Category: Presentations

Very Interesting PowerPoint About Russian Dam/Power Plant Disaster

September 1st, 2009 by

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A TapRooT® User sent me this PowerPoint this morning. I’m always interested in preliminary failure analysis and this one is quite interesting. Here is the link to download the PowerPoint (.pps):

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The Final Group Exercise in Our Two 2-Day TapRooT® Incident Investigation and Root Cause Analysis Courses in Houston

June 25th, 2009 by

Time for a math lesson….. 60 students divided into two classes equals 14 final group exercises and presentations which equals 14 separate incidents analyzed using TapRooT®. Now that was a good day!
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Final Presentations at the Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Manchester, England

March 22nd, 2009 by

Here’s the tough crowd that critiques each presentation.

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Here’s the course participants with new confidence presenting what happened, why it happened, and what they are going to do to keep the incident from happening in the future.

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After just two days of training these students go back to work much more confident in their ability to find and fix the root causes of accidents, incidents, near-misses, quality problems, and process upsets.

If you would like your staff to be able to confidently lead a root cause analysis, consider sending them to a public TapRooT® Course. Or call us at 865-539-2139 about scheduling on-site training for 10 to 32 employees in a class.

Monday Accident & Lessons Learned: Holiday Safety Tips

December 1st, 2008 by

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The PowerPoint below was sent to me several years ago by a TapRooT® User.

I’m sure all of the tips come from accidents and are lessons learned that could be shared with your employees.

If you have a good Holiday Safety PowerPoint with lessons learned that you would like to share, e-mail me at “info” @ “taproot.com”.

Thanks

Mark

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(click to download a Holiday Tips PowerPoint)

Mark Paradies Speaks at NISO Conference Dinner in Ireland

October 17th, 2008 by

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Thursday night, Mark gave a talk on human error and root cause analysis at the National Irish Safety Organization pre-Conference Dinner in Trim. It was an excellent dinner and a receptive, interested audience.

Friday, Mark Paradies and Linda Unger will be at the NISO Conference and have a stand in the exhibit area.

Stop by if you are in Ireland!

Summit Comment from Corie Doyle

July 15th, 2008 by

Another comment from a 2008 TapRooT® Summit attendee:

Corie Doyle
(.wmv format)

What I learned at the 2008 Summit

July 14th, 2008 by

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I was so busy at the 2008 Summit that I really didn’t have a chance to take a break from Sunrise to Sunset.

That’s why I didn’t provide minute to minute reporting on what I was learning at the Summit – I just didn’t have a chance to write.

I did take some notes and I thought that readers might be interested in what I learned. Therefore, I will share my “A-Ha’s” here for everyone to read.

1. I learned from Darby Allen that 5-10% of all profits are consumed by the costs of accidents and incidents. The costs include hidden costs. For example:

  • Fines
  • Legal
  • Investigation
  • Productivity Loss
  • Retraining
  • Lost Production/Missed Orders
  • Sullied Reputation
  • Hidden Equipment Damage

2. I learned from Dave Prewitt that senior management needs a single source (a single database) that has all failure data and costs in it. This includes audit findings. That senior management can then use the data to build an organization that is resistant to disaster because they proactively ensure that systems are safe.

3. I learned from Lt. Col. Hayles that big organization naturally tend to cover up senior management failings and look for scape goats when big things go wrong. That this is a natural part of “protecting the mission of the organization”.

4. I received lots of good ideas about TapRooT® and the TapRooT® Software from the TapRooT® Advisory Board Meeting.

5. I really enjoyed the great people at the Summit and had a wonderful time at the Reception/Birthday Party where I got a chance to catch up with two old friends – David Busch and Kevin O’Connor.

6. I learned from Carolyn Griffith that the UK Rail Accident Investigation Board spends 7 months training one of their new investigators. Also, that a “no blame” policy is a major part of their investigations.

7. I heard many user best practices at several best practice sharing sessions including the TapRooT® User Best Practices Session run by Linda Unger and Michele Lindsay. I’ll try to do a separate write up of these later.

