The UK Rail Accident Investigation Branch has released their annual report for 2012. CLICK HERE to download the report.
Carolyn Griffiths, the Chief Inspector at the RAIB, starts the report with an interesting observation … that they see some accidents types happen over an over again from one year to the next. She says that this is evidence that the industry needs to do more.
That brings up two important questions …
1) Are you reviewing your accident history on a periodic basis and have you looked for recurring events?
2) If you have noticed recurring events, why are they happening? Why haven’t you be successful in preventing recurrence?
Some serious thought is needed to learn from our past experience and to make sure that we don’t relive history.
We offer advanced trending courses that can help you really understand performance at your facility.
See information about the course here:
Trending is NOT too hard. Watch what these kids are doing…
© Copyright 2013 By System Improvements Inc. Used by Permission.
WHAT IS YOUR PURPOSE?
Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.
For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.
Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.
The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.
This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…
WAITING FOR BIG ACCIDENTS
Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?
I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:
Near-Misses Not Reported
If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.
Hazards Not Recognized
Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).
Shortcuts Become a Way of Life (standards not enforced)
This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.
Process Safety Not Understood
We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.
Ineffective Root Cause Analysis
If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.
Inadequate Corrective Actions
I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?
Corrective Actions Not Implemented
Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.
Trends Not Identified
If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.
INVESTIGATING PAPER CUTS
Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.
Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.
WHAT SHOULD YOU DO?
You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.
“An ounce of prevention is worth a pound of cure.”
If you can’t see yourself ending up in jail because of an accident, how about your attorney’s office?
What’s the point of the headline?
You have a choice. You can either be proactive and prevent accidents or reactive and fight fires after the accidents occur.
What is better … hiring good lawyers to keep you out of jail after a fatal accident or spending time and effort being proactive to prevent the accident from happening?
In both cases, TapRooT® is a great tool for finding and fixing the root causes of problems. But we believe being proactive is much better than being reactive.
Would you like to be proactive in preventing fatalities? Then attend the Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT®.
Whatever you do, DON’T sit by idly waiting for a major accident to occur. Develop you plan to improve performance and prevent fatalities and serious injuries from happening.
Do it today or you may have plenty of time to contemplate your plan while sitting in a jail cell!
New Report: Hospital Errors are the Third Leading Cause of Death in the US and Improvement is Too SlowPosted: October 31st, 2013 in Medical/Healthcare, Performance Improvement
The Leapfrog Group issued a press release about hospital safety scores that once again showed that errors in hospitals are deadly and that improvement of patient safety is occurring too slowly. See the press release at:
Here is more discussion about the most recent rating results:
And here is a site where you can look up the ratings of the hospitals near you:
What can you do to start improving performance at your hospital? Advanced root cause analysis – TapRooT® – can tell you what needs to be fixed.
Learn how TapRooT® can help your hospital improve patient safety by attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Here’s our upcoming worldwide course schedule:
Just click on your continent to see courses closer to you.
And if you are already TapRooT® Trained, attend the Improving Healthcare Quality and Patient Safety Track at the 2014 Global TapRooT® Summit near Austin, Texas. See the track topics by clicking on the fourth button in the left column at:
You will learn best practices from other hospitals and from other industries from around the world.
Found two calculators for the cost of accidents on MSHA’s web site.
The first estimates the annual accident costs at your site when you plug in your annual number of fatalities, your annual number of lost work day cases, and your annual number of reportable cases without a lost workday.
The second calculator estimates the impact of accidents on profits/sales at your company.
Both bof these calculators are generic (not just for mining injuries) based on National Safety Council data.
See both calculators at:
His article in Metals Engineering Quarterly starts with …
“Progress — like freedom — is desired by nearly all men, but not all understand that both come at a cost. Whenever society advances — be it in culture and education or science and technology — there is a rise in the requirements man must meet to function successfully. The price of progress is acceptance of these more exacting standards of performance and relinquishment of familiar habits and conventions rendered obsolete because they no longer meet the new standards.”
