News

Root Cause Analysis Tip: TapRooT® is more than a Root Cause Analysis Tool – TapRooT® is Your Performance Improvement Partner!

Posted: April 16th, 2014 in Root Cause Analysis Tips, TapRooT, Video

If you are reading this you probably already know about TapRooT® as a root cause analysis system. If you don’t, watch this:

 

But we want to do more for our clients than helping them fix problems once and for all. We want to help them get a great return on investment from their improvement efforts.

Therefore, we don’t stop by just making TapRooT® the best root cause analysis system that we can invent. We continuously try to find new ideas, new methods, new ways for our clients to be more effective and efficient in their improvement efforts. And we also try to keep them passionate about their improvement efforts so their work can be sustained through the difficulties that people encounter when they try to may positive change occur.

But how do we get this information to the people who need it? Those out their on the factory floor, the oil rig, or even in the corporate boardroom? By several methods.

BLOG

First, we publish most of what we learn on the Root Cause Analysis Blog.

From these root cause analysis tips, to recent news about accidents, to articles about career development, to course pictures, to Summit information, to TapRooT® software update information, to job openings for TapRooT® users, to our Friday jokes (yes, you can have a sense of humor about improvement), we try to make what we write interesting, short, and to the point so that we communicate things that you may need to know without wasting a bunch of your time.

e-NEWSLETTER

Because many folks don’t have the time to jump on-line and read the blog every day, we take the information shared on the blog and condense it into a weekly newsletter. We are still experimenting to find the best format for this information to make it readable (or maybe “scannable” is a better word) so that you can pick out what is important to you and learn quickly. 

I know that everyone is busy but I think improvement information is important so that I hope you take the few minutes required to skim the weekly e-mail to see if there is anything important that you need to read and, if you can’t get to it right then, that you print it out for your professional reading stack.

SUMMIT

The main way we get the bulk of the details about new improvement ideas out to TapRooT® Users is the annual Global TapRooT® Summit. If you were at the 2014 Summit, you know the value of the best practice sharing and advanced improvement knowledge that goes on at the Summit. You also know that we have excellent keynote speakers to pass along great information and keep you motivated to make improvement happen. To find out more about the Summit, see the Summit web site:

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

We like to think of ourselves as you performance improvement partners. And now you know how we try to get the latest information to you to help you develop the most effective performance improvement program possible.  

Root Cause Analysis Tip: Targeting Investigations

Posted: April 2nd, 2014 in Root Cause Analysis Tips

 

 

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A client complained, “I just can’t get everything investigated using TapRooT®.” I asked, “What are you investigating?”

The answer?

“Everything.”

They were investigating lost-time injuries, medical treatment cases, reportables, near-misses, equipment failures, quality issues, issues management was interested in, the list went on and on …

Don’t get me wrong, I think you can learn valuable information from investigations of small problems. But you have to have a limit. They needed to target their investigations on their highest priority improvements. They need to answer the question: “What are the most important things to improve?”

For example, if your objective is to prevent fatalities, you certainly would investigate fatalities. But you would also investigate incidents with the potential for fatalities. They could be medical treatment cases, near misses, equipment failures, or even serious rule violations. But you would NOT investigate problems that could not produce a fatality … even if it might be a lost-day or medical treatment case. That’s focus!

When resources are scarce, you must focus on your most important improvement opportunities. Once fatalities have been eliminated you can target your efforts on the next issue.

This focus helps you manage your improvement initiative to fit your resources. What if you don’t have enough resources for your most important improvement initiative? Then you have justification to ask for additional resources for the high priority objective.

Don’t be overwhelmed. There are only 24 hours in a day. Target your investigations.

 

Root Cause Analysis Tip: Why do supervisors perform BAD root cause analysis?

Posted: March 26th, 2014 in Investigations, Performance Improvement, Root Cause Analysis Tips, TapRooT

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I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…

BLAME GAME

Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.

Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!

NO TIME/TRAINING

Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.

What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.

As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.

NO REWARDS

The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.

Learn more about TapRooT® Training at: http://www.taproot.com/courses

Root Cause Analysis Tip: Performance Tells You If Your Root Cause Analysis is Adequate

Posted: March 18th, 2014 in Root Cause Analysis Tips, Summit

At a meeting people were benchmarking their root cause analysis efforts. Several declared their root cause analysis systems adequate because they “thought” the reports found root causes. 

