Category: Pictures

TapRooT® Training Around the World: New Zealand

July 12th, 2018 by

Here is a glimpse into a recent in-house 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group in New Zealand. In just 5 days through TapRooT® Training, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

TapRooT® Techniques within the 5-Day course included SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon completion of the course, the students received a certificate of completion and a 90-Day Subscription to TapRooT® VI online.

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. We thank Narelle Wright at Practical Solutions Group for sharing these pictures of the interaction and 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 is a listing of our upcoming 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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 to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Singapore

July 11th, 2018 by

TapRooT® Instructor Malcolm Gresham, certified in TapRooT® instruction since 2006, was recently in Singapore teaching students the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group. In a course taught by one of our expert TapRooT® instructors, you will understand how to troubleshoot and identify the root cause of any issue and/or incident. We thank Narelle Wright for sharing these pictures of the interaction and 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 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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 to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Onsite Course, Ensign Energy, Neuquén, Argentina

July 10th, 2018 by

TapRooT® Instructor Piedad Colmenares sent us some “course captures” of the recent 2-Day TapRooT® Root Cause Analysis Training class she taught in Neuquén, in chilly Argentine Patagonia, onsite at Ensign Energy.

Piedad says, “Despite the intense cold of winter, it was a very special course. We shared experiences, and it was also very pleasant to experience the excitement of the World Cup. It was very exciting to receive the gift they gave me: a shirt of the Argentine soccer team, autographed by all the students.” Piedad gives a shout-out of thanks to all the participants of the Ensign Energy onsite course.

In a 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 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 a few of our upcoming courses:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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.

Monday Accident & Lessons Learned: Fatal Accident While Unloading a Truck

July 9th, 2018 by

WKBW TV reported that two employees were killed when a stack of Corian counter tops that weighed 800 pounds per slab (11 slabs total) fell on them. The accident occurred at 1:30 a.m. and the employees were pronounced dead at the scene.

The company issued a statement that said:

“We’re saddened to report that a tragic accident occurred this morning at our facility in Lockport, NY that resulted in the death of two of our colleagues. We’re working with our safety team and local law enforcement to understand the circumstances under which this tragedy occurred. Our deepest sympathies are with their families and our Lockport team members.”

OSHA will be conducting an investigation of the deaths. OSHA has investigated two other serious injuries at XPO facilities elsewhere in New York state.

What was the Hazard in this accident?

The heavy, high-piled load.

Who were the targets?

The two employees.

What were the Safeguards?

From the newspaper articles, we don’t know.

We also don’t know any of the reasons for the Safeguard’s failure.

The root cause analysis will have to determine the Safeguards, why they failed, and if they were sufficient. (Do we need additional Safeguards?)

In the TapRooT® System, a SnapCharT® would be used to collect and organize the information about what happened.

Then the failed Safeguards would be identified.

Next, the failed Safeguards (Causal Factors) would be analyzed to find their root causes using the Root Cause Tree® Diagram.

Once the root causes for all the Safeguards were found, the team would start developing corrective actions.

The Safeguards would be reviewed to see if after they were strengthened, if they would be adequate. If they would not be adequate, either additional Safeguards would be developed or the process could be modified to reduce or remove the hazard. For example, stack the counter tops no more that 16 inches high.

To improve the Safeguards that failed, you would address each of the root causes by developing SMARTER corrective actions using the Corrective Action Helper® Module of TapRooT® Software.

What is a SMARTER corrective action?

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

To learn more about the TapRooT® System, SnapCharT®, Safeguard Analysis, Causal Factors, the Root Cause Tree® Diagram, the Corrective Action Helper® Module, the TapRooT® Software, and SMARTER, attend one of our 2-Day or 5-Day TapRooT® Courses. Here is a list of the dates and locations of the courses being held around the world:

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

Happy 4th of July

July 4th, 2018 by

4th

In the US we celebrate declaring our independence from The British crown on the 4th of July. It was a great risk for a minor colony to stand up to the world’s mightiest power. Perhaps were were foolish or you might say reckless … but the outcome was a system without a king and with a constitution that affirmed and guaranteed our God given rights.