Read and consider the entire article here …
If you answered a hornet’s nest, you are correct!
It’s the first one I’ve ever seen in person in the wild (with real, live hornets buzzing in and out).
What does this have to do with root cause analysis?
Practice the skills you learn in a TapRooT® class by analyzing everyday situations. In this example, let’s look at Energy – Safeguard – Target.
What is the ENERGY?
I guess I would call it a biological source of Energy – HORNETS!
What is the TARGET?
Anything that disturbs the nest. It could have been me if I moved any closer.
What are the SAFEGUARDS that protected me from the hornets?
In this case, the only safeguard was my own awareness when walking through the woods.
That’s a pretty weak human performance safeguard. But this time it worked!
Should I have removed the hazard? No way! That’s much more risk that just leaving the area and remembering where the nest is.
How many “awareness” safeguards do you depend on at work? Is that really good enough? Should you be removing the hazards?
That’s your root cause analysis tip to think about for today!
Want to learn more about TapRooT®, advanced root cause analysis, and Energy – Safeguard – Target Analysis (we call it Safeguard Analysis)? Then attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the upcoming worldwide public course schedule at:
I remember this song from when I was a kid. Watch Johnny Cash sing it here:
Here’s the lyrics:
They gave him his orders down at Monroe, Virginia,
Saying, “Steve, you’re way behind time;
This is not 38, but it’s Old 97,
You must set her into Spencer on time.”
He turned around, saying to his black, greasy fireman,
“Just heave in a little more coal,
And when we reach that White Oak Mountain,
You just watch Old 97 roll.”
It’s a mighty rough road from Lynchburg to Danville,
And Lima’s on a three-mile grade;
It was on that grade that he lost his air brakes,
You can see what a jump he made.
He was going down grade, doing ninety miles an hour,
When his whistle began to scream;
They found him in the wreck, with his hand on the throttle.
He was scalded to death by the steam.
A message arrived at Washington Station,
And this is what it read:
Those two brave men who pulled Old 97
Are lying in Danville, dead.”
Oh, ladies, you must take warning,
From this time on and learn:
Never speak harsh words to your true loving husband,
He may leave you and never return.
Here’s another version that might be easier to hear…
What’s the lesson learned from this accident/song?
The original lesson was …
So now all you ladies … you’d better take a warning
From this time on and learn
Dont you speak hard words to your true lovin’ husband
He may leave you and never return – poor boy!
But our perspective on safety has changed. Now everyone has the right to return home in one piece.
Accident should be prevented. Especially fatalities.
How can you prevent fatalities? If you would like to learn the latest strategies, attend the 2014 pre-Summit Course:
Don’t miss this chance to learn to stop the train wrecks before they happen!
Here’s another version of the song from The Beverly Hillbillies Show!
No sad lesson learned with this version … Let’s make sure there are no sad lessons learned at your facility!
When I started reading this article by Karl Stephan, I thought … “Oh no. Here we go again.” What made me think that? This statement:
“Home to a large number of refining and petrochemical plants and other high-tech industries, Texas has had more than its share of explosions, fires, leaks of toxic and polluting chemicals, and other chemical-related accidents.”
After all, I thought, how could he know that Texas had more than their fair share of chemical accidents? Fair share by what standards? Amounts of chemicals produced? Employment? After all, should accidents be allotted equally to all states no matter what there industrial mix is?
But I my first impression was wrong. The article turned into a discussion of a real problem. You can’t find accurate statistics about chemical accidents. Even worse, you can’t get agreement on what chemical incidents should be reported and who they should be reported to.
The article doesn’t propose any wonderful solution, but it is worth reading. So see:
The article starts with:
“Did you know that 95 million workdays per year are lost due to slip-and-fall injuries?”
It also provides these facts:
- 9 million people go to the hospital each year due to slips, trips, and falls.
- Slips, trips, and falls are the number one cause of workers’ compensation claims costing, on average, $20,000 per claim.
- The average time off due to a fall accident is 38 days.
