Category: Pictures

Monday Accident & Lessons Learned: HOW MANY INCIDENTS DOES IT TAKE TO LEARN???

September 24th, 2018 by

Is it acceptable to have incidents occur over and over again?

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The Daily Mail (a UK paper), ran an article about repeat incidents at a UK hospital (pictured below).

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This first was a hospital acquired infection that caused a patient to sue and win a six figure payout. I’ll let you read the article to find out what essential part of his anatomy that he lost.

That settlement had just been negotiated when a second patient had the wrong testicle operated on. And a third patient had a lesion removed from the wrong brest.

The Daily Mail reported that the hospital spokesperson claimed:

“Southend University Hospital continues to be compliant with the national recommendations
on learning from deaths through better engagement with bereaved families and carers,
strengthened governance arrangements for mortality monitoring by newly introduced
medical examiner roles and increased transparency.”

It would sure make me a more confident patient if the performed advanced root cause analysis and implemented corrective actions to STOP repeat incidents rather than having repeat incidents and “continuing to learn.”

They also said:

We are pleased our mortality indicator score has consistently decreased since
June 2017 and is now within the expected range for the first time since June 2015
.”

Stopping killing patients is a great idea. I’d suggest a better goal. STOP sentinel events including ALL never events.

Investigating never events and learning isn’t enough to make this happen. Hospitals need to become proactive in their improvement programs.

Are you interested in advanced root cause analysis and becoming proactive in your improvement program?

I would suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We hold them around the world … including Europe. See the upcoming courses held around the world by CLICKING HERE.

Want to learn more about proactive improvement? Attend the 2019 Global TapRooT® Summit in Houston, TX. Learn from industry leaders from around the world how they proactively solve problems. get more Summit info HERE.

When is a leak in a nuclear reactor minor?

September 20th, 2018 by

NewImage

I saw an interesting article in the Military News yesterday. The headline read:

Navy: ‘Minor’ moisture leak in nuclear plant prompts sub’s return to Groton base

This caused me to think of several things…

First, if a ship has to return to port, the leakage was not minor.

Second, I’m glad they returned to port for repairs. Much better than having the leak progress into an accident.

Third, why did we hear about this?

The article doesn’t give many details about the problem and the Navy spokesperson downplayed the significance by calling coming back into port for a leak:

…not uncommon, and ensures the ship is maintained at a high state of readiness.

I guess I was in the Navy a long time ago when things like that were uncommon.

In fact, back then if something like this happened, there would not have been a press release. The ship would have gone ito port, been fixed, and gone back out to sea.

Los Angeles class subs are getting old (USS Pittsburgh is over 30 years old) and I hope the Nuclear Navy really is maintaining the high state of readiness that they are known for.

How is your maintenance program? Need help troubleshooting equipment problems? Consider having an TapRooT®/Equifactor® Course at your site. Contact us by clicking here.

How Could the Best Process Safety Advice Come from the 1960s/1970s?

September 19th, 2018 by

RickoverS1W

There are many “experts” in process safety. Their advice has become laws in the USA and Europe. But accidents continue. Why?

Perhaps we should go back to the real expert on process safety – Admiral Rickover.

What did he have to say about process safety (or as he put it, reactor safety)? What are we missing in our current efforts to improve process safety? See this set of articles about normalization of deviation and learn what the expert – Admiral Rickover – had to say about process safety:

http://www.taproot.com/archives/54027

 Then read his semi-official biography:

Rickover: The struggle for Excellnce

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Click on the book above to purchase it on Amazon.

TapRooT® Around the World: Denver

September 18th, 2018 by

Thanks to Marcus Miller for sending in this course photo from Denver! It’s not too late to get into the picture and advance your career!