That got me thinking? “How did they know?”

They hadn’t performed a separate investigation. They only reviewed what was presented. And most of the time the people were reviewing the results of a 5-Why investigation (notoriously inconsistent).

So I asked myself how I would judge the adequacy of a root cause analysis. My answer seemed simple: RESULTS! If a company’s root cause analysis efforts are adequate, they won’t have repeat fatalities. They won’t have repeat near-misses of fatalities or serious injuries. They won’t have repeat quality issues. They won’t have to perform corrective maintenance for the same serious mechanical failure. If they are a hospital, they won’t have repeat sentinel events or near-misses of sentinel events.

If they have adequate root cause analysis, problems will be solved once and for all. If they have repeat problems, there is something wrong with their root cause analysis and/or corrective actions.

And since most incidents are repeat incidents at most facilities, the investigation is not only missing the root cause of the incident, but also, the root cause of why previous incidents failed to solve the problem.

But here’s the real answer … We all probably need to improve our root cause analysis and corrective action systems!

Even if we get good (adequate) results, we may be able to get BETTER RESULTS MORE EFFICIENTLY.

Where can you get ideas to improve your root cause analysis system and your corrective action program? At the 2014 Global TapRooT® Summit coming up on April 7-11. Don’t miss this chance to make your root cause analysis system produce results that are even better than adequate. See:

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

News & Current Events: In the Wake of Fukushima, The Natural Resources Defense Council’s Newest Report Condemns the NRC’s Hydrogen Generation Safety

Posted: March 12th, 2014 in Current Events, Root Cause Analysis Tips, Root Causes

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From the Natural Resources Defense Council’s Report Preventing Hydrogen Explosions In Severe Nuclear Accidents: Unresolved Safety Issues Involving Hydrogen Generation And Mitigation

“The Nuclear Regulatory Commission is failing to meet the statutory standard of “adequate protection” of the public against the hazard of hydrogen explosions in a severe reactor accident.

After Fukushima Daiichi’s three devastating hydrogen explosions, the NRC decided to relegate investigating severe accident hydrogen safety issues to the lowest-priority and least proactive stage of its post–Fukushima Daiichi accident response.

NRDC believes that the NRC should reconsider its approach and promptly address severe accident safety issues involving hydrogen.”

Click this link to read the full report: http://www.nrdc.org/nuclear/hydrogen-generation-safety.asp

A short synopsis of the findings:

NRDC Report: U.S. Nuclear Safety Regulators Ignore Severe Accident Hydrogen Explosion Risks Despite Fukushima Tragedy

http://www.enewspf.com/opinion/analysis/50805-nrdc-report-u-s-nuclear-safety-regulators-ignore-severe-accident-hydrogen-explosion-risks-despite-fukushima-tragedy.html

An in-depth interpretation of the findings:

US Nuclear Safety Regulators Continue to Ignore Lessons of Fukushima for Severe Accident Hydrogen Explosion Risk at US Reactors

http://switchboard.nrdc.org/blogs/cpaine/us_nuclear_safety_regulators_c.html

What do you think? Share your opinion in the comments.

Fukushima Photo courtesy of: http://www.globalresearch.ca/articlePictures/fukushimafire.bmp

Root Cause Analysis Tip: Improve Your Incident Investigations and Root Cause Analysis

Posted: February 27th, 2014 in Performance Improvement, Root Cause Analysis Tips, Summit

If you are a TapRooT® User, you are already have improved your root cause analysis and incident investigation just by attending TapRooT® Training. But what can you do to get even better? To improve beyond your initial TapRooT® Training? To make your company’s incident investigations and root cause analysis world-class?

ATTEND THE 2014 GLOBAL TapRooT® SUMMIT!

 And choose the Incident Investigation & Root Cause Analysis Best Practices Track. What’s in the track?

 

  • Advanced Causal Factor Development (Ken Turnbull)
  • Interviewing: De-Coding Non-Verbal Behavior (Barb Phillips)
  • Getting Your Root Cause Analysis PhD (Mark Paradies)
  • Expert Facilitation of Investigations Using the TapRooT® Software (Brian Tink)
  • Infamous Accident (Alan Smith, Alan Scot, & Harry Thorburn)
  • Measure Your RC System: The Good, The Bad, and The Ugly (Ralph Blessing & Brian Dolin)
  • Slips, Trips, & Falls: The Science Behind Walking (Robert Shaw)
  • The Business End of Equipment Reliability (Heinz Bloch)

 Plus you will hear great keynote speakers to give you practical improvement ideas and get you motivated to make change happen.