So today when you are celebrating somewhere in the US, remember those who risked all for the freedoms we enjoy today and those who stand ready to do that today.

Happy Independence Day!

Testimonial Tuesday

July 3rd, 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® take 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:

  • “Great interactive exercises to better understand the basics of SnapCharT®.” – Aspinall
  • “Very informative section on how to correctly identify causal factors.” – Neil
  • “Excellent software that quickened the process.” – Tony
  • “Great group exercises working in small teams using the Root Cause Tree®.” – Fox

5-Day Client Testimonials:

  • “I enjoyed the “Putting It All Togehter” unit, because it helped me remember all the things we have learned and how to implement these strategies.” – Einini
  • “Great approach to actually solving issues and behaviors.” – Anonymous
  • “Enjoyed working through a real incident. Very beneficial.” – Evan
  • “It wasn’t all lecture, the practical hands-on training was great.” – Robby

 

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 your 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

Caption Contest!

July 2nd, 2018 by

A new month means a new caption contest! This month’s caption contest photo comes from my husband, Jared.

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 July 23, 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!

Remembering An Accident: Ixtoc I Oil Spill

June 27th, 2018 by

On June 3, 1979 the Ixtoc I ,located in the Bay of Campeche in the Gulf of Mexico, exploded and caught fire at 3:30 AM. The Ixtoc oil spill became one of the largest oil spills in history.

So what happened?..

On June 2nd, the day before the blowout, the drill hit a spot with soft sedimentary soil that caused a bit weight reduction, also known as a break. This break unfortunately, caused a fracture in the wells’ piping that resulted in a complete loss in mud circulation drilling. As PeMex and Sedco argued over the best course of action oil began to build up in the west well column. Once the decision was made to remove the drill it was a little to late. Pressure had built to up extremely high, dangerous, and unstable levels. This caused a surge of mud to race up the drill pipe and spill onto the drilling platform. After the surge of mud multiple safety failures occurred creating a chain of events that resulted in the disastrous blow out.

 

After the blow out the now escaping oil ignited, and once it came into contact with gas fumes from a motor that powered the derrick aboard the platform the Ixtoc exploded at 3:30 am. The fire burned until about 10:00 am the next day. The fire caused the Sedco 135 drilling tower to collapse leading to the total loss of the drilling rig. Oil continued spilling out of the destroyed well for a total of 290 days, until the well was finally capped on March 23, 1980.

 

To learn more about the Ixtoc I Oil Spill click here.

 

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

 

Practice, Feedback, & Improve (Develop Skills)

June 27th, 2018 by

With any new skill that you learn, you need practice to implant the skill into long term memory. To get better at the skill, you need more practice and feedback (coaching).

The same is true of the skills you learn in a TapRooT® Course. You need to practice your new investigation and root cause analysis skills and get feedback (coaching) on ways to improve what you are doing.

Who will provide you with that feedback? Here are some ideas:

  1. Set up a peer review group. The members of this group should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and have experience doing investigations.
  2. Have a senior manager become an expert in root cause analysis and provide feedback on investigations when performing senior manager reviews.
  3. Have experts from System Improvements review your incident investigations as they progress, CONTACT US to find out how to get these reviews scheduled.

If you have only attended the 2-Day TapRooT® Root Cause Analysis Course, consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. You will get more practice with the essential TapRooT® Techniques and learn the advanced techniques including:

  • Cognitive interviewing techniques
  • Critical Human Action Profile (CHAP)
  • Change Analysis
  • Proactive use of Safeguard Analysis
  • Equifactor® Equipment Troubleshooting

Plus you will discuss human error and ways to improve human performance.

Here is a link to the upcoming public 5-Day TapRooT® Training schedule for courses held around the world:

http://www.taproot.com/store/5-Day-Courses/

For anyone interested in advanced root cause analysis training, CLICK HERE for more information.

TapRooT Around the World: Perth, Australia

June 26th, 2018 by

Here’s a peek into the recent 2-Day TapRooT® Root Cause Analysis Training Course in Perth, Australia, taught by Malcolm Gresham at the Practical Solutions Group. In a 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 Narelle Wright for sharing these 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:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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 Course, ENI in Italy

June 25th, 2018 by

Kudos to Randy Creek for sending in these pictures that lend insight into his recent 2-Day TapRooT® Root Cause Analysis Training onsite course at ENI, the Italian multinational oil and gas supermajor headquartered in Rome, and Italy’s largest industrial company. In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our experienced professional instructors.

