Category: Performance Improvement

Monday Accident & Lessons Learned: How Much Root Cause Analysis Can You Buy for $5.6 Million Dollars?

February 23rd, 2015 by

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Here are the headlines from The Bakersfield Californian:

“CPUC proposes $5.6 million fine against PG&E for 2012 demolition fatality in Bakersfield”

As reported by the papper, one of the findings of the PUC that led to the fine was:

“PG&E gave the CPUC an accident analysis prepared by Cleveland, as well as the utility’s own evaluation. But commission staff said both ‘failed to provide an adequate or comprehensive root cause analysis for the incident’ to help determine corrective actions.”

So here are some questions to consider:

  1. Do you require that your contractors perform adequate accident investigations?
  2. What root cause tools do your contractors use? Shouldn’t they be using TapRooT®?
  3. Are you waiting for fatalities to require better root cause analysis and incident investigation? Why don’t you have someone attend an 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course ASAP (this month?).
  4. Isn’t it time that you learned how to use root cause analysis proactively to stop fatalities before accidents happen? You should attend the Using TapRooT® Proactively Course.

How many lessons can your company learn from this accident?

Interested in Operational Excellence?

February 11th, 2015 by

System Improvements has promoted operational excellence for over a decade (almost two). The TapRooT® Root Cause Analysis System is an excellent to to use both for reactive and proactive analysis to solve problems and achieve operational excellence.

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SI is now a sponsor of the Operational Excellence Society.  You can join the society for free. See:

http://opexsociety.org

And click on the “register” button on the top of the page.

Why is Performance Improvement (and Root Cause Analysis) Essential?

February 11th, 2015 by

Sometimes I get the impression that some managers think that performance improvement is an optional activity that can be cut to meet budget goals. That view surprises me because I think that performance improvement is an essential activity that can’t be cut because it supports activities that:

  1. Stop Fatalities
  2. Reduces Regulatory Conflict
  3. Avoids Major Financial Losses
  4. Keeps Clients Happy
  5. Eliminates Bad Press
  6. Improves Operational Efficiency and Equipment Reliability

After all, can you really afford deaths, regulatory initiatives, major losses, unhappy clients, bad press, and broken, inefficient operations?

If your performance improvement program isn’t world class, you are inviting disaster. And disaster is expensive. Every cent you save by reducing effective performance improvement efforts will come back to you in expensive accidents, incidents, plant upsets, equipment downtime, and regulatory headaches.

So, the next time management has a great idea to cut the performance improvement budget, remind them what the budget does for them. Remind them of the losses avoided and the good nights of sleep they get and how bad it will be when things go haywire.

Where does your company need to apply root cause analysis?

February 4th, 2015 by

Root cause analysis is frequently used by safety and quality professionals to improve performance by analyzing the causes of accidents and issues and correcting their root causes so the accidents/issues don’t happen again.

In addition, forward thinking companies apply root cause analysis proactively to stop safety accidents and quality issues BEFORE they happen. (See http://www.taproot.com/courses#Proactive for information about our proactive use of TapRooT® Course.)

But where else should root cause analysis be applied at your company? Here are five ideas …

IT – Ever have computer issues, network issues, or computer security problems? Great candidates for root cause analysis. We’ve had people attend our public TapRooT® Courses and have onsite TapRooT® Courses to train IT folks how to find and fix the root causes of technical IT issues.

HR – Have you ever gad a union grievance because a union member was unfairly fired? Perhaps your HR department should use root cause analysis to identify the causes of disciplinary issues?

Operations/Facility Management – Safety/quality issues aren’t the only problems that operations and facility managers need to solve. Process down time, process upsets, schedule slippage, and building issues can all be investigated and fixed using root cause analysis.

Engineering – Engineers often investigate problems. They should be doing systematic root cause analysis (TapRooT®). But that can save millions of dollars if they learn to use Root Cause Analysis proactively to stop problems in the design stage of projects. All engineers should attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It should be a standard part of their career development. Do you need to set up on-site training for your engineers? Contact us by CLICKING HERE.

Maintenance – It may be OK to have the occasional equipment failure occur. But I’ve seen way to many companies that have repeat equipment failures because the root causes of the equipment problems are not being addressed (and, even worse, are not even being analyzed). This can be costly. Replacement parts and maintenance personnel time can be expensive. Worse yet, equipment problems left unsolved can lead to safety accidents (when maintenance people are rushing to fix an issue that never should have happened), quality issues (when equipment failures cause quality issues), or cost overruns or missed schedules (because vital equipment was down). Isn’t it time your maintenance folks had a systematic troubleshooting/root cause analysis method (Equifactor® and TapRooT®)?

That’s some ideas to get you started. I think you will be amazed how much TapRooT can help your company improve performance if it is systematical applied to all sorts of problems and issues that really need effective fixes.

Can Being Cheap Cost Your Company Big Bucks? … Let Me Count the Ways!

January 29th, 2015 by

I was thinking about the ways that trying to be cheap when doing root cause analysis could cost companies millions of dollars, when a discussion with a legal counsel gave me an additional idea. Then I thought,

I need to share these ideas to keep people from making these mistakes.”

 1. CHEAP INVESTIGATIONS

I’ve seen many companies assign supervisors to investigate accidents “in their spare time.” This is definitely a cheap investigation. But the problem is that the results could cost the company millions of dollars.

For example, let’s say that a near-miss doesn’t cost anything and no one is seriously injured. Therefore, a supervisor does a quick investigation without looking into the problem in too much detail. He recommends re-training those involved and the training is conducted days later. Case closed!

However, the root causes and failed safeguards for a bigger accident are never fixed. Nearly a year later, a major accident occurs that could have been prevented IF the root causes of the previous near-miss had been found and fixed. However, because a “cheap” investigation was performed, the causes were never identified and 10 people died needlessly. The company spent $1 million on an OSHA fine and almost $100 million more on legal and settlement costs.

What do you think? Was the savings of a cheap investigation worthwhile?

One key to a world-class incident investigation and root cause analysis program is to spend time identifying which “small incidents” are worthy of a good investigation because they have the potential to prevent major accidents. These near-misses (of a big accident) should be treated as seriously as the big accident itself with a thorough investigation , management review, and implementation of effective corrective actions to prevent recurrence of the causes (and, thus, the big accident that’s waiting to happen).