Are you interested in attending a TapRooT® Training Course? Click on the links below to view our upcoming courses to a city near you.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

TapRooT® Around the World: Cork, Ireland

September 18th, 2018 by

Look into the Two-Day TapRooT® Techniques course in Cork, Ireland, where students and TapRooT® Instructors Thomas Di Giacomo and Chris Vallee gathered at the Imperial Hotel Cork on South Mall. Attendees enjoyed a bit of history along with the TapRooT® course, as guests such as Sir Walter Scott, William Thackeray, Franz Liszt, and Charles Dickens have stayed at the hotel.

In the span of the two-day course, students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Upon course completion, attendees received a certificate and a 90-day subscription to TapRooT® VI, the online software service.

Many thanks to Tom and Chris for capturing and sharing these great pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

What does a bad day look like?

September 18th, 2018 by

Because signage matters, right?

TapRooT® Around the World: Johannesburg, South Africa

September 13th, 2018 by

Take a look into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, taught by TapRooT® Instructor Sanjay Gandhi. We are grateful to Sanjay for sharing these pictures that show teamwork, the TapRooT® learning experience, and a great time in the process!

Through TapRooT® Training with our exceptional instructors, students learn to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Is It Better To Be Fast or Good?

September 12th, 2018 by

Imagine the old west. Two gunslingers standing 20 yards apart. It’s time to draw.

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Would it be better to be fast or good? As Wyatt Earp said:

Fast is fine. Accurate is final.

What does this have to do with root cause analysis?

I had someone ask me the other day:

How long should a simple root cause analysis take?

If you use Spin-A-Cause™, the answer is about 5 seconds.

Spin A Cause

But you have to answer the question …

Do you want FAST or GOOD?

But what if you could have BOTH?

That’s what the 2-Day TapRooT® Root Cause Analysis Training and the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about. Fast and Good simple investigations.

We selected the minimum number of powerful root cause analysis tools and built a simple process to perform simple investigations fast and accurately.

How long does it take to apply these techniques? Maybe 30 minutes to an hour once you have the information you need to answer the questions. Maybe slightly longer. Maybe longer yet if the incident turns out not to be “simple.”

The biggest variable is collecting the information (evidence). The second biggest variable is the requirements of your investigation system (presentations to management and approval red tape).

So if you are ready to be fast and good, sign up for one of our public 2-Day TapRooT® Root Cause Analysis Courses today. Here are the upcoming dates and locations:

http://www.taproot.com/store/2-Day-Courses/

Or have a course at your site. Contact us for a quote by clicking HERE.

What does a bad day look like?

September 11th, 2018 by

Because who doesn’t want to take a trip in their hot tub?

What makes a great root cause system?

September 5th, 2018 by

What makes a great root cause system?

That’s a question that I started researching back in 1985. What would I say is the answer to that question 33 years later? Here are some of my best ideas…

1. Guides Investigators: The root cause system needs to guide investigators to the real, fixable root causes of human performance and equipment reliability problems. Most root cause system don’t do this. Cause-and-effect, 5-Whys, fishbone diagrams, Why Trees, and Fault Trees all require someone on the team to know the right answer. This is especially troublesome when it comes to human error because most investigators have not been trained in human factors. Thus they are guessing at the causes of human error.

2. No Blame: Blame is probably one of the biggest obstacles to finding the causes of incidents. If people think that the outcome of an investigation will be blame, you won’t get their full and free cooperation. You will start having mystery incidents where no one knows what caused the problem. In fact, you might get the Bart Sympson response:

Bart simpson I didnt

That doesn’t lead to a great root cause analysis.

Some root cause systems actually have “blame categories.” (See this LINK.) Other people think that blame makes sense. (See this LINK.) But in TapRooT®, you look for causes – not blame. And if someone did something on purpose (sabotage or horseplay), you find it using the system and rule out other causes.

3. What Happened: You have to understand what happened BEFORE you can understand why it happened. That’s why I see many people adding a “time line” to the use of 5-Whys. If you don’t understand the sequence of events, you can’t understand the causes of what went wrong. A thorough understanding of “What happened?” is a must for great root cause analysis.