 

 

 

 

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:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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.

Monday Accident & Lessons Learned: Why is Right of Way Maintenance Important?

June 18th, 2018 by

Here is another example of why right of way maintenance is important for utility transmission and distribution departments …

Wildfires

An article on hazardex reported that the California Department of Forestry and Fire Protection (Cal Fire) said in a press release that 12 of the wildfires that raged across California’s wine country were due to tree branches touching PG&E power lines.

Eight of the 12 fires have been referred to county District Attorney’s offices for potential criminal prosecution for alleged violations of California laws.

The fires last October killed 44 people, burned more than 245,000 acres, and cost at least $9.4 billion dollars of insured losses. PG&E has informed it’s shareholders that it could be liable costs in excess of the $800 million in insurance coverage that it has for wildfires.

PG&E is lobbying state legislators for relief because they are attributing the fires to climate change and say they should not be held liable for the damage.

What lessons can you learn from this?

Sometimes the cost of delayed maintenance is much higher than the cost of performing the maintenance.

Can you tell which maintenance is safety critical?

Do you know the risks associated with your deferred maintenance?

Things to think about.

TapRooT® Around the World: Onsite Course, Billingham, UK

June 15th, 2018 by
With TapRooT® Instructor Derek Rutherford teaching a recent onsite course for CF Industries in Billingham, UK, the class was focused on investigation preparation and their presentations. In a 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. Thanks, Derek, for the glimpse into your class!

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:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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 or 865.357.0080.

TapRooT® Around the World: Denver, CO

June 13th, 2018 by

Chris Vallee was recently in Denver, CO, teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and sent us these photos. Looks like everyone is having a good time and learning the TapRooT® methodology.

Did you miss out on our course in Denver? That’s okay! Below are some of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. In our course, you will learn how to troubleshoot and identify the root cause of any issue and/or incident by one of our expert instructors.

You can start by registering today. It’s easy! If you are looking for a different location, click here to browse TapRooT® courses.


Perth, Australia, June 18, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Portland, OR, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Dallas, TX, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

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

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

Dubai, UAE, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses

TapRooT® Users – Use It ALL

June 13th, 2018 by

NewImage

I had an interesting question from a TapRooT® user the other day.

“When will you be adding something to TapRooT® to deal with human performance issues?”

I had to stop and think. Of course, our whole design effort was to make TapRooT® the world’s best system for analyzing and fixing problems due to human error. But I realized that we had made the use of TapRooT® so transparent that this user, and probably others, didn’t know what they had.

They might not know that TapRooT® can them help fix:

  • human errors
  • human performance issues
  • company culture problems
  • behavior issues
  • management system failures
  • simple incidents
  • complex accidents
  • audit findings

TapRooT® can be used reactively (after an accident) or proactively (before a major accident). The application of TapRooT® is really flexible.

We’ve made this flexibility and applicability completely transparent. You don’t have to be a human performance expert (a Certified Ergonomist – like I am) to use the system and get great results.

We’ve made difficult analysis so easy that people don’t know all the power they have.

How can a TapRooT® User learn more about what they have?

  1. Read the blog and the weekly TapRooT® Friends & Experts Newsletter. Sign up for the newsletter HERE.
  2. Join the TapRooT® LinkedIn discussion group HERE.
  3. Attend advanced TapRooT® Training – the 5-Day TapRooT® Advanced Team Leader Training.
  4. Attend the annual Global TapRooT® Summit.
  5. Read TapRooT® Root Cause Analysis Leadership Lessons.

That’s a good start and two of the ideas are free.

Get as much as you can from the tools and processes that you already know – TapRooT®.

And if you have any questions, leave them as a comment here or contact us by CLICKING HERE.

New Study Suggests Poor Officer Seamanship Training Across the Navy – Is This a Generic Cause of 2017 Fatal Navy Ship Collisions?

