Category: Success Stories

Why Does TapRooT® Exist?

March 28th, 2017 by

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

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

Monday Accident & Lessons Leaned: Learning from a Lack of Accidents

April 20th, 2015 by

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As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section:

Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 for more than 160 million work-hours. This equals one lost-time incident for every 6.2 million hours on the job. These numbers are a testament to our safety record and a reason why we are in the top tier of safest companies in the industry.

CB&I’s lost time incident rate is 50 times better than the industry average (.03 compared to 1.5). That might make you wonder, how do they do that?

Answering that question is learning from a lack of accidents!

Here are a couple of thoughts that I have…

First, when you see this kind of success, you know it is because of management, supervisory, and employee involvement in accomplishing a safe workplace. Everybody has to be involved. There can’t be finger pointing and blame. Everybody has to work together.

Second, I know CB&I is a TapRooT® User. CB&I has trained TapRooT® Investigators to find and fix the root causes of incidents and, thereby, keep major accidents (LTI’s and fatalities) from occurring.

So, congratulations CB&I on your excellent performance! Congratulations on the lives you have saved and the injuries you have avoided!

If you are interested in having industry leading safety performance, perhaps you should get your folks trained to find and fix the root causes of problems by using advanced TapRooT® root cause analysis. Find out about our courses at THIS LINK.

And consider attending the 2015 Global TapRooT® Summit on June 1-5 in Las Vegas. You can:

  • meet industry leaders who are achieving world-class performance
  • benchmark your programs with their programs
  • learn industry leading best practices
  • get motivated to take your safety performance to the next level.

See the 2015 Global TapRooT® Summit schedule at:

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

How Arkema Implements and Succeeds with TapRooT®

May 16th, 2012 by

From Ron Zanoni, manager of Occupational Safety, Arkema, Inc.

Setting the stage

As the manager of occupational safety for Arkema, Inc., a global chemical company, protecting the safety, health and welfare of our employees is paramount to everything I do.  Our Americas-based operations include 34 facilities across the United States, Canada and Mexico with approximately 2,400 employees working in three main business groups: Vinyl Products, Industrial Chemicals and Performance Products. I know that accidents happen, but I always try and learn from them and absolutely aim to create an environment that prevents them from occurring in the first place.  With complex and diverse production and manufacturing facilities as well as thousands of employees, safety awareness and prevention is at the core of our corporate culture.   That’s where TapRooT® fits in.

TapRooT® delivers comprehensive investigative process

I’m a checklist-type of person who likes structure and having a roadmap to assist me in investigations.  Having the right people as part of an analysis is critical, but knowing how to communicate, query and build a solid knowledge base among the right people is even more important to getting to the root cause of any incident.  TapRooT® helps us to arrive at a point to show true, unbiased facts that lead to corrective actions.  By using TapRooT® and implementing advanced company-wide safety programs, we are able to deliver a safer working environment at all of our facilities; I am very proud of that.

Using TapRooT® to find root causes

We started using TapRooT® more than 15 years ago.  We learned early on that it offered good methodology and had a solid structure for our incident investigations that ultimately helped us arrive at the root causes of incidents.  Once we started implementing TapRooT® in our discovery phases, our levels of investigations deepened and we could complete investigations and determine the root causes with reliable corrective actions.  Prior to that, the company didn’t have a standard method of analyzing incidents for root causes, and our corrective actions didn’t consistently address the root causes of the incidents when they were identified.  TapRooT® helped address our needs and enabled us to be more thorough and consistent in our high risk investigations.

TapRooT® in action

To give you an idea how this comes to life for us via TapRooT®, here’s an example: one of our employees was seriously injured at one of our production facilities. Instead of immediately penalizing the employee for not following certain procedures, using TapRooT®, we implemented a very thorough and unbiased investigation to look at the incident with a 360-degree view to see if there were other factors to consider. TapRooT® enabled us to identify equipment difficulties, management system issues, human engineering issues, supervision issues and employee procedural issues, all of which played a part in the incident.  From this information, we were able to establish and implement corrective actions that we use to this day across our company.  TapRooT® led us to more comprehensive investigation results, which ultimately made us better as a company.