2. CHEAP CORRECTIVE ACTIONS

I’ve seen companies try to perform a thorough root cause analysis only to try to take the cheap way out when it comes to corrective actions.

You have probably all seen “cheap” corrective actions. Try these:

  • Caution workers to be more careful when …
  • Re-train employees to follow the procedure.
  • Re-emphasize to employees the importance of following the rules.

These seem cheap. (Cautioning employees is almost free.) But the change very little and will be forgotten in days or at least in several months. Plus, new folks who join the organization after the caution, re-train, or re-emphaize occurs, won’t get the repeated emphasis.

What happens? The incident tends to repeat after a period of time. And repeat incidents can be expensive. Thus by saving on corrective actions, you may be costing your company big bucks.

Instead, for investigations that could prevent major accidents, investigators should propose (and management should insist upon) corrective actions that remove the hazard, remove the target, or significantly improve the human factors of the safeguards that are used to prevent a repeat of the accident. These may not be cheap but they will be infinitely more effective.

What if one of these three choices can’t be implemented? Then one or more additional safeguards that are effective should be developed.

3. CHEAP TRAINING

The legal counsel that I was talking to told me that MOST “TapRooT® Users” he ran into during their preparation for trails had never been formally trained in TapRooT®. The attorney had attended one of our public TapRooT® Courses. He was amazed that management at fairly major companies would assign people who had never been to ANY formal root cause analysis training to investigate serious incidents that had potential for expensive legal outcomes.

In one instance, the person using TapRooT® had obtained one of our old TapRooT® Books from a friend. He then “used” the technique after reading “some” of the book. He didn’t have a Root Cause Tree® Dictionary or a Corrective Action Helper®. However, his reading didn’t provide him with the knowledge he needed to use TapRooT® correctly when investigating serious incidents (or not serious ones for that matter).

Don’t get me wrong, the TapRooT® Book is a great read. But I would never recommend it as the only source of training for someone who will be investigating serious accidents (fatalities and major environmental releases). What would I recommend? The 5-Day TapRooT® Advanaced Root Cause Analysis Team Leader Training.

The attorney also mentioned that he frequently meets TapRooT® Users who are out of practice using TapRooT® and really need a refresher because they don’t have many serious accidents to investigate and don’t get any feedback even when they do an investigation. My answer to that was ….

  1. They should be using TapRooT® proactively to get practice using the techniques.
  2. They should set up a company peer review process to help users get better at applying the techniques.
  3. They should attend the Incident Investigation and Root Cause Analysis Track at the Global TapRooT® Summit at least every two years to keep up with the latest improvements in the TapRooT® Techniques.

By the way, what had the “cheap training” cost the company? Over $50 million dollars in settlement costs.

HIGHLY QUALIFIED, COMPETENT, PRACTICED TapRooT® INVESTIGATORS ARE IMPORTANT INVESTMENTS

The first thing management needs to understand is that they need to invest in their incident investigators. Saving on training on root cause analysis is a stupid idea.

THOROUGH ROOT CAUSE ANALYSIS OF INCIDENTS THAT COULD HAVE BEEN MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS

Once you have excellent investigators, make sure they have the time and resources needed to investigate all incidents/near-misses that have a potential to become major accidents. Saving money on investigations is a fool’s mission.

CORRECTIVE ACTIONS THAT COULD PREVENT MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS

Management should insist upon effective corrective actions that go beyond training. Saving money by implementing “cheap” corrective actions is a false savings that will come back to haunt the company.

DON’T MAKE THESE MISTAKES! Invest in effective root cause analysis and prevent major accidents from occurring.

Even in Humor, You can learn about Root Cause and People from Dr. Deming

January 22nd, 2015 by

Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…

… your own actions.

… your understanding of other peoples actions.

… your past corrective or preventative actions.

Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.

To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance  excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.

To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit

If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw

Will Falling Oil Prices Put the Cost-Cutting Ax to Safety Improvement?

January 22nd, 2015 by

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It’s easy for a CEO and management to claim to support safety. But the proof comes when times get tough.

The price of oil has declined more that 50% in just six months. That has the oil field in crisis mode. Knee jerk budget cuts, travel restrictions, and layoffs have already started.

What does this mean to safety improvement? Many oil industry safety professionals get ideas about ways to improve by attending the TapRooT® Summit, networking with industry leaders and performance improvement experts, hearing about the latest best practices that will help them solve their toughest problems, and developing plans to take safety to a whole new and better level. But if travel budgets are slashed and conferences are not allowed, these new best practices won’t be learned, safety improvement will stop, and lives that could have been saved will be lost.

Now is the time for management to show their commitment to safety improvement. They can stand up, resist the fear of low oil prices, and demand that safety improvement continues even in times of budget restraint.

After all, safety is not just a priority that can be discarded when times get tough. Safety is a value that must be supported every day, year in and year out, in good times and bad, or people will start to believe that safety is option and the only real value is profit.

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Don’t let safety improvement become an unsupported slogan. Register for the TapRooT® Summit today!

Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014

January 19th, 2015 by

UK Rail Accident Investigation Branch Press Release…

The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.

NewImageYellow engineering trolley underneath the train after the collision (image courtesy of Carillion)

The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley. 

The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.

To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.

Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.

RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.

RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.

The RAIB investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

- – – – – 

What can we learn BEFORE the investigation is complete?

First, this “near-miss” was actually a hit.

In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.

Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.

Does Your CEO Care? Should Your CEO Care?

January 6th, 2015 by

One of the main complaints I hear is that management doesn’t provide enough support for performance improvement programs, accident/incident investigations, and root cause analysis.

One thing I’ve learned is that if senior management really cares, the rest of management will usually fall in line (or get fired).

That brings me to these questions …

Does your CEO care about performance improvement,
incident investigation, and root cause analysis?

Should they care?

Now for the answer…

An oil company had a fire on an offshore production platform. The fire knocked out a significant portion of the company’s gas production right in the middle of the heating season. The incident was mentioned on the front page of The Wall Street Journal because it would impact the company’s quarterly earnings.

What do you think? Did the CEO care?

How about the CEO at BP or Transocean when the Deepwater Horizon exploded, burned, and sank? Do you think they cared?

Or the CEO of Dixie Crystals when the factory in Savannah, GA, blew up?

