TapRooT® recently held a 5-Day Advanced Root Cause Analysis and Team Leader Training Public Course in Sao Paulo, Brazil.
Check out our schedule for many more Public Courses around the world.
Interested in an Onsite Course for your company? Click here to inquire.
Makes you think that tattoo shops need a spell/grammar checker! I know I need one! (Did you see all the mistakes?)
Here are some photos of the recent Onsite TapRooT® course at Fresenius in Reynosa, Mexico.
Click here to inquire about an Onsite Course at your workplace.
Click here to see the many locations of our Public Courses.
SAVE THE DATE for our Global TapRooT® Summit this June 1-5 in Las Vegas. Click here for more information.
The employees of Stracon in Lima, Peru worked hard at their recent Onsite TapRooT® Course taught by Hernando Godoy.
Interested in having an Onsite TapRooT® Course at your company? Click Here.
Learn why the Global TapRooT® Summit coming up this June 1-5 is the perfect training and networking opportunity for your company.
TapRooT® instructor Chris Vallee taught a 5-Day Root Cause Analysis and Team Leader Training public course in Singapore. Thanks for the pictures.
For more information on Public TapRooT® Courses around the world, click here.
To inquire about an Onsite TapRooT® Course specifically for your company, click here.
1. Where was the first TapRooT® Summit (then called the TapRooT® Conference) held?
c) San Antonio
2. How many TapRooT® Summits have been held since the first Summit?
3. In what year was the first TapRooT® Summit Held?
4. Who was presented with the “Most Beloved Speaker” Award?
a) Ed Skompski
b) Mark Paradies
c) Beverly Chiodo
d) ED Hill
5. Counting this year, how many times has the Global TapRooT® Summit been held in Las Vegas?
6. Where was the largest (by attendance) Global TapRooT® Summit ever held?
d) Las Vegas
7. How was JR Ewing connected to the Global TapRooT® Summit?
a) He invented it.
b) People from his oil company always attend.
c) He was involved in a TapRooT® investigation.
d) A JR look alike attended the TapRooT® Summit reception in 1998 at the Southfork Ranch.
8. How many Summit Best Practice Tracks are there at this year’s Global TapRoot® Summit?
9. You can customize your Summit schedule by picking topics from different Best Practice Tracks.
10. Last years Global TapRooT® Summit was held in?
a) Las Vegas
Check the comments field below for the answers!
And don’t miss the 2015 Global TapRoot® Summit. For more information see:
A press release from the UK RAIB:
RAIB is investigating an incident that occurred at 17:25 hrs on Saturday 7 March 2015, in which train reporting number 1Z67, the 16:35 hrs service from Bristol Temple Meads to Southend, passed a signal at danger on the approach to Wootton Bassett junction, Wiltshire. The train subsequently came to a stand across the junction. The signal was being maintained at danger in order to protect the movement of a previous train. However, at the time that the SPAD occurred, this previous train had already passed through the junction and was continuing on its journey. No injuries, damage or derailment occurred as a result of the SPAD.
Wootton Bassett junction is situated between Chippenham and Swindon stations on the Great Western main line and is the point at which the line from Bristol, via Bath, converges with the line from South Wales. It is a double track high speed junction which also features low speed crossovers between the up and down main lines (see figure below for detail).
Wootton Bassett junction in 2012 – the lines shown from left to right are the Up Goods,
Up Badminton, Down Badminton, Up Main and Down Main (image courtesy of Network Rail)
The junction is protected from trains approaching on the up main from Chippenham by signal number SN45, which is equipped with both the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS). This signal is preceded on the up main by signal SN43, which is also equipped with AWS and TPWS. The maximum permitted line speed for trains approaching the junction from this direction is normally 125 mph. However, on 7 March, a temporary speed restriction (TSR) of 85 mph was in place on the approach to signal SN45. A temporary AWS magnet had been placed on the approach to signal SN43 to warn drivers of this TSR.