What TapRooT® has meant to our business

* Better safety conditions, low OSHA recordable injury rate ratings

* Commitment to our company’s Responsible Care® program

* Company-wide corporate standards for investigations

* Unbiased, fact-based comprehensive investigations

From the information gleaned from our TapRooT® investigations — preventative measures and corrective actions — our incidents rates has declined dramatically over the years; and we proudly continue to earn top OSHA ratings for workplace safety.  In addition, we are able to more thoroughly uphold management’s and the company’s commitment to the Responsible Care® initiative.

TapRooT® delivered many different methodologies into one compact, concise problem-solving system that we could eventually implement company-wide in the United States.  The consistency and effectiveness of our investigations improved across all facilities.  Today our U.S. sites have TapRooT®-trained personnel onsite to lead investigations of major incidents and major near misses. That is our corporate standard.

How TapRooT® Leads to More Productive Investigations, Reduced RIRs

May 9th, 2012 by

A TapRooT® Success story from Tom Howe, Oilfield Project Group HSE Manager/TapRooT® Champion, Oceaneering

Setting the stage for why we implemented TapRooT® in our business
We initially started using TapRooT® in 2002 in order to improve the quality of our investigations and to apply our corrective actions efforts on the core issues, as opposed to the symptoms. This became a requirement of our HSE management systems and one of our 7 Core HSE Processes. We began to use TapRooT® to more thoroughly review injuries and near hits when they occurred in order to avoid repeat performances. We didn’t want to just know that incidents happened and implement a quick fix; we wanted to know why they happened and how to correct the root causes to prevent reoccurrence.

TapRooT® as a safety partner
Safety is paramount in everything we do, and TapRooT® has helped us manage some of the risk. Oceaneering is a global provider of engineered services and products primarily to the offshore oil and gas industry, with a focus on deep water applications. Through the use of applied technology expertise, we also serve the defense and aerospace industries. With facilities around the world and with staff working with remotely operated vehicles, mobile offshore production systems, subsea intervention and installation services as well as manned diving, safety of our employees is vital. TapRooT® has been a vital partner for us for years in ensuring a safe and productive work environment.

RIRs on the decline
Our recordable injuries have been steadily going down over the last decade and I’ve seen a dynamic reduction in injuries. And, at the same time the number of employees has increased more than four times to more than 10,000 currently. While we’ve steadily expanded our business our injury rate has declined. TapRooT® has assisted us to instill a safer, more effective work environment for all of our employees. How is this possible? With our ongoing focus on safety combined with the tools, investigative methods and corrective actions that are a result of our TapRooT® use. We have been able to utilize our HSE processes to focus on the root causes of hazards, potential injuries and injuries more regularly and consistently.

In addition to the number of injuries declining, we have seen a decline in the severity of injuries. This is not to minimize any injury, just to state that we continue to work to improve the safety of the overall workplace environment. We have reduced hazards by the corrective actions and preventative measures we are able to put into place.

Creative thinking, out-of-the-box corrective actions
TapRooT® has assisted us in understanding the cause(s) of an injury and/or incident. With that understanding we can create high-quality corrective actions based on root causes. Knowing the root cause of an incident and having levels of corrective action established we have provided our team leaders with the ability to think out of the box and create the best solutions for the situation.

Company TapRooT® proficiency
We want our people who are conducting investigations to be confident in every step of the process. We have core TapRooT® leaders who can lead investigations and we have ongoing training for and communication with our staff to keep them current on policies, root causes, corrective actions and safety training as needed

TapRooT® Techniques Contribute to Evolution of Improved Safety Environment and Policies

May 2nd, 2012 by

A TapRooT® Success Story from Mike Rodriguez, Exploration, Drilling, and Wells Safety Specialist, ConocoPhillips Alaska, Inc.

In the beginning . . .
We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations, which since then has been structured around the 7 steps of TapRooT®. This evolution for us has helped us create an incident investigation committee and more comprehensive training among management that we continue to build on each year.

TapRooT® is a thinking tool
From our experiences, TapRooT® is a wonderful “thinking” tool—we have more employees exposed to it, more employees understanding the importance of our key findings and more employees appreciating the impact corrective actions can have on all of us. All of this leads to better communication among our teams of employees.