 

  • Christine Cashen – Why Briansorm When You Can Brain El Niño?
  • Carl Dixon – A Strange Way to Live
  • Mark Paradies – World Class Performance Improvement
  • Edward Foulke – Sweeping Workplace Safety Changes
  • Rocky Bleier – Be the Best You Can Be

 There’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility. And we know that you learn more when you are having fun so this won’t be a stuffy technical meeting that puts you to sleep. You will be involved and motivated.

Want to get even more out of your Summit experience? Then attend of the advanced pre-Summit Courses. I would recommend one of these if you are interested in making your TapRooT® implementation even better:

 

And you don’t have to worry that you will waste your time at the TapRooT®∞ Summit. We GUARANTEE your experience.

Attend the Summit and go back to work and use what you’ve learned.
If you don’t get at least 10 times the return on your investment,
simply return the Summit materials and we’ll refund the entire Summit fee.

With a guarantee like this one, you have nothing to lose and everything to gain!

Don’t procrastinate! Register today and be one step closer to the world-class incident investigation  and root cause analysis process that you know your company needs.

Root Cause Analysis Tip: Six Ways to Improve Root Cause Analysis/Incident Investigation Efficiency

Posted: December 5th, 2013 in Pictures, Root Cause Analysis Tips, TapRooT

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Have you read your 2008 TapRooT® Book from cover to cover? If you do, you will find there are many topics that can help you improve investigation efficiency. Appendix C specifically calls out these six:

1) A well thought out strategy

2) The use of technology

3) Management understanding

4) Preparation

5) Help from people in the field

6) Proper use of a SnapCharT®

Each of these is explained in detail in pages 466 – 471 of the book. If you are interested, crack open your book and get reading! You’ll find there is lots more to learn and use!

If you don’t already have your own copy, get some ideas about what’s in the TapRooT® Book by reviewing the table of contents at:

www.taproot.com/archives/2837

Order the TapRooT® Book at:

www.taproot.com/store/Books/

But don’t procrastinate! There’s important information in the book that can help you save lives, time, and money.

Root Cause Analysis Tip: Why Do Root Cause Analysis?

Posted: November 14th, 2013 in Performance Improvement, Pictures, Root Cause Analysis Tips, Video

© Copyright 2013 By System Improvements Inc. Used by Permission.

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WHAT IS YOUR PURPOSE?

Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.

For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.

Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.

The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.

This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…

WAITING FOR BIG ACCIDENTS

Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?

I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:

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Near-Misses Not Reported

If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.

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Hazards Not Recognized

Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).

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Shortcuts Become a Way of Life (standards not enforced)

This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.

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Process Safety Not Understood

We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.

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Ineffective Root Cause Analysis

If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.

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Inadequate Corrective Actions

I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?

Corrective Actions Not Implemented

Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.

Trends Not Identified

If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.

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INVESTIGATING PAPER CUTS

Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.

Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.

WHAT SHOULD YOU DO?

You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.

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An ounce of prevention is worth a pound of cure.”
Benjamin Franklin

Monday Accident & Lessons Learned: Mining Equipment Accidents

Posted: November 11th, 2013 in Accidents, Root Cause Analysis Tips

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What were the safeguards that were in place and failed that allowed this accident to happen?

Leave your ideas as comments.

Note that failed safeguards are usually causal factors on your SnapCharT®.

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Could you have fixed the broken safeguards or added additional safeguards before this accident happened?

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 5

Posted: November 7th, 2013 in Root Cause Analysis Tips, Summit, Video

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 5, Carl shares the mantra he learned during his recovery: “No fear, no weakness.” He learned many more life lessons, and shares one last song with us in this final installment of Carl Dixon’s inspiring story.

Click here to view Part 1.

Click here to view Part 2.

Click here to view Part 3.

Click here to view Part 4.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis Tip: How Can You Get Help With a Difficult Investigation?

Posted: October 31st, 2013 in Investigations, Root Cause Analysis Tips

What do you do when you are faced with a difficult investigation (root cause analysis)?

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The first place to start is your TapRooT® Book!

Review Chapter 4. You will find information that will help you with difficult investigations.

After that, what’s next?

