Category: Presentations

Making a Business Case for Improvement

October 9th, 2009 by

“Making a Business Case for Improvement” was a presentation by Dave Janney at the 2009 TapRooT® Summit.


Finding Time for Process Excellence – No Fuel, No Progress

October 9th, 2009 by

“Finding Time for Process Excellence – No Fuel, No Progress” was presented by Kevin McManus at the 2009 TapRooT® Summit.

Finding_Time_for Improvement_Presentation

What’s New in the ISO 31000 Risk Management Standard

October 8th, 2009 by

Here is Jim Whiting’s presentation for “What’s New in the ISO 31000 Risk Management Standard” from the 2009 TapRooT Summit.

(Color version)

What’s New in the ISO 31000 Risk Management Standard

(Black and white version)

What’s New in the ISO 31000 Risk Management Standard B&W

Pursuit of World Class EH&S

October 8th, 2009 by

“Pursuit of World Class EH&S” was a 2009 TapRooT® Summit best practice session presented by Dennis Osmer.

Pursuit of World Class EH&S

8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement

October 8th, 2009 by

“8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement” was presented by Kevin McManus at the 2009 TapRooT® Summit.

8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement

Practical Tools to Stop Worker Error

October 8th, 2009 by

2009 TapRooT® Summit best practice session “Practical Tools to Stop Worker Error” presented by Ralph Brickey, Jeff Hubbart and Chris Vallee. (Click the “Full Screen” button at the top right of the document to view the document in its entirety.)

Practical Tools to Stop Human Error

Summit – Day 1 – What’s Going On?

October 7th, 2009 by

I’m in a session on Success Stories from TapRooT® Users that have applied advanced root cause analysis techniques. Theresa Guay from Irving Oil gave an excellent talk about their use a TapRooT® to make pretty dramatic improvements in safety.

Right now, Ron Pryor is providing a very interesting talk on a kaizen project to improve environmental performance. He’s showing the Iowa’s largest SnapCharT®.

Wish you could be hear to hear the really useful lessons learned.


(Picture of Ron presenting and Iowa’s largest SnapCharT®. Boy … Ron sure is moving fast!)

Implementing Aspects of Process Safety in Non-Process Safety Facilities

October 7th, 2009 by

Implementing Aspects of Process Safety in Non-Process Safety Facilities was presented by Randy Bennett at the 2009 TapRooT® Summit.

Implementing Aspects of Process Safety in Non-Pocess Safety Facilities

Accident Presentation: Analyzing the Attack on the USS Stark

October 7th, 2009 by

Best practice presentation “Analyzing the Attack on the USS Stark” presented by Shane Deichman at the 2009 TapRooT® Summit. (Click the “full screen” button at the top right of the documents for best view).


USS Stark Offical Report

Accident Presentation: Analyzing 230 Environmental Incidents in 5 Months

October 7th, 2009 by

“Analyzing 230 Environmental Incidents in 5 Months” is a 2009 TapRooT® Summit best practice session presented by Buck Griffith and Kevin McManus. (Click “full screen” on the top right of the document for best view.)

Analyzing 230 Incidents in 5 Months V2

The Myths & Realities of Fatigue

October 5th, 2009 by

Bill Sirois, Senior Vice President & COO, Circadian Technologies, provided this informative white paper about the myths and realities of fatigue. Bill will be presenting “How Fatigue Impacts Human Error” at the 2009 TapRooT® Summit. (Click the “Full Screen” button at the top right of the document to see the document in its entirety.)

The Myths & Realities of Fatigue

Summit Opening Presentation – What the Summit is All About

October 1st, 2009 by

Here’s a link the Summit Opening Presentation (PDF format). It will help you get a better idea what the Summit is all about. (It’s big so it will take a few minutes.)

Very Interesting PowerPoint About Russian Dam/Power Plant Disaster

September 1st, 2009 by


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):


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.


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.





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


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” @ “”.



(click to download a Holiday Tips PowerPoint)

Mark Paradies Speaks at NISO Conference Dinner in Ireland

October 17th, 2008 by


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:

Here is a link to the audio slide show:

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.


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:

Marciawieder-3 Nikkistone-2  Images Ralphhayles-2  Images Carolyn Griffiths-3 Edward Frederick-5

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

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:

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:

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:

And attend her talk: You Can Make Improvement Happen

To register for the 2008 TapRooT® Summit, see:

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