Category: Quality

Trending “Bad Practice” Recommended as “Best Practice”

August 11th, 2010 by

I was just looking at a “Best Practice” from a nuclear utility about
trending …

Oh No!

I saw lot’s of “bad practices” listed as best practices.

What happens if you adopt a bad practice as a good practice? You get bad result! And when those bad results are related to trending it means that you will waste effort responding to trends that don’t exist and miss trends that do exist.

I won’t say which nuclear utility it was, but you need to be careful when accepting advice about trending – I’ve seen lot’s of bad practices out there.

Let’s talk about just a few of the “bad practices” that were recommended in this industry “best practice” …

1) They mentioned Pareto Charts but didn’t mention the 80/20 rule (Pareto Principle) that it is based on and how it controls the use of Pareto Charts for choosing which targets to attack first. This could lead to choosing items to improve that really are NOT that significant.

2) They recommend pie charts and matrixes to analyze data. I would never recommend using these as the appropriate Pareto Chart would be much better (and you only have to learn a single method for analysis).

3) For trending over time they recommended a mixture of techniques including making “trend lines” with linear, second order, third order, and fourth order polynomial approximations. This will lead to false trends and management knee-jerk reactions. (Just what you are trying to avoid.)

4) They then made a graph that looked like an XmR Chart or Process Behavior Chart but they didn’t provide the proper mathematical methods for setting the Upper Control Limit (UCL) which we call an Upper Process Limit (UPL).

They said:

“The UCL for each trending category and subcategory is set by mutual agreement between the trend group and the line organization responsible for the program, process, or issue that category or subcategory represents. Organizations typically started with initial UCL calculated on the basis of the mean over a specified time frame (usually 18 months) plus two standard deviations above the mean …”

Ahhh! This is exactly what Dr. Deming said NOT to do. Management arbitrarily setting and changing limits.

The 3 sigma limits were proven by extensive testing by Dr. Walter Shewhart back in the 1930’s. This has been accepted by quality experts around the world. Why would the nuclear industry “best practice” choose a different basis (and not explain how they chose to derive it). All this new standard will do is cause more “false alarms” and more knee-jerk reactions.

5) They didn’t show any appropriate techniques for trending infrequent data. This can lead to missing serious trends and management believing that they can’t detect trends in infrequently occurring data. (And thus even more knee-jerk reactions.)

Why is this bad practice that is represented as a good practice so troubling? Because we have been teaching best practice trending techniques based on a foundation of science and accepted math for over a decade. Everyone in the nuclear industry should now have someone at their plant that understands these advanced trending techniques. Yet no one has challenged this false “best practices.” Some are probably thinking about adopting it!

Where can you learn the advanced trending techniques that can help you understand and improve your facility’s performance? At this pre-Summit course:

Advanced Trending Techniques

Don’t miss this course that is only offered once a year.

Also, please don’t think that this course is ONLT for nuclear industry root cause analysis trending. It will work in any industry. We’ve had attendees appy it at:

  • Hospitals
  • Mines
  • Oil Refineries
  • Oil Platforms
  • Manufacturing Facilities
  • Chemical Plants
  • Utilities (fossil and transmission & distribution)
  • Government Agencies

Class size is limited. Sign up today!

Medical device problems hurt 70,000+ kids annually

July 26th, 2010 by

..”About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.”

..”Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.”

..”The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.”

…”Malfunction and misuse are among possible reasons”

I read the article and then asked “AND”? There is so much more information that needs to be collected and compared.

… “is there damage with this equipment for children and adults?”

… “is there a difference between different manufacturers for the same types of equipment?”

…”what allowed 70,000 incidents to occur without having the root causes listed already?” …. yes I know there are patient and company privacy issues but that is not a good excuse!

So what would your next steps be? (more…)

Equipment Failure Event: Cracks that could cause the engines to fall off on the Boeing 767

July 21st, 2010 by

“The FAA safety order affects 138 planes registered in the United States out of a global fleet of 314 planes. Aviation officials in other countries usually follow the FAA’s lead on safety of U.S.-manufactured planes.”