Or the CEO at GM when she was called to testify in front of Congress about ignition switch problems that resulted in fatal auto accidents?

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These are examples of CEO’s that definitely cared AFTER THE FACT. They wished someone had stood up before the accidents and stopped the problems before they reached the CEO’s attention. And they all claimed to have no advance knowledge of the problems that lead to the accidents.

Therefore, the CEO should care and it may be your job to prevent the accidents that could happen so that your CEO never knows that they should care. Never has to appear in front of cameras and say that s/he is sorry. Never has to face a mad Congressional committee.

Perhaps you occasionally need to remind people how important it is to investigate small problems with the potential to become big problems and effectively fix the issues so that the CEO never hears about your facility.

That’s when you can explain why using the best advanced root cause analysis technique (TapRooT®) is so important and why senior management should be interested in ensuring that the company’s performance improvement program is best-in-class. 

Save Time and Effort … Stop Having Accidents by Using TapRooT® Proactively

December 30th, 2014 by

Have you been to a TapRooT® Course? Then you learned something about applying TapRooT® proactively to stop accidents and incidents. However, many TapRooT® Users I talk to after a course have never applied TapRooT® proactively. They have just been to busy to find the time.

Why are they so busy? Of course, all companies have been through downsizing, lean, and right-sizing programs that have cut staff to bare bones levels. This allows time to do your job and perhaps a few unexpected tasks (like accident investigations). But they just don’t have time to be proactive.

But I’ve found that this is self-limiting thinking. Because if you can squeeze in just a little time to be proactive, the time and effort saved by avoiding accidents will more than pay back the time you apply to proactive improvement.

Here’s an example.

A refinery always had safety accidents during their turnaround. The increased workload and extra contractors working 24 hours a day meant that the potential for accidents was at a peak. And, when they happened, they always seemed to be at the worst place at the worst time causing expensive turnaround delays. What could be done to correct the problem?

Be proactive.

The refinery decided to be to be proactive and apply TapRooT® as part of a safety observation program. They trained safety observers how to use TapRooT® to perform safety audits and then INCREASED their staff during the turnaround. They had safety coverage 24 hours a day in the field using TapRooT® proactively to find and fix problems BEFORE they could turn into accidents. What happened? The turnaround had the best safety record ever. And there were no expensive incidents to cause delays.In fact, their safety statistics during the turnaround were better than their stats during normal operations (when there was much less risk).

Want to learn more about applying TapRooT® proactively? We have a new course for TapRooT® Users that will be held on June 1-2, 2015 (just before the TapRooT® Summit) in Las Vegas. Click on the link below to find out more about the course and using TapRooT® proactively:

http://www.taproot.com/taproot-summit/pre-summit-courses#ProactiveUse

Keeping Your Regulator Happy

December 23rd, 2014 by

In many industries (nuclear, pharmaceutical, biotechnology, medical device, healthcare, aviation, and many others), an unhappy regulator means a bad day. 

What do you need to do to keep a regulator happy? 

First, regulators hate surprises. There’s nothing worse to a regulator than hearing about a accident at one of their regulated facilities. Or hearing that one of their products has injured someone. 

If you can prevent surprises, you will have a happy regulator.

Next, if something does go wrong, regulators expect a thorough and credible root cause analysis that includes proposing effective corrective actions that will keep the problem from happening again. (Regulators hate repeat problems.)

That’s why TapRooT® has been an important part of performance improvement programs at companies in regulated industries including the nuclear industry, pharmaceuticals, aviation, and healthcare.

First, it helps the companies develop effective corrective actions for the problems they are having.

Second, by investigating and fixing incidents that have a potential for more serious outcomes, the companies prevent major accidents (surprises for their regulator).

Want to learn more about TapRooT® and how it can keep you in good graces with your regulator? I’d suggest attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Not only will you learn to apply advanced root cause analysis reactively to investigate accidents and incidents, but also you will learn to use the tools proactively to stop accidents before they happen. In addition, you will receive the TapRooT® Software to improve your investigation productivity.

Don’t wait. You don’t want an unhappy regulator. And many of our courses fill up and have a waiting list (they are that popular). So, sign up today. See the list of upcoming public 5-Day TapRooT® Courses at:

http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training

Click on your continent to see the courses near your location.

Keeping TapRooT® Investigations Out of Court

December 18th, 2014 by

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We would all agree that performing accident investigations and investigations of quality issues to prevent repeat accidents is a good idea. But some may be reluctant to perform investigations because of the legal liability they think the investigation report may represent.

Of course, they are at least partially right. Frequently, significant accidents result in lawsuits. And if your investigators aren’t careful, they may put poorly chosen words or even un-true statements in their investigation reports. Thus, company counsel or outside counsel may prefer that the actual accident investigation reports be excluded from evidence in a court proceeding to reduce the liability that an accident investigation report may represent.

Excluding a report performed after an accident to look for ways to prevent future accidents is a protected activity under federal law. FRE Rule 407, Subsequent Remedial Measures, states:

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

How can you help preserve your right to exclude your report from discovery and use at trial? Outside counsel for one of our clients has suggested that all TapRooT® users add one of the following preambles or appendices to every TapRooT® Investigation. We thought this sounded like a good idea, so we are passing along the following preambles or appendices for you to consider when writing your investigations….

For safety investigations at a company, the preamble suggested by the attorneys is as follows:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

COMPANY TapRooT® Investigation Preamble

In order improve COMPANY’s overall safety performance and to prevent or significantly reduce the likelihood of the same or a similar work-related incident/injury/illness (“incident”) from reoccurring, COMPANY conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant performance problems and/or equipment failures that may arise from time to time during its operations. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow COMPANY to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within COMPANY’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes COMPANY management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of COMPANY’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures COMPANY may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging COMPANY to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage COMPANY to take, or at least not discourage them from taking steps in furtherance of added safety.

Incidents, injuries and illness may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors and/or vendors. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT® inasmuch as COMPANY management has no control over errors made by these vendors except expected conformance with their duties owed to COMPANY.

