Category: Performance Improvement
“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.
No matter what the industry and even if the root causes found for an issue were accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions while on the other extreme, some use the Trial and Error Method… with a little bit of.. this is good enough and they will tell us if it doesn’t work.
You can use the formal methods listed above or it can be as simple for some risks, to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with a couple of basic rules first:
1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)
2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. Hint, it is okay to use outside sources too.
3. Never forget or lose site of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!
4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.
Simple… yes? maybe? Feel free to post your examples and thoughts.
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
What do you think of this accident investigation and lessons learned?
John Lehman, the youngest Secretary of the Navy who fired the oldest admiral ever, says that Obama’s decision to promote the head of the Nuclear Navy after just two years will put the best safety record in the world at risk.
Here’s a link to the article: http://www.wsj.com/articles/obama-torpedoes-the-nuclear-navy-1432591747
What do you think?
When a major accident happens, look out. The tradition is for “heads to roll.”
That’s right, people get fired.
Who get’s fired? Those that are seen as “part of the problem.”
You need to be part of the solution.
Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.
Then you are part of the answer … Not part of the problem.
Or you could just sit around and wait to get fired.
The choice is yours.
Get trained to use TapRooT® root cause analysis to solve problems. See:
Last week I had someone contact me on LinkedIn to ask if I knew of any free root cause analysis tools to use to investigate accidents.
Yup, they exist. But would you bet your career, your management’s future, and people’s lives on a free answer to significant problems?
Haven’t you heard the old saying:
You get what you pay for!
That got me thinking … How much money do companies lose choosing the cheapest answer rather than the best answer?
Not long ago I saw an article by equipment reliability expert Heinz Bloch about the the true cost of quality. It was an eye opener. (By the way, did you know that Heinz is presenting three talks at the 2015 Global TapRooT® Summit?)
And how many people have you seen that recommend cheap training answers for corrective actions that you know won’t be effective. The incident will happen again causes more loses.
I had someone else tell me that their company was saving money by not having people attend the 2015 Global TapRooT® Summit even though the Summit is guaranteed to produce a return on investment of 10 times the Summit’s cost. They are missing guaranteed improvements and falling behind those who aren’t:
Penny wise and pound foolish.
Don’t make the same mistake.
Adopt the best answer and save.
Attend the 2015 Global TapRooT® Summit on June 3-5 in Las Vegas. Register at:
Do you have incidents that happen over and over again?
Do you have repeat equipment failures?
Does your hospital have similar sentinel events that aren’t solved by your root cause analysis?
How much are these repetitive problems costing your company?
Stop making excuses and try something NEW that can help you stop repetitive problems…
IDEA #1: Attend at TapRooT® Course to stop repeat incidents.
Choose from the:
- 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
- 3-Day Equifactor®/TapRooT® Equipment Troubleshooting & Root Cause Analysis
- 2-Day TapRooT® Healthcare Root Cause Analysis Course
- 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course
These courses are guarantee to help you find root causes that you previously would have overlooked and develop corrective actions that both you and your management agree are more effective.
IDEA #2: Attend the Creative Corrective Actions Course.
Hurry, this course is only offered on June 1-2, prior to the TapRooT® Summit. If your creativity for solving problems is getting stale, this is the course you need to attend.
IDEA #3:: Attend the 2015 Global TapRooT® Summit in Las Vegas on June 3-5.
The Summit is a proven place to network and learn valuable best practices that can help you solve your toughest problems. Each Summit is unique, so you don’t want to miss one. And this year’s Summit is rapidly approaching. Register today at:
Click below to download a report from the European Major Accidents Reporting System (eMARS) about contractor related safety.
I was at a conference yesterday and one of the talks was about advanced root cause analysis. The presenter’s company had their own “home grown” root cause analysis system and they discovered that they were not getting consistent results. Improvement was needed!
They studied their system and discovered something that was missing – management system causes. In the TapRooT® System we have called these “Generic Causes” since we copyrighted the first TapRooT® manual in 1991.
It made me think … Why did they wait 24 years to discover something we’ve known about since before 1991?
Next, I talked with an engineer who had been trained in a common cause and effect system. He wasn’t too pleased with the results he was getting. He wanted to know how TapRooT® could help. Was it different?
I shared how TapRooT® works (see this LINK for the explanation) and it took quite a bit of effort to get beyond the cause and effect model that he thoroughly understood so that he could understand why he was missing things. He was really smart. He asked very insightful questions. He latched onto the reasons that the less systematic cause and effect analysis led to inconsistent results. He saw how TapRooT® could help investigators go beyond their paradigm and get consistent results.
By the end of this second conversation I started thinking … How did we get so far ahead of common root cause systems?
I think I know the answer.
It starts with the Human Factors training that I received at the University of Illinois. It really showed me how to think about human centered design – including designing a root cause analysis system that people could use consistently.