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“The order only applies to 767s that have the original pylon design. Boeing changed the design after the problem first became known…. FAA issued a safety order for these planes in 2005 requiring inspections for cracks every 1,500 flights. The new order accelerates that schedule to every 400 flights or every 90 days, whichever is later.”

read more here:http://news.yahoo.com/s/ap/20100721/ap_on_bi_ge/us_boeing_safety_order

Root Cause Analysis Tip: The Myth of the Cost of Poor Quality

July 21st, 2010 by

One of the biggest trends in quality improvement was the term “The Cost of Poor Quality” tied with “Zero Defects”, with many COPQ financial models popping up in many Fortune 500 companies. In the safety world there was a similar drive with the term Cost of Compensation tied with “Zero Injuries” and OSHA driven recordables to be tracked.

The Quality Iceberg

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The Safety Iceberg

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Yet the focus for both safety and quality were lead by lagging visible indicators. In other words good or bad, the findings are just too late. You march your troops with the “Zero Defects” and “Zero Injuries” flags raised and once you reach your destination you turn around and see who and what equipment you have left.

Now don’t get me wrong, identifying and being able to comprehend the end damage is a vital part of the process and unfortunately not realized by some. It is just NOT where you should focus your drive and effort.

So what now you may ask? “Build quality in… do not inspect quality in!”

The phrase above often goes to deaf ears because it is misunderstand. “If you do not assess the quality of your work, then how do you know if it is to standards,” people would ask. “I have to trust everybody’s work?” In the safety world the phrase “Safety must be part of every action we do,” is often trumpeted. But how?!

Start with these 3 steps first:

1. First things first, Quality and Safety are NOT silo’s and they should work together. Setting up a task that can be worked efficiently, correctly and safely by employees is a combined goal and SHOULD NOT be competing goals.

To save money, many companies do not cross-train employee’s from different departments. Why not if it makes sense? For example, while many of our clients started using TapRooT® Root Cause Analysis in their safety departments first, the more people saw the process used, the more operations and facilities come onboard for the same training.

Now this cross-training concept also works in the opposite direction. As the quality department leaders started working with the safety, quality tools from Stakeholder Analysis to Force Field Analysis were also shared with the safety department. After all, inside all world class companies are different departments that are all part of the same company with one goal.

2. Building Quality and Safety into a process starts in the beginning stages of planning but can be recovered after the employees try to use an existing process (it just costs more time and money!).

When our clients use our Root Cause Analysis process to investigate defects and incidents it soon becomes apparent that the opposite of each one of our root causes are best practices that can be implemented proactively.

While most Quality Experts are excellent at mapping out front end value streams, process maps and spaghetti maps, there is often a gap in knowledge of research and industry best practices in human engineering, communication, procedures, training and work direction. So if you were a Quality Professional and had access to multiple experts in front of you everyday, would you utilize them? Here is small list of courses that can give you best practice access: Best Practice Courses

3. No process, no matter how well designed is perpetually stable and it must be audited/assessed periodically based on risk for unknown and known changes…. note: this is not the same thing as “inspecting in quality”!

This is one of the most misunderstood ingredients relating to Inspections.

If you have a hold point inspection that must be completed by an Independent Inspector BEFORE a task can be completed or a part received or shipped, you are admitting that you have a high risk potential that is not capable of being completely mistake proofed.

– OR-

You have a process or task where you have not truly identified the human and equipment behaviors with their associated Root Causes, and have decided that it is worth spending the extra money and time to inspect instead of fixing the problem. You refuse to build in quality.

Now this is not saying that you should not target high risk tasks proactively and continually audit or assess these areas to ensure nothing has changed or is different. This type of inspection must still occur.

The Building Blocks of a Good Quality Program… is it in the Name?

July 8th, 2010 by

TQM, TQC, TOC, PDCA, Six Sigma, Lean, Lean Sigma, MBO, 8D… just to mention a few Quality Programs many in the world of Quality have been exposed to…. but is it the name of or the effectiveness of the process that make a good Quality Improvement Program? Seems like a silly question until you have lived in the world of change.