Measurable accountable successes
One of our most visible points of success for us as a division is our lower TRIR in recent years. Our TRIR used to be in the 4-5 range and I am proud to say it now has been reduced to below 1. HSE changes combined with more proactive use of TapRooT® tools and techniques and the resulting key findings have contributed to this improvement.

It’s all about an evolution
Using TapRooT® certainly helps improve each and every investigation we conduct. However, it goes way beyond that for a company to derive the greatest benefits from implementing TapRooT®. If we simply took the findings and filed them away, who would they help? Corporate culture ultimately changes as a result of TapRooT® investigations and learned corrective actions. This information – the key findings — empowers management to instill even stronger communications, policies and safety environments in the workplace. I am invigorated knowing that information we uncover will lead to even better health and safety standards for our employees. We are no longer afraid to ask ourselves “what is it about our organization that contributed to failure.” We learn, adjust and evolve in order to eliminate issues and incidents as well as to continually improve our workplace.

Via TapRooT® we learn from even minor incidents
We had an employee in the field close a truck door on his hand causing injury to himself. This was a medical treatment incident; protocol required us to institute an investigation. Our response might have been simply: was the employee distracted, was the employee multitasking and just not paying attention, was it simply human error, was the employee wearing safety gear (gloves), etc. While all of these questions are critical to the process, we knew we couldn’t stop there. One of TapRooT®’s highest attributes is its ability to help us drive important questions to show intention versus activation in a policy and/or incident. What we learned was critical to field and safety ops for all employees. From this incident and our TapRooT® process we learned that an important communiqué has been omitted from the protocol/policy distributed to employees. We also learned that field operations and company policymakers must work even closer together before policies are distributed in order to take into account a broad range of scenarios and real-world applications. With TapRooT® our investigations are more forthcoming and revealing than in years past. It comes with knowledge and technology. We are getting better every day.

For me it has been rewarding to see the important changes we can make in our safety policies from even a minor incident. Key findings are uncovered, implemented and shared. The sharing of best practices and policies is a maximum benefit for everyone. This really energizes me because our safety team knows we can be on the cutting edge for the company.

Safety comes first
Success has to be defined within the business we’re in. We want to complete the job on time or under budget and safely. Safety always goes to the front if needed. We don’t compromise on safety for the sake of schedule, time or money. They are always equal values in stature, but safety comes first, and TapRooT® helps us continually improve and evolve in this area.

Using TapRooT To Improve the Quality of Root Cause Analysis at Nuclear Power Plants

March 15th, 2011 by

Challenge
The quality of root cause analysis at our five nuclear power plants was criticized by reviewers such as the Nuclear Safety Review Boards, Nuclear Oversight (Quality Assurance), and corporate executives. Our critics noted repeat failures, and stated that the investigations often missed the mark and had weak corrective actions. We needed to find a system that would produce consistent quality root cause analysis.

Action
An improvement plan was developed and implemented. Elements of the improvement plan included process improvements to increase line manager involvement, use of an Events and Causal Factor chart, use of an investigation charter, use of a root cause report checklist, and implementation of the TapRooT system.
We obtained a TapRooT License Agreement for the five Commonwealth Edison nuclear plant sites, plus the corporate office. Since we were in the midst of a merger, and some of our merger-partner sites were also TapRooT customers, the final License Agreement includes all 10 nuclear plant sites plus the corporate office. We also sent a core group of investigators to a 5-day advanced class.
We replaced our in-house 5-day root cause analysis class with the 2-day TapRooT class and installed SnapCharT and Root Cause Tree® software programs on the Local Area Network at each site. We also conducted orientation sessions for plant senior managers.
By the end of April 2001, we had conducted at least one 2-day TapRooT? class at each plant site.