Second, I was fortunate enough to work in the Nuclear Navy where there was an excellent process safety culture and for Du Pont where there was an excellent industrial safety culture. This helped me see how management systems made a difference to performance. (My boss and I at Du Pont actually coined the phrase “Management System” that is now commonly used throughout industry.)
Third, I was well trained by my mentor at the University of Illinois, Dr. Charles O. Hopkins, how to do applied research. So the research I did studying root cause analysis in the mid-1980’s and early 1990’s really paid off when we created the TapRooT® System.
Fourth, we had a really good team that brought out the best in each other during the early development.
Next, we were lucky to have some excellent clients in the nuclear, oil, and aviation industries that were great early adopters and provided excellent feedback that we used to quickly improve TapRooT® root cause analysis in the early and mid-1990’s.
Finally, I made friends with and/or listened to many industry gurus who were experts in safety, process safety, quality, and equipment reliability. Their influence was built into TapRooT® and helped it be a world-class system even in it’s early stages. These experts included:
- Jerry Ledderer, aviation safety pioneer
- Dr. Charles O. Hopkins, human factors pioneer
- Smoke Price, human factors expert
- Larry Minnick, nuclear safety expert
- Rod Satterfield, nuclear safety expert
- Dr. Alan Swain, human reliability expert
- Heinz Bloch, equipment reliability expert
- Admiral Hyman Rickover, father of the Nuclear Navy and process safety expert
- Dr. Christopher Wickens, human factors expert
- Dr. Jens Rassmussen, system reliability and human factors expert
- W. Edwards Deming, quality management guru
- Admiral Dennis Wilkerson, first CO of the Nautilus and first CEO of INPO
That’s quite a list and I was lucky to be influenced by each of these great men. Their influence made TapRooT® root cause analysis far ahead of any other root cause tool.
So that’s why I shouldn’t be surprised that others are finally catching on to things that we knew 25 years ago. Perhaps in a century, they will catch up with the improvements we are making to TapRooT® today (with the help of thousands of users from around the world).
If you would like to learn the state-of-the-art of root cause analysis and not wait 25 to 100 years to catch up, perhaps you should attend a TapRooT® Course in the next month or two. See our course schedule for upcoming public courses at:
And get information about all the courses we offer at:
And if you would like to learn about the state of the art of performance improvement, attend the 2015 TapRooT® Summit coming up on June 1-5 in Las Vegas. Get more information and download the brochure at:
But don’t wait. Every day you wait you will be another day behind the state-of-the-art in root cause analysis and performance improvement. Don’t be left behind!
TapRooT® Root Cause Analysis
Changing the Way the World Solves Problems
Because of the low oil prices, the registration for the 2015 Global TapRooT® Summit by people in the oil and gas industry is down.
As a business owner, I can understand that when your revenues shrink, you need to cut costs. However, as a smart business owner, I know that some expenditures are BUSINESS CRITICAL. If you cut these expenses you aren’t “cutting fat”, you are cutting “meat and bone” and, as a result, future performance will suffer.
The 2015 TapRooT® Summit should be on your list of BUSINESS CRITICAL expenditures that should NOT be cut unless you plan to file for bankruptcy and go out of business. Let me explain why …
First, managers may get the impression that conferences, especially those in Las Vegas, are a boondoggle. Conference attendees are just going for a good time. This IS NOT TRUE with the TapRooT® Summit.
People work hard at the TapRooT® Summit to learn valuable best practices and new ideas for improving performance that they will come back to work and implement. Participants arrive early and stay late to have additional discussions with new people they meet. Attendees make detailed plans of what they are going to do when they get back to work.
Of course, the Summit is NOT all work and no play. We want you to have a good time. And we think that adds to the learning experience. But I think we do a much better job than any other conference I’ve attended at getting people involved in the learning process.
In 1993 I started planning the first the Summit because there was not a place for professionals interested in practical performance improvement and root cause analysis to get together, network, discuss the latest practical improvements and research, and get motivated to return to the fight to change performance for the better. I was not looking to create a conference full of fluff or the same old thing. Rather, I wanted the conference to push the state-of-the-art and promote all of our best users to make themselves even better. That same theme is the basis for the TapRooT® Summit that we are holding in June.
In addition, the purpose of the Summit is not to make money for System Improvements. At best, we break even. Often, we eat a loss. But we think it is worthwhile for our instructors (who are required to attend) and our users (who we hope will attend). The fee involved helps defray the cost of holding the Summit (which you might guess is considerable).
By why should people from the oil industry attend the 2015 TapRooT® Summit?
Because the oil industry just can’t afford another tragic accident. Even in these times of low oil prices, the industry needs to be redoubling their efforts to improve safety and environmental performance. And that’s where the 2015 Global TapRooT® Summit comes in.