…..”Six Sigma is not the same as TQM”

…. “Lean Six Sigma is definitely better than Six Sigma”

…. “Is it a Lean Project or a Six Sigma Project?”

Each new buzz was normally preceded by a period of frustration, low morale and a loss money followed by blame or a feeling of hopelessness. Often employee’s were also taught the term of “empowerment” which led to suggestions with no follow up by management. Each time a new process with a new name was introduced, we would “throw the baby out with the bath water.” So a new name was also perceived by many as reinventing the wheel in the name of rebuilding an Effective Quality Program.

So why reinvent the wheel? Why not forgot the name, identify the strengths and weaknesses of your current quality program processes and improve what really needs to be improved. This is the proper way to spend your money and time for the best return on investment and acceptance of your employees.

So the burning platform, pain and frustration felt by many in charge of ensuring quality processes sustain, is still a current issue addressed by many professionals that I met at ASQ World Conference this year. They were not arguing on whether it was 8D or Lean Six Sigma. The good thing is that many are realizing that numerous tools and processes previously divided into opposing teams can be combined without a large new program investment.

With that said one area of common interest by many at the ASQ Conference was Root Cause Analysis. The interest was not in how to calculate significance or sigma level because most there could calculate these with their eyes closed. The interest was in how to reduce bias, widen root cause perspectives and to add more qualitative substance behind the numbers. There were two Root Cause Booths at the conference….. guess whose booth had the most traffic, the TapRooT® Booth where we were able to share a portion of our process that could easily be combined with all the current processes listed above to gain more value and quality sustainability.

Every other week on this blog, I will dig a little deeper into current Quality Program frustrations. To help guide these posts to your quality needs, please chime in and post your issue of the week.

Here is the previous article in case you missed it: http://www.taproot.com/content/category/quality/

When is the last time you have Experienced Riyadh, Saudi Arabia?

June 29th, 2010 by

While this was my third tour to Saudi Arabia, this was my first true Saudi Culture experience while in Riyadh. My first two trips were with the United States Air Force for two tours of duty. These pictures are posted with great appreciation to the employees (my friends) from the Saudi Food and Drug Authority.

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Until recently, skyscrapers were not allowed to be built (a night time picture from the skybridge)…..

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Experiencing Authentic Arabic Cuisine

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History of and formation of a Unified Saudi Arabia
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The first Medical Devices in Saudi Arabia
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Root Cause Analysis Tip: An ASQ discussion on Quality, Root Cause Tree, and the Ishikawa diagram (also called fishbone diagrams or cause-and-effect diagrams)

June 16th, 2010 by

Dave Janney and I recently had a great opportunity personally talking one to one to over 450 plus ASQ (American Society for Quality) Members in St. Louis at the ASQ World Conference. There were 1,000 plus members present but I want to focus on the one on one discussions in this tip of the week.

Discussion Tip 1: “The TapRooT® Root Cause Tree is definitely more than a Fish-Bone and 5-Why tool!”

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A Director of Quality walked up to our booth and looked at the back of our Root Cause Tree. Seeing some of the Basic Cause Categories such as: Human Engineering, Management System, Training, Work Direction……. He stated, “that looks a little like the Categories on the Ishikawa Diagram, what is the difference? Why would I as an expert need to use it?”

So I put him through the test and covered up the multiple research and industry based Root Causes under our Basic Cause Category of Human Engineering. Then calling this the “Man/Person” section of the Diagram I asked, ” with your expert knowledge with man/person in quality, what human engineering questions would you ask?”

He stopped and realized that this was not his area of expertise. We have 7 areas of expertise to help you analyze your problems… In simpler form, you as the quality director have 7 more experts sitting next to you that are usually not present when developing your Ishikawa diagram.

Also remember, it is not how many questions you ask! What you ask and how you ask it is what will give you an effective Root Cause Analysis.

Discussion Tip 2: “I already have a list of common Root Causes developed by ABC Inc., why get a new process?”

This question came from a Tier 1 Supply Quality Leader. So my first question was, “which category do you see selected most often during a Root Cause Analysis?” His response, “depends on which department lead the investigation.”

