Category: Presentations

Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 3)

April 11th, 2012 by

This week is our third and final installment of Mark Paradies’ Summit talk on process safety in the Nuclear Navy.

In this 35-minute clip, you’ll learn how Admiral Rickover’s process safety standards compare to OSHA and CCPS standards, and what that means for your safety program.

Click here for Part 1.

Click here for Part 2.

Note: We are trying a new video hosting service. Please let us know in the comments if you have trouble viewing this.

Next week, we’ll begin our 13-week series sharing best practices from users like you at our 2012 Global TapRooT® Summit.
You won’t want to miss these innovative tips!

Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 2)

April 4th, 2012 by

Last week, we shared Part 1 of Mark Paradies’ Summit talk on Process Safety.

Click here for Part 1.

He shared some of his experience in the Nuclear Navy and discussed the fact that large accidents like Deepwater Horizon could be prevented by following important process safety regulations.

This week, in Part 2, Mark discusses Admiral Rickover’s process safety principles and why they matter to your process safety improvement.

Come back next week for the third and final part of this series!

Update: Click here for Part 3.

Root Cause Analysis Tip: TapRooT® Summit Session on Process Safety (Part 1)

March 28th, 2012 by

This week’s Root Cause Analysis Tip comes straight from our 2012 Global TapRooT® Summit.

If you missed Mark Paradies’ session on “What Does Management Need to Know About Improving Process Safety?” don’t worry. We will be sharing it on the blog over the next three weeks.

Today is Part 1.

Mark began by showing this comedy clip on Deepwater Horizon:

(If you can’t see YouTube videos at work, click here.)

And continued on with his discussion on Process Safety:

(Having trouble seeing the videos? Refresh your browser page.)

Come back next Wednesday for Part 2 of his Process Safety Talk, in which he discusses Admiral Rickover’s “Big Three” nuclear navy safety regulations and more from his congressional testimony after the accident at Three Mile Island.


Update: Parts 2 and 3 have been posted!

Click here for Part 2.

Click here for Part 3.

What Management Needs to Know About Process Safety Improvement (or Why We Continue To Have Process Safety Accidents)

May 16th, 2011 by

I’m giving this talk in Bruges, Belgium for Total today and posted a PDF of the talk here so people who attended could get copies of the slides.

Click on the object below to download it…


As usual, the slides don’t tell the whole story. So if you would rather hear this talk, plan to attend the TapRooT® Summit on February 29 – March 2, 2012, in Las Vegas.

Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

February 21st, 2011 by

Stopping Future Accidents by Correcting Problems That Did Not Cause The Accidents Being Investigated

Submitted by: James Watson, Regional Specialist, System Safety Branch
FAA, Alaska


TapRooT® investigation often identify actions and conditions that didn’t cause the actual accident being evaluated but that could be significant and, if not corrected, could combine with other factors to cause a future accident.


These factors that the thorough analysis of TapRooT® helped identify are included in the presentation to management at the end of the talk (after the root cause analysis and corrective actions have been reviewed). This review includes explaining and discussing each of these potentially adverse factors with management. At a minimum, management is aware of these potentially adverse factors and the review often leads to discussion of additional corrective actions to address these issues.


Accidents that might have happened are avoided by implementing corrective actions for problems identified during a root cause analysis that didn’t cause that accident but could have cause additional accident and were corrected by proactive corrective actions.

Influencing Without Authority TapRooT® Session…. People at Work!

November 5th, 2010 by

Often people have the right ideas, the right plans and a need to get it done. Problem is that it is not always you who can drive the change. During the Summit we held a session that generated discussion on Stakeholders and Influence Centers.

Check out the multiple active group discussions during this workshop. Click on the Image to play the Video.

Sam 0212

For the link to the slides that generated these active discussions and a link to more formal analysis go here:

Bugs, Infection and TapRooT® Root Cause in Philadelphia

November 5th, 2010 by

When is the last you used TapRooT® Root Cause Analysis to investigate a Caterpillar?

The people below in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training held in Philadelphia got to talk about this one.


What’s New In The TapRooT® Software?

November 4th, 2010 by

I have received several requests from our San Antonio Summit attendees for a copy of our ‘What’s New In The TapRooT® Software?” breakout session.  So without further ado, here it is…Click Here

Jeff Skiles – Co-Pilot of “Miracle on the Hudson” Landing – To Tell His Story at the Summit

September 7th, 2010 by

Skiles Jeff-1

I just got off the phone with Jeff Skiles who was the co-pilot of the US Airways flight that made an emergency landing in the Hudson River. It was a flight that could have had a tragic end but instead, everyone made it off the plane. After the conversation, I know we are going to have another great Keynote Speaker at the Summit.

Jeff said that he tells his story but provides some of the behind the scenes information that most people don’t know about. Information that helped them be successful that day but also might help you at your facility. The lessons aren’t just about aviation. They can be applied in any industry where things can go wrong and consequences can be severe.

So make sure that when you plan your trip, you plan to stay until the end of the Summit to hear Jeff’s talk. He’ll be speaking from 10:35-11:55 (followed by the TapRooT® Summit Charity Golf Tournament).

For the complete Summit schedule, see:

Mark’s Talk About the Heinrich Pyramid (Safety Pyramid) at the European Safety Committee of the Conference Board

June 1st, 2010 by

That’s me and the interested participants at the Conference Board…


Below is a copy of a PDF of the PowerPoint that I used.


BP/Tranocean Rig BOP Failure: The Smoking Gun Paper

May 7th, 2010 by

Little is known (or at least has been released) about the actual failure of the Blowout Preventer on the Deepwater Horizon. However, a technical paper (2003) has surfaced that may be a “smoking gun” if it is found that maintenance was deferred on the BOP to reduce costs of drilling.