Look at the talks and workshops in all the track at the 2015 Global TapRooT® Summit (CLICK HERE). Perhaps you should be working to improve performance by learning from some of these sessions:
- Improving your corrective actions
- Improving your root cause analysis and grading your investigation reports
- Proactively improving equipment reliability
- Developing proactive performance metrics to spot problems before accidents happen
- How to stop “normalization of deviation”
- How to give good feedback to employees by praising character rather than results
- How to track errors and defects/waste on a daily basis
- How to conduct a root cause analysis of multiple similar events
- Find the gaps in your performance improvement program
That’s just a sample of what you could be learning about if you attend this BUSINESS CRITICAL meeting.
But learning IS NOT all that happens at the Summit. The Summit is also about MOTIVATION.
When your company is suffering and people are being laid off, it’s easy to lose your motivation and sink into despair (maybe even desperation). But 2015 Global TapRooT® Summit will send people back to work INSPIRED to make improvement happen even in difficult times.
What might inspire them? Try these Keynote Speakers:
- Dan Quiggle, an aid to President Reagan, will talk about the lessons he learned about leadership from President Ronald Reagan. I don’t care what your politics are, his stories will provide you with motivation to go back to work and make change happen.
- Walter Bond, and NBA star and business owner, will inspire you with a message about self-motivation to become the best.
- Dr. Beverly Chiodo, voted the best speaker we have ever had at the Summit and known as the “Doctor of Encouragement”, will share her inspiring stories about the right way to provide feedback to inspire people to do the right thing for the right reason.
- Alan Smith and Mhorvan Sherret, both retired senior detectives from Scotland who worked accidents in the North Sea, will discuss responding to major accidents. You will once again be inspired by their stories to stop accidents BEFORE they can happen.
- Captain Richard Phillips, the real life inspiration for the movie Captain Phillips (staring Tom Hanks), will share his real life experience. You think you are going through hard times? Think again.
- SAVE LIVES
- PREVENT INJURIES, and perhaps
- SAVE YOUR BOSS’S JOB.
Monday Accident & Lessons Learned: How Many People Will Die Waiting for Management to Implement an Effective Improvement Program?April 27th, 2015 by Mark Paradies
You see the results of ineffective improvement programs in the headlines …
Ten Die in Refinery Explosion
Four Asphyxiated in Confined Space Accident
Fire Kills There Workers
Forklift Accident Kills Teenage Worker
Scaffold Collapse Kills Two Construction Workers
Trench Collapse Kills Father of Three
Welder Killed When Tank Explodes
Eleven Killed in Offshore Platform Explosion
Mine Accident Kills 13
Perhaps you think these were just bad days. That accidents just happen. The truth is that most fatalities are the result of bad programs. They were accidents waiting to happen. If management had effective reactive and proactive improvement programs, these accidents, and others ones like them, would not have had to happen.
- Why didn’t management push for better safety improvement?
- Why wasn’t improving their improvement program one of their highest (or their highest) priority?
- How many people have to die to get management’s attention and make them get excited about investing in effective improvement?
The fatalities continue while we wait for the answer.
If YOU are excited about improving your improvement program and PREVENTING FATALITIES, I have a few ideas for you …
- Take your senior manager on a hazard walk around. Go to one or two places in your plant and challenge the manager to spot all the hazards (sources of energy that could cause a fatality). Did they miss height, lack of breathable air, moving equipment, or other sources that you have seen? Next, take several sources of energy and ask what are the safeguards that keep a fatal accident from happening. Then ask for each safeguard, when was the last time that the manager heard of an audit of the effectiveness of that safeguard? When was the last time the manager checked the effectiveness of that safeguard? Do this once a week and the manager will start thinking hazards, safeguards, and audits of safeguards effectiveness.
- Take your manager to the 2015 TapRooT® Summit. They will network with the leaders in performance improvement that attend the Summit and they can benchmark their improvement efforts against others. They will probably find that they have some good practices to share. But they will also discover some gaps in their programs that need improvement and best practices to make that improvement occur.
- Have on-site training for your management team. Consider the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. Or the Proactive Use of TapRooT® Course. One company even had all their Senior Project Managers (who manage construction programs over $500 million) attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. One of these senior managers pulled me aside to tell me that it was the most valuable management training he had ever had!
Don’t just sit around waiting for management to get excited about improvement after major accident. Prevent the accident. Get them excited about preventing fatalities!
Grading Your Investigations – Summit Best Practice Session 2 at the 2015 Global TapRooT® Summit in Las VegasApril 23rd, 2015 by Mark Paradies
Mark Paradies is organizing the “Grading Your Investigations” session at the 2015 Global TapRooT® Summit.
At this session participants will use an Excel spreadsheet (download your copy below) to grade a typical incident investigation from your facility.
All participants attending this session are asked to bring an investigation report from your facility and the Excel spreadsheet available below preloaded onto a device so that you can participate in the exercise that will teach attendees to grade their company’s investigations using the spreadsheet.