Results
The initial reaction to the TapRooT system by investigators, line managers, and reviewers has been positive. Investigators like the structured approach. Line managers like the consistent results. Reviewers like the consistent quality. Investigators and line managers also like the savings of time for the 2-day class rather than a 5-day class. The investigators also like the SnapCharT® software.
Our reviewers use a 10-question checklist to grade our root cause analysis reports. Prior to the introduction of the TapRooT system in September 2000, the average report score was about 50%. Since the introduction of the TapRooT system, the average report score has risen to about 75%. We anticipate continued improvement as we train additional investigators.
The improvement in the report ratings and the investigators’ and managers’ opinions about our new system (TapRooT) might not seem like a major improvement, but we have been working for years to improve our root cause analysis and have tried several other systems. Getting this consistent and significant improvement this far along in our quest for better root cause analysis clearly demonstrates to us the value of the TapRooT System.
One more piece of evidence that shows how much we value the progress that we have made. Our energy delivery districts (transmission and distribution) needed improved root cause analysis to analyze human performance problems that result in outages for our customers. They have been looking for a way to effectively and consistently evaluate their incidents. The corporate nuclear staff presented the TapRooT? System to the corporate energy delivery staff, and they decided that the system would help them effectively improve performance. They are obtaining a license to implement TapRooT and install the software for the 10 mid-West energy delivery districts to provide our customers with increased power reliability while Exelon realizes cost savings.

Improving Worker Safety By Fixing the Root Causes of On-The-Job Hazards

March 15th, 2011 by

Challenge
Our ongoing, sustained effort is to make jobs safer and to reduce (and eventually eliminate) on-the-job injuries. Our mechanics were faced with complex procedures, electrical energy, and the potential for falls and hazards that Otis does not completely control (since we are working on the customer’s site). However, in Russia our mechanics also faced hazardous elevator ?emergency? controls and a lack of regulation that made it more difficult to be safe while working.
Our Otis internal audits (a proactive way to find problems) produced scores that showed that improvement was possible. But how do we analyze and fix the real causes of the problems?

Action
In 1998, one of the corporate staff members attended a course on root cause analysis. The staff member used the systematic root cause analysis techniques he learned to solve problems. He found that a structured process helped identify real problems that were previously being overlooked. He also found that the system, called TapRooT®, helped identify fixable causes for these problems that, when corrected, were effective in improving safety.
In 1999, Otis decided to adopt the TapRooT System around the world. Courses were held in the United States, Holland, Singapore, and Brazil . I was one of the environment, health, and safety professionals that attend the course in Amsterdam . We decided to use the process to analyze our safety problems and develop improvements that would reduce risk to our employees and improve the results of our audits.

Results
We started applying TapRooT to analyze our safety problems in 1999. One of the first problems we attacked was the failure of our mechanics to comply with safety instructions in our procedures. The question and answer process in the TapRooT Root Cause Tree® helped us identify the root causes of the problems with the procedures. This helped us simplify the procedures and make them easier for the mechanics to use.
We also found that we needed to improve the enforcement of the use of safety instructions in the procedures. Supervisors now use their regular conversations with the mechanics to reinforce adherence to the safety instructions. We also instituted safety audits to measure compliance and take additional actions to improve compliance (if needed).
But our efforts were NOT just focused on procedures. We also found that we needed to improve the processes and devices that were being used for isolation of electrical energy and for fall protection.
Because electrical isolation devices are no longer required by law, Otis customers often do not want to pay for these devices. Our root cause analysis showed that these devices were essential for our employees? safety. Therefore, we decided to supply these devices at our own cost to provide the highest possible safety for our mechanics.
Root cause analysis also helped us discover and fix a problem with our fall protection equipment. The old equipment sometimes caused internal injuries due to the sudden jerk when the person?s fall was stopped. We developed new gear that had an extra absorbing mechanism to reduce internal injuries.
Finally, we had problems with the safety of workers on top of elevator cars when the ?emergency call? system (a special problem in Russia ) was used. We developed special procedures based on our root cause analysis to help protect our workers.
We have now used TapRooT for over a year and a half. We have eliminated or reduced hazards and we have improved the usage of our safety instructions.
This improvement can be seen in our audit evaluation scores. Each month and quarter each Otis facility evaluates the risks that employees face and submits a report to corporate headquarters. These reports are then evaluated by a committee and a score is assigned. Better results get a higher score.
In 1999 (our first year of using TapRooT), our average score improved to 173 out of 240 possible points. In 2000, our average score improved still further to 200 out of 240 possible points (a good score by comparison with other European Otis facilities). We believe that using TapRooT to find root causes has been an essential element of our improvement efforts, and we will continue to use it to improve even more in the future.

Using TapRooT to Quickly Investigate & Learn from a Production Incident

March 15th, 2011 by

Challenge
To quickly (within two weeks while repairs are being made) and without requiring excessive support of plant personnel, investigate and learn how to prevent the recurrence of the collapse of a process tank that caused severe damage to the tank and significant costs for its replacement.