8. I learned from Chris Vallee (Six Sigma Black Belt and TapRooT® Instructor) that SnapCharT®s and Swim Lanes can be combined into a powerful Lean/Six Sigma tool.

9. That even though I had studied the accident at Three Mile Island extensively, I could learn much more by listening to an operator who was at the panel (Ed Frederick).

10. I learned from Marcia Wieder that dreams and visions are similar and that fear is the biggest roadblock to achieving your dreams (vision).

11. That I need to practice if I am going to play golf!

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I also learned so things in general about the Summit that others should know about…

1. That there were many outstanding sessions that people told me about (and that I wanted to attend) but that I couldn’t go to. Therefore, bring several people from your facility to cover all the applicable sessions that you want to learn from.

2. That you should come early and stay late. This helps you learn more.

Start by attending one of the many pre-Summit courses.

Next, come down early in the morning and have a leisurely breakfast while networking with other participants.

Don’t plan to leave early. Plan to stay over Friday night and leave Saturday morning.

3. That people love to share best practices. We had 10 Best Practice sharing sessions at the 2008 Summit that were focussed on allowing participants to share their knowledge with others. These were some of the highest rated sessions of the Summit because the calibre of the attendees at the Summit is so exceptional.

4. That people love to be inspired. Speakers that inspire are always highly rated. Heinz Bloch, Marcia Wieder, Nikki Stone, and Beverly Chiodo inspired their audience and helped people leave the Summit energized to make a difference when they returned to work.

5. That even with a crowd that is as enlightened at people at the TapRooT® Summit, it is hard not to blame people for mistakes. This became apparent after Lt Col Hayles talk. Some of the people I spoke to just could get by his mistake when he pulled the trigger in a friendly fire incident. They could see how he was set up for the accident by factors beyond his control. And that to prevent future friendly fire accidents, you must go beyond “being more careful next time.”

6. That a hot room for one is a cold room for another. Temperature is an individual preference.

Here are some things I already knew, but were reinforced by the Summit:

1. We have great clients that are industry leaders. I’m always impressed by the discussions we have and how willing participants are to share their best practices.

2. I have a great staff that knows what they are doing, plans well, and handles unexpected changes with panache (style, grace, and a flair for excellence).

3. That even the best in any industry can learn from others. Even the best companies can improve.

4. That even companies with the most to learn, have best practices that others can learn from.

5. That some of the most eye opening lessons come from outside your industry (if you can translate from their terminology to yours).

6. That having a good time and learning are not mutually exclusive activities.

7. That TapRooT® really is an exceptional root cause analysis tool that is changing the way the world solves problems.

8. That EVERY facility and company that uses TapRooT® should have someone at the Summit. We guarantee that what you learn will produce a return on investment at least 10 X the cost of your attendance or you get your money back. So start planning to attend in 2009!

Spring 2008 ASQ Automotive Excellence Magazine

May 4th, 2008 by

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In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.

Monday Accident & Lessons Learned: Simple Construction Fatality Investigation – Were the Root Causes Identified?

April 28th, 2008 by

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WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

The Sessions to Attend if You Are Interested in Safety & Risk Management Best Practices

March 26th, 2008 by

The TapRooT® Summit has 10 “Best Practice Tracks” focussed specific topics. One of those topics is:

Safety and Risk Management Best Practices

The purpose of this posting is to provide those interested in safety and risk management with a little better idea of the talks and discussion sessions they will experience if the attend the Safety & Risk Management Best Practices Track at the TapRooT® Summit.

Here is a list of sessions with a brief description of each session:

1. Hazard Recognition: The First Step in Safety & Risk Management – Peter Berkholz, Engineering Manager, Capability Resources

Peter will discuss practical strategies to identify hazards in the workplace and methods to get employees to spot and correct problems.

2. CHANGE

Dealing with Obstacles that Make Change Difficult – Hal Curry, Consultant, hal Curry & Associates

Managing the Risks Associated with Change – Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia

All safety improvement programs involve change. Hear these two talks that discuss change, obstacles to change, and risks associated with change.