4. Consistency: If two different teams performed the root cause analysis would they find the same root causes? many root causes systems fall short here. The analysis depends on who is on the team. And it often depends on the conclusions the investigators reach before the investigation starts. Sometimes people just set out to find their favorite causes. They are consistent … but a different team may have different favorite causes.

5. New Ideas: Does your root cause system stimulate new ideas to solve problems? It should. It should provide investigators with guidance to help people fix the root causes they find.

6. A System: You root cause analysis tool is not enough unless it is a system. A set of tools designed for a purpose. There should be a process with steps and tools to use to achieve those steps.

7. Flexibility: You should be able to use your root cause system for simple incidents or major accidents. That’s a test of the system’s flexibility. You can’t afford to train people on two systems (one for simple incidents and one for major accidents). And even if you can, you will have to get them practiced in multiple systems (which is difficult).

8. Promotes Trending: You should use the data from your root cause analysis system to understand performance and spot trends. Does your system have a built in categorization that is designed to promote accurate trending?

9. Management Understands: Your system has to be understood by your management. In fact, it should be designed so that the end result is a east-to-undertand management presentation. One that explains what happened, what cause the problems, and what we need to do to stop future incidents.

10. Great Training: What good is a great root cause analysis system if you don’t have great training to get people to understand and use the system? You may want to inquire about the number of trainers and their experience. Can they support you around the world?

11. Proven Effective: Has the system been proven to be effective by users around the world? Do the have success stories from around the globe? Reference that you can believe?

12. Software Support: Does the system have effective software that makes the system even easier to use? Can that software be tied to other systems (safety or quality software)?

13. Continuously Improved: Is the system being continuously improved? What are the plans for future improvements?

That’s a pretty thorough list. What system meets all those criteria? The TapRooT® Root Cause System. Talk to us about all of these advantages that the TapRooT® System can bring to your company.

CLICK HERE to contact us and get more information.

TapRooT® Around the World: 3-Day Equifactor® in Bogota, Colombia

September 5th, 2018 by

Here’s a glimpse into a recent 3-Day Equifactor® course in Bogota, Colombia, taught by TapRooT® Instructors Hernando Godoy and Piedad Colmenares. We really appreciate Diana Munevar for sharing these pictures that show teamwork, the TapRooT® learning experience, and a great time in the process!

The 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course is designed to help investigators troubleshoot equipment problems to get the information they need to find and fix the root causes of equipment-related failures. These tools can be used by equipment troubleshooting experts, maintenance and equipment reliability specialists, or other investigators who don’t have an extensive understanding of equipment engineering.

Through TapRooT® Training with our exceptional instructors, students learn to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Onsite at TransCanada in Mexico

August 31st, 2018 by

Here’s a glimpse into recent TapRooT® Root Cause Analysis Training courses, held onsite in Mexico at TransCanada. The courses were taught by TapRooT® Instructors Marco Flores, Jesus Alonso, and Piedad Colmenares. We appreciate Piedad passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Analyzing Great Britain’s Workplace Fatality Statistics: Up or Down?

August 29th, 2018 by

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Good news! Workplace deaths in the UK are down. Or are they up? Here’s the stats from the UK HSE

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Note that the 2017-2018 are provisional.

These figures don’t include fatal diseases, fatal accidents on non-rail transport systems (for example, driving), and fatal errors in hospital care that kills patients. The items not included are consistent from year to year.

The total number of deaths in the statistic period covered for 2017-2018 were 144. That’s down from 233 deaths in the 2007-2008 year. But it is up from the 135 deaths in 2016-2017.

They also look at the statistics in several different ways.

KINDS

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INDUSTRY

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AGE

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LOCATION

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COMPARED TO OTHER EUROPEAN COUNTRIES

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HOW DO YOU EVALUATE STATISTICS?

These different graphs and comparisons should get you thinking about how you evaluate your incident/accident statistics. What kinds of stats should you be trending and how will they help you evaluate your performance improvement initiatives.