Incident Summary
During the T&I period for a large petrochemical manufacturing process, a large tank collapsed due to the rapid condensation of steam that was being used to steam out the tank for maintenance work.
The rapid condensation occurred when the deluge system was accidentally activated when an electrician removed a faulty bulb in one of the relays for the deluge system’s electrical power supply.

Investigation

The investigation was performed at a facility that was licensed to use the TapRooT System. Although the license included the right to use the TapRooT System training materials, none of the people involved in the incident had received the training before the incident. Therefore, the investigation started by providing the participants a brief introduction to the TapRooT System and the tools they would use.
A TapRooT trained facilitator was chosen to lead the investigation. He had been to the TapRooT 5-Day Team Leader Course. He decided to use lunch hour (lunch was being catered) to conduct meetings with plant personnel participating in the investigations to save their time and avoid interruptions to the turnaround.
At the first meeting the team members learned about TapRooT and drew their first E&CF Chart to better understand what happened. It took four sessions one to three days apart (a total of 9 hours) to complete the investigation and develop corrective actions that will help prevent this type of incident from recurring.

Results

In this short period of time interesting problems were uncovered and difficult issues were addressed. TapRooT helped us logically and quickly lay out what happened and understand the specific root causes.
The two most impressive items about this investigation were:

  1. The generic problem that was uncovered that we are convinced we would not have uncovered if we had not been using TapRooT. We found an issue of the reluctance to remove any safeguard from service (like the deluge system) when a system is removed from service for maintenance. Issues uncovered included how to decide when a safeguard should be disabled and the timing of when to disable the safeguard.
  2. The efficiency of the investigation process and the ability of the team to quickly adapt to using TapRooT. Just nine hours of team time were used to investigate a fairly complicated production problem. This investigation was conducted during hectic “turnaround” tempo operations with minimal impact on the operations and maintenance organization.

As a result of this investigation we instituted a new checklist to be used during preparation for taking systems out of service. This checklist addresses the effect of safeguards that will be left in service, the hazards posed by safeguards left in service, and, if a safeguard is to be taken out of service, the process and timing for removing the safeguard from service.
We believe that this new checklist will fill an important gap in our maintenance planning process. After reviewing our past experience, we estimated that the insight from lessons learned from this one incident could save Huntsman over a million dollars a year by eliminating the sometimes expensive and dangerous unplanned events that happen during maintenance.
Improving performance is never really completed. This is just one example that demonstrates how we will continue to use the TapRooT System to improve safety, productions, and maintenance. But I think it clearly demonstrates that all investigations don’t have to be long drawn-out affairs to learn lessons of great value.

Using TapRooT to Reduce the Severity of Ergonomic Illnesses and Cut Workers’ Comp Costs

March 15th, 2011 by

Challenge
I took over responsibility for HSE at a research, production, administration, and distribution facility that was having problems with ergonomic illnesses. These types of illnesses were especially troubling in our order entry and distribution areas. I had previously been trained in TapRooT® and knew how it could help people to quickly find root causes without the negative connotations usually found in investigations. Therefore, I thought that this would be an excellent candidate for a pilot program.

Action

We licensed our facility and had System Improvements personnel train a core group of 25 investigators from the various organizational units that would be investigating these and other incidents. We then performed root cause analysis of the ergonomic incidents and implemented immediate corrective actions. One of the actions was to encourage earlier reporting of these injuries/illnesses.

Results

Reporting of ergonomic illnesses increased by up to 40% in some areas. This was even higher than expected, but the early reporting of ergonomic illnesses helped us reduce the illness’s severity. By fixing the root causes and getting early treatment, we could avoid surgery. This was a positive step for employees and our company. The severity of ergonomic incidents for the entire facility was reduced while the frequency of reporting the incidents increased. The most dramatic improvement was in the customer service department. The severity decreased from 96.4 to 0.0 !
The impact of this improvement is significant. It means much less pain and suffering for our employees by fixing problems early – before significant injuries occur. Long term it also means reduced cost for ergonomic illness related surgeries and lost time during rehabilitation. This is reflected in the the cost of our self-insured workers compensation costs which we have saved on average over $1 million per year for the past six years.

