Next time it is snowing, and you think you are having a bad day … it could be worse …
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St. John’s, Newfoundland, Canada
Upcoming TapRooT® Public Courses:
For more information regarding our public courses around the world, click here.
Thanks to Harry Thorburn for these photos from a recent Onsite Course in Champagne, France.
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The sun is shinning, you have a new convertible, … what could go wrong?
See, don’t you feel better already? (By comparison.)
Thanks to the instructors of these TapRooT® Courses who sent us these great pictures of recent courses around the world!
For more information regarding our Public and On Site Courses around the world, click here.
Rome is a great place for a spring vacation. The sights, the food, and the shopping are amazing!
And when you can combine the trip with some great TapRooT® Training (a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course), you are getting two great experiences at once!
The 2-Day TapRooT® Course is a great value. In two days you will learn how to apply the standard TapRooT® Tools (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, the Corrective Action Helper®, and SMARTER) to find and fix the root causes of problems.
What kind of problems can you solve using TapRooT®?
- Major safety accidents
- Drug/medical device quality issues
- Medical sentinel events
- Process safety accidents/incidents
- Equipment reliability issues
- Neat-miss accidents
- Production issues
- Cost overruns
- Schedule slippage issues
- Customer complaints
- Security issues
- Product waste issues
- Hardware/software failures
And that’s just to name a few!
And the instructors scheduled to teach the course are Mark Paradies and Linda Unger – the inventors of TapRooT®!
The course is being held at a great hotel in the center of Rome. Watch this video for a bird’s eye view of the location…
Here’s the hotel’s web site:
As you can see, the hotel is just a couple of blocks from the Pantheon. And near many of Rome’s tourist attractions.
You probably won’t get an opportunity like this again. Because this course is so special, you should register today for the March 18-19, 2015 course to make sure you save your spot! Also, get your hotel reservation set. You don’t want to miss this great training in a great location.
If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.
When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?
What is the difference?
Why are fatal traffic accidents seemingly acceptable?
Could we learn from fatal car accidents and make sure they never happen again?
What would have to change to make this learning possible?
Could we save 10,000, 20,000, or 30,000 lives per year here in the US?
Sometimes a good day is just so close…
Bring in the New Year with a trip to St. John’s, Newfoundland, Canada! Our TapRooT® instructors will be teaching a 2-Day Incident Investigation and Root Cause Analysis Course on January 19-20. Not only will you learn an incredible amount of beneficial knowledge for your company, but you’ll also get the chance to visit this beautiful, historic city. St. John’s is considered to be the oldest English-founded city in North America. It’s English culture, beautiful harbour and colorful architecture gives it a distinct difference from the rest of Canada.
RocketFood: This quaint bakery and fresh food cafe has been recognized on the Food Network and several international magazines meaning it can’t be anything less than delicious.
Raymond’s: If you’re interested in a more gourmet, fancier atmosphere then visit Raymond’s.
ONE11 Chophouse: A great steak isn’t all this high-rated chophouse has to offer. The warm, fine dining experience is one of the best around.
Newman Wine Vaults: Enjoy a variety of flavors of fresh wine at one of Newman’s Wine Vaults.
East Coast Trail: Would you consider yourself an outdoor enthusiast? Take a hike on the East Coast Trail and see views of St. John’s that you can’t see anywhere else.
Commissariat House: The rich history of St. John’s is something to take in and enjoy. Experience a piece of it at the Commissariat House.
Ready to register for this course? Click Here
Want more information on our other international TapRooT® Public Courses? Click Here
Root Cause Analysis Tip: What is a corrective action worth? – A Gambler’s View of Corrective Actions (A Best of Article from the Root Cause Network™ Newsletter)December 3rd, 2014 by Mark Paradies
Adapted from the January 1995 Root Cause Network™ Newsletter, Copyright © 1995. Reprinted by permission. Some modifications have been made to update the article.
A GAMBLER’S VIEW OF CORRECTIVE ACTIONS
WHEN TO BET/WHEN TO FOLD
A winning gambler knows the odds. He knows that in the long run, he can beat the odds. Therefore, he looks for opportunities to bet more when the odds are in his favor. And when the odds are against him, he folds and waits for a better hand.
Preventing accidents is a numbers game. The pyramid blow provides a typical example of the ratio of accidents to incidents to near-misses to unsafe conditions.
In this pyramid, every incident must have the potential under slightly different circumstances to become the major accident at the top of the pyramid. Also, every near miss must have the potential to become an incident that could have become the top level accident. Finally, every unsafe condition could have caused a near-miss that could have become an incident that could have become the top level accident.
Thus, every unsafe act included at the bottom level of the pyramid must have the potential with the right set of circumstances to “cause” the top level accident.
The ratio above might not be exact. Your facility might be different. But we will use the ration of 1000 unsafe acts for every major accident as a starting point for out calculation of odds that we describe below.
The point is that every corrective action that fixes an unsafe condition has some odds of being the corrective action that could be preventing a major accident. Thus, we should try to understand the value NOT ONLY of the benefits that the corrective action immediately brings, BUT ALSO the reduction in the odds of a major accident that this corrective action provides.