Caution of the day, if the investigator is steering the analysis then you have a Root Cause Tool that allows bias instead of facts to run the investigation. The analogy is like telling your inspectors to measure the dimensions of a cube. Each person selects their favorite measuring device and goes at it. Just do not expect them to come up with identical end measurements.

Our TapRooT® process takes you through a standard/robust question process that needs facts to say yes to or no to and not opinions. It is this true and tried process (20 years in use) that allows the Quality Inspectors to remain consistent.

Now don’t get me wrong, TapRooT® Root Cause does not replace the quantitative tools used by certified quality leaders. It does however improve the qualitative portions of your analysis.

Look for more Quality Tips and Articles to come…. there is just so much more to continuous improvement. Question? Comments?

Quality Manufacturing Article of the Week: The balance between production, product safety, and speed

June 10th, 2010 by

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I read this article today in ASQ Quality News Today: “Toyota’s Safety Blitz May Delay Product Plan”.

Read this excerpt and then think about it for a minute: “Some analysts warn that product development will slow as Toyota takes more time to review its quality and safety processes, and diverts resources to those areas.”

Is “warn” the right word of the day. In TapRooT® Root Cause Analysis Training we teach problem facilitators not to be judgmental when writing down facts…. it is best to keep a root cause analysis objective and nonemotional. Of course most of us are all human so what did you feel or infer when you heard the word “warn”?

My thoughts? Isn’t the rapid pace of new products tied to the current massive recalls? “Warn” sounds like there is worry that new products in the pipeline may now have to be delayed which $$$ people feel may be bad for future return on investment based on expected delivery dates?

Now the good news is the great response to the quote above from project general manager for vehicle safety Seigo Kuzumaki. He stated that shifting resources to safety was the right compromise at the right time. “Toyota needs to move faster to respond to customer needs,” he said.

..any comments?

Medical Checklists: Peter Provonost on CNN

March 8th, 2010 by


We discussed the use of checklists in the medical industry in a previous blog entry.  Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University.  He was selected in 2008 as Time Magazine’s Top 100 Most Influential People.  He had a great discussion on the use of checklists in medical industry, specifically hospitals.  He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists.  He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed.  Quite a statement!  Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development.
What do you think?  With so much research indicating the benefits of checklists, why have they not yet come into widespread use?

Monday Accident & Lessons Learned: Toyota Lawsuits

February 15th, 2010 by

It was just a matter of time before the flood of Toytota lawsuits started. Here’s an article about two of them…

http://www.benzinga.com/markets/company-news/125905/toyota-tm-sued-over-fatal-accidents

Whenever accident get this much press, you know that lawsuits will follow. That’s a “lesson learned” that shouldn’t be forgotten. If Toyota had found the root causes of these accidents and fixed them two years ago, they wouldn’t be facing these serious lawsuits.

One more thing. How serious are these lawsuits? I saw one blog posting saying that he wouldn’t be surprised if Toyota declared bankruptcy because of the lawsuits. I don’t think that’s possible … how many suits would it take to make Toyota go bankrupt? But the fact that somebody might suggest it makes one think twice about what the final cost of this quality/safety issue will be.

More Bad News for Toyota: “Transportation chief criticizes Toyota’s reaction time”

February 3rd, 2010 by

An AP story published in the Houston Chronicle says that Transportation Secretary Ray LaHood said that Toyota was:

“…dragging its feet on safety concerns over its gas pedals, suggesting the automaker was ‘a little safety deaf’ to mounting evidence of problems.”

He also said that:

“… federal safety officials had to ‘wake them up’ to the seriousness of the safety issues that eventually led Toyota to recall millions of cars such as its Camry and Corolla. That included a visit to Toyota’s offices in Japan to persuade them to take action.

The article also said:

“… the government was considering civil penalties for Toyota over its handling of the recalls …”

This kind of press couldn’t come at a worse time as Toyota struggles with this quality/safety issue and the bad press that it has generated.

How much damage to your reputation can a quality/safety issue do? Toyota is finding out the hard way.

