Taproot

DEATH TOLL

What kills more people in the US than industrial accidents, highway accidents, and airline accidents combined?

Mistakes in hospitals.

The technical term for these mistakes is “Sentinel Events.”

Estimates of the deaths caused vary. We use estimates because there are no accurate statistics on the total number of deaths caused by mistakes in hospitals. There is no national reporting requirement.

Even though there is no national reporting requirement, studies show that despite over a decade of effort to stop sentinel events, no progress is being made. Some studies actually show the problem getting worse. And this problem isn’t unique

WHY NO IMPROVEMENT

Why can’t we improve? There are a number of factors that make improvement difficult:

1. Healthcare Complexity

2. Poor Root Cause Analysis (RCA)

3. Inadequate Corrective Actions

4. Not Enough Management Attention

We will review all of these factors and what we can do about them in the following sections.

HEALTHCARE COMPLEXITY

Medical practice keeps getting more complex. More complex technology. More drugs with more interactions. More pressure to work faster and be more efficient. The result? More chances to make errors with catastrophic consequences. At the same time, downsizing means less staff to catch errors.

Healthcare complexity calls for increased, proactive application of system reliability and human factors solutions to improve health¬care delivery.  Intelligent, resilient design can make complex systems reliable. Plus, staffing needs to be assessed to ensure adequate coverage to apply error-catching activities.

POOR ROOT CAUSE ANALYSIS

After a decade of using RCA to analyze sentinel events, the lack of progress indicates a failure of healthcare root cause analysis.

What’s wrong? A majority of healthcare facilities use inadequate RCA systems including fishbone diagrams, 5-Whys, and healthcare derived root cause checklists. These “simple” techniques are inadequate to analyze complex healthcare sentinel events.

Not only are the RCA systems inadequate, the RCA training is also inadequate. People are assigned to investigate healthcare sentinel events with little or no training. They are lucky to attend a free one to eight hour session provided at a professional society meeting or sponsored by an insurance provider.

But healthcare investigators face another factor that makes root cause analysis even more difficult: BLAME. More than your everyday blame that comes with every accident. Medical malpractice seems designed to make people less open – less willing to cooperate wholeheartedly with investigators.

Furthermore, doctors who are independent contractors are naturally suspicious of investigators who seem to question their judgment and put their credentials at risk. Is it any wonder that we haven’t made progress?

Despite some of the factors that are difficult to address, picking an advanced root cause analysis system and getting people trained shouldn’t be hard. After all, there is TapRooT®!

The TapRooT® System was designed to be used for simple and complex investigations. It has been applied successfully in healthcare settings and has improved performance of complex systems. The 2-Day and 5-Day TapRooT® Courses have been customized for on-site training of healthcare investigators to help them with demanding investigations. Problems solved!

POOR CORRECTIVE ACTIONS

Inadequate root cause analysis is just the start. Typically, we see the weakest corrective actions applied to prevent repeat sentinel events.

Those familiar with the terminology “hierarchy of controls” applied in industrial and process safety may know what I am pointing out. Healthcare corrective actions often include the application of new standards that depend on human reliability. When these fail, investigators recommend some of the “re” corrective actions, including: re-train, re-mind, and re-emphasize (discipline).

But these are the weakest possible corrective actions (see pages 127 -129 in your 2008 TapRooT® Book.) More effective corrective actions include another type of “re” corrective action. Removing the hazard or the target. Or, re-engineering the process to improve system reliability and decrease human error without adding additional tasks for people to cope with.

These types of corrective actions and more are the result of a TapRooT® investigation when investigators apply the suggestions in the Corrective Action Helper® and apply Safeguards Analysis as part of the development of their solutions.

MANAGEMENT ATTENTION

One might say that the cause of all the previous problems is inadequate management attention to performance improvement at healthcare facilities. Part of this inattention can probably be attributed to the fact that most healthcare administrators aren’t trained in advanced performance improvement techniques. Even the few who have had Six Sigma training don’t know about advanced root cause analysis and, therefore, don’t know about the action they could take to make performance improvement happen.

Plus, hospital administrators need to become more involved in the analysis, review, and approval of sentinel event investigations. Involvement can bring them face-to-face with the challenges people are experiencing in the field. Trained managers reviewing a SnapCharT® can see beyond blame to real action to improve performance. They can see their contribution to errors that come from understaffing and fatigue. They can become a knowledgeable part of the team fighting sentinel events.