- Occupations with the most slips, trips, and falls are food servive workers, nurses, janitors, and police officers.
- Slips, trips, and falls account for 65% of all work days lost due to injury.
Isn’t it time you did something about slips, trips, and falls at your company? Start planning now to attend the 2014 pre-Summit courses titled “Preventing Slips, Trips, and Falls“.
Rob Shaw, expert in preventing slips, trips, and falls from the UK Health & Safety Laboratory, is coming to the US to share the results of his research. This includes practical exercises to reduce the likelihood of slips, trips, and falls at your facility.
For more information, CLICK HERE.
Also, sign up for the 2014 Global TapRooT® Summit. You can learn best practices to improve safety from industry leaders and experts from around the world. CLICK HERE for more Summit info.
Before you can analyze root causes, you need to decide what you are looking for. The first definition of a “root cause” used by TapRooT® was:
“The most basic cause (or causes) that can reasonably be identified
that management has control to fix and, when fixed,
will prevent (or significantly reduce the likelihood of) the problem’s recurrence.”
But in 2008, we published a new definition for a root cause:
“A Root Cause is the absence of a best practice or the failure to apply knowledge
that would have prevented the problem.“
Therefore, root cause analysis is:
“The process of looking for the problems that can be fixed
when best practices and knowledge are applied.”
That may seem like a simple definition, but in finding root causes, the devil is in the details.
In the more than 30 years we have spent developing TapRooT® and improving it until is is an international best practice for root cause analysis, we have found several steps to finding root causes that just can’t be overlooked.
First, you have to understand the sequence of events that lead to an accident or incident BEFORE you can understand why it happened. This understanding comes from careful investigation and collection of facts and organizing those facts into a timeline.
In TapRooT® Courses, we teach investigators to start each investigation by drawing a SnapCharT® – a graphic “picture” of what happened and the facts around each step in the sequence of events.
Second, once the sequence of events and facts surrounding them are understood, investigators are taught to organize the events and facts and identify Causal Factors that, if eliminated, would have prevent the incident or made it less severe. Causal Factors are NOT root causes. Instead, the are the problems that are caused by the root causes. They are usually failed safeguards that were suppose to prevent the accident. These failed safeguards are often related to human errors and equipment failures that need to be prevented in the future to keep the accident from recurring.
Once the Causal Factors have been identified, the investigator is taught to look for each Causal Factor’s root causes.
That’s right. We aren’t looking for the root causes of the accident. Instead, we are looking for the root causes of the Causal Factors that came together on that particular day in that particular sequence to cause the accident. The root causes have often been around for years waiting for just the right sequence of events with the right Causal Factors to cause the accident.
In TapRooT®, we teach a technique called the Root Cause Tree® to help an investigator find the root causes of the Causal Factor. In most other root cause tools, the investigator is limited by their knowledge when analyzing root causes. In other words, that can’t find root causes that they aren’t aware of.
The Root Cause Tree® provides guidance to investigators to get them to consider potential causes beyond their preexisting knowledge by using a set of question and definitions to expand the potential causes that an investigator considers. This set of questions is an eye opener to both new investigators and experienced professionals because of the depth and breadth of the root causes that they are encouraged to consider.
In addition, once investigators get practiced using TapRooT®, they find they do a much better job collecting evidence earlier in an investigation because their eyes have been opened to new lines of inquiry that they previously would not have considered.
Once the specific root causes of the Causal Factors of an accident have been found, TapRooT® Courses teach investigators to look for generic causes.
Generic cause analysis takes the investigator from a root cause to the systemic reasons that the root cause was allowed to exist. For example, if a problem was caused by a valve not being labeled, generic cause analysis would check to see if other valves were also not labeled and, if they weren’t, why labels weren’t being applied (or were being lost) throughout the facility.
Once the root causes and generic causes are identified, the investigators are taught to use two tools – Corrective Action Helper® and SMARTER – to develop effective corrective actions that address the root and generic causes.
