Category: Pictures

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

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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

Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)

May 9th, 2018 by

Find the Root Cause

I hear people say that 5-Whys is a good root cause analysis system for “simple” incidents. So, I thought I would show a simple incident that was provided as an example by a very experienced 5-Why user and compare it to the analysis that would be performed using TapRooT®.

Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, is the source of the example – a robot failure. He used the example to teach employees the 5-Why technique while he was at Toyota. Here is the example as he described it…

1.    Why did the robot stop?

–    The circuit has overloaded, causing a blown fuse.

2.    Why did the circuit overload?

–    There was insufficient lubrication on the bearings, so they locked up.

3.    Why was there insufficient lubrication on the bearings?

–    The oil pump on the robot is not circulating sufficient oil.

4.    Why is the pump not circulating sufficient oil?

–    The pump intake is clogged with metal shavings.

5.    Why is the intake clogged with metal shavings?

–    Because there is no filter on the pump.

For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.

Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.

TapRooT® Root Cause Analysis

TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with either the TapRooT® 5-Step Process for low-to-medium risk incidents or the the TapRooT® 7-Step Process for major investigations. The 5-Step Process is shown below…

To start investigating the problem, one gathers evidence and draws a SnapCharT® (shown below being drawn by a team in a TapRooT® 2-Day Root Cause Analysis Course).

Notice that the 5-Whys that Mr. Ohno asked in the example above turned out to be mainly the sequence of events leading up to the failure in the  SnapCharT® (shown below).

The SnapCharT® makes the example event easier to understand than the 5-Why example above. Plus, the SnapCharT® goes beyond the 5-Whys by indicating that there was no low oil pressure alarm.

In TapRooT®, if the investigator decides that there is more to learn, the investigator continues to collect evidence (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.

First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?

Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?

The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.

Notice that in TapRooT®, we complete the collection of evidence about what caused the metal filings and what caused the filter to be missing. These were significant issues that were left out of the 5-Why analysis. This type of omission is common in 5-Why analyses – even when experts apply 5-Whys. Thus the problem isn’t with the investigator or their training – it is embedded in the 5-Why system.

Causal Factors

Once one understands what happened, the third step is to identify the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. A simple technique called Safeguard Analysis is used to do this. The four Causal Factors for the Robot Stops incident were identified as:

  1. Mechanic A uses cloth to cover openings in system.
  2. Mechanic A does not report metal shaving contamination.
  3. Mechanic B does not install oil filter.
  4. Operator does not know oil pressure is low.

Where Mr. Ohno only had one root cause, TapRooT® has already identified four Causal Factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys: that it usually focuses on a single cause and misses additional causes (and the needed corrective actions for those root causes that aren’t identified).

TapRooT® Root Causes

In fourth step of the TapRooT® 5-Step Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).

For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend  attending a 2-Day or 5-Day TapRooT® Course.

However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”

This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.

Copyright © 2015 by System Improvements, Inc.
Used by permission. Duplication prohibited.

In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).

Thus, it was determined that if the operator needed an oil pressure display/alarm (displays NI root cause) to make the detection of a problem possible (errors not detectable root cause). If the display/alarm had been present, then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.

The corrective action for these two root causes would be to install a bearing lube oil pressure indicator and a low bearing lube oil pressure alarm to notify the operator of impending equipment problems before the bearing would lock up.

After analyzing just one Causal Factor using the TapRooT® Root Cause Tree® we have found that even an expert like Taiichi Ohno could miss important root causes when using 5-Whys. But there is more. There are still three more Causal Factors to analyze (and then Generic Causes – an optional technique in the 5-Step Process).

Why would you use a root cause tool with known, proven weaknesses? Why would you risk lives, your corporate reputation, and large sums of money on an inferior approach to problem solving? If something is worth fixing, it is worth fixing it right! Learn and apply TapRooT® Advanced Root Cause Analysis to find the real root causes of problems and effectively fix them. Attend an upcoming course to learn more.

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

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But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

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 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

Press Release: CSB to Investigate Husky Refinery Fire

April 26th, 2018 by

CSB

Washington, DC, April 26, 2018 –  A four-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that reportedly injured multiple workers this morning at the Husky Energy oil refinery in Superior, Wisconsin. The refinery was shutting down in preparation for a five-week turnaround when an explosion was reported around 10 am CDT.

According to initial reports, several people were transported to area hospitals with injuries. There have been no reports of fatalities. Residents and area schools near the refinery were asked to evacuate due to heavy smoke.

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit the CSB website, www.csb.gov

Here is additional coverage of the fire …

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http://www.kbjr6.com/story/38049655/explosion-injuries-reported-at-husky-energy-superior-refinery?autostart=true

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

Is April just a bad month?