3. Root Cause Analysis of Major Accidents

Lexington Airport Runway Mix-Up – Ken Turnbull, Consultant & TapRoot® Instructor

Cameco Cigar Lake Mine Flood – Mark Wittrup, Cameco

Investigating Fatalities – Mario Chacon, Cal OSHA (invited)

Those interested in safety can learn a lot from the accidents of others. This session focusses on three different discussions about major accidents. First, Ken Turnbull will share how TapRooT® can be applied to public information about an accident to analyze it and learn lessons. Next, Mark Wittrup will present the results of a TapRooT® investigation of an expensive mine flooding accident. Then, Mario Chacon from Cal OSHA will share lessons from fatality investigations.


4. Advanced Behavioral Management: Developing a Modern Safety Culture – Bob King, Director of HSE Training/Consulting, Woodland Grange, UK and Neil Roberts, Consultant, Woodland Grange, UK

Safety culture is a big topic in many industries (nuclear power, oil and refining, aviation, …). Instead of hearing the same perspectives that we have all heard, we decided to bring a fresh look at the topic from Woodland Grange in the UK. Bob King and Neil Roberts will share their experience and advice on developing and establishing a “modern” safety culture.

5. Panel Discussion: Is There a Tradeoff Between Process Safety and Industrial Safety – Panelists: Miles Kajioka (ConocoPhillips), Valarie Barnes (US NRC), Bob King (Woodland Grange), and Ken Turnbull (Consultant, previously with Texaco)

The explosion at the BP Texas City Refinery caused many to question their Process Safety Management programs. In a sworn deposition, the Process Safety Manager at BP Texas City implied that resources were diverted from process safety and used to improve industrial safety. The implication was that in any plant with limited budgets, any investment in industrial safety could be seen as taking resources away from process safety. The panel will provide their views on this “tradeoff” and discuss with participants things that can be done to make programs complimentary rather than competitive.

6. TapRooT® User Success Stories From Healthcare and Industry – Facilitators: Linda Unger and Barbara Phillips

Three TapRooT® Users (to be determined closer to the Summit) will share recent successes improving performance by applying the TapRooT® System. Learn from the best practices of others and apply their ideas to improve performance at your facility.

7. The Good, The Bad, and The Ugly: Rating Improvement Programs and Incident Investigations – Tom Brower, Consultant

Is your program Good, Bad, or Ugly. Rate it and see. Compare your program to others at the session. And learn techniques to rate your company’s incident investigations.

8. Senior Executive Involvement in Safety

Bringing Safety to the Corporate Board – Dave Prewitt, VP, FedEx

What the Corporate Board Needs to Know About Safety – Bob King & Darby Alan, Woodland Grange, UK

What does the Corporate Board need to know about safety? With new corporate manslaughter laws in countries around the world, perhaps more than they currently know. Part of the Chemical Safety Board’s investigation of the explosion at BP’s Texas City Refinery implied that senior management and the Corporate Board needed to know more about safety and the impact of budget decisions upon safety. because of these issues, we invited Dave Prewitt, VP at FedEX, and Bob King and Darby Alan of Woodland Grange in the UK to speak about getting senior management, and even the Corporate Board, involved and aware of safety.

9. Planning Your Improvements – Facilitated by TapRooT® Instructors

A session that allows time for you to develop your improvement plans, get them reviewed by an experienced TapRooT® Instructor, and then benchmark them with other Summit participants.

Beyond the Safety & Risk Management Best Practice Trach sessions, there are five interesting Keynote speakers:

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Marcia Wieder, Nikki Stone, Lt Col Ralph Hayles, Carolyn Griffiths, and Ed Frederick. For more information about their talks, see:

http://www.taproot.com/keynote_speakers.html

So if you are interested in improving safety and managing risk, sign  up for the TapRooT® Summit and register for the Safety & Risk Management Best Practices Track. See:

http://www.taproot.com/summit.php

Also consider attending one of these related courses prior to the Summit:

Risk Management Best Practices
Innovation & Creative Solutions
Hazard Recognition Best Practices

For more information about these courses, see:

http://www.taproot.com/pre-summit_courses.html

Summit Closing Keynote Speaker Will Help You Make A Performance Improvement Dream Come True

March 25th, 2008 by

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Some call it a vision. Some call it a dream. But every improvement program needs a goal. Do you have a vision of what performance would look like if you could achieve the ideal state at your company? Achieving that vision is what Marcia Wieder, America’s Dream Coach, is all about. As the closing Keynote Speaker at the TapRooT® Summit, she will show you how to achieve your dreams and make your vision a reality.