Finally in TapRooT® Courses, investigators are taught to present their finding to management so that management can understand what happened and the actions they need to promote to prevent recurrence of the accident.
That’s it! Using TapRooT®, root cause analysis is a systematic, repeatable, auditable process that is focused on finding and fixing the real root causes of problems so that future accidents and incidents can be prevented.
Want more information about TapRooT®? See:
For the various types of TapRooT® Root Cause Analysis Courses, see:
And if you are interested in TapRooT® Training, see our public TapRooT® Root Cause Analysis Courses that we hold around the world at:
Or to arrange a TapRooT® Root Cause Analysis Course at you site, CLICK HERE.
by Mark Paradies
Someone recently asked me:
“How is TapRooT® different from other root cause analysis tools?“
While answering the question, I concluded that it was the wrong question. The question should have been:
“Why is it that so many industry leaders have chosen TapRooT®
to be their standard for finding and fixing the root causes of problems?“
It’s not what makes TapRooT® different … It’s what makes TapTooT® clearly superior that should be the focus of the question and my answer.
Some people just don’t get this line of questioning. They say things like:
“Every techniques has its advantages and disadvantages.“
They just don’t understand that people can’t be trained in every technique.
Companies can’t afford to train everyone to be a guru problem solver.
Companies need a “best answer.” A root cause system that has been intelligently designed to meet the needs of the people in the field. People doing real investigations. A system they can adopt as a standard.
The techniques in this standard system need to be “human factored” – designed with the limitations and capabilities of the users in mind.
When designing TapRooT®, Mark Paradies and Linda Unger not only used the human factors expertise that Mark brought to the development, but also worked with outstanding human factors experts (including Dr. Charles O. Hopkins and Smoke Price).
They human factored the TapRooT® System to make it usable. That makes it superior.
But the development efforts didn’t stop there.
Mark got reviews and comments from safety and reliability experts from a number of industries including aviation (Jerry Lederer, father of aviation safety), nuclear power and nuclear weapons (Larry Minnick, nuclear plant safety expert, and Paul Haas, DOE human factors & safety expert), and the oil/petrochemical business (Heinz Bloch, equipment reliability guru).
Those named are just a sample … not an exhaustive list. There were many more TapRooT® Users who helped in the early TapRooT® development efforts.
This made TapRooT® grow beyond one philosophy – beyond a single industry perspective.
Investigation + Root Cause Analysis
All this knowledge helped us develop not just a root cause analysis system, but something more … an investigation and improvement process that includes built-in human factored root cause analysis and troubleshooting tools.
When people tack root cause analysis on to an already completed investigation, they are missing the power of the techniques to help the investigator collect and evaluate investigative information.
That’s why TapRooT® is not just root cause analysis. TapRooT® is root cause analysis meshed with troubleshooting, an investigation process, and performance improvement processes (both reactive and proactive).
The whole system is made to work together seamlessly.
That’s different and superior!
Don’t Start Off Looking for “Why?”
I don’t want to give away all the secrets that make TapRooT® superior, but I will share a few more that should help people trying to decide if they should attend TapRooT® Training.
First, unlike many root cause analysis tools (think 5-Why’s or any cause-and-effect based system), TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.
That’s a key difference.
One of the big drawbacks of many systems is that people using them jump to conclusions about why something happened before they understand what happened. It’s a natural human tendency. In fact, the more knowledge about a problem someone is, the more likely they are to think they automatically know the answer.
In TapRooT®, an investigator’s first goal is to build a complete SnapCharrT®.
A SnapCharT® visually shows what happened and as much information as can be gathered about the factors that surrounded what happened before one starts looking for root causes.
Users find this initial focus a major advantage because it helps them avoid the “blame trap” and the trap of jumping to conclusions.
Expert System Helps Investigators See Beyond Their Current Knowledge
The next major advantages of TapRooT® is the way TapRooT® looks at root causes and the tool used to guide investigators to the root causes of the problems causal factors.
