Are you sending people to our Public TapRooT® Training?
Or are you having a TapRooT® Course at your site?
And arranging TapRooT® Training at one or more of your facilities around the world?
If you want to choose your dates, now is the time to get your onsite courses scheduled.
And if you want to choose a particular public course, now is the time to get your folks registered!
A great 2-Day TapRooT® course in Ecuador at AGUIP!
A Report from the UK Rail Accident Investigation Branch:
Structural failure caused by scour at Lamington viaduct, South Lanarkshire, 31 December 2015
At 08:40 hrs on Thursday 31 December 2015, subsidence of Lamington viaduct resulted in serious deformation of the track as the 05:57 hrs Crewe to Glasgow passenger service passed over at a speed of about 110 mph (177 km/h). The viaduct spans the River Clyde between Lockerbie and Carstairs. Subsequent investigation showed that the viaduct’s central river pier had been partially undermined by scour following high river flow velocity the previous day. The line was closed for over seven weeks until Monday 22 February 2016 while emergency stabilisation works were completed.
The driver of an earlier train had reported a track defect on the viaduct at 07:28 hrs on the same morning, and following trains crossed the viaduct at low speed while a Network Rail track maintenance team was deployed to the site. The team found no significant track defects and normal running was resumed with the 05:57 hrs service being the first train to pass on the down line. Immediately after this occurred at 08:40 hrs, large track movements were noticed by the team, who immediately imposed an emergency speed restriction before closing the line after finding that the central pier was damaged.
The viaduct spans a river bend which causes water to wash against the sides of the piers. It was also known to have shallow foundations. These were among the factors that resulted in it being identified as being at high risk of scour in 2005. A scheme to provide permanent scour protection to the piers and abutments was due to be constructed during 2015, but this project was deferred until mid-2016 because a necessary environmental approval had not been obtained.
To mitigate the risk of scour, the viaduct was included on a list of vulnerable bridges for which special precautions were required during flood conditions. These precautions included monitoring of river levels and closing the line if a pre determined water level was exceeded. However, this process was no longer in use and there was no effective scour risk mitigation for over 100 of the most vulnerable structures across Scotland. This had occurred, in part, because organisational changes within Network Rail had led to the loss of knowledge and ownership of some structures issues.
Although unrelated to the incident, the RAIB found that defects in the central river pier had not been fully addressed by planned maintenance work. There was also no datum level marked on the structure which meant that survey information from different sources could not easily be compared to identify change.
As a result of this investigation, RAIB has made three recommendations to Network Rail relating to:
- the management of scour risk
- the response to defect reports affecting structures over water
- the management of control centre procedures.
Five learning points are also noted relating to effective management of scour risk.
For more information, see:
TapRooT® course in Colombia recently had a great group!
For more information on our TapRooT® courses, click here.
When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.
The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.
This modern definition of a root cause leads to this definition of root cause analysis:
Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring.
Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.
Even though a decade had passed since proposing this new definition, I still have people ask:
“Why did you change the definition? I liked it like it was!“
Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.
The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!
The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.
This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.
The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.
One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.
That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.
Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.
For a report from the UK Rail Accident Investigation Branch, see:
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.
As a TapRooT® User, you probably know that Mark is one of the co-creator’s of the TapRooT® Root Cause Analysis System and a co-author of the TapRooT® Book series. You have probably heard that he has all sorts of experience with root cause analysis and incident investigation. But did you know that …
Mark is a Certified Professional Ergonomist (CPE).
He was the 85th person to be certified in ergonomics and human factors by the Board of Certified Professional Ergonomists. Mark has worked extensively on projects to improve human performance and reduce human errors.
His Masters Degree research at the University of Illinois was focused on the proper roles of operators and automation for the next generation of nuclear power plants (human factors function allocation).
Before starting System Improvements, he worked on projects to improve aspects of human performance including procedures usability and usage, and operator, maintenance, and technical training.
He also developed systems for managing performance improvement in a resource limited environment.
He used his human factors knowledge and experience to build into the TapRooT® System the ability to analyze and fix human performance/human behavior issues.
Mark was in Admiral Rickover’s Nuclear Navy (a High Reliability Organization).
Mark has studied high reliability organizations. But Mark has one major advantage over most of those who do academic research and speak about high reliability organizations … He has worked in a high reliability organization – the Nuclear Navy (the original high reliability organization). Therefore, he knows what works, why it works, and what doesn’t work BECAUSE HE HAS BEEN THERE. He understands Admiral Rickover’s management systems and practical methods to guard against normalization of deviation.
Mark has a unique understanding of process safety.
Marks has two engineering degrees (BSEE and MS Nuc E), human factors training, and experience working in Admiral Rickover’s Nuclear Navy (where he achieved his Engineer Certification). This gives him a unique understanding of process/nuclear safety. He has written about this experience (see this LINK) and provided talks for companies interested in improving their process safety systems and senior management understanding of process safety. (See part of his Summit talk in 2012 HERE.)
Mark has developed trending techniques for infrequently occurring safety and quality data.
Mark used the work of statistical experts Dr. Donald Wheeler, Dr. Walter Shewhart, and W. Edwards Deming to develop techniques to find statistically valid trends of infrequently occurring accident data. Mark is working on a new book about performance measurement and trending that will be published in 2017. Watch for the next trending course based on his work being held prior to the 2018 Global TapRooT® Summit.
Mark has practical experience.
In his spare time between working for high reliability organizations (the Nuclear Navy and Du Pont) and leading System Improvements, Mark designed and built roads (driving a bulldozer, track loader, excavator, and dump trucks), produced hardwood lumber from trees, and helped design two houses. While working in college getting his BS in Electrical Engineering, he was a field supervisor (in actual agricultural fields) and a cable TV installation and repair man. While still in high school, Mark worked in agricultural jobs, construction, retail, and ran his own lawn mowing and landscape business.
That’s a little more about the lessor known facts about Mark’s experience and expertise. If you have questions for Mark or would like him to consult with you about your improvement efforts, contact him at this LINK, or call 865-539-2139.
Lessons learned from six trains passing through an emergency speed restriction at excessive speed. For the complete story. see this post from the UK Rail Accident Investigation Branch:
Arturo de la Garza died last July after a long career improving safety and many years teaching TapRooT®.
Arturo was one of our first clients outside the US. Linda and I taught a course for him for the safety people at Cydsa in Monterrey, Mexico.
Arturo was a Chemical Engineer and had lost of chemical plant experience including plant management before joint Cydsa’s corporate staff.
When Arturo retired from Cydsa, he went to work for Cemex and then left Cemex to become one of out contract TapRooT® Instructors. For over a decade he taught courses for SI in Mexico and South America until he was 80 years old.
We will miss his good humor and knowledge and we know that all the instructors who taught with him and clients with whom he shared his knowledge will miss him as well.
In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:
“The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.“
Additionally, he said:
“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”
That seems like a “Blame Vision” statement.
That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:
“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”
Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:
We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.
Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:
The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.
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