SIMPLE PLAN TO IMPROVE

Each day, hundreds of lives are lost because we haven’t won the battle to defeat sentinel events. Don’t wait for the entire healthcare industry to wake up to the problems and solutions. Don’t wait for regulatory requirements to force your facility into action. Start today with the tools that are at hand.

1. Bring the message to management. Get them involved. They should feel that EVERY sentinel event at their facility is a personal failure to address the causes!

2. Adopt an advanced root cause analysis system – TapRooT® – including the latest root cause analysis software and database to help you learn from small incidents to prevent major sentinel events.

3. Get the training that your facility needs in root cause analysis. This includes training for hospital administrators, staff, and your performance improvement experts.

Start with a customized 2-Day TapRooT® Course for senior management. Follow that with a 2-Day TapRooT® Course for those who are frequently involved in sentinel event investigations and a 5-Day TapRooT® Course for those who facilitate sentinel event investigations.

4. Once you complete steps 1-3, you are ready to start continuous improvement efforts. Start by attending the TapRooT® Summit healthcare track to find out what other leaders in the field of healthcare are doing to continue improvement efforts.

Don’t wait. People are dying waiting for improvement to occur. Start today!

(Reprinted by permission from the February Root Cause Network™ Newsletter, Copyright © February, 2012)

Evaluate this claim published in Business Insurance:

“Construction-related accidents in New York dropped 18% in 2011, thanks in large part to new safety laws the city began rolling out four years ago, according to the city’s Department of Buildings.”

How would you evaluate this claim?

Leave you comments here.

For the rest of the article, see:

http://www.businessinsurance.com/article/20120127/NEWS05/120129900?tags=%7C308%7C305%7C340%7C84%7C303%7C304%7C92

Last year, a Delta employee lost his leg when it was crushed by the wheel on a jetway in Knoxville, Tennessee.

I had a little extra time waiting for my flight to Atlanta from Knoxville last Friday so I asked the gate agent about the accident and what had been done to prevent a repeat. She said they were now required to have a spotter to make sure that no one got near the wheels while the jetway was moving (the wheels aren’t visible from the jetway controls).

That’s a Human Action Safeguard.

She also said that no one is allowed to use the stairs or get near the wheels while the jetway is in motion. That was already true when the accident happened but it was re-emphasized to everyone after the accident.

That’s a rule “quasi-Safeguard” that requires human action (compliance) to work.

Thus, a near-fatal accident had two human action related Safeguards that are meant to prevent recurrence of the accident.

Here is a graphic from our root cause analysis training…

Now let’s evaluate the corrective actions used to prevent a possible future fatality using the graphic above…

First, we made a rule that required a spotter during moving of the jetway. This is a human action related Safeguard implemented through a rule. That is the second weakest type of corrective action (#5).

Reemphasizing a rule that previously failed (the second corrective action used) is a training related human performance Safeguard and is the weakest corrective action to prevent recurrence of the accident (#6).

What do you think? If you had a serious accident (lost leg due to crushing) and it had the potential to be fatal, would two weak corrective actions be enough?

Maybe we should start at the top of the hierarchy in the figure above and see what is the strongest reasonable Safeguard that we can employ is…

1. REMOVE THE HAZARD

The Hazard in this case is the jetway weight and moving pinch point when the jetway is in motion. This is difficult to remove. (At least I can’t think of a way to do it.)

2. REMOVE THE TARGET

With current aviation operations, people are required to direct the plane while parking, unload baggage, refuel the plane, etc. Perhaps someday this will be done robotically, but for now, removing people from the jetway environment seems unlikely.

3. GUARD THE TARGET

This one is possible. See this photo below from Frankfurt …

They have implemented a guard to keep people away from the wheels.

Is it 100% perfect? No. People can go around the guard (jump over it?).

Is it better than warning people to be careful?

Yes!

So I sent the photo above to the Knoxville airport management. We’ll see if there are changes in the future to implement a stronger Safeguard to the potentially fatal Hazard.

ARE WE DONE?

NO!

This corrective action (if implemented in Knoxville) only fixes one small set of Hazards – jetway pinch-points in Knoxville. This Hazard exists at airports around the world.

For corrective actions to the Generic Root Cause, Delta would need to get airports around the world to guard the Hazard.

Next time you board a plane at your local airport, see what kind of Safeguard is in place. If you don’t see any, send the airport management (you can usually find a “contact us” link at the airport’s web site) a link to this posting.

ONE MORE THING TO LEARN

How do you develop corrective actions? Do you start at the top of the Safeguard hierarchy and work your way down or do you start at the bottom and work your way up?