To hear a little of the type of advice America’s Dream Coach will provide at:

http://www.dreamcoach.com/video/0405_speaker_demo.wmv

And attend her talk: You Can Make Improvement Happen

To register for the 2008 TapRooT® Summit, see:

http://www.taproot.com/summit.php

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Best Rated Speaker Ever Returning to 2008 TapRooT® Summit

March 20th, 2008 by

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Dr. Beverly Chiodo, Professor at Teas State University, was a Keynote Speaker at the 2007 TapRooT® Summit. It is very unusual for us to have a Keynote Speaker back. There are so many interesting speakers and we want attendees to come back year after year to get new points of view. But so many attendees in 2007 asked us to have Dr. Chiodo back, and to have her expand on the topic of Character Based Behavior Change, that we had to break with our past rules and invite Dr. Chiodo to return.

First, Dr. Chiodo will repeat last year’s talk, “Character Driven Success,” in the 2:40 Human Error Reduction & Behavior Change Best Practice Session on Thursday. People who saw the talk last year as a Keynote who would like to see it again, should sign up for this session. If you didn’t see her talk last year and you want to know what the buzz is all about, get to this session!

Then on Friday, Dr. Chiodo will go beyond last year’s talk with a follow up talk in another Human Error Reduction & Behavior Change Best Practice Session. The talk, titled “Changing Behavior by Praising the 49 Character Traits” is for anyone truly interested in ethical, effective methods to change behavior and who wants to hear interesting, practical advice.

To learn more about this  blockbuster Summit, the great networking, and the best practice sharing (including videos from attendees at the 2007 Summit), see:

http://www.taproot.com/summit.php

Lessons From the Inside at TMI

March 15th, 2008 by

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I can still remember when I first heard about the accident at Three Mile Island. I was on a bus heading out to S1W (a Nuclear Navy Prototype Reactor in the desert in Idaho). I was partly snoozing and the bus driver had a transistor radio playing. The music was interrupted for breaking news. The commercial nuclear power reactor at Three Mile Island was having some sort of problem – perhaps a meltdown! The on-the-scene reporter was interviewing a farmer near the plant. He said his cows weren’t acting right and that morning he could “…taste the radiation…”.

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Ed Frederick, Keynote Speaker at the TapRooT® Summit,  was a member of the Control Room crew at the onset of the Three Mile Island Unit 2 accident on March 28, 1979. The decisions made, and actions taken by Mr. Frederick and the rest of the crew on that morning resulted in a partial meltdown of the reactor core. The accident is the only General Emergency and evacuation associated with nuclear power in the United States. The accident at TMI was the subject of intense public interest and is still remember each year in television news.

But the accident at TMI happened back in 1979. What could we possibly learn that’s new from such an old accident?

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Look at the various “facts” that are available at various places on the internet:

http://americanhistory.si.edu/tmi/
http://www.nucleartourist.com/events/tmi.htm
http://www.tmia.com/

http://www.pbs.org/wgbh/amex/three/

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/tmi.htm

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/aftermath.htm

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/whathappened.htm

http://video.google.com/videoplay?docid=8348815263023489062

http://www.threemileisland.org/

http://www.uic.com.au/nip48.htm

http://en.wikipedia.org/wiki/Three_Mile_Island_accident

http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/3mile-isle.html

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(Picture of damaged core)

The causes for the accident at TMI and the experiences related by someone who was “investigated” after the accident are just as applicable today as they were back in 1979. And they are applicable across industries around the world. That’s why I’ve been asking Ed to speak at the Summit for years – the lessons are important for everyone who is interested in investigations and performance improvement to learn. And this year Ed will share his inside view of the accident and the aftermath.