In TapRooT®, we realized that accidents aren’t quite like falling dominoes. In fact, most accidents have multiple causes that existed prior to the accident and just never came together in the exactly wrong fashion at one point in time to cause the accident. Sometimes people call this coincidence “bad luck.” Engineers and statisticians may think of using Monte Carlo methods to simulate the seemingly randomness of real life.
Because of this, TapRooT® encourages investigators to identify all the causal factors and to find each causal factor’s root causes. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each causal factor that contributed to an accident.
Think about this as multiple opportunities to improve performance by improving multiple defenses to keep accidents from happening.
The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. Nobody has anything close to our tree.
Most of the development effort of the Root Cause Tree® was focussed on helping people in the field find the causes of human performance (including behavioral) problems.
The Root Cause Tree® is unique in the guidance it gives investigators in analyzing human performance issues including an expert system to start the troubleshooting of human errors, the categorization of best practices that is embedded in the tree, and the guidance for each category built into the Root Cause Tree® Dictionary.
Some say that the goal we set out for the Root Cause Tree® is impossible to achieve. We wanted to capture 90 – 98% of the root causes of human error in the categories on the tree. They say that it is impossible to include ALL the causes of human error in a model. Instead, they say that one should start out with an open mind and analyze each problem from scratch.
There are two problems with this argument.
First, the human brain thinks categorically. For example, the language we use to describe an accident is based on words (categories). So even if you try to start with an open mind, your brain is already categorizing.
We have found that the vast majority of investigators have not had specialized training in human factors. Therefore, they don’t know what they should be looking for (they don’t have the categories in their brain). This makes it almost impossible for them to identify the causes of human errors and develop effective corrective actions.
That’s why they revert to the standard answers of blame (counseling and discipline solutions), training, and, when all else fails, writing a procedure. It’s not that these answers are always wrong. It is that these answers are just a small fraction of what needs to be done to improve human performance. And the Root Cause Tree® provides a much more complete answer.
Second, we never said the Root Cause Tree® has all the answers.
The Root Cause Tree® is just the best list we’ve ever seen. We think it is closer to the 98% end of the scale than to the 90% end. And we know it is much more complete than the answers in the models carried in the heads of the people who come to our training. Thousands of users that we train each year tell us that TapRooT®’s Root Cause Tree® expands the universe of problems they can find and solve …. It does not restrict their problem solving efforts.
Having designed TapRooT® and spent over 20 years improving it, I could go on with other major and minor advantages that we’ve worked so hard to incorporate into the TapRooT® System. But I’ll stop here with one more reason that TapRooT® is superior…
We started with a great design but we didn’t stop.
We search for and implement ideas that make TapRooT® ever better, including ideas from international experts and our TapRooT® Advisory Board (60+ people from industry leading companies).
Better training, better software, and better techniques.
Continuous improvement keeps TapRooT® the state-of-the-art in root cause analysis and makes it superior.
TapRooT® as Your Root Cause Analysis Standard
Of course, there are more advantages to using TapRooT® – reasons that industry leaders around the world have standardized on just one method of root cause analysis. But by now you are probably thinking…
“Why haven’t we standardized on TapRooT® yet?”
Seems like a great idea.
Get started by attending one of our public TapRooT® Courses.
See the complete schedule at:
These courses come with a money-back guarantee:
Attend a TapRooT® Course. Go back to work and apply what you have learned. If you don’t find root causes that you previously would have overlooked and if you and your boss don’t agree that you develop better corrective actions that are more effective, just return the course materials and any software supplied and we will refund the entire course fee.
That’s how confident we are that you will feel the difference.
TapRooT® isn’t just different, it’s superior.
Already Using TapRooT®? Get Better!
How do those that already use TapRooT® keep up with the newest TapRooT® improvements to sustain their programs and build on their success?
They attend the TapRooT® Summit.
That’s the best way to learn even more.
For information, see:
and get registered!
Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.
Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.
Often FDA findings are found by an external audit. To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction? Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?