As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section:
“Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 for more than 160 million work-hours. This equals one lost-time incident for every 6.2 million hours on the job. These numbers are a testament to our safety record and a reason why we are in the top tier of safest companies in the industry.”
CB&I’s lost time incident rate is 50 times better than the industry average (.03 compared to 1.5). That might make you wonder, how do they do that?
Answering that question is learning from a lack of accidents!
Here are a couple of thoughts that I have…
First, when you see this kind of success, you know it is because of management, supervisory, and employee involvement in accomplishing a safe workplace. Everybody has to be involved. There can’t be finger pointing and blame. Everybody has to work together.
Second, I know CB&I is a TapRooT® User. CB&I has trained TapRooT® Investigators to find and fix the root causes of incidents and, thereby, keep major accidents (LTI’s and fatalities) from occurring.
So, congratulations CB&I on your excellent performance! Congratulations on the lives you have saved and the injuries you have avoided!
If you are interested in having industry leading safety performance, perhaps you should get your folks trained to find and fix the root causes of problems by using advanced TapRooT® root cause analysis. Find out about our courses at THIS LINK.
And consider attending the 2015 Global TapRooT® Summit on June 1-5 in Las Vegas. You can:
- meet industry leaders who are achieving world-class performance
- benchmark your programs with their programs
- learn industry leading best practices
- get motivated to take your safety performance to the next level.
See the 2015 Global TapRooT® Summit schedule at:
One of the final steps in performing a TapRooT® Root Cause Analysis is finding Generic Causes.
What is a Generic Cause? It is the reason that a root cause is widespread.
For example, a root cause for an error made while using a procedure might be that the procedure has more than one action per step.
4. Remove the drum lid and the polyethylene liner lid, place liner in prepared drum and place in loading position at the final packaging hut. Insert plastic bag in drum liner. Seal the plastic bag with tape to the inside of the drum loading insert.
The fix for this specific root cause might look something like this:
4. Remove the drum lid and the polyethylene liner lid. . . . . . ___
5. Place liner in prepared drum. . . . . . . . . . . . . ___
6. Place prepared drum in loading position at the final packaging hut. . ___
7. Insert plastic bag in drum liner. . . . . . . . . . . . ___
8. Seal the plastic bag with tape to the inside of the drum loading insert. ___
If the team then went to check other procedures and found that this problem was widespread, they would then have a generic problem. The question then becomes: “Why is the problem of ‘more than one action per step’ so widespread? What is the generic Cause that allows us to produce poor procedures?
The root cause analysis team may find that the people writing procedures have no guidance for writing procedures and no training on how to write procedures.
This should cause the team to look for other generic procedure problems.They might also find that procedure formats are confusing, the level of detail is inconsistent, there are excessive references, and the graphics need improvement.
The Corrective Action Helper® Guide provides guidance to fix these kinds of Generic Causes. But the widespread generic procedure problems probably indicate that the company or site doesn’t really know how to produce good procedures. Therefore, the Corrective Action Helper® Book recommendation to fix specific Generic Causes might not be enough guidance.
For example, the Corrective Action Helper® Guide says that for generic “greater than one action per step” problems, the investigators should consider:
“…a general procedure improvement program to remove multiple actions per step from the rest of the facilities procedures.”
However, if the procedures are in really bad shape, more must be done.
Of course, the Corrective Action Helper® Guide provides even more information – references. And if the investigators read the suggested reference, they may look for the additional problems and develop a plan to improve their procedures that is more comprehensive.
That would be great. But how many read the references? My guess is … not that many. After all, in today’s downsized, super-efficient workplace, people just don’t have time.
That’s why System Improvements is here to provide assistance.
If you run into generic problems that you think may be important to fix, we can help.
At a minimum, we can coach your team on the development of generic corrective actions.
Beyond that, we can put an evaluation team together to evaluate the scope of the Generic Cause and develop a plan to improve performance by eliminating the Generic Cause and upgrading current systems.
Finally, if you really need help, we can put together a team to help implement the fix. In this cause, a team of experienced procedure writers to help your company fix their current procedures and coach your procedure writers how to write better procedures in the future.
We can even make rerun visits to audit the status of the corrective actions and the work of your procedure writers.
So when you find a Generic Cause that you know your company isn’t good at fixing (or doesn’t have the time to explore and fix), remember that System Improvements can help.
Don’t let problems repeat because Generic Causes are left un-fixed. Get help. Call us at 865-539-2139 or CLICK HERE to send us a message. We can help you improve!
Antoine de Saint-Exupery
Usually you think about goals when you are setting budgets or maybe at the start of the year. But now that we are well into the year (the first quarter is complete), it might be time to review your goals and your progress on them for the year (and into next year).