Here’s a link to the paper (Earl Shanks, Transocean, presented at the Offshore Technology Conference, 2003):


Here’s one of the “smoking gun” quotes:

Because of the pressure on getting the equipment back to work, root cause analysis of the failure is generally not performed.”

Ah … a failure to perform root cause analysis to save time (and big bucks) during drilling.

Another quote:

In general, operating reliability (of the BOP) is maintained on rigs mostly through regular maintenance intervals rather than specifying a reliability of a system or a component to minimize maintenance.”

The article also said:

“… this is a very expensive approach, and it is also an opportunity to introduce human error into the system.”

Most of the paper is about ways to improve the design and reliability of Blowout Preventers. But the vultures are circling. And the smoking gun quotes above will mean trouble if it is found that any maintenance was skipped or if the BOP had a poor reliability record.

If maintenance was skipped and/or if the BOP had a poor reliability record, you will hear the cry that BP is once again trading lives (as at the BP Texas City explosion) and the environment (as at the corrosion related oil leaks in their pipeline at Prudhoe Bay). Actually, many don’t need evidence. They will start saying it already!

Could these Answers Affect your Investigations – Live Q&A Session with OSHA

April 29th, 2010 by

This is a link to an April 26 chat session with OSHA. Interesting answers.

Here is just one question and answer:

[Comment From Greg Hellman, BNAGreg Hellman, BNA: ]
OSHA has placed an injury and illness prevention program rule on its agenda for the first time. Could such a rule address musculoskeletal disorders in some way?
Monday April 26, 2010 1:27 Greg Hellman, BNA

David (OSHA):
The i2p2 standard is not a substitute for other OSHA standards. It provides a mechanism to achieve the culture change needed in this country to effectively address workplace safety and health issues. It will be the employer’s responsibility to identify all hazards in their workplace, which may include ergonomics, falls, amputations, electrocutions, work-related respiratory disease (such as occupational asthma), etc. The i2p2 standard simply provides a mechanism for employers to identify hazards; however, the control of those hazards will be required by existing OSHA standards and the general duty clause, as is currently the case.

New Approach to Root Cause Analysis Can Help Clear Up Misconceptions

April 26th, 2010 by

Quality Progress Magazine published a new article written by System Improvements’ President, Mark Paradies which can be read on the Quality Progress website:

You don’t have to be a member to access the article — free registration allows you access to ASQ’s “open-access” articles and case studies.

You can also find this article on page 32 of the April edition of Quality Progress magazine.

Article highlights:

• Cause and effect analysis has inherent limitations that may result in root cause analysis misconceptions and hinder problem-solving efforts.

• Problem solvers need help analyzing human performance issues.

• A new definition of root cause could help people realize a systematic process beyond cause and effect is needed for root cause analysis.

Monday Accident & Lessons Learned: TN OSHA Fatality Investigations

October 12th, 2009 by

“Lessons from TN OSHA Fatality Investigations” was a best practice session presented by Steve Hawkins at the 2009 TapRooT® Summit.

Taproot part 1 Hawkins

Keys to Successful Safety Culture Change

October 11th, 2009 by

“Keys to Successful Safety Culture Change” was a best practice session presented by Michele Lindsay and Mike Kelly at the 2009 TapRooT® Summit.

Keys to Successful Safety Culture Change

Healthcare Root Cause Analysis Presentations: CSI Stanly

October 11th, 2009 by

“CSI Stanly” was a 2009 TapRooT® Summit best practice session presented by Debra Smith.


Ideas for Reliability Improvement

October 11th, 2009 by

“Ideas for Reliability Improvement” was a best practice session presented by Tim Thompson at the 2009 TapRooT® Summit .


Persistent Equipment Failures and their Solutions

October 11th, 2009 by

“Persistent Equipment Failures and their Solutions” was a best practice session presented by Ken Bloch at the 2009 TapRooT® Summit.

KBloch TapRooT 2009

How to Become Best in Class in Equipment Reliability by Maximizing Uptime

October 11th, 2009 by

“How to Become Best in Class in Equipment Reliability by Maximizing Uptime” was a best practice session presented by Heinz Bloch at the 2009 TapRooT® Summit.

TapRooT Summit Nashville 2009_2_

Spanish Track at the 2009 TapRooT® Summit

October 9th, 2009 by

Here are best practice presentations from the Spanish speaking Track at the 2009 TapRooT® Summit.

From presenter, Marco Flores:

analis de tendencias avanzado A Marco Flores


From presenter, Piedad Colmenares:



From presenter, Jose Grisi:

jgf_De la Intención a la Acción

How Fatigue Impacts Human Error

October 9th, 2009 by

“How Fatigue Impacts Human Error” was a best practice presentation presented by Bill Sirois at the 2009 TapRooT® Summit.

Impact on Fatigue on Behavior and Human Error

How to Prove Fatigue was the Cause of an Accident

October 9th, 2009 by

“How to Prove Fatigue was the Cause of an Accident” was a best practice presentation presented by Bill Sirois at the 2009 TapRooT® Summit.

2009 Taproot Presentation

Implementing TapRooT® Across Sisters of Mercy Health System

October 9th, 2009 by

“Implementing TapRooT® Across Sisters of Mercy Health System” was a 2009 TapRooT® Summit best practice session presented by Susan Sinclair.

TapRooT_Presentation_compressed _2

Using TapRooT® to Review Emergency Drills

October 9th, 2009 by

“Using TapRooT® to Review Emergency Drills” is a 2009 TapRooT® Best Practice Presentation presented by Heidi Reed.

Getting_Ahead_of Hindsight

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