April 24th, 2018 by

I was reading a history of industrial/process safety accidents and noticed that all the following happened in April:

Texas city nitrate explosion

April 16, 1947 – 2,200 tons of ammonium nitrate detonates in Texas City, Teas, destroying multiple facilities and killing 581 people.

Deepwater horizon

April 20, 2010 – A blowout, explosions, and fire destroy the Deepwater Horizon, killing 11. This was the worst oil spill in US history.

West texas

April 17, 2013 – 10 tons of ammonium nitrate detonates in West, Texas, destroying most of the town and killing 15 people.

Maybe this is just my selective vision making a trend out of nothing or maybe Spring is a bad time for process safety? I’m sure it is a coincidence but it sure seems strange.

Do you ever notice “trends” that you make you wonder … “Is this really a trend?”

The best way to know is to apply our advanced trending techniques. Watch for our new book coming out this Summer and then plan to attend the course next March prior to the 2019 Global TapRooT® Summit.

Are you ready for quality root cause analysis of a precursor incident?

April 17th, 2018 by

Many companies use TapRooT® to investigate major accidents. But investigating a major accident is like closing the barn door after the horse has bolted.

What should you be doing? Quality investigations of incidents that could have been major accidents. We call these precursor incidents. They could have been major accidents if something else had gone wrong, another safeguard had failed, or you were “unlucky” that day.

How do you do a quality investigation of a precursor incident? TapRooT® of course! See the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book.

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Or attend one of our TapRooT® Root Cause Analysis Courses.

Where to Start When Finding Root Causes

April 11th, 2018 by

I had someone ask me the other day …

”Where do I start when finding root causes?”

To me, the answer was obvious. You need to understand what happened BEFORE you can understand why it happened.

That’s why the TapRooT® System starts by developing a SnapCharT® of what happened.

Here is a simple example.

Someone sprains their ankle while walking to their car in the parking lot.

What is the root cause.

You might think the obvious answer is …

“They didn’t have their eyes on path!”

But you are jumping to conclusions! You don’t know what happened. So start here…

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You are starting to develop the story of what happened. You keep working on the story until you have clearly defined Causal Factors …

SprainSnapwCF

That’s a lot more information! It isn’t as simple as “eyes on path.”

Now you are ready to start identifying the root causes of each of the four Causal Factors.

So, that’s where you need to start to find root causes!

Who Invented Operational Excellence?

March 28th, 2018 by

Who Invented Operational Excellence?

Admiral Hyman G. Rickover

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As a Navy Nuclear Power trained officer, I experienced the rigors of achieving operational excellence first hand.

Rickover explained that there were a series of principles that helped the Nuclear Navy achieve excellence but the top three were:

  1. Total Responsibility
  2. Technical Competence
  3. Facing the Facts

Read about these three principles in a series of articles that I wrote:

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

 Rickover lived out this quote:

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He fought against the lax standards that the Navy practiced and implemented a system of excellence to run the Navy’s nuclear reactors.

You might think that he would be praised and lauded by the Navy for his success. Instead, he had to fight every inch of the way to steer a course true to his principles. And the oldest Admiral ever was fired by the youngest Secretary of the Navy ever. Sometimes that’s how Washington politics works.

Want to read more about Rickover’s life and how he developed his concepts of operational/process excellence? Read his semi-official biography (written by the official Nuclear Navy historian Francis Duncan) Rickover – The Struggle for Excellence. (Picture of the book at the top of the page.)

Root Cause Analysis Audit Idea

March 22nd, 2018 by

Screen Shot 2018 03 22 at 3 02 19 PM

In the past couple of years has your company had a major accident?

If they did, did you check to see if there were previous smaller incidents that should have been learned from and if the corrective actions should have prevented the major accident?

I don’t think I have ever seen a major accident that didn’t have precursors that could have been learned from to improve performance. The failure to learn and improve is a problem that needs a solution.

In the TapRooT® root cause analysis of a major accident, the failure to fix pervious precursor incidents should get you to the root cause of “corrective action NI” if you failed to implement effective corrective actions from the previous investigations.

If this idea seems like a new idea at your facility, here is something that you might try. Go back to your last major accident. Review your database to look for similar precursor incidents. If there aren’t any, you have identified a problem. You aren’t getting good reporting of minor incidents with potential serious consequences.

If you find previous incidents, it’s time for an audit. Review the investigations to determine why the previous corrective actions weren’t effective. This should produce improvements to your root cause analysis processes, training, reviews, …

Don’t wait for the next big accident to improve your processes. You have all the data that you need to start improvements today!

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Success Stories

If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

Investigation Detects Lack of Experience in Experienced Personnel And Leads To Job Simulation To Improve Performance Submitted by: Errol De Freitas Rojas, SHE Coordinator Company: ExxonMobil, Caracus, Venezuela Challenge We investigated a Marine incident where an anchor cable picked up tension during maneuvers and caused a job to be stopped. We needed to find the …

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