THE COST OF A MAJOR ACCIDENT
To calculate the value of preventing a major accident, we need to calculate the potential cost of a major accident at your facility.
Of course, we don’t know the exact cost of the biggest accident (or even a typical major accident) that you face at your company. After all, they still don’t know what the cost of the Deepwater Horizon accident will be even after years of litigation. So, we have to make an educated guess that can be scaled to show how the cost could change.
For example, we might say that the cost a typical major accident would be $1,000,000,000.
Then, if you think your accident might be ten times worse (or ten times less), you can multiple or divide the results we calculate by 10.
ASSESSING THE ODDS
Why do we have to use “odds” to perform this calculation? Because you can’t tell exactly which unsafe condition will be related to your next major accident. We don’t know what corrective action that we implement today will prevent the next Deepwater Horizon, Three Mile Island, or Exxon Valdez type accident that costs billions of dollars. No one is that prescient. That’s why preventing major accidents is a numbers game. To prevent the next major accident you must reduce thousands of unsafe conditions.
Because the exact odds of any one unsafe act being a key factor in the next accident is unknowable, we assign equal potential to every unsafe condition that has potential to cause a major accident.
If the pyramid above represents your accident pyramid, then for every major accident, there are 1000 unsafe conditions that could contribute to it. Or another way to think about it is that we can’t predict the exact combination of factors that will cause the next major accident but if we do 1000 things to fix problems that could be involved in a major accident, we will stop one major accident.
Thus the odds that any one corrective action will stop a major accident is 1000 to 1.
CALCULATING THE VALUE OF A CORRECTIVE ACTION
I’ve seen people value corrective actions by using the value of the incident they would prevent.
For example, if the failure of a machine caused a delay that lost the company $100,000, the value of the corrective actions to prevent future failures would be $100,000. It’s never clear to me if this value should be divided between all of the corrective actions (for example, if there are 10 corrective actions, each would be worth, $10,000) or if each corrective action is worth $100,000. But the idea is that the corrective actions can be valued by the costs that will be saved from future similar incidents prevented.
What this equation leaves out is the value of an even worse accident that could also be prevented by the corrective actions.
Thus to calculate the value of a corrective action, you not only need to calculate the direct benefit, but also the amount that that corrective action contributed to the prevention of a major accident (if, indeed the corrective actions could help prevent a major accident).
But let’s stop here to correct misconceptions. A corrective action meant to stop paper cuts probably have very little value in preventing major accidents. Thus, we are not assigning severe accident risk to every corrective action. We would only assign the value to corrective actions that could help prevent major accidents.
The, the value of a corrective action is the direct cost that the corrective action saves us PLUS the value of the unknown major accident that it could prevent divided by the odds.
For example, if a corrective action saved us $10,000 in direct costs for a similar incident and if the value of a major accident at your facility is $1,000,000,000 and if we estimate that it will take correcting 1,000 unsafe acts to prevent the next accident, the value of our corrective action is…
VALUE = $10,000 + ($1,000,000,000/1000)
VALUE = $10,000 + $1,000,000
VALUE = $1,010,000
Thus valuing corrective action at their benefit for preventing a similar incident is UNDERVALUING the corrective actions.
And I believe we frequently undervaluing corrective actions.
Because we aren’t considering the value that a gambler sees. We are folding when we should be betting!
We should be investing much more in effective corrective actions thereby win by preventing the next major accident.
YOU CAN IMPROVE THE ODDS
There is even better news that can help you make the corrective actions you implement even more valuable (effective).
The TapRooT® Root Cause Analysis System can help you do a better job of analyzing potential problems and developing even more effective corrective actions for the root causes you uncover.
Think of TapRooT® as a luck rabbit’s foot that increases your odds of winning.
Of course, TapRooT® is much better than a lucky rabbit’s foot because instead of being built upon superstition, it is built upon proven human performance and equipment reliability technology that makes your investigators much more effective.
So don’t wait. Stop undervaluing your corrective actions and if you haven’t already started using TapRooT®, see our upcoming courses list, click on your continent, and get signed up for a course near you (or in a spot that you would like to visit).
Want more information on our Onsite courses? Click here.
A woman, trying to board a London Underground train, stopped when the doors of the train shut. But her scarf swung forward and was trapped in the doors.
As the train pulled forward, she was dragged along the platform. A member of the staff tried to catch hold of her and help, but this caused her to fall to the platform.
The scarf was eventually pulled from around her neck and into the tunnel, still trapped in the train door.
The woman suffered injuries to her neck and back but was lucky that she wasn’t dragged into the tunnel and onto the tracks.
What are the lessons learned? See the UK RAIB report.
Or just stop wearing scarfs!
Here is my Thanksgiving posting. I post it every year, lest we forget.
In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!
One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.
During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.
The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.
With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.
Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.
The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.
Is this the root cause of Thanksgiving?
This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:
“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”
William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.