Even though COMPANY makes every effort to determine what happened during an incident and to minimize future incidents through the COMPANY investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT® determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside COMPANY retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

For quality investigations subsequent to an issue with a product, the following preamble/appendix is suggested:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

VENDOR TapRooT® Investigation Preamble

In order improve VENDOR’s overall quality performance and to prevent or significantly reduce the likelihood of the same or a similar quality issues from reoccurring which may lead to work-related incident/injury/illness or client related issues (“incident”), VENDOR conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant quality and/or performance problems and/or equipment failures that may arise from time to time during the use or manufacture of its products. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow VENDOR to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within VENDOR’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes VENDOR management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of VENDOR’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures VENDOR may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging VENDOR to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage VENDOR to take, or at least not discourage them from taking steps in furtherance of added safety and quality.

Incidents, injuries, illness, and quality issues may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors, vendors, and/or clients. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT inasmuch as VENDOR management has no control over errors made by these third parties except expected conformance with their duties owed to VENDOR.

Even though VENDOR makes every effort to determine what happened during an incident and to minimize future incidents through the VENDOR investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside VENDOR retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

Of course, before adopting any advice to reduce potential liabilities in future courtroom actions, you should consult your own in-house or outside counsel. They may modify the forms provided above or have other wording that they prefer.

So consider the advice provided above and get your own protective wording added to all your standard reports. We are looking at ways to add this to the TapRooT® Software and we’ll let you know when we’ve figured out a way to do it. Until then, we suggest manually adding the wording to your official final reports.

Can TapRooT® Help You Stop Quality Issues?

December 16th, 2014 by

Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:

“Can TapRooT® be used to solve quality issues?”

I was surprised by the question. Of course, the answer is YES!

We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.

Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?

The only answer was … We had not told him!

Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors. 

Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.

For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.

That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.

So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!

Attend one of our public 2-Day, 3-Day, or 5-Day TapRooT® Courses and find out how well TapRooT® can help you solve your toughest issues.

Risk Assessments: Move Beyond Behavior Based Safety

December 9th, 2014 by

Risk Assessments are necessary in all safety processes, particularly to move programs beyond Behavior Based Safety (BBS).

At least qualitative Risk Assessments (RA) need to be included during any safety-related discussions or interactions, conversations, and meetings. RA are needed every time any safety-related decision needs to be made; and therefore, to move safety programs beyond traditional BBS principles and practices.

RA in safety processes, including BBS – type programs, improve decision-making by making them less subjective, emotional and biased. Safety decision-making needs to be based on the comparative risk levels of the options under consideration. Any chosen safety decision needs to be the option for which the likelihood and quantum of benefit and gain outweighs the likelihood and quantum of loss and harm more than for any other option.

Which option provides the best chance of gain and benefit at both personal and corporate levels?

One such illustrative example is related to un-demonizing the term “shortcut”.

The original, best definition of a shortcut is very simple, positive and with no emotive undertones:

“a smarter, better way of doing a job”

or

“the method, procedure that best reduces the time / $ / energy needed to achieve business objectives.”

Can a shortcut ever be an appropriate, lower risk and authorized job method? And how?

In any safety discussions between managers, supervisors and workers, this definition can help clarify the troublesome distinction between “finding a shortcut,” and “taking a shortcut without an authorized risk assessment.” Finding is undeniably “smart.” Taking without RA is patently “dumb.”

Issues of workplace complexity and relationships between managers, supervisors and workers need to be addressed to be able to move safety programs and cultures beyond BBS principles and practices. Workplace relationships are based on trust, respect, credibility, encouragement, and valued appreciation of jointly-found solutions of challenges and issues. RA provides processes needed in relationship-based safety RBS.

Positive relationships include establishing and holding common beliefs that we want everyone to come to work with their brains as well as their brawn, (and hopefully their hearts), because we all recognize that it is in everyone’s interest for everyone to be always challenged to find smarter better ways of doing our jobs. That is what business is about! It is the never-ending goal of finding smarter, more efficient, more effective, more productive and safer (lower risk) ways of doing our work.

However, too often we tell our people we need and want their “shortcut” ideas for more efficiency and productivity, but as soon as they do give them we jump on them and label their suggestions with negative emotive labels such as “violations” or “breaches” of existing rules and describe them in meaningless, undefined terms such as “unsafe acts” or “at-risk behaviors”. Use of these negative, emotion-loaded terms actually discourages searching for the deep underlying root causes of an apparently stupid, careless, and lazy “violation.”

It is more appropriate to use non-emotive descriptors such as “variations,” “adaptations,” “departures,” or very simply “work-arounds.”

All day-to-day safety meetings, discussions, and personal risk taking behavioral choices involve BBS questions such as:

  • Which procedure or method is safer (lower risk) than another?
  • Which is the safer tool, plant, equipment for this job?
  • Which risk control option is better than the others?
  • Which route should be taken?
  • Which control panel design is less error-provoking than the other?
  • Which roster is best for managing fatigue?
  • What is the appropriate time that we need to allocate to this incident investigation?
  • What to say and how to interact / converse with my peers, supervisors and managers?

These real examples of safety optioneering processes make a compelling argument for doing at least a qualitative (but preferably a Semi – Quantitative) Risk Assessment.

In fact, Risk Assessments will be recognized as definitely needed every time any safety-related decision needs to be made and therefore can move safety programs beyond traditional BBS principles and practices often confused and undermined by subjective beliefs, biases and perceptions.

How can you improve your confidence in the accuracy, reliability, consistency of Risk Assessments?

Learn Best Practices in the training courses being offered as below.

Houston, Texas
May 20-21, (Weds-Thurs)

To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505HOUS20.html

Calgary, Canada
May 27-28, (Wed-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505CALG27.html

Las Vegas, Nevada
June 1-2 (Mon-Tues before the TapRooT® Summit)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1506LASV01-RISKMGMT.html

IN-HOUSE Courses are also available. Contact us for a quote.

Jim WhitWhiting.Jiming, an international expert in risk management and root cause analysis will be conducting the courses detailed above. The courses are the updated versions of a highly successful course that he has been offering for a number of years to over 200 attendees at Pre-Summit courses at past TapRooT® Summits. Due to increasing requests for more offerings of the course, the TapRooT® folks and Jim have decided to offer three RAMBP PUBLIC Courses in North America in 2015.

Jim was on Committees developing the Risk Management Standard AS/ISO 31000 which has been adopted word for word by US standard bodies as ANSI Z690.2 and Canadian bodies as CAN/CSA/ISO 31000. He has developed Risk Assessment unique tools and processes for maximizing the confidence of the results of assessments need to make all safety-related decision-making such as – what is a tolerable risk ?