I suggest Enforcement needs improvement is not the only problem. To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators. Here is our upcoming courses link: http://www.taproot.com/store/Courses/
To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit. http://www.taproot.com/content/wp-content/uploads/2012/02/RileyandGorman.pdf
Then check out the quality track in the upcoming 2014 Summit in April. http://www.taproot.com/products-services/summit
With all our knowledge, why do we continue to have deadly process safety accidents?
Process safety accidents are accidents that kill people not by standard industrial safety hazards like falls from height or contact with electrical lines. Rather, process safety accidents happen when a potentially hazardous process fails.
OSHA and the EPA have written regulations to attempt to control these accidents – fires and explosions – in the chemical industry. But process safety accidents happen in more industries than chemical manufacturing plants and refineries. Examples include the Deepwater Horizon oil drilling accident, the fertilizer explosion in West, Texas, (a distribution site), airline crashes, nuclear plant accidents, grain elevator dust explosions, etc. The list goes on and on. You might even include patient safety accidents at hospitals.
Why, when we know how to make these processes work reliably, do accidents continue? I believe management doesn’t understand the keys to running a high reliability operation at a high hazard facility. These lessons go beyond OSHA/EPA regulations and require a commitment and understanding by senior management of the technology being managed and of the processes to ensure safety. And I spoke about these concepts at the 2010, 2012, and 2013 TapRooT® Summits. If you missed these talks, you can see them by CLICKING HERE.
That will get you started. But you should also plan to attend one of our Best Practices for Reducing Serious Injuries and Fatalities Course on October 24-25 in Knoxville, TN. CLICK HERE for more information.
People usually have a reason they attend TapRooT® Training. They are trying to improve an aspect of their business performance. But they don’t usually have any idea of ALL the ways TapRooT® can help their company improve. This list provides ideas for you to think about:
• Better accident/incident investigation to improve safety.
• Improve lean/six sigma programs by applying advanced root cause analysis.
• Find the root causes of equipment failures and improve equipment reliability.
• Proactive analysis of business processes to eliminate human error.
• Proactive analysis of potentially fatal tasks to prevent fatalities and serious injuries.
• Improved root cause analysis of near-miss accidents with potential for fatal injuries.
• Analysis of cost overruns/schedule delays.
• Analysis of customer complaints.
• Improved pre-job safety analysis to prevent injuries.
• Analysis of production outages.
• Analysis of environmental permit violations to improve permit compliance.
• Improve behavior-based safety by analyzing observations that have potential for serious injuries.
• Human resources analysis of disciplinary cases using root cause analysis.
• Improved audits/assessments using root cause analysis for audit planning and corrective action development.
• Pre-startup proactive equipment reliability analysis.
• Provide accurate statistics for analysis of programmatic issues.
• Development of human performance improvement audit checklists.
Anything in the list catch your eye?
If you haven’t already attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, maybe you should.
Also, consider attending our 2014 Global TapRooT® Summit near Austin, Texas, on April 7-11.
What Happens When a Root Cause Analysis Conflicts with Management Expectations … What do you do to manage sensitive investigations?Posted: July 9th, 2013 in Accidents, Current Events, Investigations, Performance Improvement
One of the most difficult root cause analyses is one that deals with safety culture and management systems.
Although I have no first hand knowledge of this case described in the link below, I would guess this is a good example of how a division can grow between managers and analysts when a root cause analysis becomes sensitive. Read this Associate Press article to get some background material:
Once a root cause analyst decides they have to go to the press to “restore the focus on safety,” you know that the analyst thought that the root cause analysis report/presentation didn’t get the attention that the analyst thought was deserved. I would say that this desperate move is both a failure for the analyst and for management – nobody is a winner and everybody loses.
How can a company avoid this difficult situation? I think there are three things needed:
1) A root cause analysis system that is based on facts and guidance in the areas of management systems/culture.
2) Selecting knowledgable analysts that have the ability to work with management and help them see where improvements are needed and constantly upgrading the analyst’s skills.