If your company has a world-class implementation of TapRooT®, you will have investigation coaches that can help you with difficult investigations. These coaches have attended the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, have experience with difficult investigations, and probably have attended several of the Global TapRooT® Summits.

What if your company doesn’t have coaches or they aren’t available?

Call us! call 865-539-2139 and ask to speak to one of our TapRooT® Instructors. They may be able to coach you over the phone.

If more extensive help is needed, they can help you get a facilitation agreement in place an provide an on-site facilitator from our many experienced instructors.

Don’t stumble along with questions unanswered. Start with the book and work your way down the list to find help when you need it!

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 4

Posted: October 31st, 2013 in Root Cause Analysis Tips, Summit, Video

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 4, Carl shares about his painful time in the hospital and seeing his wife jump into action to do everything she could for him to recover from his accident. Make sure you watch until the minute 3:00 – he sings a powerful song about this time in his life.

We’ll share his talk with you in a series of installments over the next couple of weeks.
Come back next week for Part 5!

Click here to view Part 1.

Click here to view Part 2.

Click here to view Part 3.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis Tip: What’s The Incident – What’s the Causal Factor?

Posted: October 24th, 2013 in Accidents, Current Events, Root Cause Analysis Tips, Video

CLICK HERE for an article about a fish kill near Honolulu.

It seems that there was a 1,400 ton leak from a molasses pipeline from loading molasses tankers.

The sugary “pollutant” killed thousands of fish.

The dead fish, now being cleaned up by the Hawaii Department of Health, attract sharks, eels, and barracuda (the natural cleanup crew).

Because of the increased risk in shark attacks to surfers, swimmers, and snorkelers, beaches have been posted with an advisory to stay out of the water.

So, up to this point, what is the incident? (The incident in the statement in your circle on your SanpCharT®.)

Leave your answer as a comment here.

But next, if someone ignored the warnings, and entered the water, and was bitten by a shark, would that change the incident? Or would it be a completely separate incident?

Leave your answer in the comments.

Finally, can you already see any causal factors that you should explore as an investigator?

Leave your answer here in the comments.

By the way, is this video a potential corrective action?

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 3

Posted: October 24th, 2013 in Root Cause Analysis Tips, Summit, Video

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us.

In Part 3, we learn how Carl Dixon became a part of The Guess Who & April Wine.

We’ll share his talk with you in a series of installments over the next couple of weeks.
Come back next week for Part 4!

Click here to view Part 1.

Click here to view Part 2.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis & Career Development Tip: How to Improve Investigation Efficiency

Posted: October 17th, 2013 in Career Development, Career Development Tips, Root Cause Analysis Tips

It’s frustrating to invest months completing a major investigation only to have it sent back to you for modification because management did not agree on the purpose and scope of the investigation. There is a way to avoid this that takes a little time upfront, but it’s well worth it when all of your efforts are appreciated and approved in the end.

Here are two important tips that will help avoid misunderstanding with management:

1. On major investigations, the investigator (or team) should provide management with frequent updates to keep them in the loop of the progress and potential findings.

2. If the team intends to make recommendations for corrective actions, they should be reviewed in advance with key managers whose departments will be affected. (For example, if a department will have to change the way they do something, or have to supply resources to implement the corrective actions, include them in the loop.)

Management understanding is just one of the tips highlighted in the 2008 TapRooT® Book. If you received a book in TapRooT® Training and skipped over Appendix C, you missed some other ideas that will make your job easier. If you don’t have a book you can learn more about what’s in it here:

www.taproot.com/archives/2837

Doing an investigation once with everyone on the same page saves time — a little extra effort toward management understanding can help you attain your goal and take a step forward in your career development.

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 2

Posted: October 17th, 2013 in Root Cause Analysis Tips, Summit, Video

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us. One of the best pieces of wisdom he shares in Part 2 is “The lessons you learn the hard way last the longest.” Learn the story behind Carl Dixon’s wise words by watching the video below!

We’ll share his talk with you in a series of installments over the next couple of weeks. Come back next week for Part 3!

Click here to view Part 1.

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Carl Dixon Shares Life Lessons at the Global TapRooT® Summit – Part 1

Posted: October 10th, 2013 in Root Cause Analysis Tips, Summit, Video

Carl Dixon, Canadian rock star of The Guess Who, spoke at our 2013 Global TapRooT® Summit. After his devastating car accident, he learned some inspiring life lessons and shared them with us. Don’t worry, he didn’t forget to share a song or two with us as well. (Make sure you watch until 9:37 to see his performance.)

