One of the best places is the TapRooT® Summit.

Have a look at the Summit Schedule.

 Look at all the topics in all the sessions.

One of my favorite sessions is the TapRooT® Users Share Best Practices session.

As one of the attendees told me last year …

You sit at a table with people from leading companies from around the world.
The people you are talking to are really smart.
And they share their best ideas. You share yours.
And everybody gets even smarter. It is amazing
.”

 Another way to meet and discuss topics at the Global TapRooT® Summit is to participate in the opening session. 

Most conferences start off slow. NOT the Global TapRooT® Summit.

We start off with a description of the improvements we’ve made to TapRooT® in the past 12 months and what you can learn at the Summit. Then we immediately go to the networking activity where you will meet someone from your industry, someone from a different industry, and an expert. That’s three new contacts in the first hour of the Summit. AND you get rewarded for your work.

Don’t miss out on the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. You know you don’t know everything and you will enjoy meeting really smart people and sharing best practices that will help your company be even better in 2017!

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

February 10th, 2016 by

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.)

 

EssentialsBook

Book 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

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:

 http://www.taproot.com/products-services/taproot-book

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. 

Times are Tough … How Can TapRooT® Root Cause Analysis Help?

February 4th, 2016 by

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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!

FIRST

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.

For example:

  • 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

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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 …

WATCH OUT!

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. 

SECOND

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.

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THIRD

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.

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Good news:

  • 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:

http://www.taproot.com/products-services/taproot-book

FINALLY

If you need help, give us a call. (865-539-2139)

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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.

What will YOU do to make 2016 better than 2015?

December 2nd, 2015 by

2016

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.

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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.

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