News

Root Cause Analysis Tip: Process Safety with Mark Paradies – Part 3

Posted: June 12th, 2013 in Root Cause Analysis Tips, Summit, Video

At the 2013 Global TapRooT® Summit, Mark Paradies gave a General Session talk about Process Safety.

Watch the third installment here:

Learn more about our 2014 Global TapRooT® Summit at http://www.taproot.com/summit.

Did you miss the first installment? View it here: : http://www.taproot.com/archives/38433

The second? View that here: http://www.taproot.com/archives/38566

Root Cause Analysis Tip: Process Safety with Mark Paradies – Part 2

Posted: June 5th, 2013 in Root Cause Analysis Tips, Summit, Video

At the 2013 Global TapRooT® Summit, Mark Paradies gave a General Session talk about Process Safety.

Watch the second installment here:

Learn more about our 2014 Global TapRooT® Summit at http://www.taproot.com/summit.

Did you miss the first installment? View it here: : http://www.taproot.com/archives/38433

Root Cause Tip – Work Direction

Posted: May 29th, 2013 in Root Cause Analysis Tips

I wanted to take some time today to discuss one of our basic cause categories on the TapRooT® Root Cause Tree®; Work Direction.

Work Direction includes the near root causes of preparation, selection of worker, and supervision during work.

image001

The main focus of my comments is on preparation; however, let me touch on the other two first.

Selection of worker is fairly straightforward; the person(s) is (are) not properly qualified for the task or are in some way not capable of performing the task. It is the supervisor’s responsibility to ensure workers are qualified and capable.

Supervision during work ensures that there is a “reasonable level” of supervision and also includes a very important consideration, crew teamwork. Since “reasonable level” is debatable, there can be differing interpretations and opinions on this, and one must consider that each situation is different. However, in my experience, this root cause can be overused. Every situation or task cannot be expected to have someone there to oversee a trained adult, so be careful not to use that as a crutch and blame lack of supervision for every problem.

Which brings me to preparation; this is everyone’s responsibility, not just the supervisor’s. You have self-directed teams as well as people working alone, and preparation is needed whether a supervisor is present or not. I have seen the tendency to cross off work direction when a supervisor is not directly involved. Remember, someone is always in charge, whether they have the title of supervisor or not.

No preparation is straightforward. Work Package/Permit NI includes JSA/JHA’s and risk assessments as well as things requiring a work package or permit. I often see people trying to fit JSA’s into other areas, but this is where it fits on the tree.

Pre-job briefings are another root cause I feel can be overused, or used as a “crutch.” Briefings can tell people things that are specific to the shift, anything out of the ordinary, any specific risk, crew coordination, etc. However, can the supervisor or person in charge tell a trained adult everything they might need to know today? Here is an example:

Someone made an error because they did not use a required procedure (and they know it is required). A student selects pre-job briefing as a root cause because………..”if the supervisor had told them to use the procedure in the pre-job…..” But they are a trained adult who knows the procedure is required! I think that is taking things a little too far.

The same concept applies to walk-thru NI; I see less abuse on this one, but remember, walk-thrus are for infrequently occurring tasks, not something I do every day.

Make sure you are being very deliberate when going through the Root Cause Tree®, use the dictionary, and of course, the evidence. One of the common things I see among new users is the tendency to “go shopping when they are hungry.” What do I mean by that? Here is the analogy:

When you were a kid, your Mom gave you $20 and said milk, bread, and eggs. You went to the store and got the three items. So far, so good. But on the way to checkout, you passed the cookies…..and the chips…and the candy. The problem is when you got to the checkout you had to pay the bill. And when you got home Mom asked the dreaded question; “where is my change?” In this scenario think of the checkout as your corrective action program and your Mom as the boss. Eventually you must account for everything, and if you load up your corrective action program with cookies, what happens to the important stuff? No one knows……..at least until they try to clean up the open items.

Be careful and happy investigating.

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 5

Posted: May 23rd, 2013 in Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This is the second part of the Q & A portion at the end of the session, in which participants discuss SIF situations in their workplace with Mark.