Your investigators should have their corrective actions evaluated to see how effective they will be. For potentially fatal accidents, I would recommend using the top three strongest on the list and sometimes allow the fourth if somehow the top three aren’t possible.

The bottom two can be allowed in combination with the top 4, but I would never allow them to be the only corrective action if a fatality was possible.

Stop taking the easy way out. Learn a lesson from this accident (and the corrective actions). Improve your corrective action process by using the strongest possible corrective actions.

The Sun reported that damage to the Costa Fortuna, previously blamed  on a collision with a whale, may have been caused by the vessel hitting rocks (running aground) in May of 2005 near Sorrento, Italy.

See the article here:

http://www.thesun.co.uk/sol/homepage/news/4081095/Costa-Concordia-bosses-blamed-previous-accident-of-Costa-Fortuna-in-2005-on-crash-with-whale.html

I don’t think that I’ve ever seen a major accident with fatalities that didn’t have a previous incident that could have been investigated, learned from, and thereby prevent the follow on accident IF they had applied advanced root cause analysis and implemented SMARTER corrective actions.

Ah, the ever popular safety stand down. If people make mistakes, it must be time to have one.

See the story in the Atlanta Business Journal at this link:

http://www.ajc.com/business/mistakes-idle-workers-at-1310276.html

The article says:

“A TVA spokeswoman told the Chattanooga Times Free Press that the construction ‘stand down’ ordered to start at noon Wednesday was to continue ‘until the errors discovered are clearly communicated to all personnel.’”

Will communicating the “errors” really improve performance?

A TVA spokesperson said:

“TVA had not yet determined if the mistakes were due to carelessness but a ‘root cause analysis’ was being conducted.”

Carelessness as a potential “cause”?

TVA’s top executive, Tom Kilgore, said:

“When workers return to the site on Monday, they will join foremen and supervisors to review an error that occurred in December that had the potential for fatal consequences and that was identified earlier this week at Watts Bar Unit 2. Also to be reviewed is a second incident that occurred this week which could have resulted in a severe injury or worse if it had happened under slightly different circumstances.”

That tool box safety meeting shouldn’t take too long. From the report, they don’t know the root causes yet. All they seem to know is that two mistakes were made. I guess “foremen and supervisors” will just tell employees to “be more careful” and not to make errors. Then everything will be OK.

After that, employees will be willing to cooperate in an open and revealing root cause analysis. Especially when they know that management is looking for those who may have been careless.

We all know that the best way to keep people from being careless is to fire those who are found to be careless. If you fire careless people frequently, everyone will be happy and careful!

Another quote from the article:

“Nuclear Regulatory Commission Region 2 spokesman Roger Hannah said Friday that such work stoppages at nuclear plants are ‘not uncommon’ and probably occur every two or three years. Hannah said they are ‘not exclusive to the nuclear industry.’”

Wonder why they need a stand down every two or three years if they have an effective performance improvement program? I guess people need to be reminded to be more careful every two or three years.

Maybe we should just schedule these stand downs in advance? We could call it  human performance preventive maintenance. Every two years we would give people a day off to think about being more careful and “Presto!” … no more human errors.

Or even better! Rate people on their potential for carelessness on a scale from 1 to 10. Then every year fire the worst 10%-20% of the careless employees! 

Do these actions sound like the Deming Red Bead Experiment to anyone? If you don’t know what the Red Bead Experiment is, see the following videos…

Now read these quotes:

NRC’s “…Hannah declined to speculate about any possible penalty for TVA. He said TVA would assess both nuclear safety and workplace safety issues.”

And …

“The problems were discovered in routine TVA inspections and follow heightened NRC scrutiny on other TVA nuclear plants.”

Ahhh… now we are getting to the “root cause” of the stand downs.

It will look like management is doing something.

Management would hate to look like they are doing nothing.

A stand down makes them look like they are doing something. 

The more people stand down, the more dramatic the effect.

Thus, a stand down may keep the NRC from descending upon a nuclear utility.

If NRC management starts to believe that TVA has multiple troubled plants with multiple reasons for concern about human performance and human reliability, that could result in a special inspection. A special inspection is bad. When multiple regulators descend upon a nuclear utility, they always find things that need to be improved. If too many areas need improvement, the NRC could order reactors shut down until the “culture” is changed.

An NRC ordered shut down is bad news for the utility. “Changing the culture” can take years, cost millions of dollars, and result in many managers being fired. That’s much worse than the impact of a simple stand down for a few days. Thus, a stand down is a cost-effective way to keep the NRC happy – at least for a while – even if the stand down has no lasting impact on human performance.

