Category: Root Cause Analysis Tips

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Stop Assumptions in Their Tracks!

February 13th, 2018 by

Assumptions can cause investigators to reach unproven conclusions.

But investigators often make assumptions without even knowing that they were assuming.

So how do you stop assumptions in their tracks?

When you are drawing your SnapCharT®, you need to ask yourself …

How do I know that?

If you have two ways to verify an Event or a Condition, you probably have a FACT.

But if you have no ways to prove something … you have an assumption.

What if you only have one source of information? You have to evaluate the quality of the source.

What if one eye witness told you the information? Probably you should still consider it an assumption. Can you find physical evidence that provides a second source?

What if you just have one piece of physical evidence? You need to ask how certain you are that this piece of physical evidence can only have one meaning or one cause.

Dashed Boxes

Everything that can’t be proven to be a fact should be in a dashed box or dashed oval on your SnapCharT®. And on the boxes or ovals that you are certain about? List your evidence that proves they are facts.

Now you have stopped assumptions in their tracks!

Why You Should Use the TapRooT® Process for Smaller Investigations

February 7th, 2018 by

“If the hammer is your only tool, all of your problems will start looking like nails.”

Per Ohstrom shares how TapRooT® is used to investigate smaller incidents by demonstrating the methodology. Are you using the 5-Whys to investigate these types of incidents? The 5-Whys won’t take you beyond your own knowledge. Find out how TapRooT® will!

How to Make Incident Investigations Easier

January 31st, 2018 by

Ken Reed talks about the differences between an investigation for a low-to-moderate incident and a major incident. Find out how TapRooT® makes both types of investigation easier to manage.

Want to learn how to investigate a major/minor incident with all of the advanced tools? Sign up for an upcoming 5-day training!

Want to start with just the essential skills for performing a root cause analysis on a minor or major investigation? It’s a great place to start with a minor investment of time. Sign up for an upcoming 2-day training!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Where Do You Get Ideas To Improve Root Cause Analysis?

January 31st, 2018 by

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Mark Ed 2

 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

L M Astronaut

Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

Linda1988

Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

Bestpractice

People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

Why do people try to make root cause analysis so difficult?

January 17th, 2018 by

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I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

Why Should I get the New TapRooT® Books?

January 9th, 2018 by

When someone calls me for help with an investigation, I often ask them what color TapRooT® Book they have. Sometimes they want to know..

What difference does it make what color my book is?

The answer is that it let’s me know how long ago they took TapRooT® Training and what version of the TapRooT® System they are using.  It is always sad to see people struggling with an issue we solved by improving TapRoot® and they just don’t know about the improvement.

Over the almost three decades that we have been developing TapRooT®, we have made major improvements. If you are still using the system that came in three-ring binders, you are back in the 1996 version of the system.

You might think that NOBODY would be using that outdated a version of the system but someone sent me a review of TapRooT® that they read and … sure enough … the review was of the 1996 book. So to people still using the three-ring binders: Update your documentation to the newest version and you will be shocked.

If you have the green book, you are working from the 2000 revision. You are working from a system from the same millennia. Update to the new version and you will jump ahead 16 years.

If you have the thick black book, you are working from the 2008 version. You too will be pleasantly surprised by what we have learned in the last eight years and how we have improved the usefulness of the TapRooT® Books.

And what is the latest version? These books are also black but there are  smaller and there are eight of them (currently book five and eight are still in production).

What do these books look like and how are they an improvement over the older 2008 book?

BOOKS 3 & 4

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Above is the Investigation book set. It includes:

These are the books that cover using TapRooT® to find the root causes of everything from small/minor incidents to major accidents.

How are they an improvement over the older 2008 TapRooT® Book? Well … we took everything we have learned in the last eight years and used it to improve our documentation. And the first things we learned is … LESS IS MORE. That’s why we broke the books up into separate topics. You can just read what is applicable to what you are doing. But how specifically is the investigation set improved over the old book?

  • The set includes the latest Root Cause Tree® and Dictionary that make the system even better with improved definitions in the Dictionary and an new category (language) in the Communication Basic Cause Category.
  • The Essentials Book is a an easy read (only 100 pages long). It guides you through a new 5 step process that makes TapRooT® easy to use for simple investigations. This improves your simple investigations while saving time.
  • The Major Investigations Book explains the whole TapRooT® System and includes the traditional 7-Step Investigation Process. The book includes improved TapRooT® Techniques, detailed examples of each technique, and even better ideas to help you identify your Causal Factors before you start analyzing their root causes.
  • The set also references the latest TapRooT® Software (Version VI).

The ideas we have for improving low-to-medium risk investigations alone are worth buying the new set.

Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is included in the 2-Day TapRooT® Root Cause Analysis Training. The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training include Book 4: Using TapRooT® Root Cause Analysis for Major Investigations, and Book 3.

But that’s just two (Books 3 & 4) of the new books. What else is there and what new information is in the other six books? Read on…

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BOOK 1

Until Book 1: TapRooT® Root Cause Analysis Leadership Lessons was written, we really didn’t have a book that explained the concepts of TapRooT® Root Cause Analysis to management. Now we have produced a concept book that is just 70 pages long (think of it as a bedtime story for management). When management asks what they need to know about TapRooT®, Book 1 is the place to start.