Watch it here:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877
Part 2: http://www.taproot.com/archives/37972
Part 3: http://www.taproot.com/archives/38015
Part 4: http://www.taproot.com/archives/38276

Root Cause Analysis Tip: Don’t Miss Out on Advanced Root Cause Analysis Training

Posted: May 22nd, 2013 in Courses, Pictures, Root Cause Analysis Tips, TapRooT

Screen Shot 2012-04-17 At 3.56.49 Pm 2

In 2012, a little over 12,000 people were trained to use TapRooT® to find and fix root causes.

That’s a record.

If the first quarter of 2013, course registrations are up. We think 2013 will see even more people in TapRooT® Courses.

That good news for the people who will have their lives saved, see product quality improved, see hospital patient safety improved, and get better equipment reliability at their facility … when TapRooT® is applied as part of a performance improvement program (see success stories by clicking here).

What’s the bad news? The popularity of TapRooT® Training means that sometimes our public courses are filling up early. Sometimes even two months before the course takes place.

Also, our training schedule for on-site courses is filling up.

What does that mean to you? If you are planning to attend a specific public TapRooT® CourseSIGN UP EARLY.

If you want to have a course at your site, get it scheduled NOW! (Contact us by CLICKING HERE.)

 Content Wp-Content Uploads 2013 03 Photo-Transport-Companies

Root Cause Analysis Tip: Process Safety with Mark Paradies – Part 1

Posted: May 21st, 2013 in Root Cause Analysis Tips, Summit, Video

At the 2013 Global TapRooT® Summit, Mark Paradies gave a General Session talk about Process Safety. We’ll have it here for you on the blog for the next few weeks.

Watch the first installment here:

Learn more about our 2014 Global TapRooT® Summit at http://www.taproot.com/summit.

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 4

Posted: May 16th, 2013 in Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This is the first part of the Q & A portion at the end of the session, in which participants discuss SIF situations in their workplace with Mark.

Watch it here:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877
Part 2: http://www.taproot.com/archives/37972
Part 3: http://www.taproot.com/archives/38015

Root Cause Analysis Tip: Don’t Ask “Why” During an Interview

Posted: May 15th, 2013 in Root Cause Analysis Tips

Why NOT Ask Why?

Some people teach the “5-Why” technique for root cause analysis as their preferred method to solve problems. If you have read this blog for very long, you’ve probably been convinced that 5-Whys is at best a rudimentary technique with many inherent flaws. But you may not know that asking “Why” during an investigation interview is also a mistake.

In the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, we spend a majority of the second day teaching fact finding and interviewing. This section of the course highlights an advanced interviewing technique called “Cognitive Interviewing”.

Cognitive Interviewing helps the interviewee recall information that they might have otherwise forgotten or thought too unimportant to share. The Cognitive Interviewing training in our course emphasizes that the interviewer should not ask the interviewee “Why?” during the interview.

Why not ask Why? Because the question elicits justifications from the interviewee rather than getting them to share additional information from their long term memory. The “Why?” question is seen by the interviewee as accusatory (Why did you do that?) rather than a request for more information.

What should the interviewer do? Cognitive Interviewing teaches a systematic process to get the interviewee to tell their story, recalling as much as they can from their long term memory. It also teaches the interviewer to ask “What” and “How” questions to get additional information (instead of “Why?”).

Find out more about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course by CLICKING HERE.

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 3

Posted: May 9th, 2013 in Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This week, Mark shares his lessons learned, including making sure your investigators really dig in when it comes to root cause analysis. He recommends exploring human factors, fatigue, and using the Corrective Action Helper® to go beyond additional training.

Watch the full 4-minute video now:

If you’d like to look at the process safety talk he mentions at 1:46 in this video, click here for his series from last year’s Summit.

Click here for Admiral Rickover’s testimony to congress about Process Safety.

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877
Part 2: http://www.taproot.com/archives/37972

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 2

Posted: May 2nd, 2013 in Best Practice Presentations, Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This week, Mark discusses using safeguards analysis proactively. He says, “If you’ve got a single safeguard that’s [based on] human performance, that should be a danger bell going off in your mind.”