How much money can TapRooT® save your company?

December 9th, 2014 by

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s about a 40000% instant ROI.

That made me think … do TapRooT® Users think about how much they are saving their company?

Do they track the savings?

Do they know how much problems are costing their company and have a goal for cost saving?

Let me know if you have saved money for your company by leaving a note below as a comment…

Monday Accident & Lessons Learned: Fatal Auto Accidents

December 8th, 2014 by

REDWRECK

If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.

When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?

What is the difference?

Why are fatal traffic accidents seemingly acceptable?

Could we learn from fatal car accidents and make sure they never happen again?

What would have to change to make this learning possible?

Could we save 10,000, 20,000, or 30,000 lives per year here in the US?

Root Cause Analysis Tip: What is a corrective action worth? – A Gambler’s View of Corrective Actions (A Best of Article from the Root Cause Network™ Newsletter)

December 3rd, 2014 by

Adapted from the January 1995 Root Cause Network™ Newsletter, Copyright © 1995. Reprinted by permission. Some modifications have been made to update the article.

A GAMBLER’S VIEW OF CORRECTIVE ACTIONS

WHEN TO BET/WHEN TO FOLD

A winning gambler knows the odds. He knows that in the long run, he can beat the odds. Therefore, he looks for opportunities to bet more when the odds are in his favor. And when the odds are against him, he folds and waits for a better hand.

Preventing accidents is a numbers game. The pyramid blow provides a typical example of the ratio of accidents to incidents to near-misses to unsafe conditions.

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In this pyramid, every incident must have the potential under slightly different circumstances to become the major accident at the top of the pyramid. Also, every near miss must have the potential to become an incident that could have become the top level accident. Finally, every unsafe condition could have caused a near-miss that could have become an incident that could have become the top level accident.

Thus, every unsafe act included at the bottom level of the pyramid must have the potential with the right set of circumstances to “cause” the top level accident. 

The ratio above might not be exact. Your facility might be different. But we will use the ration of 1000 unsafe acts for every major accident as a starting point for out calculation of odds that we describe below.

The point is that every corrective action that fixes an unsafe condition has some odds of being the corrective action that could be preventing a major accident. Thus, we should try to understand the value NOT ONLY of the benefits that the corrective action immediately brings, BUT ALSO the reduction in the odds of a major accident that this corrective action provides.

THE COST OF A MAJOR ACCIDENT

To calculate the value of preventing a major accident, we need to calculate the potential cost of a major accident at your facility.

Of course, we don’t know the exact cost of the biggest accident (or even a typical major accident) that you face at your company. After all, they still don’t know what the cost of the Deepwater Horizon accident will be even after years of litigation. So, we have to make an educated guess that can be scaled to show how the cost could change.

For example, we might say that the cost a typical major accident would be $1,000,000,000. 

Then, if you think your accident might be ten times worse (or ten times less), you can multiple or divide the results we calculate by 10.

ASSESSING THE ODDS

Why do we have to use “odds” to perform this calculation? Because you can’t tell exactly which unsafe condition will be related to your next major accident. We don’t know what corrective action that we implement today will prevent the next Deepwater Horizon, Three Mile Island, or Exxon Valdez type accident that costs billions of dollars. No one is that prescient. That’s why preventing major accidents is a numbers game. To prevent the next major accident you must reduce thousands of unsafe conditions.

Because the exact odds of any one unsafe act being a key factor in the next accident is unknowable, we assign equal potential to every unsafe condition that has potential to cause a major accident.

If the pyramid above represents your accident pyramid, then for every major accident, there are 1000 unsafe conditions that could contribute to it. Or another way to think about it is that we can’t predict the exact combination of factors that will cause the next major accident but if we do 1000 things to fix problems that could be involved in a major accident, we will stop one major accident.

Thus the odds that any one corrective action will stop a major accident is 1000 to 1.

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CALCULATING THE VALUE OF A CORRECTIVE ACTION

I’ve seen people value corrective actions by using the value of the incident they would prevent.

For example, if the failure of a machine caused a delay that lost the company $100,000, the value of the corrective actions to prevent future failures would be $100,000. It’s never clear to me if this value should be divided between all of the corrective actions (for example, if there are 10 corrective actions, each would be worth, $10,000) or if each corrective action is worth $100,000. But the idea is that the corrective actions can be valued by the costs that will be saved from future similar incidents prevented. 

What this equation leaves out is the value of an even worse accident that could also be prevented by the corrective actions. 

Thus to calculate the value of a corrective action, you not only need to calculate the direct benefit, but also the amount that that corrective action contributed to the prevention of a major accident (if, indeed the corrective actions could help prevent a major accident).

But let’s stop here to correct misconceptions. A corrective action meant to stop paper cuts probably have very little value in preventing major accidents. Thus, we are not assigning severe accident risk to every corrective action. We would only assign the value to corrective actions that could help prevent major accidents.

The, the value of a corrective action is the direct cost that the corrective action saves us PLUS the value of the unknown major accident that it could prevent divided by the odds.

For example, if a corrective action saved us $10,000 in direct costs for a similar incident and if the value of a major accident at your facility is $1,000,000,000 and if we estimate that it will take correcting 1,000 unsafe acts to prevent the next accident, the value of our corrective action is…

VALUE = $10,000 + ($1,000,000,000/1000)

VALUE = $10,000 + $1,000,000

VALUE = $1,010,000

Thus valuing corrective action at their benefit for preventing a similar incident is UNDERVALUING the corrective actions.

And I believe we frequently undervaluing corrective actions.

Why?

Because we aren’t considering the value that a gambler sees. We are folding when we should be betting!

We should be investing much more in effective corrective actions thereby win by preventing the next major accident.

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YOU CAN IMPROVE THE ODDS

There is even better news that can help you make the corrective actions you implement even more valuable (effective).

The TapRooT® Root Cause Analysis System can help you do a better job of analyzing potential problems and developing even more effective corrective actions for the root causes you uncover. 

Think of TapRooT® as a luck rabbit’s foot that increases your odds of winning. 

Of course, TapRooT® is much better than a lucky rabbit’s foot because instead of being built upon superstition, it is built upon proven human performance and equipment reliability technology that makes your investigators much more effective.