Of course, we would like leaders to learn much more about a tool that should be in their leadership tool kit but Book 1 is a starting point to get management to understand the basis for TapRooT® and how it will help them improve safety, quality, productivity, and environmental compliance.

To learn more about this book, CLICK HERE, or order your copy at: http://www.taproot.com/store/TapRooT-R-Philosophy.html.

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BOOK 2

Book 2: TapRooT® Root Cause Analysis Implementation, is for those in charge of an improvement program. It explains how TapRooT® can be used to improve an already existing program or part of a completely new improvement effort.

Making this a separate book (89 pages long) helps the right people get the right information to make their improvement program much more effective.

What’s in the book?

  • The “Just Do It!” method of getting started.
  • How to add TapRooT® Root Cause analysis to an existing 6 Sigma, Lean, 8-D, Process Safety, Behavior-Based Safety, or other improvement initiative.
  • Building a best-in-class improvement initiative.
  • A checklist to evaluate your improvement efforts.

If you are serious about improvement and in charge of a program to make improvement happen … this book is for you. Order it HERE.

Book 5

This book is close enough to finished that I can explain what you will find in it when it comes out. If you are interested in equipment troubleshooting and root cause analysis, this is the book for you.

Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability, explains how to use TapRooT® and Equifactor® to solve equipment problems. The new book explains the techniques and includes a paper version of the equipment troubleshooting tables from the TapRooT® VI Software all in one book. That makes this a much handier reference.

We expect this book to be available in the 1st half of 2018. Watch our newsletter for more information.

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Book 6

Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, explains how to build TapRooT® root cause analysis into your audits and proactive improvement efforts. It’s only 57 pages long and is a great compliment to books 3 and 4.

It describes the 7-step process for using TapRoot® in an audit and how to build TapRooT® techniques into your proactive improvement efforts.

When you order the book HERE, you will also get the latest:

  • TapRooT® Root Cause Tree®
  • TapRooT® Root Cause Tree® Dictionary
  • TapRooT® Corrective Action Helper® Guide

What’ new about book 6? It is the latest information about using TapRooT® to audit performance. It can be used for safety or quality audits. It’s a very fast read.

This book is included in the course materials for the pre-Summit TapRooT® for Audits Course.

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Book 7

Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills, is all about information collection. We’ve never had a book specifically about this topic. In the past you had to find some of the information provided here buried in the steps of the old 2008 TapRooT® Book.

But this book is more than just a rehash of the information about interviewing and evidence collection. In  addition to information about planning your evidence collection, emergency response and scene management, and the TapRooT® investigation process, it includes:

  • The 3 P’s and an R of evidence collection. (People, Paper, Physical, and Recordings)
  • The TapRooT® 12-Step Interview Process (Cognitive Interviewing)
  • Decoding non verbal behavior
  • Building your investigation kit
  • An initial observation form
  • An interview preparation form
  • An evidence log
  • How to use Change Analysis and CHAP as part of an interview/evidence collection process

That’s a lot to pack into a 93 page book! Buy this book by CLICKING HERE.

Book 8

This book is also still in production but is also expected in the first half of 2018. Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management, explains the state-of-the-art in performance measurement and trending.

If you have ever wondered how you can prove that you have improved or if a “negative” trend is actually significant, this is the book for you.

In addition, the book explains what management should know about trends. This information can keep them from being misled by false trends and how to use trends to manage improvement initiative.

The math involved isn’t complicated, but it is beyond some of the common “trending” graphs that you may be using now.

This book is included in the pre-Summit Advanced Trending Techniques Course. Watch our newsletter for more information on when the book will be available.

KEEP UP TO DATE! If you don’t have the latest TapRooT® Books that apply to your work, order them today!

Root Cause Tip: Causal Factor Development

January 4th, 2018 by

Error, mistake, Causal factor

Human Error?

 

Hi, everyone.

I thought I’d do a quick discussion on some ideas to help you when developing Causal Factors on your SnapCharT®.

Let me start out by stressing the importance of using the definition of a Causal Factor (CF) when you are looking at your SnapCharT®. Remember, a Causal Factor is a mistake, error, or failure that, if corrected would have prevented the incident, or mitigated it’s consequences.  The most important part of the definition are the first few words:  mistake, error, or (equipment) failure.  As you are looking for CFs, you should be looking for human error or mistakes that led directly to the incident.  Remember, we aren’t blaming anyone.  However, it is important to realize that almost all incidents are “caused” by someone not doing what they were supposed to do, or doing something they shouldn’t.  This isn’t blame; this is just a recognition that humans make mistakes, and our root cause analysis must identify these mistakes in order to find the root causes of those mistakes.