We’ll share his talk with you in a series of installments over the next couple of weeks. Come back next week for Part 2!

Carl Dixon will be speaking at our 2014 Global TapRooT® Summit as well! Learn more about our Summit by clicking here.

Root Cause Analysis Tip: ENERGY – SAFEGUARD – TARGET

Posted: October 10th, 2013 in Human Performance, Performance Improvement, Pictures, Root Cause Analysis Tips

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What’s that in the distance hanging from a tree?

If you answered a hornet’s nest, you are correct!

It’s the first one I’ve ever seen in person in the wild (with real, live hornets buzzing in and out).

What does this have to do with root cause analysis?

Practice the skills you learn in a TapRooT® class by analyzing everyday situations. In this example, let’s look at Energy – Safeguard – Target.

What is the ENERGY?

I guess I would call it a biological source of Energy – HORNETS!

What is the TARGET?

Anything that disturbs the nest. It could have been me if I moved any closer.

What are the SAFEGUARDS that protected me from the hornets?

In this case, the only safeguard was my own awareness when walking through the woods.

That’s a pretty weak human performance safeguard. But this time it worked!

Should I have removed the hazard? No way! That’s much more risk that just leaving the area and remembering where the nest is.

How many “awareness” safeguards do you depend on at work? Is that really good enough? Should you be removing the hazards?

That’s your root cause analysis tip to think about for today!

Want to learn more about TapRooT®, advanced root cause analysis, and Energy – Safeguard – Target Analysis (we call it Safeguard Analysis)? Then attend a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. See the upcoming worldwide public course schedule at:

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

Root Cause Analysis Tip: Extent of Cause … Extent of Condition

Posted: October 3rd, 2013 in Accidents, Investigations, Root Cause Analysis Tips

In the nuclear industry, the terms “extent of cause” and “extent of condition” are often used and misused.

But the theory of extent of cause and extent of condition go far beyond the nuclear industry and are the reason for writing this root cause analysis tip … everyone needs to understand and apply the theory of extent of cause and extent of condition in their root cause analysis efforts.

Therefore, I will define each of the “extents” and then provide an example from the wind turbine industry.

First, let’s look at extent of condition. Extent of condition evaluations are usually done soon after an accident to decide if additional immediate actions are needed to address the risk of additional failures while a root cause analysis is being conducted.

My definition of extent of condition is:

The presence of similar conditions (Causal Factors in TapRooT® terminology) across the organization.

Usually, extent of condition looks for similar equipment related conditions. For example, if a bearing fails, are similar bearings used in similar circumstances or equipment that could also fail?

Extent of condition can also be applied to human error related Causal Factors. For example, if a valve is opened accidentally, are there similar valves that might be opened accidentally?

The trick to performing an extent of condition evaluation is to decide how “similar” the condition/Causal Factor has to be. For example, on the equipment side, does the bearing have to be the identical type in exactly the same service? Evaluating this “sameness” will be a matter of engineering judgment and the risk presented by additional failures before a complete root cause analysis and corrective actions are completed.

Second, let’s look at extent of cause. Extent of cause is usually performed after the specific root causes are identified for a set of Causal Factors that led to an incident/accident. The extent of cause is used to decide if a specific root cause needs to be analyzed to find the Generic Causes behind the specific root causes. This can lead to more extensive corrective actions.

My definition for extent of cause is:

The presence of similar specific root causes in other similar situations across the site/organization.

Once again, the part of this evaluation that requires judgment is … “How similar is similar?”

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Let’s look at a real example from the wind turbine industry to help illustrate these definitions and their use. This example is outlined in a story in Wind Power Monthly at this link:

http://www.windpowermonthly.com/article/1191977/analysis—siemens-acts-fix-bonding-issue-behind-blade-breaks

In this example, a turbine blade failed in service. Before the root cause analysis was finished, another turbine blade of the exact type (B53) failed under very similar circumstances.

The obvious question at this point is … how extensive is the application of the B53 blade? It was found that 700 wind turbines (mostly in the US) used that blade. The manufacturer then asked users to curtail use of the affected turbines. That’s an extent of condition temporary corrective action.

The “extent of condition” in this case was limited to just the B53 blade because two of those blades had failed. However, one might ask if the manufacturer should have looked at other blades as well. Could the problem (adhesive bond failure at the attachment point for the blade) have affected other types of blades?