A diagram of the layout of Wootton Bassett junction – note that some features have been omitted for clarity (not to scale)
The train which passed signal SN45 at danger consisted of steam locomotive number 34067 ‘Tangmere’, and its tender, coupled to 13 coaches. The locomotive is equipped with AWS and TPWS equipment.
The RAIB’s preliminary examination has shown that, at around 17:24 hrs, train 1Z67 was approaching signal SN43 at 59 mph, when it passed over the temporary AWS magnet associated with the TSR. This created both an audible and visual warning in the locomotive’s cab. However, as the driver did not acknowledge this warning within 2.7 seconds, the AWS system on the locomotive automatically applied the train’s brakes. This brake application should have resulted in the train being brought to a stand. In these circumstances, the railway rule book requires that the driver immediately contact the signaller.
The RAIB has found evidence that the driver of 1Z67 did not bring the train to a stand and contact the signaller after experiencing this brake application. Evidence shows that the driver and fireman instead took an action which cancelled the effect of the AWS braking demand after a short period and a reduction in train speed of only around 8 mph. The action taken also had the effect of making subsequent AWS or TPWS brake demands ineffective.
Shortly after passing the AWS magnet for the TSR, the train passed signal SN43, which was at caution. Although the AWS warning associated with this signal was acknowledged by the driver, the speed of the train was not then reduced appropriately on the approach to the next signal, SN45, which was at danger. Because of the earlier actions of the driver and fireman, the TPWS equipment associated with signal SN45 was unable to control the speed of the train on approach to this signal.
As train 1Z67 approached signal SN45, the driver saw that it was at danger and fully applied the train’s brakes. However, by this point there was insufficient distance remaining to bring the train to a stand before it reached the junction beyond SN45. The train subsequently stopped, standing on both the crossovers and the up and down Badminton lines, at around 17:26 hrs. The signalling system had already set the points at the junction in anticipation of the later movement of 1Z67 across it; this meant that no damage was sustained to either the train or the infrastructure as a result of the SPAD.
The RAIB has found no evidence of any malfunction of the signalling, AWS or TPWS equipment involved in the incident.
The RAIB’s investigation will consider the factors that contributed to signal SN45 being passed at danger, including the position of the temporary AWS magnet associated with the TSR. The investigation will also examine the factors that influenced the actions of the train crew, the adequacy of the safety systems installed on the locomotive and the safety management arrangements.
RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.
We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation.
These findings will be available on the our website.
There are 15 potential Pre-Summit Courses to choose from in June and five of the courses are new. That’s probably why so many people are asking which course would be best for them. Therefore, I thought I’d share my thoughts to help people make the best choice.
First, the 15 Courses are:
- 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
- Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis
- Advanced Causal Factor Development Course
- Advanced Trending Techniques
- TapRooT® Analyzing and Fixing Safety Culture Issues
- Risk Assessment and Management Best Practices
- TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training
- Getting the Most from Your TapRooT® Software
- Hazard Recognition
- Proactive Use of TapRooT®
- NEW Interviewing & Investigation Basics
- NEW Combating Fatigue
- NEW Understanding and Stopping Human Error
- NEW Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement
- NEW Creative Corrective Actions
Next, let me say that I like all these courses. I’ve hand-picked them to be included before the Summit because I think they will help you solve some of your biggest problems. But I understand that you can only attend one of these courses and that you want to pick the best one, so I’ll offer some advice.
If you haven’t attended a TapRooT® Root Cause Analysis Course before, then you should consider attending the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. This is the basic/starter TapRooT® Course that all investigators/root cause analysts should take. It will make the Summit much more valuable if you understand how the TapRooT® Root Cause Analysis System works. And it will help you perform much better investigations of safety, quality, and production issues. This course (like all Pre-Summit Courses) is completely guaranteed. We know that you and your management will agree that you will find root causes that you previously would have missed and develop much more effective corrective actions.