Let’s start with the Top 10 Goals that would be applicable to most TapRooT® Users. Take a moment to review them, see if any of them are on your list, and reflect on how you are doing on achieving them.
Then, once you have contemplated your goals, I have a suggestion for you to consider for each goal.
So let’s get started. Here are the Top 10 Goals.
TOP 10 IMPROVEMENT GOALS
1. Improve safety to eliminate fatalities and serious injuries at our facilities. (If you are at a hospital, you might modify this goal to be: “Improve patient safety to eliminate sentinel events.” If you are responsible for equipment reliability you could say: “Improve equipment reliability to eliminate unexpected key equipment downtime.” If you are responsible for quality, you might say: “Improve quality before a major quality issue impacts a customer.”)
2. Improve management participation in improvement efforts.
3. Improve employee participation in improvement initiatives.
4. Motivate people to exhibit positive behaviors that result in success at work and at home.
5. Learn proven best practices from industry leaders that you can apply to your improvement initiatives to make them more effective.
6. Improve corrective actions so that problems never repeat once they are effectively investigated and fixes are implemented.
7. Learn how to stop “normalization of deviance” to ensure safety policies are effectively applied.
8. Develop proactive performance measures to better understand trends in safety, equipment reliability, and production performance.
9. Become a better TapRooT® User to continuously improve your root cause analysis initiatives.
10. Identify the gaps in improvement initiatives and find ways to turn those gaps into strengths in the future.
These top ten goals are rather safety oriented, but if you are responsible for equipment reliability, quality, production, patient safety, you can modify the goals with your improvement efforts in mind and the “safety” list can be converted into a patient safety list, an equipment reliability list, or a production efficiency list.
Now, see how many of these goals match those goals on your top 10 list…
Do you have some goals that you need to add to your list?
How are you doing this year meeting your goals?
Have you made enough progress in the first quarter so that you feel confident
that by the end of the year you will have accomplished all of these goals?
TapRooT® Training and the 2015 Global TapRooT® Summit can help you achieve all 10 of these goals. How? Read on …
GOAL 1. Improve safety to eliminate fatalities and serious injuries at our facilities. (If you are at a hospital, you might modify this goal to be: “Improve patient safety to eliminate sentinel events.” If you are responsible for equipment reliability you could say: “Improve equipment reliability to eliminate unexpected key equipment downtime.” If you are responsible for quality, you might say: “Improve quality before a major quality issue impacts a customer.”)
Did you know that the best way to eliminate a problem is to become proactive in fixing problems? That means you must identify problems and fix them (using TapRooT® Root Cause Analysis) BEFORE an accident, sentinel event, equipment failure, quality issue, or production failure occurs.
How are you becoming more proactive? Here are several suggestions…
Proactive Improvement Suggestions
- SAFETY: Did you know that there is a “Proactive Use of TapRooT®” Course? It was developed to teach people how to become more proactive by using TapRooT® Root Cause Analysis to find and fix the causes of problems before major accidents happen. If you are trying to be more proactive, this just might be the course for you. WARNING: There is only one public “Proactive Use of TapRooT®” Course scheduled for this year. It is on June 1-2 in Las Vegas during our PreSummit.
- If you want to become more proactive, register NOW by CLICKING HERE.
- Get more information by clicking here.
- Consider attending the 2015 Global TapRooT® Summit where you will learn about developing proactive performance measures as part of the Safety Improvement Track. Register for both the Summit and the course by CLICKING HERE.
- EQUIPMENT RELIABILITY: If you are interested in improving equipment reliability by the use of effective troubleshooting and root cause analysis tools AND you would like to use those tools proactively, I have a suggestion. First, if you haven’t already attended an Equifactor® Course, sign up for the one on June 1-2 in Las Vegas. These techniques come highly recommended and are based on a combination of the work done by equipment reliability expert Heinz Bloch and root cause analysis expert Mark Paradies. Then you can stay for the “Equipment Reliability Improvement and Troubleshooting” Track at the 2015 Global TapRooT® Summit where you will meet Heinz Bloch and Mark Paradies and hear the latest information about improving equipment performance.
- PATIENT SAFETY: Improving patient safety has been a focus of the Global TapRooT® Summit since the late 1990s. This year we’ve combined a pre-Summit 2-Day “TapRooT® Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement” Course with the “Improving Healthcare Quality and Patient Safety” Track at the Summit so that those who aren’t familiar with TapRooT® can learn the techniques and discover how to apply them proactively to improve patient safety.
- See the course details by clicking here.
- See the 2015 Global TapRooT® Summit Healthcare Quality and Patient Safety Track schedule by clicking on the track button at this link: http://www.taproot.com/taproot-summit/summit-schedule.
- Register for both the course and the track by CLICKING HERE.