So don’t wait. Stop undervaluing your corrective actions and if you haven’t already started using TapRooT®, see our upcoming courses list, click on your continent, and get signed up for a course near you (or in a spot that you would like to visit).

Root Cause Tip: Audit Your Investigation System (A Best of The Root Cause Network™ Newsletter Reprint)

November 26th, 2014 by

AUDIT YOUR INVESTIGATION SYSTEM

AUDIT TO IMPROVE

We have all heard the saying:

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Tom Peters changed that saying to:

“If it ain’t broke, you aren’t looking hard enough.”

We can’t improve if we don’t do something different. In the “Just Do It” society of the 1990’s, if you weren’t improving, you were falling behind. And the pace of improvement has continued to leap forward in the new millennium. 

Sometimes we overlook the need to improve in places that we need to improve the most. One example is our improvement systems. When was the last time you made a comprehensive effort to improve your incident investigations and root cause analysis? 

Improvement usually starts by having a clear understanding of where you are. That means you must assess (inspect) your current implementation of your incident investigation system. The audit needs to establish where you are and what areas are in need of improvement.

AREAS TO AUDIT

If we agree that auditing is important to establish where we are before we start to improve, the question then is:

What should we audit?

To answer that question, you need to know what makes an incident investigation system work and then decide how you will audit the important factors. 

The first research I would suggest is Chapter 6 of the TapRooT® Book (© 2008). This will give you plenty of ideas of what makes an incident investigation system successful.

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Next, I would suggest reviewing Appendix A of the TapRooT® Book. Pay special attention to the sample investigation policy and use it as a reference to compare to your company’s policy.

Next, review Appendix C. It provides 16 topics (33 suggestions) to improve your incident investigation and root cause analysis system. The final suggestion is The Good, The Bad, and The Ugly rating sheet to rate your investigation and root cause analysis system. You can download a copy of an Excel spreadsheet of this rating system at:

http://www.taproot.com/archives/46359

Next, review the requirements of your regulator in your country. These will often be “minimum” requirements (for example, the requirements of OSHA’s Process Safety Management regulation. But you obviously should be meeting the government required minimums.

Also, you may have access to your regulators audit guidance. For example, OSHA provides the following guidance for Process Safety Management incident investigations:

12. Investigation of Incidents. Incident investigation is the process of identifying the underlying causes of incidents and implementing steps to prevent similar events from occurring. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. The incidents for which OSHA expects employers to become aware and to investigate are the types of events which result in or could reasonably have resulted in a catastrophic release. Some of the events are sometimes referred to as “near misses,” meaning that a serious consequence did not occur, but could have.

Employers need to develop in-house capability to investigate incidents that occur in their facilities. A team needs to be assembled by the employer and trained in the techniques of investigation including how to conduct interviews of witnesses, needed documentation and report writing. A multi-disciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened, and why. Team members should be selected on the basis of their training, knowledge and ability to contribute to a team effort to fully investigate the incident. Employees in the process area where the incident occurred should be consulted, interviewed or made a member of the team. Their knowledge of the events form a significant set of facts about the incident which occurred. The report, its findings and recommendations are to be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigation process should clearly deal with all involved individuals in a fair, open and consistent manner.

Also, OSHA provides more minimum guidance on page 23 of this document:

https://www.osha.gov/Publications/osha3132.pdf

Finally, another place to network and learn best practices to benchmark against your investigation practices is the TapRooT® Summit. Participants praise the new ideas they pick up by networking with some of the “best and brightest” TapRooT® Users from around the world.

Those sources should provide a pretty good checklist for developing your audit protocol.

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AUDIT TECHNIQUES (PROTOCOL)

How do you audit the factors that are important to making your incident investigation system work? For each factor you need to develop and audit strategy and audit protocol.  

For example, you might decide that sharing of lessons learned with employs and contractors is a vital part of the investigation process. The first step in developing an audit strategy/protocol would be to answer these questions:

  1. Are there any regulatory requirements for sharing information?
  2. What is required by our company policy?
  3. What good practices should we be considering?

Next, you would have to develop a protocol to verify what is actually happening right now at your company. For example, you might:

  • Do a paper audit of the practices to see if they meet the requirements.
  • Go to the field to verify workers knowledge of past best practices that were shared.

Each factor may have different techniques as part of the audit protocol. These techniques include:

  • paperwork reviews
  • field observations
  • field interviews
  • worker tests
  • management/supervision interviews
  • training and training records reviews
  • statistical reviews of investigation results

To have a thorough audit, the auditor needs to go beyond paperwork reviews. For example, reading incident investigation reports and trying to judge their quality can only go so far in assessing the real effectiveness of the incident investigation system. This type of assessment is a part of a broader audit, but should not provide the only basis by which the quality of the system is judged.

For example, a statistical review was performed on the root cause data from over 200 incident investigations at a facility. The reviewer found that there were only two Communication Basic Cause Category root causes in all 200 investigations. This seemed too low. In further review it was found that investigators at this facility were not allowed to interview employees. Instead, they provided their questions to the employee’s supervisor who would then provide the answers at a later date. Is it any surprise that the supervisor never reported a miscommunication between the supervisor and the employee? This problem could not be discovered by an investigation paperwork review.

Don’t forget, you can use TapRooT® to help develop your audit protocol and find the root causes of audit findings. For example, you can flow chart your investigation process as a Spring SnapCharT® to start developing your audit protocol (see Chapter 5 of the 2008 TapRooT® Book for more ideas).

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WHO SHOULD AUDIT & WHEN?

We recommend yearly audits of your improvement system. You shouldn’t expect dramatic improvements every year. Rather, if you have been working on improvement for quite some time, you should expect gradual changes that are more obvious after two or three years. This more like measuring a glacier moving than measuring a dragsters movement. 

Who should perform these audits?

First, the system’s owner should be doing annual self-assessments. Of course, auditing your own work is difficult. But self-assessments are the foundation of most improvement programs.

Next, at least every three years you should get an outside set of eyes to review your program. This could be a corporate auditor, someone from another site, or an independent (hired) auditor.