Is there a better approach?

How about honest recognition of mistakes big and small? Once the mistake is recognized,  management could require a thorough, effective, advanced root cause analysis of any problem that could result in significant impact on plant safety, personnel safety, radiation exposure, environmental performance, or plant performance. Management could then insist upon the development and implementation of effective (SMARTER) corrective actions. Part of those corrective action could include effective communications about what happened and why it happened (the real root causes) to all employees that are impacted by the issue or the corrective actions.

What if you really want to stop having stand downs (and the incidents that cause management to call for stand downs)?

Management needs stop being REACTIVE by being PROACTIVE.

Management needs to shift from reactive root cause analysis to advanced PROACTIVE root cause analysis and stop problems before incidents happen. (We teach how to do this in our 5-Day TapRooT® Course.)

I’d recommend that TVA stop blaming workers (calling them careless) and start finding and fixes the real root causes of problems. Rather than a show stand down for the NRC, use effective advanced root cause analysis – both reactively and proactively – to improve performance and avoid issues that require stand downs every few years.

Show stand downs haven’t resulted in improved performance in the Nuclear Navy or the nuclear power industry (as evidence by the fact that they are repeated over and over again) and they should not be accepted by the NRC as effective management action. Rather, knee-jerk use of a stand down should be seen as a sign of weak management. Management that does not know how to improve human performance.

Avoid this scenario at your facility. Make sure that your management understands how to use advanced root cause analysis both reactively and proactively. Get your advanced root cause analysis program effectively implemented and then continue to improve it every year. And this advice is not just for nuclear utilities. Rather, it applies to every industry where mistakes may cause major accidents – oil, refining, chemical plants, aviation, railroads, shipping, pipelines, pharmaceutical manufacturers, mining, hospitals, …

Where can you learn best practices to continuously improve root cause analysis and human performance? Start at the 2012 Global TapRoot® Summit in Las Vegas on February 29 – March 2. See the schedule for all nine Summit Tracks at:

http://www.taproot.com/summit.php?t=schedule

Don’t wait to register. The Summit is only a month away. Get registered today.

I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.

The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.

Sources of Root Cause Analysis Failures by Mark Paradies is published by:

Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.

Used by Permission.

What is it that produces a safe environment with safe workers? Is it people with the right attitude… is it a reduced risk environment… or is it both? Do we need reward or punishment… or both? How do different cultures interact successfully to work safely? What is the best environment for a person to work in physically? How does one know?

Listening to a radio show recently about people trying to get out of debt, the host said this, “it is not the math that got them in the situation it is the behavior; that is why changing the behavior is the first step.” It was in reference to people who wanted to know why the had to pay off small debts first and not the large credit cards with high interest.

Point being, that the more one practices a behavior, the higher the probability that the behavior becomes habit. Providing a better environment with the right tools increases the ability to perform the behavior. It is with this in mind that the sessions below were put together:

Wednesday

• Proactive Prevention of Injuries and Accidents Due to Human Error
  Ergonomic and Human Performance Improvement
  Working Across Languages and Cultures

Thursday

• Changing Behavior By Praising the 49 Character Traits
  Criminal Prosecution of Accidents
  Using Training Simulation to Improve Human Performance
  Design for Reliable Performance

Friday

• Using FACT to Measure & Analyze Fatigue (Both Reactive & Proactive)
  Planning Your Improvements

To read more about each session go here: 

http://www.taproot.com/summit.php?t=schedule

One more thing …

Before the Summit there is a pre-Summit course that you should be considering …

Stopping Human Error

Just click on the link above for more info.

The course and the Human Performance and Behavior Change Best Practice Track make a great one-two punch for improving human performance. Plus, you will save $200 off the course fee when you attend both.

Don’t miss the remarkable knowledge available in the course and the Summit. Register today!

Have you written down your improvement goals for 2012?

New Year’s Eve has passed … so you probably did … right?

Not only that, but you’ve probably developed metrics that show you your progress.

And Process Behavior Charts of those important metrics so you can tell if significant trends are occurring.

(See Chapter 5 of your 2008 TapRooT® Book …

or attend the pre-Summit TapRooT® Advanced Trending Techniques Course – February 27-28 in Las Vegas – to learn how to apply advanced trending tools.)

WHAT!?! You haven’t written down your goals and developed metrics?

Get HOT!

Writing down your goals makes achieving them much more certain.