With this definition in mind, let’s talk about what is NOT a CF.  Here are some examples:

  • “The operator did not follow the procedure.”  While this may seem like a CF, this did not lead directly to the incident.  We should ask ourselves, “What mistake was made because someone did not follow the procedure?”  Maybe, the operator did not open the correct valve.  Ah, that sounds like a mistake that, if it had not occurred, I probably would not have had the incident.  Therefore, “Operator did not open valve VO-1” is probably the CF.  Not following the procedure is just a problem that will go under this CF and describe the actual error.
  • “Pre-job brief did not cover pinch points.”  Again, we should ask ourselves, “What mistake was made because we did not cover pinch points in our pre-job brief?”  Maybe the answer is, “The iron worker put his hand on the end of the moving I-beam.”  Again, this is the mistake that led directly to the incident.  The pre-job brief will be a piece of information that describes why the iron worker put his hand in the pinch point.
  • “It was snowing outside.”  I see this type of problem mis-identified as a CF quite often.  Remember, a CF is a mistake, error, or equipment failure.  “Snowing” is not a mistake; it is just a fact.  The mistake that was made because it was snowing (“The employee slipped on the sidewalk”) might be the CF in this case, again with the snowy conditions listed under that CF as a relevant piece of data.

Hopefully, this makes it a little easier to identify what is and is not a CF.  Ask yourself, “Is my Causal Factor a mistake, and did that mistake lead directly to the incident?”  If not, you can then identify what actually lead to the incident.  This is your CF.

Want to learn more? Attend our 2-day Advanced Causal Factor Development course February 26 and 27, 2018 in Knoxville, Tennessee and plan to stay for the 2018 Global TapRooT® Summit, February 28 to March 2, 2018.

See TapRooT® Explore How They’re Changing the Way the World Solves Problems

December 14th, 2017 by

We’re pleased to announce that Mark Paradies’  interview on Worldwide Business with kathy ireland® is scheduled to air on Fox Business Network as sponsored programming.

CLICK HERE to view the recent press release.

Please reference the broadcast information below. You may also reference the channel finder below for market by market air times.

Air Date
December 17, 2017
Network and Time
Fox Business Network – 5:30pm EST
Channel Finder
http://www.foxbusiness.com/channel-finder.html

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Not Near-Misses … They Are Precursors

December 5th, 2017 by

I had an epiphany today.

Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?

I think part of the problem may be the terminology.

Near-miss just doesn’t sound very serious. After all … it was a miss.

But what if we called these incidents PRECURSORS.

A precursor tells you that something IS going to happen unless you change.

If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.

You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.

One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.

Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.

Just a thought…

How Do You Get Started Using TapRooT® to Improve Your Root Cause Analysis?

November 21st, 2017 by

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Start where you are, with what you have.
Make something of it and never be satisfied.
George Washington Carver

When someone asks me where they should start when implementing TapRooT® to improve root cause analysis, my answer is ALWAYS:

It depends on where you are.

Your company vision makes all the difference in deciding what you need to do first to implement TapRooT® as you problem solving tool of choice.

What is your corporate vision? It is one of these three:

  • Blame Vision
  • Crisis Vision
  • Opportunity to Improve Vision

If you don’t know about these three types of “Vision,” read about them in the TapRooT® Root Cause Analysis Leadership Lessons book.

If your company looks for problems as an opportunity to improve, you are in luck! Your company has the Opportunity to Improve Vision and you have a high probability of success! You can begin with any of the “getting started” sections of the book, TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems.

There are three main places to start that are described in the book…

Chapter 1 describes the most frequently used way to start using the TapRooT® Root Cause Analysis System: “Just Do It.” This is a fast way to see the benefits that TapRooT® Root Cause Analysis provides.

Chapter 2 describes incorporating the TapRooT® Root Cause Analysis Tools into an already existing improvement system. If you have implemented Lean, Six Sigma, TQM, RCM, TPM, ISO, Operational Excellence, Process Safety Management, Patient Safety, Behavior Based Safety, or HU, this might be the place that you choose to start implementing TapRooT®.

Chapter 3 describes a complete implementation of TapRooT® based on the best practices we have observed from TapRooT® Users from around the world. This guide to audit a “complete” implementation may seem complex. Perhaps that is why so many TapRooT® Users start with the simpler methods described in Chapters 1 and 2 and use Chapter 3 as their ultimate goal.

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Read TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems and learn more about implementing TapRooT® at your site. Or give us a call at 865-539-2139 or contact us through our web site by CLICKING HERE to discuss your options.

But whatever you do … DON”T WAIT. Problems aren’t going to get any smaller while you wait to improve your root cause analysis.

Put your root cause analysis data to use

November 20th, 2017 by

 

“Just as the introduction of electricity shifted the world’s industrialized economies into higher gear a century ago, digital technologies are fueling economic activity today. This time, however, the transformation is unfolding exponentially faster.” from Digital America: A Tale of the Haves and Have Mores, McKinsey & Company

We live in an age of information, data is collected in evermore places and shared between people and machines in the IoT. Data collection and analysis is becoming easier and easier, with apps, new devices and software.

Still, in the construction industry 30% to 60% of contractors surveyed in the recent Construction Technology Report use manual processes or spreadsheets to manage takeoff, estimating, subcontractor prequalification, bids and data collection. Fewer than half of contractors responding to the survey use mobile apps for daily reporting, worker time entry, managing safety, or tracking job performance.

When it comes to investigating issues and doing root cause analysis, the TapRooT® approach yields effective and consistent results across different industries. For several years software has been available to support teams with their investigations. Now in it’s 6th version, the TapRooT® software offers the highest productivity. Charting incidents is easy, powerful tools assist with identifying Causal Factors and Root Causes, as well as with writing Corrective Actions.

New and improved graphing tools makes it easy to plot data, and trends can be better captured, over time. Watch this short video, or read more here. Stay tuned for updates about a future smart phone App.

#taproot_RCA

Five Trends that Will Impact Companies in Environment, Health and Safety in 2018

November 17th, 2017 by

As we approach 2018, now is a good time to look at some external trends to gauge what is coming down the pike. At System Improvements we recently fired up the crystal balls, and spotted five trends that will impact companies:

  • Proactive Safety Culture,
  • Reporting Capability
  • Focus on Prevention
  • Work force changes
  • Increased Drug Use

Let’s look at each of these.

Proactive Safety Culture: Executives continue to get more involved, safety is seen as an improvement opportunity and something to be managed, rather than a liability driven by chance or “workers unsafe actions”. Preventive methods will be used more, like work site evaluations, audits, functional job analysis, and ergonomics training. Instead of having impossible goals like “Zero Harm”, companies will set improvement KPIs, then investigate, track and trend incidents and near misses and put corrective actions in place

Reporting Capability: User- friendly software like TapRooT® and Enablon is available for capturing data and carrying out analysis. Mobile apps and devices like wearable technology enables rapid collection and dissemination of findings. Training is readily available to make sense of the data collected and empower the front line

Focus on Prevention: Companies take active steps to prevent injuries and promote health and safety. We will see more fitness and wellness initiatives but also focus on “intangible” issues like stress, fatigue and mental health. Companies out of line will face ever- increasing Workers Comp costs

Work Force Changes: The age distribution and values of workers are changing, with millennials entering the workforce. The shortage of skilled workers will get worse, and there will be more contract and temp workers. It will be important to involve all these groups in the EHSQ efforts. There will also be more lone and unsupervised workers, which makes behavior- based safety much more difficult to implement

Increased Use of Illegal and Legalized Drugs:  Serious safety, quality and environmental risk. Executives will have to find ways to manage the opioids cycle where injuries drive prescriptions and workers under the influence of opioids get injured again… In some jurisdictions legalization of marijuana is disqualifying a large share of the worker pool from safely operating vehicles, machinery and equipment. In the Hotels & restaurant industry, research found up to 19% of workers using drugs on a regular basis, a clear risk in e.g. kitchen areas. Alcohol will continue to be an issue, not least in Mining and Construction where up to a fifth of workers are estimated to be affected.

A good way to prepare for these trends is to do effective Root Cause Analysis. The TapRooT® methodology helps companies identify root causes of incidents, and put effective corrective actions in place. The process is also used for proactive audits, where issues can be nipped in the bud. Click here for more information: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Is TapRooT® Root Cause Analysis a Tool or the Whole Toolbox?

November 14th, 2017 by

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I had a self-proclaimed root cause analysis expert tell me that investigators needed lots of “tools” in their root cause analysis toolbox. For most people that leads to the question:

How many tools do I need to learn?

When we started to develop TapRooT® back in the 1980’s, we thought we just needed a tool. We soon learned that we needed a toolbox. So we went to work finding, developing, and refining the best root cause analysis tools and adding them to our root cause analysis toolbox called the TapRooT® Root Cause System.

You might ask:

What’s in the toolbox?

The TapRooT® 7-Step Major Investigation Process from the book, Using TapRooT® Root Cause Analysis for Major Investigations, shows all the major tools in the right column.

SI Chart 7 StepMajorInvestigation

How can you learn these techniques and “fill your toolbox” with tools proven to be successful by TapRooT® Users from around the world? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See the locations and dates for our public courses around the world at:

http://www.taproot.com/store/5-Day-Courses/

But why should you learn these tools?

First, we spent decades of research and developing choosing, developing, and refining these techniques to make them the most successful root cause analysis toolbox in the world. See our user success stories at:

http://www.taproot.com/archives/category/success-stories?s=

The research and testing we performed showed us the limitations of some common root cause analysis tools that some experts try to teach and have trouble getting their students to achieve consistent results. We based our selection of techniques on human factors principles. This makes our system robust yet easy to use.

We also decided to limit the techniques we chose to those that you would really need. Most people don’t get tremendous amounts of experience performing root cause analyses. Thus, we wanted to minimize the training and practice required to use TapRooT®. We made it so that TapRooT® can be applied to low-risk incidents (simple incidents) or medium to high-risk incidents. In that way people get experience applying TapRooT® to simple incidents so that they are practiced using the techniques when something big happens (God forbid).

Also, we built human factors experts systems (AI) into the TapRooT® System to help investigators find the root causes of human errors and equipment problems.

Finally, do other root cause analysis systems provide this course guarantee:

Attend this course, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software
and we will refund the entire course fee.

That’s a powerful guarantee. And we can offer it because of the hundreds of thousands of people we have trained who apply TapRooT® sucessfully. We know you, too, will be successful.

Why not create your own toolbox?

You could duplicate our efforts, spend decades researching and perfecting your own toolbox of root cause analysis tools. Then you could develop training courses to teach what you learned. But guess what … your system still wouldn’t be as good as TapRooT®. Why? Because while you were doing your research, we would be improving. We constantly make the TapRooT® Books, Training, and Software better.

Besides the feedback we get from thousands of users and from classes we hold around the world, we have a TapRooT® Advisory Board that makes suggestions and reviews improvement ideas. This helps us keep making the best even better.

And one last advantage that we have … very talented instructors. We have 50 instructors at various locations around the world that have extensive experience teaching and using the TapRooT® System. And these instructors are constantly sharpening their skills. We have a link on our blog with a few profiles of our instructors but we are way behind on keeping it updated. This gives us something to improve!

If you want to learn more about TapRooT®, attend a class. Or at least see the About TapRooT® page on our web site.

Interviewing & Evidence Collection Tip: Preparing Your Accident Investigation Kit

November 9th, 2017 by

 

Last week we talked about being ready for the unexpected to happen, including preparing an accident investigation grab-and-go kit. Let’s flesh that out a little more.

I mentioned that an accident investigation kit can be as simple as forms (such as a form to record initial observations of the witnesses) and a disposable camera. Here are some other ideas that are useful across industries:

Cones

Tape measure

Flashlight

Evidence tags and bags

Tweezers

Work and latex gloves

PPE

Barricade tape

Camera & tripod

Graph Paper

Witness Statement Forms

Paper, clipboard, pen

Copy of  Accident Investigation Policy

What other ideas do you have? Comment below.

Join me and Reb Brickey on February 26 and 27, 2018 in Knoxville, Tennessee for our TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about this topic.

Interviewing & Evidence Collection Tip: Are you Ready for the Unexpected?

November 2nd, 2017 by

 

No one wants an accident to happen but it’s important to be ready. Here are four things to get into place so you will be:

1. Formal investigation policy. Do you have a policy that sets out the reporting process, goals of investigation and the systematic process an investigator will use to complete the investigation? Has it been updated within the past year?

2. Emergency response. Is your response plan written down? Do you have trained responders who can administer care and who will mitigate additional damages after an accident? Has the list of first responders been evaluated within the past year (people come and go and new people may need to be trained).

3. Accident investigation training. Do all employees know how to report accidents and near-misses? Are all of your investigators trained in the systematic process of investigation set out in your investigation policy?

4. Accident investigation kit. Do you have tools and equipment that aids your investigators gathered together in a grab-and-go kit? This varies from facility to facility, industry to industry. It may be as simple as forms (such as a form to record initial observations of the witnesses) and a disposable camera.

Join me and Reb Brickey on February 26 and 27, 2018 in Knoxville, Tennessee for our TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about this topic.

KISS and Root Cause Analysis

November 1st, 2017 by

I’ve heard many “experts” claim that you need to apply the KISS principle when it comes to root cause analysis. You may hear this too and I want you to understand where these experts lead many people astray.

First, what is KISS? Keep It Simple Stupid! The acronym implies that simple solutions are better solutions. And when simple solution work (are effective) KISS is a dream come true. But remember Einstein’s quote:

Make things as simple as possible, but not simpler.

So let’s start with some of the reasons that these experts say you need to use simple techniques and debunk or demystify each one. Here’s a list of common expert advice.

  1. It’s a waste of time to use full root cause analysis on every problem.
  2. People can’t understand complex root cause analysis techniques.
  3. Learning simple techniques will get people to start thinking deeper about problems.
  4. Simple is just about as good as those fancy techniques.
  5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.
  6. You can apply those complicated techniques to just the most serious accidents.
  7. The data from the simple investigations will help you identify the more complex issues you need to solve.

I see these arguments all the time. They make me want to scream! Let me debunk each one and then you too can dismiss these “experts” the next time they try one or more of these arguments on your management team.

1. It’s a waste of time to use full root cause analysis on every problem.

I actually sort of agree with this statement. What I don’t agree with is the answer they arrive at. Their answer is that you should apply some “simple” root cause analysis technique (let’s just say 5-Whys as an example) to “solve” these problems that don’t deserve a well thought out answer.

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First, what do I have against their ideas of simple root cause analysis? If you’ve been reading this blog for a while you know what I’m going the explain, so just skip ahead. For those who don’t know what’s wrong with most “simple” root cause analysis techniques, I would suggest start reading from the top of the links below until you are convinced that most expert advice about “simple” root cause analysis is root cause analysis malpractice. If you haven’t been convinced by the end of the links … perhaps you are one of the experts I’m talking about. Here’s the list of links:

What happens when root cause analysis becomes too simple? Six problems I’ve observed. 

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Wrong with 5-Whys??? – Complete Article 

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

I believe that one of the biggest root cause analysis problems that companies face is that they are performing “root cause analysis” on problems that don’t need to be analyzed.  YES – I said it. Not every problem deserves a root cause analysis.

What problems don’t need to be analyzed? Problems that aren’t going to teach you anything significant. I call these “paper cut problems.” You don’t need to investigate paper cuts.

But some people would say that you do need to investigate every loss time injury and medical treatment case. Maybe … maybe not.

You do need to investigate an incident if it could have caused an outcome that you are trying to prevent and there are worthy lessons learned. Some medical treatment cases fall into this category. They got a cut finger but they could have lost their whole arm.

Two similar examples are provided in the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. One is a sprained ankle and one is a sprained wrist. Both came from falling down. One was judged worthy of a full but simple root cause analysis using the essential features of the TapRooT® Root Cause Analysis System. One was judged not worthy of a full investigation after a simple SnapCharT® was developed. Interested in how this works? Read the book. It’s only 100 pages long and seeing how to judge if a root cause analysis is worthwhile is worth it. (And you will learn how to apply TapRooT® simply to low-to-medium risk incidents.)

Once you know how to do a real “simple” investigation with an effective technique, you won’t need to do bad root cause analysis with an ineffective technique.

2. People can’t understand complex root cause analysis techniques.

I don’t know every “complex” root cause analysis technique but I do know that this statement does NOT apply to TapRooT®. Why? Because we’ve tested it.

One “test” was at a refinery. The Operation Manager (a good guy) thought that TapRooT® was a good system but wasn’t sure that his operators would understand it. We decided to run a test. We decided to teach a basic class to all his union stewards. Then refinery management did a focus group with the shop stewards.

I was one of the instructors and from the course examples that they analyzed, I knew that they were really enjoying finding real root causes rather than placing blame.

They did the focus group (with us in another room). I could hear what was going on. The first question the facilitator asked was: “Did you understand the TapRooT® Root Cause Analysis Technique?” One of the shop stewards said …

“If I can run a Cat Cracker I can certainly understand this! After all, it’s not rocket science!”

And that’s one of the great parts about TapRooT®. We’ve added expert systems for analysis of equipment and human performance problems, but we’ve kept the system understandable and made it easy to use. Making it seem like it isn’t rocket science (even though there is a whole bunch of science embedded in it) is the secret sauce of TapRooT®.

3. Learning simple techniques will get people to start thinking deeper about problems.

Learning to count is required before you learn calculus BUT counting over and over again does not teach you calculus.

If you don’t understand the causes of human performance problems, you won’t find the causes of the problems by asking why. And I don’t care how many times you ask why … it still won’t work.

For years we did a basic poll at the start of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. We asked:

“How many of you have had any formal training in human factors or the causes of human error?”

Only about 2% of the attendees had ANY training on the causes of human error. But almost everybody that attended our training said that they had previously been assigned to find the causes of human errors. I wonder how well that went? (I can tell you from the student feedback, they said that they really DID NOT address the real root causes in their previous investigations.)

So, NO. Learning simple techniques DOES NOT get people to “think deeper” about problems.

4. Simple is just about as good as those fancy techniques.

NO WAY.

First, I’ve never seen a good example of 5-Whys. I’ve seen hundreds of bad examples that 5-Why experts thought were good examples. One “good example” that I remember was published in Quality Progress, the magazine from the American Society for Quality (ASQ). I couldn’t stand it. I had to write a reply. When I sent the letter to the editor, they asked me to write a whole article … so I did. To see the example and my article that was published in Quality Progress, see page 32 of the link below:

Under Scrutiny: A Critical Look at Root Cause Analysis.

Simple is not “almost as good” as real root cause analysis (TapRooT®). If you would like another example, see Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

That’s it – Case Closed. Those “simple” techniques are NOT just about as good as TapRooT® Root Cause Analysis.

5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.

Once again, I’m reminding of a saying:

Why is there never enough time to do it right,
but there is always enough time to do it over? 

How many times have I seen managers misdiagnose problems because they didn’t find the root causes and then have bigger accidents because they didn’t fix the near-misses and small accidents?

The percentage of managers trained in the causes of human error is very similar to the statistics I previously provided (2%). This means that managers need an effective root cause analysis technique … just like investigators need an effective technique. That’s why the standard corrective actions they use don’t solve the problems and we have accidents that happen over and over again.

So if you don’t have time, don’t worry. You will make time to do it over and over again.

That reminds me of a quote from a plant manager I knew…

“If we investigated every incident, we’d do nothing but investigate incidents!”

6. You can apply those complicated techniques to just the most serious accidents.

I’ve seen companies saving their “best” root cause analysis for their big accidents. Here are the two problems I see with that.

FIRST, they have the big accidents BECAUSE they didn’t solve the precursor incidents. Why? because they didn’t do good root cause analysis on the precursor incidents. Thus, applying poor root cause analysis to the lessor incidents CAUSES the big accidents.

SECOND, their investigators don’t get practice using their “best” root cause analysis techniques because the “most serious” incidents are infrequent. Therefore, their investigators get rusty or they never really develop the skills they need by using the techniques on smaller incidents that could give them practice.

The key here is to learn to use TapRooT® Root Cause Analysis to investigate smaller problems. And that’s why we wrote a book about using TapRooT® for simple incidents: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Don’t wait for big accidents to find and fix the causes of your biggest risks. Find and fix them when they give you warnings (the precursor incidents).

7. The data from the simple investigations will help you identify the more complex issues you need to solve.

Why do people think that analyzing lots of bad data will yield good results? I think it is the misconception about mathematics. A good formula doesn’t provide knowledge from bad data.

If you don’t really know how to analyze data, you should attend our pre-Summit course:

Advanced Trending Techniques

As W. Edwards Deming said:

“Without data, you’re just another person with an opinion.”

And if you know much about Deming, you know that he was very interested in the accuracy of the data.

If you aren’t finding the real root causes, data about your BAD ANALYSIS only tells you what you were doing wrong. You now have data about what was NOT the causes of your problems. Go analyze that!

So data from BAD simple investigations DOES NOT help you solve your more complex issues. All it does is mislead your management.

THAT’S IT. All the bad advice debunked. Now, what do you need to do?

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

You will learn the theory behind performance improvement and you will be well on your way to understanding what management needs to do to really improve safety, quality, equipment reliability, and operational/financial performance.

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

You will know how to implement a real, effective root cause analysis system for low-to-medium risk incidents as well as major accidents.

3. If you haven’t done it already, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the list of our upcoming public 5-Day TapRooT® Courses held around the world at this link:

http://www.taproot.com/store/5-Day-Courses/

And don’t take any more bad advice from experts who don’t know what they are talking about!

PS: If you have questions or want to discuss what you read in the books, contact me (Mark Paradies) at 865-539-2139 or by e-mail by clicking HERE.

Interviewing & Evidence Collection Tip: How to Handle an Inconsistent Statement

October 26th, 2017 by

 

 

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Not every inconsistent statement is meant to deceive.

 

A new investigator may believe that if an interviewee is telling the truth, he will be consistent in his recollection of an event every single time. However, not every inconsistent statement made by an interviewee is made to intentionally deceive.

In fact, most interviewees want to be helpful. Further, an inconsistent statement may be as accurate or even more accurate than consistent claims. That is, an account repeated three times with perfect consistency may be more of a red flag to dig deeper.

The two most important things to think about when evaluating inconsistencies are the passage of time between the incident and its recollection, and the significance of the event to the interviewee. Passage of time makes memory a bit foggy, and items stored in memory that become foggy the quickest are things that we don’t deem significant, like what we ate for lunch last Wednesday. That being said, we still have to be on the lookout for possible fallacies and know how to test them.

There are four ways to decrease the possibility of innocent inconsistent statements during the interviewing process.

  1. Encourage the interviewee to report events that come to mind that are not related or are trivial. In this way, you discourage an interviewee trying to please you by forcing the pieces to fit. They do not know about all the evidence that has been collected, and may believe that something is not related when it truly is.
  2. Tell the interviewee, explicitly, not to try to make-up anything he or she is unsure of simply to prove an answer. If they don’t know, simply request they say, “I don’t know.” This will help them relax.
  3. Do not give feedback after any statement like “good” or “right.” This will only encourage the interviewee to give more statements that you think are “good” or “right”– and may even influence them to believe that some things occurred that really didn’t.
  4. Ask the interviewee to tell the story of what happened from finish to start instead of start to finish. If the interviewee is intentionally trying to cover something up, he or she will have a hard time remembering the same order to the story he or she recited the first time because the interviewee will have a greater cognitive load to bear telling the story in reverse order.

We have plans to go over many more details on how to conduct a good interview at the 2018 Global TapRooT® Summit. Join us for TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills February 26 and 27. Learn more.

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

TapRooT® provides world-class root cause analysis. But did you know that your results can vary depending upon the goodness of your implementation of the TapRooT® System?

What causes the implementation to vary? Try these factors …

  • Need to improve clearly defined.
  • Senior management support achieved.
  • Written program plan approved by senior management.
  • Proactive improvements drive improvement success.
  • Use advanced root cause analysis for both reactive and proactive investigations.
  • Improvement accomplishments being communicated successfully.
  • Adequate budget/staffing for the improvement organization.
  • Training plan implemented.
  • Employees, supervisors, managers, and contractors/suppliers willingly participate in the program.
  • Software selected, customized, and implemented.
  • Performance measures and advanced trending techniques used by management to guide the program.
  • Organizational learning occurring by effective sharing of lessons learned.
  • Plan for continuous improvement of the program is followed.
  • Leadership succession plan established.
  • Rewards program being used effectively.

This list is provided as a checklist and explained in more detail in Chapter 3 of our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to order your copy.

One more idea you might want to pursue to improve your performance improvement program. Attend the 2018 TapRooT® Global Summit in Knoxville, TN, on February 26 – March 2! It’s a great place to keep up with the state of the art in performance improvement and network with industry leaders.

Start by attending one of our advanced courses on Monday & Tuesday:

  • TapRooT® Root Cause Analysis Training
  • Equifactor® Equipment Troubleshooting and Root Cause Analysis
  • Advanced Causal Factor Development Course
  • Advanced Trending Techniques
  • TapRooT® Analyzing and Fixing Safety Culture Issues
  • Risk Assessment and Management Best Practices
  • Getting the Most from Your TapRooT® VI Software
  • TapRooT® for AuditsTapRooT®
  • Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
  • Understanding and Stopping Human Error

Then attend the Summit on Wednesday – Friday.

What’s on the agenda for the 2018 Global TapRooT® Summit? First, there are five keynote speakers:

  • Inquois “Inky” Johnson – Honor and Legacy
  • Vincent Ivan Phillips – How to Communicate Successfully
  • Dr. Carol Gunn – When Failure Becomes Personal
  • Mark Paradies – How Good is Your TapRooT® Implementation?
  • Mike Williams – Deepwater Horizon

Then there are nine different tracks that include 8 breakout sessions each. These tracks include:

  • Safety
  • Quality
  • Human Factors
  • Asset Optimization
  • Investigator
  • Patient Safety
  • TapRooT® Software
  • TapRooT® Instructor Recertification
  • Alternatives

See the Summit schedule at: http://www.taproot.com/taproot-summit/summit-schedule.

Root Cause Tip Warning: Do not define the impact level of your incident too low or too high

October 19th, 2017 by

 

When defining the Incident during a TapRooT® Root Cause Analysis and its impact to the business (the scope of your investigation), I often hear this statement…

“If we focus on the delay of correcting the problem, then less importance will be placed on what caused the problem.”

Take the scenario of a fire pump failing to turn on during a fire response test. The team originally wanted to focus on the pump failure only. Not a bad idea however, the pump could not be repaired for 2 weeks because of a spare part shortage. I pushed the team to raise the scope and impact of the investigation to Automatic Fire Suppression System out of service for 14 days.

Now this elevation of the incident does not lessen the focus on the pump failure, it does the opposite. A system down for 2 weeks elevates the focus on the pump failure because of impact and also allows the team to analyze why we did not have access to spare pump in a timely manner.

A caution also must be mentioned in that elevating the impact of an incident too high can cause a regulating agency to get involved or/and additional resources to be spent when not required.

Which problem is worse? Elevating a problem too high or not high enough? Your thoughts?

How Many Industries and How Many Countries is Your Root Cause Analysis System Used In?

October 17th, 2017 by

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I was talking to someone in the medical industry recently and they asked: “How many people in the medical industry use TapRooT®?”

I gave them several examples of major healthcare systems that use TapRooT® (including perhaps the world’s largest) but I thought … they asked the WRONG question.

The true value of a root cause analysis system is how many different places it is being used SUCCESSFULLY.

Note that this is not the same as if the system is used in a particular industry. It must be used successfully. And if it is used successfully in many other industries and many countries, that proves even more that the system is useful and will probably be useful when applied at your company.

Where is TapRooT® Root Cause Analysis applied successfully?

All over the world. On every continent but Antartica (we’ve never done a course there yet).

In what kind of industries? Try these:

  • Oil & Gas Exploration & Production
  • Refining
  • Chemical Manufacturing
  • Healthcare (Hospitals)
  • Pharmaceutical Manufacturing
  • Nuclear Power / Nuclear Fuels
  • Utilities
  • Auto Manufacturing
  • Aggregates
  • Mining (Iron, Gold, Diamonds, Copper, Coal, …)
  • Aluminum
  • Aviation (airlines and helicopters)
  • Shipping
  • Cosmetics
  • Construction
  • Data Security
  • Nuclear Weapons
  • Research Laboratories
  • Mass Transit
  • Regulatory Agencies
  • Prisons
  • Pulp & Paper
  • Engineering
  • Food & Drinks
  • Alchohol
  • Security
  • Recycling
  • Aerospace Manufacturing
  • Space Exploration
  • Pipelines
  • Agricultural Commodities
  • Steel
  • Forestry
  • City Government
  • General Manufacturing
  • Telecommunications
  • Airport Management

And that’s only a partial list.

Where can you read about the successful application of TapRooT® in some of these industries? Try these success stories:

http://www.taproot.com/archives/category/success-stories?s=

You will see examples of companies that saved lives, save money, prevent injuries, improved service, made work more productive, and stopped the cycle of blame and punishment.

The reason that TapRooT® is used by industry leaders is that it works in such a wide variety of industries in such a wide variety of countries.

But don’t just believe the industry leaders. Attend one of our GUARANTEED courses. Guaranteed? That’s right. Here is our guarantee:

  • Attend the course. Go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials and we will refund the entire course fee.

It’s that simple. Try to find a money-back guarantee like that anywhere else. We are so sure of your success that we guarantee it.

Don’t wait. Register for one of our root cause analysis courses today. For a list of upcoming public courses, see:

http://www.taproot.com/store/Courses/

Why do people jump to conclusions?

October 10th, 2017 by

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?

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And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Interviewing & Evidence Collection Tip: Get More Out of Interviews

October 5th, 2017 by

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

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