Using TapRooT to Improve Quality & Network Reliability in the Telecommunications Industry

March 15th, 2011 by

Challenge
In 1995, BellSouth Telecommunications noticed an increase in the number of service interruptions or outages caused by procedural errors. A special Quality Action Team was formed to work with an outside company that was hired to investigate the reason for the increased outages. I was a member of the Quality Action Team and worked for six months with this team and the outside company looking into the procedural incidents. When the outside company reported their findings, I believed that the report missed several items. It was incomplete. Several other members of the Quality Action Team had similar feelings. They thought the team should do more. I began to talk with several people in the industry and found out about System Improvements and the work they had been doing in the field of procedural incidents.

Action
I contacted System Improvements, got information about the TapRooT System, and convinced my boss that both he and I should attend one of their courses. Once we attended the course, we decided that TapRooT would help BellSouth truly identify our procedural problems. We had several Quality Action Team members from each of the Regional Technical Support Systems Groups to attend the 2-day class.
Immediately after this class the information began to change about the causes of the outages. The Analyst doing the interviews had new tools and, for the first time, BellSouth began to hear about problems not mentioned in the report.
The TapRooT System proved to be such a big help that BellSouth bought a license for the TapRooT System and trained all 98 Analysts in the Regional Technical Support Groups.
Since then BellSouth has made changes in the databases associated with service interruptions and outages to include information gained from a TapRooT System investigation. We then use that information to look for and solve network reliability issues.

Results
We continue to use TapRooT to identify problems and improve performance. And the results have been outstanding.
For example, in the first ten months of 1997, BellSouth has found 10 vendor document errors (which deal with procedures) and 14 internal procedure errors. Since implementing TapRooT in 1996, we have cut the procedural incident rate by 12% leading to improved network reliability.
The TapRooT System has given BellSouth the tools needed to correctly review and write procedures as well as report the incidents to upper management. The TapRooT System has also given BellSouth the knowledge to write reports in a more clear and precise manner (including what information should be in the reports to upper management).
I believe the TapRooT System has been a complete solution for BellSouth from finding “root causes” to developing fixes to reporting of the causes (and the fixes) that we find. This helps us in our quest to provide outstanding local and long distance telephone service to our customers. Just how good is our service? Well, in 1996 and 1997 we received the J.D. Power customer satisfaction award for having the best local residential telephone service. Perhaps it is a coincidence that we started using TapRooT® in 1996. However, I think it is more a reflection of the best companies will use the best tools for improving performance.

Using TapRooT to Improve Incident Investigation and Identify Fixable Causes

March 15th, 2011 by

Challenge
Prior to implementing TapRooT in 1993, we performed incident investigations but we often stopped at a level above the root cause; we missed root causes that were important; we placed blame rather than finding fixable system problems; and we didn’t have a consistent, convincing means to present our information to management. Therefore, our challenge was to improve our investigation system so that we could better prevent repeat incidents (that can be dangerous and expensive) by implementing effective corrective actions that would be approved by management and implemented in the field.

Action
In 1993 we trained six people in a 5-Day TapRooT Course. The training helped us to decided to go forward with implementing TapRooT, rewriting our investigation procedure, and training a large number of people to use TapRooT to investigate problems.
We decided to license our site to use TapRooT so that we could conduct our own courses based on the System Improvements copyrighted training material. One of the initial trainees became a certified instructor and over an 18 month period he trained about 200 people to investigate problems by using TapRooT.
After our initial implementation, we also developed the capability to record our results in a database and trend the incidents’ causes over time.
Specific Example of How TapRooT Helped
How did TapRooT help us? The best way I can explain the impact of TapRooT is to describe some specific incidents that the TapRooT System helped us investigate and prevent (by identifying root causes that we could fix by implementing practical fixes).
One example was the investigation of a large fire in a process unit. The fire resulted in a complete unit shutdown. The systematic TapRooT investigation helped us identify the misapplication of steel in the process as one of the causes.
But TapRooT didn’t let us stop there. We continued to look for the system causes that led to why the wrong metal was used. This allowed us to prove that we needed to perform a complete material verification (PMI or Positive Material Identification) to make sure that there were no other misapplications of steel in other similar parts of the process.
This verification was expensive. Without the detailed proof and logical presentation tools that are built into the TapRooT System, management might not have perceived the need to spend the money needed (and commit to the plant down time needed) to complete this verification.
What did we find? The inspections identified three additional areas that needed repair. Any one of these could have resulted in an additional fire and unexpected shutdown. Worse yet, a large fire could cause injuries or fatalities. By using TapRooT we avoided these future problems that would have eventually occurred.
As part of the TapRooT process we institutionalized our corrective actions by updating the PMI Policy. We also looked beyond the specific problem of this application of metallurgy to the generic problem of pipe wall and pipe joint thinning. (Having a database helps you develop a convincing argument that this isn’t just a one-time problem but rather is a repetitive problem that needs a refinery-wide system fix.)