- QUALITY/OPERATIONS: If you would like to apply TapRooT® to improve quality or add it to your Lean/Six Sigma Program, then you should attend the pre-Summit TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training. Then attend the “Process Quality and Corrective Action Program” Track at the 2015 Global TapRooT® Summit. Lean/Six Sigma improvement efforts can be made even more effective (and more proactive) when effective root cause analysis (TapRooT®) is embedded into the program.
- CLICK HERE to register for both the course and the track.
GOAL 2: Improve management participation in improvement efforts.
Is your management involved in your improvement efforts as much as they should be? Many say that a lack of management support is one of the major problems they have when trying to improve performance.
One thing that improvement managers must realize is that it IS NOT management’s job to stay excited about an improvement program. It is the improvement program manager’s job to keep management excited and to let them know if they fail to show support for the improvement effort.
This is especially true because of the recent downturns in the oil and mining industries. Several people have told me that travel and training bans enacted because budget cutting efforts are devastating their efforts to benchmark improvements with others and learn new best practices to keep their program moving forward. When these “global bans” get in the way of making improvement progress happen, improvement managers have to point the problem out to management and let them know that this is sending a clear message that the improvement effort is clearly NOT a top priority and clearly falls behind profitability on the list of things management cares about.
Remind your managers that cutting back on improvement is actually expensive because of the costs of poor quality, accidents, equipment failures, and production upsets.
GOAL 3: Improve employee participation in improvement initiatives.
If your employees don’t seem to be involved in improvement efforts, maybe it is because you haven’t provided the opportunity.
Have you trained your employees to use advanced root cause analysis to solve problems and to use the same tools proactively?
If you need to get your employees fully committed to improving, give them the tools they need. Have an on-site TapRooT® Root Cause Analysis Course. Call us at 865-539-2139 or CLICK HERE to request more information about an on-site course.
GOAL 4: Motivate people to exhibit positive behaviors that result in success at work and at home.
Motivating people is a difficult topic. Perhaps the best advice I’ve ever heard about motivating employees was a talk I heard from Dr. Beverly Chiodo. That’s why for the last decade I’ve had her speak at the Global TapRooT® Summit. And she is speaking again this year in two sessions. The first is the opening keynote talk on Thursday. Her talk is titled “Character Driven Success” and it is sure to make an impact on your life.
She will speak again on Thursday afternoon in a breakout session. Her talk for this session – Praising the 49 Character Traits – will give you practical ideas for changing behavior by properly praising your employees.
If behavior is important to your improvement efforts, don’t miss these two talks. Register for the 2015 Global TapRooT® Summit today.
GOAL 5: Learn proven best practices from industry leaders that can apply to improvement initiatives to make them more effective.
How do you learn about new best practices from inside and outside your industry? Inside and outside your profession?
Two standard methods are:
- Industry/professional trade magazines.
- Industry/professional conferences.
There are some excellent conferences to consider in any industry/profession.
What I’ve found is that even at the best of these conferences, there tend to be industry or professional silos. For example:
- Oil industry folks tend to learn best practices from the oil industry,
- Nuclear industry folks learn from the nuclear industry
- Aviation … aviation
- Heathcare … healthcare
- Manufacturing … manufacturing
- Quality folks tend to meet and share best practices with quality folks,
- Equipment reliability … equipment reliability
- Safety … safety
And to make matters worse, we then tend to look inside our own geographic area/culture/language. US people attend conferences in North America. Europeans … Europe. Australians … Australia.
That’s why when we created the TapRooT® Summit we wanted to do something very different. We wanted to cross geographic, industrial, and professional boundaries.
And we wanted to create an environment where benchmarking and sharing experience is fun.
The feedback that we get after every Global TapRooT® Summit is that we’ve done a very good job of that.
For example, a process safety person from a chemical plant learns best practices from a licensing engineer in the nuclear industry. A healthcare quality improvement professional learns best practices from a flight safety professional. And a nuclear safety engineer learns things from an equipment reliability specialist from a foundry.
Not only do they learn, but they have a good time doing it!
That’s why I’ve had many TapRooT® Summit participants tell me that it is the BEST networking experience that they have ever experienced. Better than any industry conference that they go to.
Thus, if you haven’t yet met your goal of learning valuable best practices that you can implement to keep your improvement program fresh and progressing, you should consider attending the 2015 Global TapRooT® Summit. See all the track schedules at THIS LINK.
GOAL 6: Improve our corrective actions so that problems never repeat once they are effectively investigated and fixes are implemented.
How is your CAPA program doing in preventing repeat incidents? If your goal is to improve, there are several ideas that I could suggest.
- Perform better root cause analysis. If you haven’t taken a TapRooT® Root Cause Analysis Course, take one SOON! See the course schedule by clicking on your region at THIS LINK.
- If you already use TapRooT® and want to improve your use of the technique, attend a 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course. See the course details (which should convince you to attend) at this LINK.