And “What gets measured, gets done!”

Don’t let important improvement initiatives get forgotten in the daily crunch to get things done.

One more idea …

Use the comment field to leave a couple of your better improvement goals and metrics here. Others can see them and get inspired to make more improvement happen at their facilities. We’ll all help each other to be challenged to get better.

Are you involved in performance improvement efforts in the healthcare industry? Then you should be planning to attend the 2012 Global TapRooT® Summit Track titled:

Healthcare Quality, Patient Safety, and Sentinel Event Best Practices

Most conferences about improving patient safety, healthcare quality, and reducing sentinel events are strictly organized by and attended by healthcare professionals. This provides good sharing of best practices within the healthcare industry, but does not provide networking or benchmarking outside the healthcare industry.

The TapRooT® Summit provides both in-industry networking/benchmarking and cross-industry/cross-functional networking/benchmarking. Here’s one healthcare industry patient safety professional talking about her experience at a previous Summit:

(.wmv format. Click above to play)

But what about the 2012 Global TapRooT® Summit? There are several sessions at the 2012 Global TapRooT® Summit that have a strictly healthcare focus:

• What does increasing expectations for healthcare quality and patient safety mean to your improvement efforts?
• Response lessons learned from the Joplin Disaster.
• Using electronic medical records to improve healthcare quality and patient safety.
• Using Baldrige criteria to achieve performance improvement.

These provide opportunities to network and benchmark with healthcare professionals.

Plus, there are also sessions that span industries and disciplines:

• Criminal prosecutions of accidents.
• Developing a fatigue risk management plan.
• Positive Contributions in facilitation and management interactions.

But that’s not all. The Keynote Speakers also provide lessons learned and best practices that cross industries.

For example, Astronaut Ken Mattingly, of Apollo 13 fame, talkes about Lessons Learned from Apollo 13 and Space Shuttle Operations.

And Dr. Beverly Chiodo talkes about Character Driven Success and how it can help your improvement program.

Also, there is a panel discussion of senior managers (Gerry Migliaccio, Senior VP at Pfizer; Vicki Hollub, President & General Manager of OXY Permian CO2 Business Unit; and Zena Kaufman, Divisional Vice President of Global Pharmaceutical Operation at Abbott Laboratories) who will discuss “What Does Senior Management Want from Incident Investigations and Root Cause Analysis?”

This is just a sample of the sessions, for the complete TapRooT® Summit schedule, see:

http://www.taproot.com/summit.php?t=schedule

I know you will find the information you take home motivational and valuable. That’s why we provide the following Summit guarantee:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

With a guarantee like this one, you have nothing to lose and everything to gain!

Are you a manager in charge of a performance improvement program?

Then you should be in Las Vegas on February 27 – March 2 at the 2012 Global TapRooT® Summit and the pre-Summit courses.

First, pick the pre-Summit course that gives you the information you need to turbocharge performance at your facility.

If you have never been trained in the TapRooT® Root Cause Analysis Techniques, I would suggest taking the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.

If you already have been trained in TapRooT®, pick from this list of valuable courses:

TapRooT® Analyzing and Fixing Safety Culture Issues

Advanced TapRooT® Trending Techniques

Stopping Human Error

Risk Management Best Practices

Fatigue Risk Management Training

Here’s what some participants had to say about the pre-Summit courses they attended…

Then sign up for the Leading Performance Improvement Best Practices Track at the Summit. You will experience five great Keynote Speakers, eight Best Practice Sessions, and a final session where you will plan your improvements.

The Best Practice Sessions for the Leading Performance Improvement Track are:

• How Pfizer Achieves Operational Excellence
• What is Culture and How Do You Identify and Solve Culture Problems
• What Does Management Need to Know About Process Safety Improvement
• Designing Your Continuous Improvement Program
• Developing a Fatigue Risk Management Program
• Criminal Prosecution of an Accident
• Response Lessons from the Joplin Disaster
• TapRooT® Implementation Success Stories

But that’s not all. If you choose to, you can customize your Summit experience by choosing to replace some of these sessions with sessions from the other eight tracks, including:

• Changing Behavior by Praising the 49 Character Traits
• The Day 29 Miners Died: The UBB Mine Explosion
• Developing Great Investigators
• TapRooT® Implementation, Investigations, and Process Improvements
• TapRooT® Users Share Root Cause Best Practices
• The 7 secrets of Incident Investigation & Root Cause Analysis
• Positive Contributions in Facilitation & Management Interactions
• Investigation Process Best Practices
• Working Across Languages and Cultures
• Using Baldridge Criteria to Achieve Performance Improvement

Don’t miss the sessions that will help you develop a world-class performance improvement program. Get registered today. See:

http://www.taproot.com/summit.php

Last July, a train crash in China killed 40 people. According to CNN, the Chinese government has decided to punish 54 people for their roles in the accident. The story quotes the state-run Xinhua news agency as saying:

“According to a final investigation report, the train crash was caused by major design flaws in train operating equipment, relaxed safety controls and poor emergency response to equipment failure.”