3) Management that is involved in the root cause analysis process and willing to address findings with actions that make change happen.
One more thing that can help the process succeed is a rewards system for good investigations that thoroughly look for and address management system root causes.
What have you done at your facility to improve root cause analysis and prevent missed expectations on sensitive root cause analyses?
Have you had your investigation facilitators/team leaders attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?
Have people who will investigate culture issues taken the Analyzing and Fixing Safety Culture Issues Course that we offer prior to the TapRooT® Summit?
Has management been trained to participate in root cause analyses and do they understand their role in making root cause analysis successful?
Does your management team understand the difference between managing industrial safety and process safety?
Are you learning best practices on improving root cause analysis and process improvement by having your program manager attend the TapRooT® Summit every year?
Things to think about (and a small price to pay) to keep your career on track and your company out of the papers.
Nine thousand people interested in advanced root cause analysis are connected to Mark Paradies’ LinkedIn network.
You can see his profile at:
Be one of the next thousand to join his network. Just send him an invitation by clicking on the “Add Mark Paradies to your network” link at the upper right side of his profile page at the link above.
Great video on the Inc. web site on how to motivate employees (and it’s not with money). See:
Hydrocarbon Processing reported that an independent US refiner has agreed to pay a $1.1 million dollar civil penalty for compliance problems with recordkeeping, reporting, sampling and testing at 4 US refiners. The EPA said it was the largest penalty ever for violations like these (related to testing the quality of conventional gasoline).
The question in my mind was … “Why didn’t they apply advanced root cause analysis to the early problems to avoid repeat violations at multiple refineries?”
Also … “Wouldn’t it have been better to learn proactively (applying root cause analysis techniques before violations occurred to catch and correct problems)?”
Root cause analysis isn’t just for safety. It can be used for quality, environmental. production, maintenance problems, hospital sentinel events, and many other issues. Find out how to use root cause analysis to improve performance at our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.
How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.
Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.
Here are the links:
Mark’s General Session Talk About Fatality Prevention from the 2013 Summit
I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.
For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.
Monday Accident & Lessons Learned: Accidents at Intersections Reduced After Red Light Cameras RemovedPosted: April 29th, 2013 in Accidents, Human Performance, Performance Improvement
Here’s a link to the story in the Houston Chronicle:
The story says that:
“In the five months after Houston voters forced city officials to turn off a camera surveillance system that fined motorists for running red lights, traffic accidents at those 50 intersections with 70 cameras have decreased 16 percent, according to recently released data.”
There were lot’s of reasons given by officials for this unexpected outcome. Everything from the “weather was good” to “the camera’s had trained people to be safer.”
The interesting statistic that no one mentioned was that it is usual for rear-end collision to increase when red light cameras are installed because, to avoid a ticket, people slam on their brakes when a light turns red and they get rear ended.
There are at least two lessons that I think you can learn from this article.
1. People don’t know how to trend infrequently occurring accident statistics.
In this case, no one on either side of the argument used advanced trending techniques to prove their point. Instead, they chose the statistics that best fit their argument and claimed that those stats proved their point.
2. Sometimes corrective actions can have unintended consequences.
Several times in the past we’ve discussed red light cameras as an enforcement tool and the consequences that the tool could have on accident statistics. Our general opinion is that the cameras would be great for raising revenue but would do little to improve safety. For several reasons, rear end collisions were an unintended consequence of red light cameras that tend to increase accident rates at intersections where the devices were installed. So all people looking to improve performance should learn that your corrective actions may have other consequences than the ones you intend them to have!
The story is reported at WorkersCompensation.com that Walter Cardin, Safety Manager for the Shaw Group, was convicted of 8 counts of major fraud. The charges were a result of a six year investigation by the TVA Office of the Inspector General.
Obviously it is better to really improve safety rather than lying about the statistics.
Learn to use advanced root cause analysis to improve your safety record at a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. CLICK HERE for more information about the course and HERE for our public 5-Day TapRooT® Course schedule.