For example, in the statistics above, how much of the overall decrease in fatalities is due to less work being performed in the most dangerous industries? The fatality rate has been declining in all industries but if the amount of workers in the most hazardous industries has declined significantly, this might make the overall improvement in deaths across all industries look more significant.

Thus, a more significant trend evaluation is within an industry and within a specific work type.

Why look at work types? Let’s look at the deaths in the Communications, business services and finance sector (11 in the 2017-2018 stats). This sector includes building maintenance and landscaping included in renting and leasing activities (7 of the 11 deaths).

How you count and compare things makes a big difference.

STATISTICAL SIGNIFICANCE

Another question that management often asks is:

“Is that trend significant?”

Let’s look at the total death stats. Are the increases and decreases in the graph in the first figure significant? The UK HSE says:

Screen Shot 2018 08 01 at 10 02 29 AM

In the TapRooT® Advanced Trending Techniques Course, we teach a different method to judge a significant trend. We use Process Behavior Charts.

TRENDING THE GREAT BRITAIN STATS

I used the data I could derive from the graphs on the report (note that I am making estimates on the real numbers from the graphs they provide) to draw three new graphs of fatality data. One from the 1980s. One is from 1994 to 2008. And one is from 2009 to 2018. I think you will find the results interesting.

Let’s start with the 1980’s data…

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Note that in the early 1980’s the data was fairly stable. I used that data from 1981 to 1987 to set some limits. What we can see is that the average number of fatalities was 471. The upper limit (you would expect no more fatalities than this) was 528. The lower limit (you would expect no less fatalities than this) was 413.

In 1988 the fatalities exceeded the upper limit. There were about 605 fatalities. Exceeding the upper limit leads you to believe that something changed. What was it? The Piper Alpha accident. The 167 people who died in a single accident cased the total number of fatalities to be abnormally high that year.

Also, you may note that the fatalities dropped below the lower limit in 1991. To me, it looks as if there had been an improvement in the UK’s fatalities and the system was driving to a new lower average number of fatalities. Can anyone explain this? Was it really a safety improvement or just an new way to count fatalities? Or did the type of work change?

Next, let’s look at the 1994 to 2008 data…

Screen Shot 2018 08 02 at 4 55 53 PM

I used the 1994 to 2007 data to set a new set of limits. The new average number of fatalities was 247. The new upper limit was 322. The new lower limit was 172. The data was fairly flat for 15 years (no data points outside the limits). But in 2009, we had our first point outside the limits low. Again, something was changing. Leave a comment if you have an idea what caused the change.

Now let’s look at 2009 to 2018…

Screen Shot 2018 08 02 at 4 56 18 PM

I used the data from 2009 to 2018 to set a new average and limits. The new average number of fatalities is 154. The upper limit is 187. The new lower limit is 121. In 2010 we were one fatality over the limit. Since this was a new set of limits set on data from 2009-2018, we might just say that the system was not stable at the new set of limits yet. Since then the new fatality numbers have been fairly stable with no significant changes.

Trending using Process Behavior Charts is a very good way of understanding significant trends in safety data.

What I don’t like about this county wide data is that it is an average of data across a whole country. What looks like stable data in a large average may be covering up more detailed trends. For example, mining deaths may be declining while construction deaths are increasing and the one downward trend covers up the other upward trend.

Would you like to learn more about Process Behavior Charts and how to use them to understand your safety, quality, or process and equipment reliability? We teach a course once a year on these advanced trending techniques call Trending for Managing Performance. The next course is March 11-12, 2019 near Houston, TX (Montgomery, TX). It will be held just before the 2019 TapRooT® Summit. If you are interested in trending and performance improvement, you should plan to attend both.

TapRooT® Around the World: Equifactor® Equipment Troubleshooting in Bogota, Colombia

August 28th, 2018 by

Take a look into the recent 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course in Bogota, Colombia, taught by TapRooT® and Equifactor® Instructors Hernando Godoy Garzón and Piedad Colmenares.