More Bad News for Toyota – “Four-car accident blamed on Toyota gas pedal”

February 3rd, 2010 by

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See the story here:

http://www.wtsp.com/news/local/story.aspx?storyid=124265&catid=8

How many more of these will we see? Wrecks blamed on sticking gas pedals…

Each one is bad news for Toyota.

But this one is different – read the article for the low down on why every accident may not be Toyota’s fault.

More Guessing on Toyota Recall Root Causes

February 2nd, 2010 by

Here’s a story from Fortune Magazine published on CNN Money:

http://money.cnn.com/2010/02/01/autos/toyota_mistakes.fortune/index.htm?hpt=T2

They question Toyota’s management, organization, and cost cutting efforts.

Should Toyota release their root cause analysis for the world to see to stop the speculation in the press? Or would the official root cause analysis just raise questions about the depth and accuracy of the analysis and of the resulting corrective actions? Surely it must be done by now with approved corrective actions on the way to the dealers. No matter what, it may come out as future lawsuits (and their will be many) make their way through US courts.

Missile Test Failure – Good Opportunity for Use of Advanced Root Cause Analysis

February 1st, 2010 by

The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”

The story also said:

The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.

Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!

  

How Much Can a Quality Problem Cost – Ask Toyota

January 27th, 2010 by

The Associated Press reports that Toyota is stopping production for at least a day at six assembly plants and is stopping sales of eight models until accelerator sticking problems are solved.

We wrote about this problem back on September 17 and again on November 28.

It’s a difficult investigation … let’s hope for the company and many Toyota vehicle owners, that they find the root causes and fix them soon.

The Daily Press reports “Navy reports widespread problems on Northrop’s Gulf Coast-built ships”

January 26th, 2010 by

The story in The Daily Press says:

A new round of construction problems on U.S. Navy vessels built by Northrop Grumman Corp. have spawned yet another investigation into the nation’s largest Navy shipbuilder.

Northrop, already under fire for widespread yet unrelated welding problems that surfaced two years ago at its Newport News shipyard, now faces quality issues at its Gulf Coast yards in Avondale, La., and Pascagoula, Miss., the Navy said Thursday.

All Gulf Coast vessels built by the company over the last several years are under investigation for a host of problems, including improper welds and defective engines and lube-oil systems, the Navy said.

Other bad press for Northrop Grumman Shipyards include:

Sounds like they need better root cause analysis and better corrective actions! Maybe it’s time they took a TapRooT® Course?

Poor quality over an extended period of time is an indicator that your problem reporting and corrective action programs aren’t working. Applying the same old corrective actions of blame, counseling employees, more training, and making procedures longer doesn’t solve quality issues. People stuck in the blame game need a systematic investigation process that finds the true root causes of problems and the solutions.

TapRooT® does that with proprietary, copyrighted systems and training, and patented software that comes with a money back guarantee. Nobody else stands behind their system like we do. And that’s just one of the reasons that industry leaders choose TapRooT®.

If you are interested in thorough investigation of quality problems with effective corrective actions, consider sending some of your quality professionals to a 5-Day TapRooT® Advanced Team Leader Training public course. See:

http://www.taproot.com/courses.php?d=2


Long Distance Outage Incident

September 4th, 2009 by

cnet news reports:

Qwest Communications confirmed Thursday that the company experienced a long distance outage that lasted about two and a half hours.

Wow! A two hour outage in long distance service is like a lifetime. That’s a significant quality of service issue. It would be interesting to see their root cause analysis and proposed corrective actions.

These kinds of issues (network reliability, computer reliability, service outages) can be analyzed using TapRooT® just like an equipment outage or a safety issue can be analyzed.

What we’ve found is that people make mistakes for the same kind of reasons whether they are a computer programmer, a refinery operator, or a brain surgeon. That’s why TapRooT® can be used in almost any industry and on every continent.

For more information about TapRooT®, including Success Stories from users (one from BellSouth about network reliability), see:

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

Root Cause Analysis Tip: Are Simple Techniques Sometimes the Best?

August 7th, 2009 by

I received a piece of marketing material for a webinar claiming to teach “simple” root cause analysis techniques in just one hour.