Watch the full 7-minute video now:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877

Root Cause Analysis Tip: Serious Injuries & Fatalities with Mark Paradies – Part 1

Posted: April 25th, 2013 in Root Cause Analysis Tips, Summit, Video

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

The first installment is about 6 minutes long and Mark outlines the implications of Behavior Safety Training’s SIF Model and its strengths and weaknesses.

Watch it here:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn … Stats

Posted: April 24th, 2013 in Current Events, Root Cause Analysis Tips, TapRooT

Screen Shot 2013-04-19 At 1.54.29 Pm

TapRooT® Users … Did you know there is a place where you can discuss your experience using TapRooT®, your questions, and your best practices with other TapRooT® Users? It’s on LinkedIn at the TapRooT® Root Cause Analysis Users and Friends Group.

Currently there are 1, 771 members but we hope to grow the group to include all those actively using TapRooT® (tens of thousands of people).

To join the group at:

http://www.linkedin.com/groups/TapRooT-Root-Cause-Analysis-Users-2164007/about?trk=anet_ug_grppro

And then participate by posting questions, providing your best practices, and commenting on other’s discussions.

Detailed Up-Front Machinery Quality Assessments (MQA) — a Key Prerequisite to Reliable Major Machinery

Posted: March 27th, 2013 in Best Practice Presentations, Best Practice Presenters, Equipment/Equifactor, Root Cause Analysis Tips, Summit

Heinz Bloch explained how Best-of-Class companies use MQA on critically important compressors, drivers, and essential process pumps at the 2013 Global TapRooT® Summit. The MQA effort consists of structured and well-defined reviews of vendor experience, drawings, calculations, and other documentation. For highest possible value, MQA is often carried out before purchase orders are issued. Mr. Bloch described three distinct phases of successful MQA tasks.

8437Images-Heinz-Bloch-150-1Heinz Bloch is a graduate of New Jersey Institute of Technology (BSME, MSME, Cum Laude). After his retirement from Exxon Chemical Central Engineering (in Baytown, Texas), he worked as a consulting engineer and author of 17 books. He is the equipment/reliability editor of Houston-based Hydrocarbon Processing and has published over 460 papers and articles on reliability improvement subjects. For several decades, he has advised industry on maintenance cost reduction and reliability improvement issues and has taught over 500 equipment uptime improvement courses on all six continents.

Click on the icon below to view the presentation and learn the three phases of successful MQA tasks:

Bloch.Heinz.Detailed Up-Front-1

Root Cause Tip: What is “Behavior” and is it a “Cause” of an Accident?

Posted: March 13th, 2013 in Accidents, Human Performance, Performance Improvement, Root Cause Analysis Tips, Root Causes

Here’s the Meridian-Webster On-line Dictionary definition of “behavior”:

1. a : the manner of conducting oneself
    b : anything that an organism does involving action and response to stimulation
    c : the response of an individual, group, or species to its environment
2 : the way in which someone behaves; also : an instance of such behavior
3 : the way in which something functions or operates

Another definition that I think that management has in their heads is a “behavior” is:

“Any action or decision that an employee makes that management,
after the fact, decides was wrong.”

Why do I say that mangement uses this definition? Because I often hear about managers blaming the employee’s bad behavior for an accident.

For example, the employee was hurrying to get a job done and makes a mistake. That’s bad behavior!

What if an employee doesn’t hurry? Well, we yell at them to get going!

And what if they hurry and get the job done without an accident? We reward them for being efficient and a “go-getter.”

Management doesn’t usually see their role in making a “behavior” happen.

Behavior should NEVER be the end of a root cause analysis. Behavior is a fact. Just like a failed engine is a fact when a race car “blows it’s engine.”

Of course, a good root cause analysis should look into the causes for a behavior (a mistake) and uncover the reasons for the mistake and, if applicable, the controls that management has over behavior and how those controls failed when an accident occurred.

A bad decision or a human error that we call a “behavior” isn’t the end of the investigation … it is just the beginning!

