Category: Quality

5-Day TapRooT® Public Course with Software Included Feb 21-25, 2011 in Mumbai, India

November 1st, 2010 by

With so much recent interest from India based companies to hold an onsite course in India, we decided to hold a possible public course February in Mumbai.

Companies in India new to TapRooT® are not always ready to set up an onsite class for 10 or more employees until they see what they can do with what they learn. With enough interest and commitment from you, we will have a 5-day public course.

Please contact or and let us know how many employees you want to send to the course.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Description: Learn all the TapRooT® tools, and also many advanced skills that a Team Leader needs to collect information, analyze root causes, and develop effective fixes that will help your company improve performance.

Course Fee: $2,395 USD plus GST/VAT
3 or more attendees, each save:-$100

Fee Includes: Includes TapRooT® single user software, TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.

Who Should Attend: Environment, Safety, and Health Managers Quality Managers, Hospital Risk Managers, Hospital Quality Assurance Professionals, Equipment Root Cause Experts, Governement Regulatory Investigators (MSHA, OSHA, EPA, UK HSE, FAA, FRA, MMS, NRC, DOT, DOE, CSB, NTSB, …) Safety Engineers, Coordinators, Professionals Reliability & Maintenance Engineers, Design Engineers, Facility Managers, Quality Auditors.

If you want to be the root cause analysis expert at your company, then this course is for you. This course is especially valuable for people interested in analyzing the causes of human error. You’ll earn rules and theories to help you improve human performance, including how to improve procedures, training, communications, human engineering, supervision, and management systems. You’ll also learn ways to improve your company’s investigation processes and procedures.

Best Regards,

Chris Vallee
Senior Associate, Instructor
Six Sigma Black Belt
Human Factors

System Improvements, Inc.
1.865.539.2139 ext. 106

TapRooT® Changing The Way The World Solves Problems

Get the Right Management Support for Your Improvement Program, Incident Investigations, and Corrective Actions

September 22nd, 2010 by

I can’t count how many times have I heard people complain:

We just can’t get management support!

From these complaints, I would guess that lack of management support for improvement programs, incident investigations, and implementation of corrective actions are significant issues at many companies.

But there is more to lack of management support than just people complaining. Failure of management to support improvements can be a factor in major accidents. For example, the BP Texas City refinery explosion could have been prevented by a corrective action that was deferred. It would have cost less than $150,000 to tie the pressure reliefs from the raffinate unit into a knockout drum and flare that was being installed at a nearby unit. But the improvement was cancelled to save money. (I would call that a lack of management support.)

What can we do to solve this problem? To get the proper level of support for improvement programs, incident investigations, and corrective actions? Don Harrison has answers and techniques that can help you get the support you need and keep that support over the months and years needed to make improvement happen.

I learned about Don’s organization and the techniques they teach about a decade ago. I attended his two-day course that teaches strategies to improve and accelerate project implementation. We’ve had people from Don’s company talk about sponsorship and implementation improvement at past Summits. But this is the first time the inventor of many of the techniques that Implementation Management Associates (IMA – Don’s company) – Don Harrison – will speak at the Summit.


Don’s talk – “Getting Sponsorship Right: The Most Critical Factor in Implementation” – is perfectly on target for those who need to improve management support of improvement initiatives, incident investigations, and corrective action implementation.

Stop complaining. Get to the Summit and learn how to get the management support you need to make change happen. Register at:

Food Quality Issue Causes Baby’s Death – Deemed a “Medical Accident”

September 17th, 2010 by

Can an equipment issue and an operations problem cause a quality issue that causes a sentinel event?


It did in Ireland seven years ago. And the results of the investigation have just come to light.

The Irish Times published the following accident scenario.

1. A computer on a production line at at B Baun Medical froze (an equipment issue) and caused the line to stop.

2. The bag of adult food from the line was discarded.

3. The normal practice of flushing out the pipe that fed the line wasn’t accomplished because of “human error” and shift “changeover”.