Longer Term Results
In January 1997, when performing the inspections implemented as a result of our previous TapRooT investigation, we found thinning of a piping joint on a process unit furnace. We shutdown the furnace to make repairs that cost about $270,000. If the inspection (implemented after the incident investigation described above) had not been performed, the pipe would have failed. The cost of repairing a catastrophic failure would have been much higher (possibly ten times as much) and could have led to personnel injuries.
The total impact has been so broad and pervasive that it’s hard to measure in dollars. Why? Because some improvements are made by people in the field and aren’t “documented” as being attributed to implementing TapRooT. Also, it would be unfair to say that the only improvement initiative is TapRooT. Therefore in any large facility the total progress being made is not the result of a single initiative but rather the cumulative impact of all improvement initiatives. Therefore we can’t just look at our improved performance and attribute it all to TapRooT.
However, I can point to specific incidents (like the one I described here) that TapRooT helped us develop effective corrective actions that would not have been developed before we started using TapRooT.

Lessons Learned
Here at the Torrance Refinery, we are firm believers that the TapRooT System provides us with the necessary tools to determine the true root cause of an incident. This saves us investigation time and saves us the pain of having repeat incidents that we know would cost millions of dollars and cause personnel injuries.
We have also learned that we needed to apply TapRooT “across the board.” If we tried to apply TapRooT only occasionally, we lost proficiency and missed opportunities to catch problems when they were small (before big accidents happened).
We also learned that we needed to trend root cause data from the incidents so that we could identify problem areas (generic causes), allowing us to eliminate whole classes of incidents by implementing generic system fixes. The database also helps us make a convincing argument that helps management see the need to implement fixes that we previously would have failed to convince them of their desirability.
We are expanding the use of TapRooT beyond safety and production issues to problems with project planning and implementation. This is leading us to new ways to improve our project initiation and approval processes and save even more money by stopping problems before they are “set in concrete.”

Using TapRooT to Improve Incident Investigations, Root Cause Analyses, and to Reduce Incident Rates at Fernald

March 15th, 2011 by

Challenge
The Fernald Environmental Management Project (FEMP) is a former uranium processing facility located approximately 18 miles northwest of Cincinnati and operated by Fluor Fernald, Inc. for the U.S. Department of Energy (DOE). In 1994, the FEMP had implemented a relatively new process of reporting occurrences to the DOE via the Occurrence Reporting and Processing System (ORPS). However, our processes for investigating and analyzing our occurrences were inconsistent and fragmented in multiple departments. Our incident investigation methods were criticized because they were too subjective and incomplete. We searched for a system that would give us an objective, comprehensive, and defendable process for incident investigations that would satisfy the DOE.

Action
In March of 1994, two of our investigators were sent to the TapRooT 5-day Incident Investigator Team Leader Course in Knoxville, Tennessee. Upon their return from the course, efforts began to obtain a site license and to implement the TapRooT system for our ORPS-related incidents.
Site-specific investigation procedures were developed and implemented that required the use of the TapRooT system for reportable occurrences. Training courses were developed and given to hundreds of managers, supervisors, union leaders and employees across the site. In concert with the implementation of TapRooT, a centralized Incident Investigation Team was created with the sole purpose of conducting all ORPS-reportable occurrence investigations, in order to promote even more consistent investigation and reporting practices.
The DOE, FEMP Management, and our Union Leadership were all immediately impressed with the TapRooT process for many reasons. Collectively, they could see that TapRooT was not only an effective process for investigating and analyzing incidents, but that it could also promote better management-employee relations, improve procedures, and be used proactively to prevent incidents before they occurred.