TapRooT® helps investigator go beyond the symptoms (the behaviors) and find the root causes that management can fix. Some of the most difficult behaviors to fix are those so ingrained in the organization that people can’t see any other way to work.

For example, the culture of cost saving/cutting at BP was so ingrained, that even after the explosions and deaths at the Texas City Refinery, BP didn’t (couldn’t?) change it’s culture – at least not in the Gulf of Mexico exploration division – before they had the Deepwater Horizon accident. At least that is what I see in the reports and testimony that I’ve reviewed after the accident.

And with smaller incidents, it is even harder to get some managers’ attention and show them how they are shaping behavior. But at least in TapRooT® tries by providing guidance in analyzing human errors that leads to true root causes (not just symptoms).

Want to find out more about TapRooT® and behavior? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. You’ll see how TapRooT® helps you analyze behavior issues in the exercises on the second day of the training. And you will learn much more. For a public 5-Day Course near you see:

http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training

How to Find Root Causes

Posted: February 27th, 2013 in Investigations, Performance Improvement, Root Cause Analysis Tips, TapRooT, Video

I’ve had so many people ask me, “How can I find the root causes of the problem?” that I’ve decided to put my experience (or at least some of it) and links to others’ suggestions (even though some of the suggestions are bad) in one location – THIS ARTICLE – about how to find root causes.

I’m going to start with a “simple” root cause analysis technique. A technique that I do NOT recommend but that I will share because it is frequently recommended by others. If you choose to use this simple technique, don’t blame me when the “root cause” you find and fix doesn’t seem to improve performance and you keep having the same accidents happen over and over again.

Next, I’ll cover more complex techniques. Some of these are souped-up versions of the simple technique. However, the complex techniques – while being more complex – still have the same inherent problems as the simple technique. Therefore, I can’t recommend these more complex techniques for serious root cause analysis of important safety, quality, maintenance, service, or production issues.

Finally, I’ll talk about the technique you should be using. A technique that was developed to avoid the problems presented by the previously mentioned simple and complex techniques. A technique that was intelligently designed to take you beyond your current knowledge. A technique that users praise for it’s repeatability, thoroughness, and effectiveness.

SIMPLE TECHNIQUE: 5-Whys

I’ve probably heard more “experts” talk about 5-Whys than any other root cause tool. Why? Because it is simple. Simple to teach and simple to use. All you have to do to find root causes is ask “Why?” five times.

Here’s an example of the technique from the technique’s creator, Tailchi Ohno:

1. “Why did the robot stop?”

The circuit has overloaded, causing a fuse to blow.

2. “Why is the circuit overloaded?”

There was insufficient lubrication on the bearings, so they locked up.

3. “Why was there insufficient lubrication on the bearings?”

The oil pump on the robot is not circulating sufficient oil.

4. “Why is the pump not circulating sufficient oil?”

The pump intake is clogged with metal shavings.

5. “Why is the intake clogged with metal shavings?”

Because there is no filter on the pump.

What do you think? Is “NO FILTER ON THE PUMP” a root cause? I think this example is a perfect example of what is WRONG with 5-Whys (and most unguided cause-and-effect  analysis).

First, they missed a whole line of questioning. Why didn’t the loss of lube oil pressure trigger an alarm or an automatic shutdown?

Another line of questioning that was missed was “Where did the metal shavings come from?” After all, metal shavings are not normally found in a well-maintained machine.

And finally,”Why was there no filter on the pump?” Did maintenance forget to install it? Did the designer fail to include it? Was it removed because it kept getting clogged?

All of these questions need to be answered but the ultimate expert, Tailchi Ohno, didn’t ask them because he thought he already had the answer.

Watch this 5-Why training video and see if you can poke more holes in their example …

OK, so according to the video, you might need to ask why more or less than five times. And in other 5-Why training they try to teach techniques to determine when you have asked enough “whys” to call the result a “root cause.” So simple might not be so simple after all.

Just watch this 5-Why example and see if you can tell when a root cause has been reached …

Five, six, ten, twenty “Whys”? Or was a root cause ever mentioned in all those why question answers?