I recently wrote about Cal OSHA spending 20% of its budget investigating a non-fatality fire at Chevron’s Richmond Refinery. See the article HERE.
The article asked the question … “Should regulators focus their efforts on bad actors (actual fatalities), accident investigations, or proactive improvement efforts?”
But this question is applicable well beyond prioritizing the efforts of regulators to improve safety. EVERYONE involved in an improvement effort has a limited budget, limited time, limited “silver bullets” of where management can focus their attention. So the question is equally applicable to everyone involved in improvement. The broader question is …
“How do you prioritize your improvement budget?“
How much effort goes into:
- accident investigation and corrective actions
- incident investigation and corrective actions
- near-miss investigation and corrective actions
- behavior-based safety
- six-sigma/lean improvement efforts
If you measure the effectiveness of the improvements that each improvement initiative produces, you could rationally budget your improvement efforts.
How do you measure trends? Do you have the advanced trending techniques you need to measure improvements in infrequently occurring statistics?
Please leave your ideas as comments here…
Lesson 1: Definiteness of Purpose
Definiteness of purpose is the starting point of all achievement. Without a purpose and a plan, people drift aimlessly through life.
Lesson 2: Mastermind Alliance
The Mastermind principle consists of an alliance of two or more minds working in perfect harmony for the attainment of a common definite objective. Success does not come without the cooperation of others.
Lesson 3: Applied Faith
Faith is a state of mind through which your aims, desires, plans and purposes may be translated into their physical or financial equivalent.
Lesson 4: Going the Extra Mile
Going the extra mile is the action of rendering more and better service than that for which you are presently paid. When you go the extra mile, the Law of Compensation comes into play.
Lesson 5: Pleasing Personality
Personality is the sum total of one’s mental, spiritual and physical traits and habits that distinguish one from all others. It is the factor that determines whether one is liked or disliked by others.
Lesson 6: Personal Initiative
Personal initiative is the power that inspires the completion of that which one begins. It is the power that starts all action. No person is free until he learns to do his own thinking and gains the courage to act on his own.
Lesson 7: Positive Mental Attitude
Positive mental attitude is the right mental attitude in all circumstances. Success attracts more success while failure attracts more failure.
Lesson 8: Enthusiasm
Enthusiasm is faith in action. It is the intense emotion known as burning desire. It comes from within, although it radiates outwardly in the expression of one’s voice and countenance.
Lesson 9: Self-Discipline
Self-discipline begins with the mastery of thought. If you do not control your thoughts, you cannot control your needs. Self-discipline calls for a balancing of the emotions of your heart with the reasoning faculty of your head.
Lesson 10: Accurate Thinking
The power of thought is the most dangerous or the most beneficial power available to man, depending on how it is used.
Lesson 11: Controlled Attention
Controlled attention leads to mastery in any type of human endeavor, because it enables one to focus the powers of his mind upon the attainment of a definite objective and to keep it so directed at will.
Lesson 12: Teamwork
Teamwork is harmonious cooperation that is willing, voluntary and free. Whenever the spirit of teamwork is the dominating influence in business or industry, success is inevitable. Harmonious cooperation is a priceless asset that you can acquire in proportion to your giving.
Lesson 13: Adversity & Defeat
Individual success usually is in exact proportion of the scope of the defeat the individual has experienced and mastered. Many so-called failures represent only a temporary defeat that may prove to be a blessing in disguise.
Lesson 14: Creative Vision
Creative vision is developed by the free and fearless use of one’s imagination. It is not a miraculous quality with which one is gifted or is not gifted at birth.
Lesson 15: Health
Sound health begins with a sound health consciousness, just as financial success begins with a prosperity consciousness.
Lesson 16: Budgeting Time & Money
Time and money are precious resources, and few people striving for success ever believe they possess either one in excess.
Lesson 17: Habits
Developing and establishing positive habits leads to peace of mind, health and financial security. You are where you are because of your established habits and thoughts and deeds.