Using Equifactor®, you can learn a more efficient, effective method to solve equipment failure and performance problems. Equifactor® integrates troubleshooting techniques and the TapRooT® Root Cause Analysis System to identify real root causes and implement lasting fixes faster and with more reliability. One single-user license of TapRooT® Root Cause Analysis software is included in this course.

The Equifactor® 3-day courses are designed for Maintenance, Reliability and Safety professionals who want a proven method of analyzing equipment problems and failures when conducting root cause failure analysis.

Many thanks to Hernando for sharing these pictures of action and insights into the great interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Caption Contest!

August 27th, 2018 by

I have decided to extend the August Caption Contest into September!

So, here is your chance to win some free TapRooT® swag! All you have to do is follow the easy instructions below.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest instructions:
1. Create your caption to the photo above in six words or lessAll captions with more than six words will be disqualified.
2. Type your caption in the comments section of this post by September 17, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Good luck and, most importantly, have fun!

Full TapRooT® Courses – Don’t Wait to Register or Schedule Your Course!

August 21st, 2018 by

I don’t usually comment on our course schedule or tell readers when courses are filling up, but this Fall looks like our public courses are getting pretty full. There are several that you need to register for soon if you want to guarantee that you or your folks get a seat reserved before the course fills up.

Courses that are filling up early include:

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DENVER – 2-Day – September 18-19

 

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CALGARY – 5-Day – September 24-28

 

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MANCHESTER – 2-Day – October 1-2

 

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ABERDEEN – 5-Day – October 8-12

 

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DUBAI – 5-Day – October 14-18

 

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EDMONTON – 2-Day – October 16-17

Click on the course names above to register for the course now before they fill up. Or, click on the link below to see the complete world-wide schedule for public TapRooT® Training:

http://www.taproot.com/store/Courses/

And don’t wait to schedule your on-site training for this Fall. The schedule will fill early. Get your courses scheduled now! CLICK HERE to contact us.

Testimonial Tuesday

August 21st, 2018 by

Are you interested in learning TapRooT®, but you’re not sure where to start? Below I’ve provided some 2-Day and 5-Day TapRooT® Training Testimonials to help you decide which course is right for you.

TapRooT® is a world-class software system designed to help investigators solve every day hurdles. TapRooT® takes the investigator beyond his or her knowledge to choose root causes that are “outside the box” of common root causes such as writing poor procedures or inadequate training.

2-Day Client Testimonials:

  • “The software is excellent and very user friendly.” – Chad
  • “Very well instructed. Great team/group dialogue with industry players.” – Dylan
  • “TapRooT® triggers good ideas when writing corrective actions.” – Daniel
  • “Learned to be more effective in defining corrective and preventative actions.” – Irma
  • “TapRooT® will be a big help in reducing reoccurring incidents by finding the true root causes.” – Todd

5-Day Client Testimonials:

  • “This system is a great tool that leads to appropriate CA’s – very beneficial.” – Dave
  • “Benefits of the 5-Day course are learning the proper and effective use of the TapRooT® Dictionary and the Corrective Action Helper guide.” – Ken
  • “Takes a lot of the biases out of the process by going through the tree.” – Phil
  • “I feel that I will have cleaner investigation with better corrective actions.” – Karri
  • “The examples of failures/incidents were very realistic and effective.” – Broch

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

 

Looking for a course near you? Find a course location and reserve you seat today by clicking on the links below.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

TapRooT® Around the World: Bogota, Colombia

August 21st, 2018 by

Here’s a peek into the recent 2-Day TapRooT® Root Cause Analysis Training Course in Bogota, Colombia, taught by TapRooT® Instructor Piedad Colmenares. In a 2-Day TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Piedad for sharing these great pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Nashville, TN

August 17th, 2018 by

Thank you, Marcus Miller, for sending in these fabulous pictures of a recent 2-Day TapRooT® Training course held in Nashville, TN. Looks like everyone is having a great time learning the TapRooT® method!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. View our upcoming public courses here.

 

 

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