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Ed will also conduct a Best Practices Session that allows investigators to practice their skills by drawing and revising a SnapCharT® based on what they “know” and answers from the person involved – Ed Frederick.

For more information on the rest of the sessions and Keynote Speakers at the Summit and to register, see:

http://www.taproot.com/summit.php

Come to IOSH and Talk About Root Cause Analysis with Mark Paradies

March 13th, 2008 by

Next week I’ll be at the IOSH Conference in Telford, England.

Why am I attending?

To hear some interesting talks and to promote advanced root cause analysis to improve safety in the UK.

If you want to talk about root cause analysis, drop by our booth (A 12 – near the entrance) and say Hi!

Hope to see you there…

Mark

Learn Corrective Action Program (CAPA) Best Practices

March 12th, 2008 by

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The TapRooT® Summit has a Best Practices Track focussed on improving Corrective Action Programs. The specific sessions for this track include:

  • “Outside the Box” Creative Solutions
  • Evaluating the Effectiveness of Corrective Actions
  • Using TapRooT® to Evaluate Common Cause and Extent of Condition
  • Better Corrective Actions by Using Corrective Action Tools
  • Management & Performance Improvement
  • How to Get and Keep Management Support
  • The Good, The Bad, and The Ugly, Rating Your Improvement Program and Incident Investigations
  • Root Cause Analysis of the Accident at Three Mile Island

For more information about the Summit, including the five blockbuster Keynote Speakers, see:

http://www.taproot.com/summit.php

What Can You Learn from the Start Up of the UK’s Rail Accident Investigation Branch?

March 11th, 2008 by

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Carolyn Griffiths is the Chief Inspector of the UK Rail Accident Investigation Branch.

The UK RAIB is an independent investigative organization that by law investigates the UK’s railway accidents and incidents. The purpose of their investigations is not to apportion blame or to enforce laws, but rather to improve railway safety and prevent future accidents. For questions about the UK RAIB see:

http://www.raib.gov.uk/about_us/index.cfm

Carolyn is a Keynote Speaker at the TapRooT® Summit in Las Vegas on June 25-27. She will speak about her experiences starting up the UK RAIB in 2004/2005 and some investigation lessons learned from the RAIB’s initial investigations.

What can you learn?

Every investigator or head of an investigation organization can learn from the experiences of others. In talking to Carolyn, I found that her approach to getting good investigations, the training she requires for her investigators, and the challenges of getting investigations completed were all interesting topics to hear about.

That’s what’s great about the Summit. You will not only hear the RAIB’s Chief Inspector talk, but also, you will have the opportunity for one-on-one conversations to ask questions, share best practices, and make a new contact in your network of professional associates.

For more Summit information and to register, see:

http://www.taproot.com/summit.php

Understanding the Limits of Some Root Cause Tools in the Hands of Your Company Experts

March 7th, 2008 by

As a TapRooT® and Equifactor® instructor for System Improvements, I get the opportunity to meet quality, engineering, safety, manufacturing, operations and medical company experts from around the world. In two or five days these experts learn the basics of the TapRooT® System for finding the root causes of problems PLUS some attend one day of Equifactor® Equipment Troubleshooting Technique for root cause failure analysis of equipment problems. These are grueling days of lecture and hands on application that does not allow much time to teach people the science behind good root cause analysis. Just as important, I do not get to show people why being an expert in your field of work can actually impede your investigation due to “tunnel vision” of the mind.

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Experts who are now using TapRooT®, have learned how to investigate with an open mind based on tons of research in human and workplace system interactions. But with all the knowledge our experts bring to the table why was this a limiting factor before TapRooT® use? After presenting at the ASQ Automotive Conference in Michigan this February, audience members wanted to know more about root cause tool limitation and expert use of rules-of-thumb. So if you want to understand more of our thinking processes in problem solving and why we have a tendency to assume we know why an incident occurred before we really know what occurred, link to the paper below.

“Why ask why when you should be asking what?”

Nikki Stone – Olympic Gold Medal Winner – Keynote Speaker at the TapRooT® Summit

March 6th, 2008 by

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Winning an Olympic Gold Medal sets you apart. You are the best on the planet at your event.