The marketing material included the quote that these basic techniques:

are sometimes the best.

Of course, they lost all credibility with me when they claimed to teach root cause analysis in 60 minutes on the web. But the e-mail made me think …

What are the minimum tools needed to perform a good root cause analysis of a simple problem?

We’ve researched this question for over 20 years and I know the answer.

First, you need to understand:

Make the answer as simple as possible, but not simplier.” (Albert Einstein)

What is the minimum needed information to find a root cause?

1. You need to completely understand what happened before you can understand why it happened. And this understanding should NOT be made through verification of a hypothesis. Rather, the understanding should be an unbiased collection of evidence.

The tool that helps people build the story of what happened using evidence that is collected is a SnapCharT®. And example of a SnapCharT® can be found at this link:

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2. Next, you need to identify all the Causal Factors. These are the problems that, if removed, would have prevented the incident or reduced its severity.

There are two techniques that are taught in TapRooT® Training to help investigators identify Causal Factors. The first is the Four Question Method and the second is Safeguards Analysis.

3. Finally, to analyze what caused the Causal Factor, you need a robust root cause analysis tool. There are many substandard tools available so … be careful. Many “experts” recommend a tool they are familiar with without doing thorough research of the tools limitations and understanding the serious shortcomings of supposedly “simple” tools. But we have dedicated our lives to understanding root cause analysis and developing a tool that does not fall into the trap of being just simple but inadequate.

The TapRooT® Root Cause Tree® have been carefully designed and tested to provide the simplest tool possible while yielding robust root cause analysis for equipment and human performance related Causal Factors. The research basis is extensive, so I won’t provide it all here. But I will provide several links so that you can start to understand it…

http://www.taproot.com/content/2008/11/07/defending-categorization-why-the-taproot-root-cause-tree-works-better-than-unguided-root-cause-analysis/

http://www.taproot.com/content/2006/02/28/the-curse-of-apparent-cause-analysis/

http://www.taproot.com/content/2007/12/04/comparing-taproot-to-other-root-cause-tools/

However, some people continue to cling to inadequate tools because they are “easy” and “sometimes the best.” (Makes one wonder when they are “sometimes the worst.”)

Usually this insistance on using easy, inadequate tools is because the person has failed to do what is needed to make real root cause analysis possible.

What did they miss? See this link to learn what is needed for efficient and effective root cause analysis:

http://www.taproot.com/content/2006/02/07/efficient-yet-effective-root-cause-analysis/

So these tools are the required minimum set (the essential tools) for a good root cause analysis. Anything less is root cause analysis malpractice.

We’ve found that a 2-day course is needed to effectively teach these tools to experienced investigators who want to apply them both reactively and proactively and then have them be used effectively.

So, don’t be fooled into economizing into “quick/easy” methods with fast but inadequate web based training. All you will get is inadequate investigations and recurring problems.

And if this approach seems to be too hard, consider skipping investigations altogether. If you aren’t going to perform an adequate investigation then you should consider that you may be better off by performing no investigation at all.

Friday Joke: Top 10 Bad Corrective Actions

July 10th, 2009 by

Found this on YouTube … It’s produced from a quality auditor perspective.


Hope your corrective actions don’t sound like those.
If any of them sound familiar, perhaps you need TapRooT® Training and the Corrective Action Helper® Book that comes with the course. For more info, see:

Using TapRooT® in a Proactive Program

July 9th, 2009 by

TapRooT® is well known throughout the world as the premier incident investigation and root cause analysis system.  In a perfect world, however, we would like to never have to do an investigation!  The only way to get there is to have a good proactive process.

Did you know that TapRooT® can also be a powerful tool in your proactive/continuous improvement arsenal?  Michele Lindsay and I are teaching the five day course in Niagara Falls this week, and Thursday is what I call “proactive day.” 

We started the day discussing how the TapRooT® 7 Step Process can also be used for audits.  After the group understood the process, we did a communication audit where the group performed an audit of 4 willing class volunteers doing a shift turnover.  We then took what we learned from the audit and did a root cause analysis and applied corrective actions.