- TapRooT® Users should also consider attending the 2015 Global TapRooT® Summit where there are several tracks that may be of interest including the Incident Investigation and Root Cause Analysis Best Practice Track, the Process Quality and Corrective Action Program Track, the Safety Improvement Track, and the Improving Healthcare Quality and Patient Safety Track.
- There is actually a pre-Summit course – Creative Corrective Actions Course – that is targeted toward people that want to develop better, more effective, corrective actions. See the details by CLICKING HERE.
At least one of those four ideas should help you jumpstart efforts to reach your goals in 2015/2016.
GOAL 7: Learn how to stop “normalization of deviance” to ensure safety policies are effectively applied.
Mark Paradies is presenting a session titled “How to STOP the normalization of deviance” at the 2015 Global TapRooT® Summit in Las Vegas in the “Human Error Reduction & Behavior Change” Track. This particular talk is in Session 5. Be sure that you are there if you are interested in this topic and want to STOP the normalization of deviance.
GOAL 8: Develop proactive performance measures to better understand trends in safety, equipment reliability, and production performance.
This is another topic being covered at the 2015 Global TapRooT® Summit. Final details of this session are not yet posted on the Summit site because the talks are still being developed. But you can be sure that new, interesting, useful information on proactive performance indicators will be presented and that you will develop indicators for your facility.
GOAL 9: Become a better TapRooT® User to continuously improve your root cause analysis initiatives.
You can start your journey to performance improvement by simply attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. But all TapRooT® Users know, this is just the start. Practice, coaching, and advanced training are part of the journey to becoming an expert root cause analysis investigator.
The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training is designed to help you become a root cause analysis expert.
But what do you do to improve your skills after you have attended a 2-Day and 5-Day Course? There are several options.
The 2015 Global TapRooT® Summit includes the following nine tracks:
- Safety Improvement
- Equipment Reliability & Troubleshooting
- Human Error Reduction & Behavior Change
- Improving Healthcare Quality & Patient Safety
- Incident Investigation & Root Cause Analysis
- Process Quality & Corrective Action Programs
- TapRooT® Software
- TapRooT® Certified Instructor
- Special Topics
This is an excellent source of knowledge to improve your performance improvement skills. But beyond the knowledge you learn, you will also make great contacts – friends – across many industries and professional disciplines that can also help you expand your performance improvement network.
Second, before the Summit, we hold special advanced training for performance improvement experts to help them refresh and broaden their skills. At the 2015 pre-Summit, the following advanced courses will be offered that you can use to become a better root cause analysis expert:
- Creative Corrective Actions
- Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement
- Understanding and Stopping Human Error
- Combating Fatigue
- Interviewing & Investigation Basics
- Proactive Use of TapRooT®
- Hazard Recognition
- Getting the Most from Your TapRooT® Software
- TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis
- Risk Assessment and Management Best Practices
- TapRooT® Analyzing and Fixing Safety Culture Issues
- TapRooT® Advanced Trending Techniques
- Advanced Causal Factor Development
- Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course
- 2-Day Incident Investigation and Root Cause Analysis Training
That’s a great list of courses full of advanced knowledge to help you improve.
When and where are the pre-Summit Courses and the 2015 Global TapRooT® Summit? The courses and Summit will be held in Las Vegas on June 1-5, 2015. Register now to make sure that you get your first choice for training.
GOAL 10. Identify the gaps in our improvement initiatives and find ways to turn those gaps into strengths in the future.
Every TapRooT® Session Track at the 2015 Global TapRooT® Summit includes a session focused on identifying the gaps in your performance improvement program and developing ideas to improve your improvement efforts to eliminate the gaps. So, if you are interested in eliminating the holes in your improvement program, attend the 2015 Global TapRooT® Summit and make your improvement efforts sizzle with new best practices, new ideas, and lessons learned from industry leaders.
That’s it. Ten goals and the ways that TapRooT® Training and the TapRooT® Summit can help you meet those goals.
Don’t waste 2015 and 2016 standing still. Get your performance improvement program moving at the speed of light by getting the training and networking that you need to accelerate your program and your career.
See the article by Heinz Bloch at:
And then attend the Equipment Reliability and Troubleshooting Track at the 2015 Global TapRooT® Summit and hear Heinz speak about the business end of equipment reliability and the foundations of Equifactor®. See the complete Summit schedule at:
The Houston Chronicle published an article by Rafael Moure-Eraso of the Chemical Safety Board that was titled: “Hazardous work takes toll on Latinos”.
In the article, Rafael Moure-Eraso claims that among Latinos “… fatality and injury rates are disproportionately high.” He provides statistics on Latino fatalities and injuries in various industries. He references a report that states the obvious (as many Latinos are recent immigrants, they tend to get lower paying and more dangerous jobs). He also states that Latinos are more likely to be at risk as residents near chemical plants (once again, obviously rich people usually don’t sit their mansions next to chemical plants and the poor are more likely to buy cheap housing in a less desirable locations – like next door to an industrial site).