MORE COMPLEX TECHNIQUES

Many root cause analysis tools start with the idea of cause and effect. Every effect is caused. If you follow the cause and effect chain back far enough, you will reach the root cause.

Most of the techniques realize that the unguided 5-Why process fails to produce adequate results. Therefore, they modify the process by putting rules or structure around the asking of why (developing the cause and effect chain). They think rules or more extensive training can solve the basic defects inherent in cause and effect.

Screen Shot 2013-02-20 At 9.50.07 Am   Screen Shot 2013-02-20 At 9.52.09 Am


Here’s an article I wrote for Quality Progress (a quality oriented professional society journal) that outlines most of the problems with cause and effect:


http://www.taproot.com/archives/36739

 

Here’s the root cause analysis example that I criticize in the Quality Progress article “Under Scrutiny” … the bug example.

Here is a You-Tube training video about a common cause-and-effect technique – a Fishbone Diagram …

Here’s what Dilbert has to say about Fishbone Diagrams …

http://www.dilbert.com/strips/comic/1993-08-27/

Another technique commonly included as a cause-and-effect analysis tool is Fault Tree Analysis. Here is a presentation oriented toward engineers about Fault Tree Analysis …

Still another version of cause-and-effect mainly used as a design evaluation tool (rather than a root cause analysis tool) is Failure Modes and Effects Analysis (or FMEA). Here is a video about FMEA …

Once again, each example presented in the above references provides proof of why the technique should NOT be used for root cause analysis. All the examples show that the techniques display the analysis teams current knowledge. The technique does NOT get beyond what the team knows. If the team doesn’t know about human factors, they won’t solve human factors problems. And worse yet, the investigators don’t even know that they don’t know. And that’s a real problem when analyzing accidents by finding the accidents’ root causes.

THE ROOT CAUSE ANALYSIS SYSTEM YOU SHOULD BE USING

Back in 1985, I started looking for a way that people in the field could be taught to find the root causes of human error and equipment failure related incidents. Because of my human factors training, I often saw causes that others couldn’t see. I knew the answer wasn’t for me to do every investigation (the ultimate root cause guru) or to put everyone through the same training and experience that I had. Instead, the answer was to develop a system that would help people be able to troubleshoot, understand, and fix problems by leading them to root causes that they previously would have overlooked.

The work over the next six years eventually lead to the development of the TapRooT® Root Cause Analysis System. And that initial development work was just the start. We, with the help of tens of thousands of users, have continuously improved TapRooT® for over 20 years.

How does TapRooT® work? Here are two links that explain the workings of the TapRooT® Root Cause Analysis System:

http://www.taproot.com/products-services/about-taproot

http://www.taproot.com/archives/496

The first link includes a TV interview I did about root cause analysis. The second link is a white paper that describes how the TapRooT® Root Cause Analysis System works.

What’s the best way to learn to use TapRooT®? One of our courses – a 2-Day, 3-Day, or 5-Day.

For those that lead difficult investigations, I would recommend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

I hope this article helped you understand some of the techniques that are available and the limitations of the common or “simple” techniques.

Please be careful when you decide “How to find root causes.” Picking the wrong technique can lead to poor analysis and corrective actions that don’t solve the real root causes. That’s why we developed TapRooT® and recommend it … because we know you really need to find and fix the root causes of serious safety, quality, production, service, or maintenance issues.

Why Do People Have Problems Finding Root Causes? Read this Article – Under Scrutiny – from Quality Progress…

Posted: February 25th, 2013 in Performance Improvement, Quality, Root Cause Analysis Tips, Root Causes

Do you have problems finding the root causes of quality problems, safety incidents, or mechanical failures? It could be becuse of the root cause analysis tools you have chosen to use. Some tools have inherent weaknesses that are “built in.”

The article attached below (as first appeared in Quality Progress, the flagship magazine of the quality professional society ASQ), explains why some techniques commonly recommended for root cause analysis (like 5 Whys) will cause problems when applied by people in the field.