System Improvements (the TapRooT® Folks) provides this type of hired audit service (contact us by calling 865-539-2139 or by CLICKING HERE). We bring expertise in TapRooT® and an independent set of eyes. We’ve seen incident investigation systems from around the world in all sorts of industries and have access to the TapRooT® Advisory Board (a committee of industry expert users) that can provide us with unparalleled benchmarking of practices.  

GET STARTED NOW

Audits should be an important part of you continuous improvement program. If you aren’t already doing annual audits, the best time to start is NOW! Don’t wait for poor results (when compared to your peers) that make your efforts look bad. Those who are the best are already auditing their system and making improvements. You will have to run hard just to keep up!

(This post is based on the October 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted/adapted by permission. Some modifications have been made to update the article.)

Root Cause Analysis Video Tip: TapRooT® Resources That Will Help You Be Proactive.

November 19th, 2014 by

Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.

For more information regarding our Public and Onsite TapRooT® Courses, click here.

Want to join us at the Global TapRooT® Summit? Click here for more information and registration.

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Was this tip helpful? Check out more short videos in our series:

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

 

Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)

November 12th, 2014 by

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At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:

  1. Management revises the facts. (Or management says “You can’t say that.”)
  2. Assumptions become facts.
  3. Untrained team of investigators. (We assign good people/engineers to find causes.)
  4. Started investigation too late.
  5. Stopped investigation too soon.
  6. No systematic investigation process.
  7. Management can’t be the root cause.
  8. Supervisor performs investigation in their spare time.
  9. Fit the facts to the scenario. (Management tells the investigation team what to find.)
  10. Hidden agendas.

What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.

What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.

Forbes Reports: “… Nuclear Navy has the best safety record of any industry.”

October 30th, 2014 by

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Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:

America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.

And no one ever discusses it.

Well, not exactly. We’ve been discussing it for years! And the philosophy that keeps the Nuclear Navy safe is outlined in our Fatality Prevention Course and at the TapRooT® Summit.

See the article at:

http://www.forbes.com/sites/jamesconca/2014/10/28/americas-navy-the-unsung-heroes-of-nuclear-energy/

The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos.

Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?

Stupid indeed.

Missed Opportunities (A Best Of Article from the Root Cause Network™ Newsletter)

October 22nd, 2014 by

 

MISSED OPPORTUNITIES

IT DIDN’T HAVE TO HAPPEN

An anesthesia machine cuts off oxygen to a patient causing extensive brain damage. The investigation team finds a mechanical defect that was undetectable without complex testing. They also find that the sentinel event almost happened before.

The baggage door on a 747 opens after takeoff, tearing off part of the plane. Four people are swept out the hole to their death. The investigation uncovers poor, less catastrophic accidents of a similar nature and a history of problems with the door on this particular aircraft.

A plant upset occurs due to corrective maintenance. A relief lifts but fails to shut when pressure decreases. Operators, initially preoccupied with other alarms, misdiagnose the problem and shut off critical safety equipment. The “impossible” accident – a core meltdown – happens at Three Mile Island. The investigation uncovers similar, precursor incidents and a history of relief valve failure at TMI.

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These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?

  • Lives.
  • Suffering for survivors and surviving loved ones.
  • Millions – no billions – of Dollars (Yen, Euros, and Pounds).

We could prevent ALL of them. Why don’t we? Don’t we know that:

An ounce of prevention is worth a pound of cure?
Benjamin Franklin

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Maybe it is:

  • Intellectual laziness?
  • Shortsightedness?
  • Just plain bad management?
  • A bad system to identify problems?
  • Bad investigation techniques?
  • Something else?

What would it take to start learning?

STEP 1: MANAGEMENT UNDERSTANDING

Your management – from the CEO down – must understand the problem … People and machines are variable (you might call them unreliable) BY NATURE.

Our job is to reduce the variability and make systems reliable and safe.

In the long run a safe, reliable system will always out perform an unreliable, unsafe systems.

Therefore, improving reliability and safety provides your company with a competitive advantage.

The competitive advantage IS NOT FREE. It requires up front effort and investment in root cause analysis and improvements. It requires persistent attention to detail.

Thus, attaining reliability and safety is the challenge.

STEP 2: GET A PERFORMANCE IMPROVEMENT & ROOT CAUSE ANALYSIS SYSTEM THAT WORKS

Although Ben Franklin’s advice seems simple, consistently identifying the right “ounce of prevention” can be complex.

How dangerous is it to reason from insufficient data.
Sherlock Holmes

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Improving safety and reliability requires a systematic approach and the use of sophisticated performance improvement techniques. You need a good performance monitoring system.

A good performance monitoring system includes:

  • self-reporting of near misses
  • reporting and instigation of accidents and incidents
  • audits, observations, and self-assessments
  • advanced root cause analysis (TapRooT®)
  • advanced statistical analysis of trends
  • understanding of how to fix human performance problems
  • training for those who make the system work

Is putting together this kind of a system a tall order? You bet. Bit it is worth it.

If you need help putting this type of system together, we have the experience to help you and we can provide the training that people need. Call us at 865-539-2139 or drop us a note.

STEP 3: USE THE SYSTEM & FIX PROBLEMS

Get your facts first.
Then you can distort them as much as you please.
Mark Twain

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Preventing accidents is NOT a quick fix. Something you can do once and forget. Management needs to stay involved. You must be consistently persistent.

Find and fix the root causes of accidents, incidents, near-misses, and audit findings.

The first measure of the effective of the system IS NOT a reduced accident rate (although this will come along quickly enough). The first measure of success is an increased rate of finding and implementing effective corrective actions.

Management needs to demand that people properly using the system to investigate problems, find their root causes, identify effective fixes, and get them implements. If management doesn’t demand this, it won’t happen.

STEP 4: NEVER STOP IMPROVING

If you aren’t better today than you were yesterday, you are falling behind. As my boss once said:

If you’re not peddling, you are going downhill.
Captain William J. Rodriguez, United Staes Navy

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Never stop looking for areas that need improvement. This should include improving your improvement system!

We can help. How? Several ways…

  1. Call us at 865-539-2139 and we can discuss your plans to improve. The call is FREE and we may be able to suggest ways to make your plan even better.
  2. We can conduct an independent review of your root cause analysis implementation, trending, and performance improvement systems. Although this isn’t free, we guarantee it will be worth the time and money. Just drop us a note to get things started.
  3. Attend the TapRooT® Summit. Each year we design the Summit to help people learn to solve the toughest problems facing industry. You will network with some of the world’s most knowledgeable performance improvement experts and peers who have faced the same types of problems that you face and found best practices to solve their problems.