The article seems to be a mix of environmental justice political speech and a call for new federal regulations to improve chemical plant safety.
He ends the article with:
“You can’t put a price on someone’s life. Latinos help drive the country’s economy working hard for companies big and small, often in dangerous occupations. They have a right to safer workplaces and communities.”
That made me think …
- Are new rights (the right to safety … whatever that is) and new federal programs really the way to improve safety in the workplace?
- Do accidents really target specific races?
- Would a federally run workplace be safer than those run by commercial companies?
- Would safety improve faster with more federal direction?
- Does the government know better than those in commercial industry how to improve safety?
- What does management at major companies need to do if they want to avoid a whole new level of “one size fits all” government regulation of process safety and industrial safety?
These are all very interesting questions that take considerable thought. I’d be interested in your opinions. Leave a comment here.
Here’s a CSB video …
What do you think? Has PSM improved in the past ten years? What can we learn?
Is “inherently safer designs” the answer?
Are PSM regulations going to stop accidents?
Are government approaches to PSM inadequate?
Are the suggestions of the CSB inadequate?
Leave your comments here.
Eliminating waste is at the core of Lean Manufacturing. But even without a lean program, any manufacturing manager knows that process downtime can be costly.
Process downtime can cause:
- delayed orders,
- missed schedules,
- missed earning projections, and
- increased costs,
Improving process reliability is the same as improving safety, quality, and equipment reliability. When a process reliability problem happens, it needs to be investigated and the root causes need to be found and fixed.
How do you find and fix the causes of process downtime? You can use the same tools that experts use to find the root causes of other to find the root causes causes of safety incidents, equipment failures, and quality issues. The TapRooT® Root Cause Analysis System.
An example of a process reliability improvement success story is share at:
And they used TapRooT® to go from losing money to a profitable operation. How did TapRooT® help? Watch the video and read about how to use TapRooT® to find root causes at:
Monday Accident & Lessons Learned: Crane Accident at Tata Steel Plant in the UK brings £200,000 Guilty VerdictMarch 16th, 2015 by Mark Paradies
Tata Steel was found guilty of violating section 2(1) of the Health and Safety at Work etc. Act 1974. The result? A fine of £200,000 plus court costs of £11,190.
HSE Inspector Joanne carter said:
“Given the potential consequences of a ladle holding 300 tonnes of molten metal spilling its load onto the floor, control measures should be watertight. The incident could have been avoided had the safety measures introduced afterwards been in place at the time.”
The article listed the following corrective action:
“Tata has since installed a new camera system, improved lighting, and managers now scrutinise all pre-use checks. If the camera system fails, spotters are put in place to ensure crane hooks are properly latched onto ladle handles.
Here are my thoughts…
- Stating that corrective actions would have prevented an accident is hindsight bias. The question should be, should they have learned these lessons from previous near-misses?
- Reviewing the corrective actions, I’m still left with the question … Should the crane be allowed to operate without the camera system working? Are spotters a good temporary fix? How long should a temporary fix be allowed before the operation is shut down?
- What allows the latches to fail? Shouldn’t this be fixed as well?
What do you think? Is there more to learn from this accident? Leave your comments here.
If your company has a major accident, the board of directors will know the cost of human error.
But human error happens every day. And the small incidents and mid-size accidents can add up to billions of dollars in waste, injuries, and warranty costs.
How much of the billion dollars in waste comes from your company? Do you keep track?
How can you know how much you should invest in stopping human error if you don’t know how much human error costs?
One thing that is for sure, if you are worried about human error, you should attend the 2-Day TapRooT® Understanding and Stopping Human Error Course taught by Joel Haight and Mark Paradies.
The course will help you understand why human error occurs and the best practices you can implement to make human action much more reliable.
The course is being held on June 1-2.
Just after this course is the 2015 Global TapRooT® Summit.
The Summit include a track titled, “Human Error Reduction and Behavior Change.” To see all the topic covered, see this link:
And click on the appropriate track button.
Register for both the 2-Day TapRooT® Understanding and Stopping Human Error Course and the TapRooT® Summit forgive days of great learning, networking, and best practice sharing. Just CLICK HERE to get started.
Monday Accident & Lessons Learned: How Much Root Cause Analysis Can You Buy for $5.6 Million Dollars?February 23rd, 2015 by Mark Paradies
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 paper, 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:
- Do you require that your contractors perform adequate accident investigations?
- What root cause tools do your contractors use? Shouldn’t they be using TapRooT®?
- 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?).
- 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?
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.
SI is now a sponsor of the Operational Excellence Society. You can join the society for free. See:
And click on the “register” button on the top of the page.
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:
- Stop Fatalities
- Reduces Regulatory Conflict
- Avoids Major Financial Losses
- Keeps Clients Happy
- Eliminates Bad Press
- 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.
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.