June 7th, 2018 by

BLAME IS NOT A ROOT CAUSE

It is hard to do a root cause analysis from afar with only newspaper stories as your source of facts … but a recent The Washington Times article shed some light on a potential generic cause for the fatal collisions last year.

The Navy conducted an assessment of seamanship skills of 164 first-tour junior officers. The results were as follows

  • 16% (27 of 164) – no concerns
  • 66% (108 of 164) – some concerns
  • 18% (29 of 164) – significant concerns

With almost 1 out of 5 having significant concerns, and two thirds having some concerns, it made me wonder about the blame being placed on the ship’s Commanding Officers and crew. Were they set up for failure by a training program that sent officers to sea who didn’t have the skills needed to perform their jobs as Officer of the Deck and Junior Offiicer of the Deck?

The blame heavy initial investigations certainly didn’t highlight this generic training problem that now seems to be being addressed by the Navy.

Navy officers who cooperated with the Navy’s investigations faced court martials after cooperating.

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According to and article in The Maritime Executive Lt j.g. Sarah Coppock, Officer of the Deck during the USS Fitzgerald collision, pled guilt to charges to avoid facing a court martial. Was she properly trained or would have the Navy’s evaluators had “concerns” with her abilities if she was evaluated BEFORE the collision? Was this accident due to the abbreviated training that the Navy instituted to save money?

Note that in the press release, information came out that hadn’t previously been released that the Fitzgerald’s main navigation radar was known to be malfunctioning and that Lt. j.g. Coppock thought she had done calculations that showed that the merchant ship would pass safely astern.

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In other blame related news, the Chief Boatswains Mate on the USS McCain plead guilty to dereliction of duty for the training of personnel to use the Integrated Bridge Navigation System, newly installed on the McCain four months before he arrived. His total training on the system was 30 minutes of instruction by a “master helmsman.” He had never used the system on a previous ships and requested additional training and documentation on the system, but had not received any help prior to the collision.

He thought that the three sailors on duty from the USS Antietam, a similar cruiser, were familiar with the steering system. However, after the crash he discovered that the USS McCain was the only cruiser in the 7th fleet with this system and that the transferred sailors were not familiar with the system.

On his previous ship Chief Butler took action to avoid a collision at sea when a steering system failed during an underway replenishment and won the 2014 Sailor of the Year award. Yet the Navy would have us believe that he was a “bad sailor” (derelict in his duties) aboard the USS McCain.

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Also blamed was the CO of the USS McCain, Commander Alfredo J. Sanchez. He pleaded guilty to dereliction of duty in a pretrial agreement. Commander Sanchez was originally charged with negligent homicide and hazarding a vessel  but both other charges were dropped as part of the pretrial agreement.

Maybe I’m seeing a pattern here. Pretrial agreements and guilty pleas to reduced charges to avoid putting the Navy on trial for systemic deficiencies (perhaps the real root causes of the collisions).

Would your root cause analysis system tend to place blame or would it find the true root and generic causes of your most significant safety, quality, and equipment reliability problems?

The TapRooT® Root Cause Analysis System is designed to look for the real root and generic causes of issues without placing unnecessary blame. Find out more at one of our courses:

http://www.taproot.com/courses

TapRooT® Around the World: Bogota, Colombia

June 6th, 2018 by

Thank you Diana Munevar for these wonderful TapRooT® training photos. Looks like everyone is having fun and learning the TapRooT® methodology.

Advance your career by putting yourself in the picture and becoming TapRooT® trained. You will learn how to troubleshoot and identify the root cause of any issue and/or incident by one of our expert instructors. You can start by registering today, it’s easy! Below are a sample of our upcoming course. If you’re looking for a different location click here to see all of our available courses.


Calgary, Canada, June 11, 2018:  2-Day TapRooT® Root Cause Analysis Training Course

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training Course

Denver, CO, June 11, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Hamburg, Germany, June 11, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Hartford, CT, June 13, 2018: 2-Day TapRooT® Root Cause Analysis Training Course

Perth, Australia, June 18, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Niagara Falls, Canada, June 20, 2018: 2-Day TapRooT® Root Cause Analysis Training Course

Auckland, NZ, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training Course

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training Course

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Is Blame Built Into Your Root Cause System?