Don’t wait for the next “missed opportunity”. Do something to make improvement happen before a major accident takes place.

Save lives – save money – save jobs – improve quality and reliability – that’s what TapRooT® is all about.

TapRooTWorld

(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)

Monday Accident & Lessons Learned: Remove the Hazard – Snow & Ice Removal

October 13th, 2014 by

What do you have planned to keep walkways clear this winter?

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Here are some tips for snow and ice removal from WeatherChannel.com: (Read tips.)

Root Cause Tip: Making Team Investigations Work (A Best of Article from the Root Cause Network™ Newsletter)

October 9th, 2014 by

Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.

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MAKING TEAM INVESTIGATIONS WORK

WHY USE A TEAM?

First, team investigations are now required for process safety related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?

Quite simply because two heads are better than one! Why? Several reasons:

  • A team’s resources can more quickly investigate an incident before the trail goes cold.
  • For complex systems, more than one person is usually needed to understand the problem. 
  • Several organizations that were involved in the incident need to participate in the investigation.
  • A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrom.)

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MAKING THE TEAM WORK

Investigating an incident using a team is different than performing an individual investigation. To make the team work, you need to consider several factors:

  • Who to include on the team.
  • The training required for team members.
  • Division of work between team members and coordinating the team’s activities.
  • Record keeping of the team’s meetings.
  • Software to facilitate the team’s work.
  • Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.

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WHO’S ON THE TEAM?

The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:

  • Engineering/technical assistance for hardware expertise.
  • Human engineering/ergonomics experts for human performance analysis.
  • Operations/maintenance personnel who understand the work practices.
  • An investigation coach/facilitator who is experienced in performing investigation.
  • A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
  • A union rep.
  • A safety professional.

TRAINING THE TEAM

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A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgement to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. Hopever, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.

What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…

  • Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
  • Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
  • People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness. 

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 KEEPING ON TRACK

 One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice. 

MORE TO LEARN

This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE. Or contact us to schedule a course at your site.

How Can We Help You? (More ways than you might think!)

October 1st, 2014 by

We can help you stop bad things from happening.

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Is your team trying to prevent fatalities?

Improve quality?

Improve your root cause analysis?

Investigate a difficult incident?

Solve equipment reliability issues?

Improve profitability?

Reduce lost time accidents and workers comp costs?

Stop sentinel events?

Improve process safety?

Meet senior management improvement expectations?

We would be glad to help.

In helping companies all over the world implement TapRooT® and train their personnel to use advanced root cause analysis, we get involved in all types of performance improvement initiatives. We see what works. We see what doesn’t. 

What are some common areas where we can help?

IMPROVE YOUR TapRooT® IMPLEMENTATION

We wrote the book on implementing TapRooT®. We know how it should be used and common ways to improve its use. We see best practices from around the world and we can help you catch up by applying best practices that you haven’t tried.

How do you get started? Call us at 865-539-2139. We’ll be glad to listen to the issues you face, what you’ve done so far to make improvement happen, and explain what you can do to take your program to the next level.

INVESTIGATION FACILITATION

Our instructors are experts in applying TapRooT® to investigate problems. accidents, incidents, quality issues, sentinel events, equipment issues, production problems, and cost overruns. We don’t “do” investigations. But we can supply an an experienced TapRooT® facilitator to help your team with a tough investigation or to review an investigation that is nearing completion. Call us at 865-539-2139 or CLICK HERE to drop us a note to get the process started. 

BECOMING PROACTIVE

Using TapRooT® to investigate accidents and stop them from happening again is good. But is even better to use TapRooT® to stop accidents from ever occurring by being PROACTIVE.

We can show you how to apply TapRooT® proactively to stop accidents, incidents, quality issues, equipment reliability problems, production problems, or sentinel events. We actually have a specific course to teach the skills you will need to apply (Proactive Use of TapRooT® Course). You can attend the public course (next one is scheduled for June 1-2, 2015 in Las Vegas) which is offered just prior to the TapRooT® Summit. Or you can contact us to have a course at your site. And we would be glad to work with you before the course to get your proactive program set up to take advantage of the tools that TapRooT® offers.

ANALYZE TRENDS

Not only do we teach a course on Advanced Trending Techniques, we can help you apply those techniques to analyze your performance issues and help you present the findings to your management. We’ve found that many TapRooT® Users have never had experience in using trends to target improvement initiatives. So we can give you the training you need to understand trending and help you do your first trend analysis to understand how trending can be applied to prevent problems. Call us at 865-539-2139 or drop us a note to find out what we can do to help you look at your trends.

SOFTWARE IMPLEMENTATION

Many people use TapRooT® Software to analyze incidents. But to get the most from your software, you need to do up front business analysis to properly implement the software. Of course, we offer a course – Getting the Most from Your TapRooT® Software – to help TapRooT® Software Administrators and TapRooT® Software Super-Users learn what is needed to set up their software for best results. But we can also consult with TapRooT® Users and Software Administrators to help them develop a TapRooT® Software implementation plan. Call us at 865-539-2139 or drop us a note for more info about this service,

CREATE AN IMPROVEMENT INITIATIVE

If you are considering starting a new performance improvement initiative, why not get us involved from the ground up? We can use our knowledge of improvement programs from around the world to help you implement a world-class initiative. We can also bring in experts that we have worked with in equipment reliability, aviation safety, construction safety, nuclear safety, human factors, process safety, lean/six sigma, and patient safety to give your program a head start. Don’t try to reinvent the wheel. Let us help you get ahead of the game. Call us at 865-539-2139 to discuss your program and find out how we can help.

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That’s just a few ideas. We have many more. But you will never know how we could have helped you unless you give as a call (865-539-2139) or drop us a note. Our initial advice is FREE and we’ll be happy to provide a quote for any services, training, or software needed to help your program become world-class. 

Don’t procrastinate – call today.

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Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
Information Technology
Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
Equifactor®
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
Technical Support

Success Stories

Reporting of ergonomic illnesses increased by up to 40% in…

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In March of 1994, two of our investigators were sent to the TapRooT 5-day Incident Investigator Team…

Fluor Fernald, Inc.
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