Under Scrutiny Only
(click the picture above to download the article)

Once you finished reading about the limitations of 5-Whys and Cause-and-Effect, sign up to learn about the advanced root cause analysis system that was intelligently designed to avoid those problems … TapRooT®.

CLICK HERE for more information about TapRooT® (including a TV interview of Mark Paradies about root cause analysis) and HERE for information about TapRooT® Root Cause Analysis Training.

Root Cause Analysis Tip: Categorization of Incidents

Posted: February 20th, 2013 in Performance Improvement, Root Cause Analysis Tips

Part of the TapRooT® Software is the ability to set up custom categorization fields for incident/accident reports.

Many companies categorize incidents as safety, quality, maintenance, production, environmental, …

The idea I’m going to share here is another way to categorize safety incidents.

In our Best Practices for Reducing Serious Injuries and Fatalities Using TapRooT® Course, we teach that there are three separate pyramids that make up the major accident pyramid – an auto safety pyramid, and industrial/occupational safety pyramid, and a process safety pyramid.

201302150925

In other words, instead of one pyramid like the one above (from Heinrich’s book, Industrial Accident Prevention, 3rd edition, 1950), there are actually at least three pyramids like the one above – one for auto accidents, one for industrial accidents, and one for process safety accidents.

Each of these separate pyramids are summed up in your “safety” data.

Why is this important? Because each of these pyramids are produced by different systems. When you add them up, you are summing unlike systems and “muddying” your data.

What do I mean by this? A trend in auto and industrial safety getting safer may mask a trend in process safety getting worse. This is especially true because the major accidents in process safety are so few and far between and the “minor injury” and “no-injury incident” equivalents in process safety may seem so minor.
In other words, you should not try to trend all three systems at once. You should trend each system – auto, industrial, and process – separately.

That’s why you need to keep track of these statistics separately by categorizing them separately under your safety data.

By the way, if BP had been doing this before the Texas City accident, they could have detected separate trends in their various systems that result in overall employee safety.

Does this make sense?

Ask questions and leave comments by clicking on the comments button below.

A Surefire Way to Keep Your Valentine’s Day Fun: Keep It Safe.

Posted: February 14th, 2013 in Medical/Healthcare, Performance Improvement, Root Cause Analysis Tips, Root Causes

The best way to keep your Valentine’s Day romantic and fun? Make food safety a priority!

A recent article on StateFoodSafety.com notes that the best restaurant to eat in on Valentine’s Day is a clean one. Here are a few of their food safety tips this Valentine’s Day:

  • Take note of the dining area and restrooms. If they do not meet cleanliness standards, it’s probably a good sign that the kitchen is also in need of more than just a light dusting. You might consider eating elsewhere for your own safety.
  • Only eat foods that are served to you hot. If the food is served to you at a lukewarm temperature, chances are that it was left sitting for too long and has allowed harmful bacteria to multiply.
  • Make sure the staff does not touch your food or the tips of your silverware with their bare hands. It’s probably not a good idea to let them sample your drink either.
  • Be wary of meat, eggs, oysters, or other raw foods that are undercooked.
  • Wash your hands properly before and after eating.

Click here to read the full article.

Photo courtesy of NPR.

What Do Repeat Incidents Mean?

Posted: January 30th, 2013 in Accidents, Root Cause Analysis Tips

The UK Rail Accident Investigation Branch Chief Inspector commented in their 2012  Annual Report that many of the rail accidents investigated are repeats of previous accidents. These included workers struck while working near the tracks, crossing accidents, and equipment failures.

These repeat failures aren’t surprising to me. I see repeat failures across many industries. In fact, repeat failures were the reason we started developing TapRooT®! We even included two specific causes for repeat failures in TapRooT®’s root causes – Corrective Actions Need Improvement and Corrective Actions Not Yet Implemented.

But what are the Generic Causes behind these two root causes? There are three common ones that I will mention here.

First, failure to perform adequate root cause analysis. Addressing symptoms rather than root causes leads to repeat incidents. Good root cause analysis should lead to effective corrective actions. Effective corrective actions should dramatic-ally reduce (or eliminate) incidents.