June 6th, 2018 by

Blame

If you want to stop good root cause analysis, introduce blame into the process.

In recent years, good analysts have fought to eliminate blame from root cause analysis. But there are still some root cause systems that promote blame. They actually build blame into the system.

How can this be? Maybe they just don’t understand how to make a world-class root cause analysis system.

When TapRooT® Root Cause Analysis was new, I often had people ask:

“Where is the place you put ‘the operator was stupid?'”

Today, this question might make you laugh. Back in the day, I spent quite a bit of time explaining that stupidity is not a root cause. If you hire stupid people, send them through your training program, and qualify them, then that is YOUR problem with your training program.

The “stupid people” root cause is a blame-oriented cause. It is not a root cause.

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What is a root cause? Here is the TapRooT® System definition:

Root Cause
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem. 

Are there systems with “stupid people” root causes? YES! Try these blame categories:
    • Attitude
    • Attention less than adequate
    • Step was omitted due to mental lapse
    • Individual’s capabilities to perform work less than adequate
    • Improper body positioning
    • Incorrect performance due to a mental lapse
    • Less than adequate motor skills
    • Inadequate size or strength
    • Poor judgment/lack of judgment/misjudgment
    • Reasoning capabilities less than adequate
    • Poor coordination
    • Poor reaction time
    • Emotional overload
    • Lower learning aptitude
    • Memory failure/memory lapse
    • Behavior inadequate
    • Violation by individual
    • Inability to comprehend training
    • Insufficient mental capabilities
    • Poor language ability
    • In the line of fire
    • Inattention to detail
    • Unawareness
    • Mindset

You might laugh at these root causes but they are included in real systems that people are required to use. The “operator is stupid” root cause might fit in the “reasoning capabilities less than adequate,” the “incorrect performance due to mental lapse,” the “poor judgment/lack of judgment,” or the “insufficient mental capabilities” categories.

You may ask:

“Couldn’t a mental lapse be a cause?”

Of course, the answer is yes. Someone could have a mental lapse. But it isn’t a root cause. Why? It doesn’t fit the definition. It isn’t a best practice or a failure to apply knowledge. We are supposed to develop systems that account for human capabilities and limitations. At best, a memory lapse would be part of a a Causal Factor.

To deal with human frailties, we implement best practices to stop simple memory lapses from becoming incidents. In other words, that’s why we have checklists, good human engineering, second checks when needed, and supervision. The root causes listed on the back side of the TapRooT® Root Cause Tree® are linked to human performance best practices that make human performance more reliable so that a simple memory lapse doesn’t become an accident.

What happens when you make a pick list with blame categories like those in the bulleted list above? The categories get overused. It is much easier to blame the operator (they had less than adequate motor skills) than to find out why they moved the controls the wrong way. Its easy to say there was a “behavior issue.” It is difficult to understand why someone behaved the way they did. TapRooT® looks beyond behavior and simple motor skill error to find real root causes.

We have actually tested the use of “blame categories” in a system and shown that including blame categories in an otherwise good system causes investigators to jump to conclusions and select these “easy to pick” blame categories rather than applying the investigative effort required to find real root causes.

You may think that if you don’t have categories, you have sidestepped the problem of blame. WRONG! Blame is built into our psyche. Most cause-and-effect examples I see have some blame built into the analysis.

If you want to successfully find the real, fixable root causes of accidents, precursor incidents, quality issues, equipment failures, cost overruns, or operational failures, don’t start by placing blame or use a root cause system with built-in blame categories. Instead, use advanced root cause analysis – TapRooT®.

The best way to learn about advanced root cause analysis is in a 2-Day TapRooT® Root Cause Analysis Course or a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the list of upcoming public courses here: http://www.taproot.com/store/Courses/.

Why do we still have major process safety accidents?

May 30th, 2018 by

I had an interesting argument about root cause analysis and process safety. The person I was arguing with thought that 5-Whys was a good technique to use for process safety incidents that had low consequences.

Let me start by saying that MOST process safety incidents have low actual consequences. The reason they need to be prevented is that they are major accident precursors. If one or more additional Safeguards had failed, they would become a major accident. Thus, their potential consequences are high.