The story also said that the probe:

“…exposed that the Ministry of Railway and the Shanghai Railway Bureau had failed to act properly after the accident and were unable to disclose relevant information on issues of social concern, leaving a negative social influence,”

So who lost their jobs or were disciplined? They include:

• Liu Zhijun, the country’s former railway minister
• Zhang Shuguang, the railway ministry’s deputy chief engineer
• Xu Xiaoming, Guangzhou Railway Group Chairman
• Miao Weizhong, China Railway Signal & Communication (CRSC) Deputy General Manager
• Zhang Haifeng, Railway Signal Design Institute Chairman

No decision has been made about criminal charges.

No for my question…

If firing people improves safety, shouldn’t China have one of the best safety records in the world? It seems that every accident in China is followed by firings, discipline, and criminal prosecutions. But this doesn’t seem to make performance better.

What do you think? Leave your comment here…

The December 2011 issue of Flight Bag (a publication of the International Air Transport Association) had the following graph…

The safety performance for western-built jet hull losses per million sectors makes 201 the best year ever for big jet aviation safety.

Can you put this data in an Process Behavior Chart (see Chapter 5 of your 2008 TapRooT® Book) and see if the trend is real?

For more about advanced trending techniques including the use of Process behavior Charts to prove a trend, attend our 2-Day TapRooT® Advanced Trending Techniques Course coming up on February 27-28 (just before the TapRooT® Summit.

This course is only offered once a year … so don’t miss out! You will learn advanced trending concepts that will help your management understand what their root cause analysis data is telling them.

Distracted driving is a problem.

The NTSB has decided that texting, e-mailing, or even chatting on a cell phone is too dangerous to be allowed.

Therefore, they are recommending that states pass laws that prohibit all use of electronic devices except those that aid the driver (like a GPS).

NTSB chairman Deborah Hersman said, “No email, no text, no update, no call is worth a human life.”

In one article, Jonathan Adkins, a spokesman for the Governors Highway Safety Association, said the recommendation was a “game changer” but said that, “States aren’t ready to support a total ban yet, but this may start the discussion.”

What do you think? Is a total ban (including all cell phone use) the right answer?

What about other activities that cause distractions?

Sometimes I wonder about the number of things that are now illegal.

Let me know your thoughts by leaving a comment here.

For more about this recommendation, see:

http://www.ntsb.gov/news/2011/111213.html

Jay Branson of Delaware OSHA wrote a great article in the December 2010 issue of Process Safety:

“Regulatory Initiative for Improving Process Safety Performance.”

Two key items about incident investigation from the article are:

1. “A key element of process safety is the incident investigation following both severe accidents and near-misses.”

Mr. Branson also writes:

“…investigations become an important part of continuous improvement…”.

This may seem obvious. After all, incident investigation is part of the OSHA PSM regulation. But many (see the next section) don’t do good incident investigations/root cause analysis and miss golden opportunities to avoid major accidents.

2. Mr Branson second comment that I would like to highlight is:

“…there is a wide range of quality of incident investigations.”

Mr. Branson writes that in their regulatory experience (Delaware),

“Some small facilities do not have the expertise
to conduct adequate root cause investigations.”

On the other hand, he writes:

“…large companies may blame the operator
rather than admit to management system failures…”.

Of course, we believe in the importance of incident investigation and root cause analysis as a part of any continuous improvement program (not just PSM). The reason we developed TapRooT® was that we saw many programs at big, medium, and small companies that need improvement.

One might have thought that by now, big, medium, and small companies would have found out about TapRooT® and improved their investigations and root cause analysis.

That got me thinking…

Maybe we need to enlist your help?

If you have friends, colleagues, or acquaintances that haven’t discovered TapRooT®, it’s time you had a talk with them.

Tell them about the public TapRooT® Courses.

Forward them a link to the success stories on our web site.

Tell them how to sign up for our free newsletter.

You’ll help them save lives and make your industry a better, safer place.

That’s a good thing for everyone.