Next, we did two exercises involving an oil boiler and learned how we might use Safeguards Analysis to find problems before an incident occurred, and we identified some significant issues that should receive a good root cause analysis. 

Finally, we discussed how TapRooT® fits into continuous improvement programs such as Six Sigma and Lean, and covered trending and moving from a reactive to a proactive environment.

The icing on the cake was when the group got to perform a live audit of a training exercise from the Niagara Falls Fire Department!  We don’t always have a chance to do something so fun but things just were going our way this particular day.  I’m pleased to report the exercise went off without a hitch and our very detailed (and tough!) auditors (the class) were not able to find any significant issues from the audit.  That is surely a good day for an auditor! 

Check out the pictures:

The auditors:

If you would like to learn more, attend the 5 day TapRooT® Advanced Root Cause Analysis Team Leader course.  See the schedule HERE.

Join me again on the blog next Wednesday for the Root Cause Analysis Tips column, where I will share some more information on the proactive use of TapRooT®.

Root Cause Analysis Tip: Interesting Article in Quality Digest About Verifying the Effectiveness of a Corrective Action

June 23rd, 2009 by

Part of a root cause analysis is the development of an effective corrective action.

But how do you know if a corrective action was effective? Here’s an good article from Quality Digest that gives you some ideas…

http://www.qualitydigest.com/inside/fda-compliance-article/verifying-effectiveness-corrective-action.html

Trouble Trending in the Nuclear Industry

May 7th, 2009 by

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I recently read 11 nuclear plant trend reports. Not one had a mathematically valid way to trend. (One did come close.)

These 11 nuclear industry trend reports are not unusual … They are typical of trend reports from various industries.

This makes one ask: “Why do so many companies have trouble trending?”

Let’s look at specific problems in the 11 reports.

First, many “trend” reports showed no trends. Three of the eleven reports didn’t even have a single graph. They were just discussions of incidents and audits in a particular quarter with discussions of “trends” with no data.

Most of the reports that had graphs used simple bar and line graphs. Bar graphs with no timeline don’t really show “trends.” They are best used to look for the Pareto Principle and help to identify the biggest problems to attack first.

One report tried to use a mathematically based approach. They used a c-Chart with limits based on 3 times the square root of the mean of the data. But c-Charts require independent data with a constant area of opportunity – which is unlikely for incident data.

The most common error made in trending reports (and by management) is looking at the number of problems in one quarter and comparing them to the next quarter. If the number of problems goes down – that’s a good trend. If the number of problems goes up – that’s a bad trend. They tend to use straight-line approximations to “project the future” (as in the example below).

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What’s wrong with this approach? Management starts reacting to noise rather than signals.

Some might say that there’s nothing wrong with trying to “fix things when they aren’t broke.” But they are wrong.

They don’t understand the cost of reacting to non-problems.

They don’t understand how employees get tired of the new improvement flavor of the week.

They haven’t thought about the negative cycle of blame, cover-up, and surprise that is all too common when major accidents occur.

What should people do? Where can they find out about the best practices in trending? First, they can read Chapter 5 of TapRooT® – Changing the Way the World Solves Problems. The new TapRooT® Book explains the problems with trending and the ways to implement best practices in performance measures and trending.200905031637.jpg

Would you like to go beyond reading? Then you should plan to attend this year’s Advanced Trending Techniques Course on October 5-6 in Nashville, Tennessee (just before the Summit).

What will you learn? First, you will learn why trending is needed and the basics of trending (including the proper way to apply Pareto Charts).

Second, you will learn the math behind Process Behavior Charts (the only chart you need to view trends over time). This math only requires addition, subtraction, multiplication, & division (no different¬ial equations).

Third, You will also learn special ways to use the charts to trend infrequently occurring accident data.

Finally, you will learn how to use your own trend data including how to improve the data and how to present it to management. Get more information about the course by clicking on the “Courses” button above.

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Angie ComerAngie Comer

Software

Barb CarrBarb Carr

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Chris ValleeChris Vallee

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Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

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Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

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Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

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Shaun BakerShaun Baker

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Steve RaycraftSteve Raycraft

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Wayne BrownWayne Brown

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