From my previous writings (a sample of links below), you know that I consider 5-Whys to be an inferior root cause analysis tool.

If you don’t have time to read the links above, then consider the results you have observed when people use 5-Whys. The results are:

  • Inconsistent (different people get different results when analyzing the same problem)
  • Prone to bias (you get what you look for)
  • Don’t find the root causes of human errors
  • Don’t consistently find management system root causes

And that’s just a start of the list of performance problems.

So why do people say that 5-Whys is a good technique (or a good enough technique)? It usually comes down to their confidence. They are confident in their ability to find the causes of problems without a systematic approach to root cause analysis. They believe they already know the answers to these simple problems and that it is a waste of time to use a more rigorous approach. Thus, their knowledge and a simple (inferior) technique is enough.

Because they have so much confidence in their ability, it is difficult to show them the weaknesses in 5-Whys because their answer is always:

“Of course, any technique can be misused,
but a good 5-Whys wouldn’t have that problem.”

And a good 5-Whys is the one THEY would do.

If you point out problems with one of their root cause analyses using 5-Why, they say you are nitpicking and stop the conversation because you are “overly critical and no technique is perfect.”

Of course, I agree. No technique is perfect. But some are much better than others. And the results show when the techniques are applied.

And that got me thinking …

How many major accidents had precursor incidents
that were investigated using 5-Whys and the corrective
actions were ineffective (didn’t prevent the major accident)?

Next time you have a major accident, look for precursors and check why their root cause analysis and corrective actions didn’t prevent the major accident. Maybe that will convince you that you need to improve your root cause analysis.

If you want to sample advanced root cause analysis, attend a 2-Day or a 5-Day TapRooT® Course.

The 2-Day TapRooT® Root Cause Analysis Course is for people who investigate precursor incidents (low-to-moderate consequences).

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is for people who investigate precursor incidents (low-to-moderate consequences) AND perform major investigation (fatalities, fires, explosions, large environmental releases, or other costly events).

See the schedule for upcoming public courses that are held around the world HERE. Just click on your continent to see courses near you.

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

May 22nd, 2018 by

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Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

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

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Avoid Big Problems By Paying Attention to the Small Stuff

May 16th, 2018 by

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

What does a bad day look like?

May 15th, 2018 by

“Joke’s on you! The neighbors actually have a flying car, and thus no need for a driveway that smoothly goes into the garage. Psssh, tires are sooooo 2015, right?”

TapRooT® Around the World: Bogota, Colombia

May 15th, 2018 by

Many thanks to Diana Munevar for these TapRooT® training photos from a three-day TapRooT® training course led by Hernando Godoy and Piedad Colmenares in Bogota, Colombia! Looks like they are having fun and learning a lot!

Put yourself in this picture. Advance your career and your development through TapRooT® training!

We are global to meet your needs. Register today for a TapRooT® Training course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.

July 16 – Auckland, New Zealand, 2-Day TapRooT® Root Cause Analysis Training

July 17 – Milwaukee, Wisconsin, 2-Day TapRooT® Root Cause Analysis Training

July 25 – Lake Tahoe, Nevada, 2-Day Root Cause Analysis Training

August 08 –  Sao Paulo, Brazil, 2-Day TapRooT® Root Cause Analysis Training

August 13 – Nashville, Tennessee, 2-Day TapRooT® Root Cause Analysis Training

August 27 – Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Training

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

September 26 – Amsterdam, Netherlands, 2-Day TapRooT® Root Cause Analysis Training

October 14 – Dubai, UAE, 5-Day Advanced Root Cause Analysis Training

 If you’re interested in pursuing a TapRooT® course that is near you or for a specific date, look further via these two links:

2-Day TapRooT® Root Cause Analysis Training

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

TapRooT® Around the World: Houston

May 11th, 2018 by

Last day of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Houston, Texas. Heidi Reed and I are looking forward to seeing our course attendees’ final presentations. It’s been an awesome week! Click here and get in the picture.

 

TapRooT® Around the World: Recent TapRooT® Course Photos

May 9th, 2018 by

Many thanks to Diana Munevar for the TapRooT® training photos from a recent course held in Bogota, Colombia. Looks like everyone there had a blast and learned a lot!

 

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

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