Second, Corrective action backlog. If you don’t implement corrective actions, they can’t work. Some management teams don’t place much emphasis on corrective action implementation. Thus, incidents that should have been prevented instead are repeated!

The third problem is ineffective corrective actions. Even if a problem’s root cause(s) is identified, an investigator or management could assign weak or ineffective corrective actions. That’s why SI developed the Corrective Action Helper® Module – to make corrective actions more effective for every type of root cause on the Root Cause Tree®. Also, in TapRooT® Training we teach using the most effective safeguards and defense in depth when developing corrective actions.

Your root cause analysis and corrective action programs should show their effectiveness by producing a dramatic decline in incidents. If they don’t, the programs need improvement. Where can you learn to improve them? At a TapRooT® 5-Day Course or at the TapRooT® Global Summit. Get more info today!

Root Cause Analysis Tip: 3 Seconds Can Kill You…

Posted: January 23rd, 2013 in Career Development Tips, Root Cause Analysis Tips

A recent study shows that even a three-second distraction can cause a colossal mistake in your work.

An experiment was done in which participants were asked to perform tasks, with or without interruptions. It only took a 2.8-second interruption to cause participants to make a mistake. This is because “the participants had to shift their attention from one task to another. Even momentary interruptions can seem jarring when they occur during a process that takes considerable thought,” says lead researcher Erik Altman.

“What this means is that our health and safety is, on some level, contingent on whether the people looking after it have been interrupted,” Altman said. ” … ensuing errors can be disastrous for professionals such as airplane mechanics and emergency room doctors.”

If you know TapRooT®, you already know how detrimental distractions can be. It comes down to the root cause “Human Engineering”. Make your work environment the safest you possibly can by turning off your cell phone and focusing of the task at hand. Take breaks when necessary and make sure you’re well rested and can complete your job in a safe manner.

If your job is to respond to crises, then by all means keep your cell phone on, but evaluate your unnecessary distractions and see if you can eliminate any.

Don’t have a high risk job? This also applies to your desk job. Turn off your cell phone and e-mail for the period of time when you really need to focus and get a certain task performed perfectly. Then check them at a designated time.

(Image from The Houston Chronicle)

Free Report: What’s Fundamentally Wrong with the 5 Whys?

Posted: January 3rd, 2013 in Investigations, Root Cause Analysis Tips, Root Causes, TapRooT

Are you settling for a “good enough” root cause analysis tool?

Click on the red report cover on the right, “What’s Fundamentally Wrong with
5 Whys.”  (Clicking the report cover will redirect you to Google Docs where you may view the report in your browser or download the .pdf.)

 

TapRooT® Holiday Safety Tips Part II

Posted: December 17th, 2012 in Current Events, Human Performance, Pictures, Root Cause Analysis Tips, Video

Last week we shared some quick tips and staggering stats on Fall Safety and Electrical Safety during the holiday season. Here are a few tips from The Electrical Safety Foundation International to keep you and your children safe when displaying your decorations.

Fire Safety

  1. Make sure your Christmas tree is fresh, and keep it hydrated by refilling the stand. It will pose less of a fire hazard this way.
  2. With artificial trees, look for a fire resistant one.
  3. Don’t use electrical ornaments or lights on trees with metallic leaves or tinsel in them.
  4. Place your tree at least 3 feet away form heat sources, including fireplaces, radiators, and heaters.
  5. 45% of home décor fires start with candles.
  6. An average of 260 homes fires begin with Christmas trees each year, resulting in 12 deaths, 24 injuries, and $16.4 million in damage.

Check out this Fire safety video comparing the flammability of a poorly watered tree and properly watered tree: Click Here

Child Safety

  1. Keep children supervised around candles and electrical lights.
  2. Never allow them to use garlands, tree lights, and cords as playthings – they pose a strangulation hazard.
  3. All small, fragile ornaments and decorations should be placed out of children’s reach, as children may break them and get hurt, or simply put them in their mouth.
  4. Cover all unused outlet with electrical tape or plastic covers.

Happy Holidays and stay safe, from all of us at TapRooT®!