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But Nikki Stone’s story goes beyond being the best. She showed exceptional dedication & persistence to come back from a career-ending injury (that prevented her from standing, much less skiing).

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Why is Nikki a TapRooT® Summit Keynote Speaker? Because people leading performance improvement initiatives need to overcome obstacles that seem insurmountable.

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After being inspired by Nikki’s determination and courage, these obstacles won’t seem so large. You can achieve success!

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Don’t miss Nikki’s Keynote address. And talk to Nikki one-on-one at the Summit reception.

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To see an interview with Nikki, click on the YouTube video below:

Is Fatigue an Issue at Your Workplace?

March 5th, 2008 by

A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.

Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.

What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).

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Bill Sirois, VP and COO of Circadian Technologies, will be presenting three sessions on fatigue and the investigation of fatigue as the cause of accidents. The sessions are:

Human Error Reduction & Behavior Change Best Practices Track:

  • The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Investigation & Root Cause Analysis Best Practices Track:

  • FACTS – Computerized Analysis of Fatigue as a Cause of an Incident

Medical Error Reduction Best Practices Track:

  • The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

For additional Summit information, see:

http://www.taproot.com/summit.php

Will Discipline Fix the CTA’s Problems?

September 14th, 2007 by

The main thrust of a comment by Mayor Daley in Chicago seems to be that if you punish enough people, future accidents will be prevented – or so an article in the Chicago Tribune implies…

At a news conference the paper quotes Major Daley saying:

“I don’t manage the CTA, [CTA President] Ron Huberman does. Any time you have an accident, you have an investigation. Then you have the proper penalties for the individual, and discipline, and that’s what they have done. They have allowed this to be thoroughly investigated, and they are not afraid of the outcome. The outcome shows there were deficiencies, and they have corrected it.”

The article states that Huberman, who appeared with Daley at a South Side news conference on an unrelated subject, said that heads rolled after the accident. He is quoted as saying:

“The director in charge of this group has been replaced. The manager in charge of this group has been replaced. The supervisor has been replaced. And the foreman has been replaced. Everyone was held ultimately accountable for this.”

The article says that the NTSB’s investigation concluded that the derailment in a stretch of Blue Line subway was caused by the CTA’s “ineffective management and oversight of its track inspection and maintenance program and its system safety program, which resulted in unsafe track conditions.” Bob Chipkevich, Director of the the NTSB’s office of railroad, pipeline and hazardous materials investigations, said the CTA’s track inspection and maintenance were the worst he had ever seen at a U.S. transit agency.

The article also mentioned that Huberman stated that:

“Significant changes have been put into place, new auditing functions have been put into place … and new technology has been put in place.”

He also said:

“You have a brand new team. This was the result of the 2006 derailment. … We have accelerated many changes, and they are in place today, making it a safe system.”

So what’s the answer? Replacing people or accelerating changes and new technology? Was it the people (who are now gone) or the politics that caused the problems? Was the poor maintenance, faked reports, and bad surveys caused by four bad people or was their a culture that caused poor performance? Did the culture change or did we just put new people into the old culture?

More stories about this accident are available at:

http://www.suntimes.com/news/metro/552146,ntsb091107.article

http://www.chicagotribune.com/news/chi-ntsb_websep12,1,3577989.story

http://www.ctatattler.com/2006/07/fire_closes_blu.html

http://www.ctatattler.com/2006/05/anatomy_of_a_tr.html

http://cbs2chicago.com/video/?id=24432@wbbm.dayport.com

http://www.ntsb.gov/Pressrel/2007/091107.htm

http://www.ntsb.gov/events/2007/Chicago-IL/presentation.htm

Mark Paradies, Developer of TapRooT® and President of SI, at NISO in Ireland

September 13th, 2007 by

I will be exhibiting and attending the 44th National Irish Safety Organization Annual Health & Safety Conference in Killarney on October 11-12. If you will be attending, please stop by our booth and I’ll demonstrate how TapRooT® works. In addition, you can get your very own Spin-A-Cause™ – the worlds fastest root cause analysis system.

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