Need to improve equipment reliability and apply advanced equipment troubleshooting techniques? Then the Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course is for you. You will learn to apply Heinz Bloch’s advanced troubleshooting techniques to understand how equipment failures occurred. You will then learn to take that information, organize it in a SnapCharT®, identify the Causal Factors, and find each Causal Factors root causes using the TapRooT® Root Cause Tree®. Even equipment troubleshooting experts that have attended this course have commented on the helpfulness of the Heinz Bloch troubleshooting tables and the TapRooT® Root Cause Analysis System.
Want to improve your TapRoot® Skills, especially your ability to identify Causal Factors? Then the Advanced Causal Factor Development Course is for you. Ken Turnbull teaches this course using recent examples of accidents, incidents, and near-misses – some straight from the press. You will get lot’s of hands-on exercise practice and instructor feedback.
Do you need to learn to trend your safety and performance data? Especially data from infrequently occurring accident statistics? Would you like to prove that you have improved performance? Or do you need to mathematically demonstrate that a “trend” really isn’t a trend, but rather, is just normal process variation? That’s what the Advanced Trending Techniques Course is all about. I developed after I saw a client’s advanced trending best practices that blew me away. This was trending that really worked and showed when a trend was real and when it was just normal process variation. It was based on advanced lean/six sigma techniques that were specially modified for low frequency accident data. But the same techniques can be applied to all your data. It truly is a one size fits all trending program that will help your management focus their improvement initiative. In the course you will learn how to draw advanced graphs and practice your skills so that you can apply the techniques to your data back home. The course is taught by Kevin McManus, a quality/safety guru, and I know that you will find it enlightening and very useful.
The topic of Safety Culture is a hot button in the nuclear, oil, and aviation industry. If you would like to analyze and improve your safety culture, then the TapRooT® Analyzing and Fixing Safety Culture Issues Course is for you. Brian Tink and Brian Tink (Jr & Sr) will show you how to use TapRooT® Tools along with culture analysis tools to analyze and fix safety culture issues. Part of this course is a practice safety culture analysis for your company. If safety culture is a hot button topic at your company, don’t miss this course.
Interested in risk assessment and management? Want to learn about the latest international standards and how they can help keep your management out of trouble? Then you need to listen to risk management guru Jim Whiting in his course: Risk Assessment and Management Best Practices. Jim shares all the latest risk management techniques and tons of documentation that you will use when you return to work
Interested in applying advanced root cause analysis techniques in a Lean, Six Sigma, or Quality program? Then attend the TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training taught by Chris Vallee. Chris is a Six Sigma Black Belt. He will show you how to use TapRooT® Techniques to analyze and fix quality problems, lean waste issues, and problems discovered using Six Sigma techniques.
Do you provide technical support for the TapRooT® Software? Are you a TapRooT® Software “Power Users” who wants to learn the latest tricks and see the latest software updates? Are you interested in the changes coming in Version 6 of the TapRooT® Software. Are you responsible for setting up the TapRoot® Software and preparing the trending fields and linking the software to other databases? Then you want to attend the Getting the Most from Your TapRooT® Software Course taught by Dan VerLinde, VP for Software Development at SI. You will be amazed how much you learn and how much better your software usage will be.
What is a hazard? Do you see them before they can cause an accident? If you are interested in Hazard recognition and elimination, then the Hazard Recognition Course is for you. Peter Berkholtz, a TapRoot® Instructor from Australia with 25 years of mining and industrial experience, will teach this practical course. Don’t let hazards sneak up on you. Recognize and eliminate them!
Did you know you could use the TapRooT® System to solve problems before they cause a crisis? If you want to stop problems BEFORE they happen, then the Proactive Use of TapRooT® Course is for you! Dave Janney developed this course after realizing that people would rather stop fatalities before they happen rather than investigate fatalities after they happen. He explains how TapRooT® can be applied to improve auditing, observations and BBS, and pre-job hazard assessments. Learn new ways to apply the TapRoot® System to proactively improve performance at your facility.