Photo 1 2

Click here to read Part 1!

TapRooT® Holiday Safety Tips Part I

Posted: December 12th, 2012 in Current Events, Pictures, Root Cause Analysis Tips, TapRooT

Last year we shared the following holiday safety tips with you. Many of you found them useful, so here they are again for your enjoyment. Stay safe this holiday season!

As you string your lights up and dust off those plastic trees, keep these tips in mind from the Electrical Safety Foundation International.

Electrical Safety

  1. Inspect your strands of lights and extension cords for damage.
  2. Attach them securely, but never nail or staple them.
  3. Extinguish all candles and unplug all lights when you leave a room or go to bed.
  4. Never use a hot extension cord.
  5. Consider battery-operated candles.
  6. Always purchase electronics from a reputable retailer.
  7. Always inspect cords for damage before plugging them in.
  8. Avoid overloading electrical outlets.
  9. Never connect more than three strands of lights together.
  10. Always unplug lights before changing a bulb.
  11. Consider LED lights, they use less energy and run cooler.
  12. Insert plugs all the way into the wall.
  13. Don’t run cords through walls or ceilings.
  14. Extension cords are only for temporary use. Make sure they are rated for the proper use, indoor or outdoor.
  15. Christmas tree and holiday décor fires result in twice the injuries and five times for fatalities per fire than the average winter holiday fire.

Fall Safety

  1. 5,800 people per year are treated in emergency rooms for falls associated with holiday decorations. Over half are ladder or roof falls.
  2. Inspect ladders for missing screws, hinges, bolts, and nuts.
  3. Use wooden or fiberglass ladders, as metal ladders conduct electricity.
  4. Use the right ladder height, ensuring that your ladder extends at least three feet past the edge of the roof.
  5. Be sure to tape extension cords down, or refrain from placing them in places where someone could trip on them.
  6. Over 4,000 injuries per year are associated with extension cords. Half of these are due to tripping over an extension cord.

Tune in next week for Child Safety and Fire Safety tips for the holidays.

Photo 1 2

Root Cause Analysis Tip – Joplin Tornado Lessons Learned Part 3

Posted: December 5th, 2012 in Best Practice Presentations, Root Cause Analysis Tips, Summit, Video

As you prepare for the 2013 Global TapRooT® Summit, enjoy this session from last year’s Summit in Las Vegas.

Ed Skompski, Sue Sinclair, Dennis Manley, and Tommy Garnett share the heart-wrenching experience of a natural disaster and what they learned in responding to the devastating tornado in Joplin, Missouri in 2011.

This 20-minute video is Part 3 of 3.
View Part 1 here. Part 2 here.

(Can’t see the video? Refresh your page.)

Are you interested in attending our 2013 Global TapRooT® Summit?

Click here for more information.

Root Cause Analysis Tip – Joplin Tornado Lessons Learned Part 2

Posted: November 28th, 2012 in Best Practice Presentations, Root Cause Analysis Tips, Summit, Video

As you prepare for the 2013 Global TapRooT® Summit, enjoy this session from last year’s Summit in Las Vegas.

Ed Skompski, Sue Sinclair, Dennis Manley, and Tommy Garnett share the heart-wrenching experience of a natural disaster and what they learned in responding to the devastating tornado in Joplin, Missouri in 2011.

This 20-minute video is Part 2 of 3.
View Part 1 here.

(Can’t see the video? Refresh your page.)

Are you interested in attending our 2013 Global TapRooT® Summit?

Click here for more information.

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
Dir. of IT & Software Development
Dave JanneyDave Janney
Workplace Safety & Quality
Ed SkompskiEd Skompski
Software and Medical Issues
Ken ReedKen Reed
Equipment and Equifactor®
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
TapRooT® Media Specialist
Steve RaycraftSteve Raycraft
Technical Support Specialist

Success Stories

The healthcare industry has recognized that improved root cause analysis of quality incidents…

Good Samaritan Hospital

In 2002, we decided that to reduce accidents, prevent…

Greater Cleveland Regional Transit Authority
Contact Us