4. The next batch to be produced was premature baby food. The Adult food that contained 126 times the allowed dose of magnesium (which was still in the pipe feeding the line) was put in the baby food packages.

5. This food was fed to a premature infant and the result was permanent, irreversible brain damage that resulted in the baby’s death five years later.

The Irish Medical Board investigated the problem within two weeks of the  incident in May of 2003. But they didn’t release the results to the family.

Finally, seven years later, the family found out what happened as a result of a coroner’s inquest which ruled the death a “medical accident”.

That reminded me of one of the Keynote Speakers at this year’s Summit on October 27-29 in San Antonio.

Linda Kenney

Linda Kenney had a sentinel event happen to her. The long difficult process led her to create the Medically Induced Trauma Support Services organization. It helps patients, their families, and doctors communicate better and heal emotionally after a sentinel event.

To hear Linda’s story and learn more about dealing with the aftermath of an accident, attend her Keynote talk at the TapRooT® Summit.

Process Safety and Operational Excellence Were Invented By Admiral Rickover

September 6th, 2010 by

Here’s an old document (1979 – in pdf format) where Admiral Rickover set out his tenets that assured reactor safety in the Nuclear Navy.

Click link below…[gview file=””]

We will be discussing his philosophy at the TapRooT® Summit in the “Lessons Learned About Excellence and Safety From Admiral Rickover” session in the Improvement Program Best Practices Track on Thursday from 10:40-12.

Don’t miss this session where where you can learn how Process Safety Management and Operational Excellence originated.

To register for the Summit, go to:

And if your were a Navy Nuc … leave your comments here about your experience in the Nuclear navy and how it changed your approach to operations, maintenance, or life.

Root Cause Analysis Tip: “Death by Data” also known as “Data Paralysis”

September 1st, 2010 by

Understanding your process data, filtering the good from the bad and detecting when there are true problems coming to light should not be like hand-sorting grains of rice.

Yet I hear this question frequently, “We have a large database and we would like to ……..?”

When I ask what processes are being measured and what data are tied to the process’ outcome, the answers are often very vague if not delayed with a, “I will get back with you, good question.”

Now most of us our good at tracking outcomes (often because we are required by Regulations) like:

… number of defects

… costumer complaints

… OSHA recordables

… Sentinel Events

With tracking outcomes however, comes the data merging error that hides the fact that all rice does not come from the same fields and cannot always be included in the same analysis. For example:

… we had a wonderful month with lower injuries in July per assigned employees.

Problem: Cannot compare the number of employees assigned in July with the other months because we had a 2 week plant shutdown.

… we count all defect opportunities and perform frequent audits but the leading indicators do not seem to predict the change.

Problem: Not all audits are created equal. Often leading indicator metrics are too global and general. In other words, “just plain rice”. When you see indicators change but there is no correlation to your lagging output metrics, stop and Go Out And Look (GOAL) at the tasks being performed to identify the correct leading metrics.

This is just the tip of the iceberg when looking at wrong data collection thoughts. Just remember just because you collect lots of data does not mean this a good thing…. you just get more grains of salt to sift through.

Below are two presentations to dig a little deeper in this thought process.

Also, check out our metrics course being offered during our October Pre-Summit. It is the only this year it is offered as a public course:

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.”


“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:

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:

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.

Sam 0017

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

Sam 0067 Sam 0071-1

Sam 0074 Sam 0077
Experiencing Authentic Arabic Cuisine

Sam 0085 Sam 0034-1
History of and formation of a Unified Saudi Arabia
Sam 0023 Sam 0048

Sam 0050 Sam 0060

The first Medical Devices in Saudi Arabia
Sam 0028 Sam 0027

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!”

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

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…

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


See the story here:

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:

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:

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:

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:

Using the TapRooT® System-tm.jpg

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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…

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:

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.

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Success Stories

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

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

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