And now for the new courses …
Interviewing and Investigation Basics: We’ve taught this course before but after we had so many positive comments about Barbara Phillips talk on Body language and interviewing at last year’s TapRooT® Summit, we decided to completely revise the course adding new material on interviewing, I think you will find this course to be engaging, useful, practical, and a good use of your time if you are interested in effective cognitive interview and non-verbal techniques and the tools and practices needed to collect information for an effective root cause analysis.
Combating Fatigue: fatigue in the workplace (and while driving) is one of the most frequent, and least investigated, causes of accidents. Studies of actual auto accidents that were video tapped inside the car for later analysis showed that actual fatigue and sleeping was often NEVER reported but was the cause of the accident. What can you do to fight fatigue at your company? Get great ideas from fatigue expert Bill Sirois. Learn to understand the risks of fatigue. Learn the five levels of defense against fatigue. Learn to build and improve a Fatigue Risk Management System (required in several industries). Understand specific methods to handle fatigue in high hazard industries. This course has been completely updated since it was last given before the 2012 Summit and we see it as completely new.
Understanding and Stopping Human Error: Mark Paradies, President of System Improvements and Joel Haight, Professor of Industrial Engineering at the University of Pittsburg, will bring their considerable knowledge of the practical application of human factors engineering to this newly developed course. The course will cover the human abilities and limitations that lead to human error, how to understand error likely situations and error causing designs, and how to apply error reducing techniques that work and to understand why some error reducing techniques that are frequently suggested are of little practical value. If you are interested in human performance and stopping human error (or at least reducing it as far as practical), then don’t miss this course.
Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement: Ed Skompski, Vice President at System Improvements, has created a 2-Day TapRooT® Course especially for the healthcare community that focuses on the analysis of the root causes of sentinell events and healthcare quality issues. The course is built around real clinical events and uses the TapRooT® System, a recognized good practice in the healthcare industry and that the terminology is recognized by The Joint Commission.
Creative Corrective Actions: You may remember this course from the past. Michele Lindsay was a TapRooT® Instructor for over a decade. But she now is a performance improvement coach at a healthcare facility. But this year she will be coming back to the TapRooT® Summit and is presenting a new course on creative corrective actions using Dr. Edward de Bono’s Six Thinking Hats™ techniques.
That’s a lot of training to choose from! But don’t wait too long to register. Seats are limited in these courses and we want you to get your first choice!
Additionally, you get a $200 discount on the training when you also attend the 2015 Global TapRooT® Summit. For more Summit info, see:
And if you have any questions about the Pre-Summit Courses or the Summit, please call us at 865-539-2139. Or CLICK HERE to drop us a note with your question.
The UK Rail Accident Investigation Branch announced the start of two rail incident investigations.
The first is an investigation of the injury of a passenger that fell between a London Underground train while being dragged by the train. See the preliminary information at:
This is an accident that was prevented from being worse by the alert actions of the train’s operator.
The second incident was container blown off a freight train. The preliminary information can be found here:
Thomas Edison said, “I failed my way to success.” Mistakes – do they help you to grow stronger or do leave you feeling beat down, afraid to try again? What would happen if you stopped berating yourself for not meeting your highest aspirations every single time?
Mistakes are not committed intentionally but we often allow them to interfere with our progress. If we step back and view them objectively, we will find a few gems of wisdom to help us along the path. Stay open and flexible and most of all, see mistakes for what they are: events that provide each of us with our unique life experiences. Not only are mistakes proof that we are out there trying something, they are proof that we are willing to suffer some risk and change to get to where we want to be.
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Rome, ItalyMarch 19th, 2015 by Mark Paradies
The students at the Rome 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course show off what they have learned as they analyze an incident from their own company as the final exercise at the course. They then present their work for critique by the rest of the class participants.
Working on their analysis…
If you want to experience the magic of the TaoRooT® Root Cause Analysis System – of how it can help you discover causes that you previously would have missed and develop much more effective corrective actions, then select a course to attend from this upcoming course list:
Or have a course at your facility by contacting us at: