Taproot

Here’s the story about the solar blast that could cause grid, communications, and GPS problems:

http://online.wsj.com/article/SB10001424053111903454504576490641577134256.html?mod=rss_US_News

From the articles:

“Cleanup crews in Idaho have finished clearing honey and an estimated 14 million bees that got loose after a delivery truck overturned on a highway.

To make matters worse… more bees not contained may mean an increase of more bears.

http://news.yahoo.com/truck-spills-14-million-bees-idaho-highway-142147287.html

http://www.dailymail.co.uk/news/article-2013995/Truck-spills-14-MILLION-bees-honey-Idaho-road-crash.html

Day One of our 2-Day TapRooT® Incident Investigation and Root Cause Analysis in Calgary, Canada.

Kevin Palardy, one of our Canadian based instructors, introducing the SnapCharT® Process. As you can see below, the course is not just a sit down and lecture course… you have to apply what you learn on each of the 7 Steps learned.

158 lives were lost on May 22nd, 2011, when Air India Express Flight 812 crashed after not aborting a landing. According to an article by Indian Aviation News,

“The court of Inquiry determines that the cause of the accident was Captain’s failure to discontinue an “Un-stabilised approach” and his persistence to continue with the landing, despite three calls from the First Officer to “go-around” and a number of warnings from the EGPWS”

According to the article being reviewed, the Government of India had inserted vide GSR No. 168(E) a very important rule to ‘The Aircraft Rules 1937′, which govern everything aviation in this country On 2009 March 13.

The rule:

75A. Reopening of Investigation – Where it appears to the Central Government that any new and material evidence has become available after completion of the investigation under rule 71, 74 or 75, as the case may be, it may, by order, direct the reopening of the same.

The article then references the findings that should reopen the case:

Here is a list of new and material evidence:

1. The fact that a huge portion of the wreckage was taken away from the crash site by locals and was sold as scrap metal. What the Court of Inquiry was inspected and studied (if at all they had done any study) was the remaining wreckage.

2. The reconstruction of the wreckage was never actually done by the CoI. The image of the reconstructed wreckage included in the report was a computer generated one.

3. While testifying before the court of Inquiry at Mangalore airport, Six survivors of the crash were made to answer a totally biased and misleading question by the CoI. The question was, “Do you think the accident occurred because of the fault of the pilot?” This was in plain violation of Rule 7.2.1 of the Manual of Accident/ incident investigation: ‘ The investigation of aircraft accidents and incidents has to be strictly objective and totally impartial and must also be perceived to be so’.

4. The “Hard Landing” circular issued by Air India is a major contributor to the accident. The CoI had chosen to ignore this vital fact.

Of course some of the issues from the article’s author stem from the investigation itself and are items that we teach our clients to avoid:

1. Spoliation of Evidence

2. Interviewing in a less effective manner which could have induced bias…. (leading the interviewee)

3. Focusing on what TapRooT® would define as a Causal Factor only and not the root causes for the Causal Factors

So the question for today’s Monday Lessons Learned is when would you, or when have you reopened an Investigation?

For More Reading:

Indian Aviation News 6/14/11

Indian Aviation News 6/08/11

If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.

To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:

• Technical tips and root cause analysis newsletters.

• Specifically designed on-site training for gaps identified as additional needs in your trending and proactive assessments.

• Feedback for our investigators through our Advisory Board and one-on-one.

• Advanced courses during our Pre-Summit (from Human Behavior, Culture Change to Equipment Troubleshooting, just to mention a few courses).

• A Summit for system experts, which include our clients, to share best practices from multiple industries.

• The TapRooT® Users and Friends LinkedIn Group where you can ask us or your peers questions.

The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:

1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)

Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.

Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:

Task Performance Levels

1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
Proficient)
3. Can do all parts of the task. Needs only a spot check of completed work.
(Competent)
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)

Task Knowledge Levels

a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)

Subject Knowledge Levels

A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
(Analysis)
D. Can evaluate conditions and make proper decisions about the subject.
(Evaluation)

By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).

Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:

1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.

2-Day TapRooT® Incident Investigation and Root Cause Analysis
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis

2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.

3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.

4. Develop in-house group sessions to discuss lessons learned.

5. Schedule refresher training to give competency levels high.

Good luck on your quest for knowledge!

Government Technology published an interesting summary of two serious computer outages that occurred in the State of Michigan.

Whenever I read about such outages, I think of the work of TapRooT® User Gerald Starling back in the 1990′s while he was at Bell South. He was one of the first people to apply advanced root cause analysis (TapRooT®) to network reliability problems after he heard about TapRooT® from a consultant at AT&T (sorry – don’t know his/her name).

Soon after, another company focused on high reliability computer operations, Tandem Computers, adopted TapRooT® for analysis of reliability issues.

Also, several government agencies adopted TapRooT® to analyze computer security issues (hackers and such).

But multiple mergers, the tech crash, and secrecy about technology issues has made it difficult to spread the word about the application of root cause analysis to computer network reliability issues.

Maybe the time is right for the spread of advanced root cause analysis across the computer industry to help improve network reliability?

If you are in the network reliability and security business, I’d suggest attending a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course to learn the TapRooT® Techniques. Plus the course includes the patented TapRooT® Software (individual user edition) for each participant.

You’ll have to do a little translation (the examples in the class are not network reliability examples – the rest of the attendees wouldn’t understand them if they were) but others have told us that the learning is directly applicable to security and reliability issues of computer networks. See for yourself. Attend one of the courses listed at:

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

Just checking to see if TapRooT® Users got their Root Cause Network™ Newsletter today. I think you will find the Six Common Culture Problems story on page one both interesting and helpful when assessing culture issues.

Here’s a copy for download if you didn’t get yours by e-mail:

Just click on the document above to download it.

Really bad weather yesterday in Knoxville. Here’s what the hail did to my Q7:

The roof at the office (picture of the edge where you can see where the hail went through the shingles):

Ed put 2-inch chunks of hail in his freezer. His car was damaged too.

And Dave’s house had an entire outside wall “shredded” by hail.

TapRooT® Users: Does this qualify as a “Natural Disaster”?

A great group of students for Kevin Palardy and I to work with and teach. With 32 being the maximum for a course, we had 7 on the waiting list. Make sure you are not on the next waiting list.

See our upcoming courses here:

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

The mine is in Mullan, Idaho, a historic mountain mining town of 840 people in Idaho’s Panhandle. Baker said additional equipment was being flown in so crews could use a front-end loader remotely to dig away material clogging the tunnel.
(more…)

“The world’s largest passenger aircraft clipped a much smaller commuter plane on a dark, wet tarmac at New York City’s Kennedy Airport, spinning it like a toy as hundreds of passengers sat in both planes. No one was injured.”

See the video here: http://news.yahoo.com/video/us-15749625/amateur-video-shows-air-france-collision-at-jfk-24877570

Alcohol or Juice?

Interesting article today titled: “Restaurant to retrain staff after mixed-drink mixup”

On Friday, Taylor Dill-Reese went to an Applebee’s in Madison Heights, Michigan, where — among other things — she ordered her 15-month-old son Dominick an apple juice.

According to the article the restaurant stated, that it would begin to serve apple juice to children only from single-serve containers at the table and would “retrain all severs on our beverage pouring policy, emphasizing that non-alcoholic and alcoholic beverages must be stored in completely separate and identified containers.”

…. for our TapRooT® trained investigators, can you think of any other root causes than training?
(more…)

This was a simple mistake that led to a serious injury.

See the report by the UK RAIB at:

http://www.raib.gov.uk/cms_resources.cfm?file=/Bulletin%20(Foxfield)%2001-2011.pdf

The Chief Counsel has released a more detailed report about the Deepwater Horizon blowout. See it at:

http://www.oilspillcommission.gov/chief-counsels-report

So far I can’t get the whole report to download, but I can download the separate chapters. Once again, a massive report … This time over 350 pages with animation of certain key technical issues.