This example demonstrates the judgment that must be used when deciding how far is far enough when performing an extent of condition evaluation. At first, no extent of cause was considered. But when the second blade broke, an extent of cause temporary corrective action (not using turbines with this type of blade) was implemented. Perhaps if a blade of a different type had failed due to a similar condition, the temporary corrective action might have been expanded to all blades using similar technologies (perhaps beyond the B53 type).

The risk of failure (a blade falling off) was real (injury of someone being struck or property damage) but was decided to be fairly limited. Perhaps in some other industry (for example, the nuclear industry), the sensitivity to regulatory and press reaction would lead to an immediate extent of cause evaluation and an even more extensive temporary corrective action. It is all in the judgment of the evaluator and management team and their risk tolerance.

The root cause analysis of the two failures showed manufacturing problems with that particular blade type. This made the extent of cause analysis fairly easy to perform in that the manufacturing process for this type blade was fairly unique. Thus, the corrective actions included inspections of B53 blades and repairs to any found to be delaminating because of the specific causes that had been identified.

Also, the generic corrective actions included addition safeguards in the manufacturing process to prevent future failures and an additional safeguard for current and future blades of this type to ensure the elimination of future failures. This demonstrates how extent of cause can be used to help develop corrective actions for Generic Causes.

Would you like to learn more about root cause analysis and preventing failures? Then attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training to learn the TapRooT® method for identifying and correcting root and generic causes. See this link for upcoming course dates around the world:

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

Or contact us by CLICKING HERE to schedule training at your site.

Root Cause Analysis Tip: What Can You Learn from Deepwater Horizon & Texas City Disasters? 2013 Global TapRooT® Summit Session – Part 4

Posted: September 26th, 2013 in Accidents, Root Cause Analysis Tips, Summit, Video

What lessons can you learn from someone else’s mistakes? Find out in this video from the 2013 Global TapRooT® Summit.

At the Summit, TapRooT® co-creator Mark Paradies shared his insights on the Deepwater Horizon and Texas City disasters.

Did you miss the previous weeks of this series? View them at the folowing links:
Click here to view Part 1.
Click here for Part 2.
Click here for Part 3.

Want to learn from more accidents like the Titanic and Piper Alpha? Join us at the 2014 Global TapRooT® Summit! Make sure you sign up for the “Infamous Accidents” session.
Click here to learn more about our Summit.

Root Cause Analysis Tip: What Can You Learn from Deepwater Horizon & Texas City Disasters? 2013 Global TapRooT® Summit Session – Part 3

Posted: September 19th, 2013 in Accidents, Root Cause Analysis Tips, Summit, Video

What lessons can you learn from someone else’s mistakes? Find out in this video from the 2013 Global TapRooT® Summit.

At the Summit, TapRooT® co-creator Mark Paradies shared his insights on the Deepwater Horizon and Texas City disasters.

Eagerly anticipating more Deepwater Horizon & Texas City lessons learned? Join us next week for Part 4.
Click here to view Part 1.
Click here for Part 2.

Want to learn from more accidents like the Titanic and Piper Alpha? Join us at the 2014 Global TapRooT® Summit! Make sure you sign up for the “Infamous Accidents” session.
Click here to learn more about our Summit.

Root Cause Analysis Tip: What Can You Learn from Deepwater Horizon & Texas City Disasters? 2013 Global TapRooT® Summit Session – Part 2

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

What lessons can you learn from someone else’s mistakes? Find out in this video from the 2013 Global TapRooT® Summit.

At the Summit, TapRooT® co-creator Mark Paradies shared his insights on the Deepwater Horizon and Texas City disasters.

If you didn’t catch that last sentence, Mark says “At the time, it wasn’t wrong by any standard that existed.”

Eagerly anticipating more Deepwater Horizon & Texas City lessons learned? Join us next week for Part 3.
Click here to view Part 1.

Want to learn from more accidents like the Titanic and Piper Alpha? Join us at the 2014 Global TapRooT® Summit! Make sure you sign up for the “Infamous Accidents” session.
Click here to learn more about our Summit.

Root Cause Analysis Tip: What Can You Learn from Deepwater Horizon & Texas City Disasters? 2013 Global TapRooT® Summit Session – Part 1

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

What lessons can you learn from someone else’s mistakes? Find out in this video from the 2013 Global TapRooT® Summit.

At the Summit, TapRooT® co-creator Mark Paradies shared his insights on the Deepwater Horizon and Texas City disasters.

Eagerly anticipating more Deepwater Horizon & Texas City lessons learned? Join us next week for Part 2.

Want to learn from more accidents like the Titanic and Piper Alpha? Join us at the 2014 Global TapRooT® Summit! Make sure you sign up for the “Infamous Accidents” session.
Click here to learn more about our Summit.

Root Cause Analysis Tip: Accident Investigations in the Age of Twitter

Posted: August 29th, 2013 in Current Events, Investigations, Root Cause Analysis Tips

Will social media change accident investigation?

That’s the topic  of a recent The Wall Street Journal article titled: “Friction Escalates In Air Crash Probe.”

It seems that NTSB Board Members are tweeting statements about accidents. Someytimes they haven’t even alerted the on-scene investigations. The article says this rush to distribute “facts” has cause the FAA and industry groups to speed up their internal investigations and responses.

Another game changer … Passenger cell phone videos! These get distributed on the news and the investigators get them later.

Is your incident investigation process up to the rigors of a twitter raised generation that expect instant facts?

Have you thought about what you should do to coordinate press releases, twitter comments of executives, and the need to be accurate when releasing accident information?

You have to prepare for accidents investigations before the accident happens or you will be overwhelmed by events.

Root Cause Analysis Tip: Accident/Incident Investigation Training – What Do We Need?

Posted: August 22nd, 2013 in Root Cause Analysis Tips, TapRooT

Accident Investigation Training – Incident Investigation Training – Root Cause Analysis Training … They are all related and people often ask my opinion … “What accident investigation (incident or root cause) training should we be doing at our facility?”

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When we wrote the TapRooT® Book (published in 2008), we knew people would have that question. That why we included a whole section in Chapter 6 (the implementation chapter) on recommended training and a training matrix:

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Each of the titles in the left column are described as well as the reasoning for that level of training.

Some interesting titles to review here are Management, the Improvement Team Leader, and Facilitators.

MANAGEMENT

The first training recommendation to review is management. Some might ask, “Why does management need training.”
My answer? because they are the customer – the user – of what comes from the root cause analysis process. Advanced root cause analysis (TapRooT®) should be an essential part of their management system – a management tool that they rely upon. And because this is an essential management tool, they need to understand their role in applying root cause analysis, how root cause analysis fits into their improvement strategy, and what people in the field need to succeed in their root cause analysis efforts.

The training matrix says that managers should take the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course. But the book explains this in more detail.

First, I would prefer that senior managers take the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as part of their management development career training. A major oil company had all their senior project managers (those managing multi-million dollar projects) attend the 5-Day Training and every manager I trained was impressed with the usable information they learned that they could apply a senior managers. These were things that they previously had not learned in their management careers.

However, getting senior managers to sit down for five days of training is next to impossible (even if the training is needed). In this case it took the President of the big oil company requiring his project managers to have the training or they could not receive their annual bonuses. (He really knew how to get their attention.)

Why would a big oil company President require the training? because he was tired of hearing excuses for fatalities. He knew these senior managers had to understand what was causing fatal accidents or they would never be successful in preventing them. And he knew that TapRooT® was the explanation for the causes of the fatal accidents. Thus TapRooT® Training became the requirement.

For those who don’t have the company president’s support for management training, I would suggest a custom course focussed on the basics of TapRooT® and what management needs to to to make sure their improvement program effectively applies root cause analysis. That’s the minimum needed for management root cause analysis training.

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IMPROVEMENT TEAM LEADERS & FACILITATORS

Improvement Team Leaders and Facilitators have the same basic training requirements – the 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course. Those who will also be investigating equipment issues should take the additional day of Equifactor® Training (that can be customized into an on-site 5-Day Course).

To continually improve their skills and keep up with the latest in performance improvement technology, we also recommend attending the Global TapRooT® Summit and a pre-Summit advanced course every year.

Two additional courses that Improvement Team Leaders should take are the Advanced Trending Techniques and the Getting the Most from Your TapRooT® Software courses. Trending and using the TapRooT® software are integral parts of any improvement team leader’s job so these courses are a must for them.

Have any questions about these training recommendations? We would be happy to discuss our recommendations with you. just give us a call at 865-539-2139. Or drop us a note by CLICKING HERE.

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