Results
As stated earlier, the primary purpose of purchasing the TapRooT system was for analyzing ORPS-reportable incidents. In the five years prior to purchasing the license, the FEMP experienced an average of over 100 reportable occurrences per year. In the five years after licensing, we have reduced our incident rate to about 46 per year.
Furthermore, the safety significance of our incidents has also been reduced. In ORPS, there are some reporting criteria that are very subjective in nature. In the first five years, incidents classified in the subjective criteria accounted for only 16% of the total incidents. Today, subjective reporting has increased to about 60% of the total number of incidents. This means that our process has worked to eliminate “significant” events and raise the significance of events that were previously considered to be minor in nature. In effect, we have taken great strides in “melting the process safety iceberg,” as illustrated in the TapRooT training.
Given the success of using the TapRooT process in ORPS, we have expanded its application to other areas, including Price-Anderson Reporting, OSHA injuries, and self-identified Concerns. As with ORPS, incredible improvements are now being realized. For example, we recently broke the site record for Safe Work Hours (8 million) and also passed the 8 year mark without a lost time injury to our construction contractors. In the area of Price-Anderson, our performance has also been exemplary in that we are one of the few DOE sites without an enforcement action on our record.

Path Forward
While our results in our targeted areas have been beyond our initial expectations, we can now envision improvement of all our processes to a previously believed unattainable level. Our goal now is the complete elimination of all incidents and injuries, no matter how small or relatively insignificant. In other words, we will strive to COMPLETELY melt the iceberg! Our Management has seen the tangible benefits of our efforts in reduced costs in insurance premiums, reduced project down-times, and the prevention of civil penalties for poor QA and Radiological Control performance.
Given our success in improving safety, performance, and reliability in our target areas, we feel that nothing is beyond our grasp. With the addition of the TapRooT® software and the Trending programs, we are well-equipped to meet our ultimate goal.

Using TapRooT to Improve Investigations by Focusing on Fixable Causes Rather Than Blame

March 15th, 2011 by

Challenge
Many of us investigate accidents that the cause seems intuitively obvious: the person involved just “goofed up.” And what is the natural corrective action for this type of problem? Because they are to blame, the most frequent corrective actions are a warning, a reprimand, or some other kind of punishment.
We hoped that for most accidents there was more to the causes than just simple human error. Why did we hope this? Because we wanted to improve performance and if “to err is human,” then we needed to find fixable causes beyond human error so that we could make improvements to the system and thereby get improved performance.
The following is an example of a typical accident that on the surface seems to be a simple human error. However, by using TapRooT® we found system causes that, when corrected, will help us prevent similar accidents.

Accident
A truck carrying 30 tons of steel rolled over while rounding a corner. The load spilled next to and under a NGL (natural gas liquid) pipeline. The driver was uninjured. Obviously this accident could have been much worse.
The natural assumption for an accident of this type on the North Slope is that either the driver was traveling too fast or the driver ran off onto a soft shoulder. Our challenge was to find out what really happened and how it could be effectively prevented in the future.

Accident Investigation
The only witness to the accident was the driver. Therefore to find out what really happened, it was essential to have his complete cooperation. Therefore we started out by explaining to him that we were going to draw a simple chart (an Events & Causal Factors Chart) to lay out the complete sequence of what happened. That we would start out by letting him tell us in his own words what happened from start to finish. Then, once he was finished we would draw the chart and ask questions. He seemed very comfortable with the approach so we continued.
The result of using this simple process (part of the TapRooT System) was amazing to both of us (the two investigators). The more he talked the more we realized how little we really knew about what had occurred.
After he completely told us his story and we started to draw up the E&CF Chart and ask him questions, it became obvious to us that the driver felt that he was completely responsible for the accident and that he wanted to help us so that we could keep similar accidents from happening to other drivers.
The driver told us that he had a minor breakdown and was concerned about being a little late. So he called his boss on his cell phone. When he hung up the phone he realized that he was in the middle of a sharp corner. He jerked the wheel to stay on the road. Jerking the wheel caused the load to shift (it wasn’t properly secured). The sudden shifting of the load caused the truck to flip.
We focused on two factors: the distractions that caused the driver to not fully be aware of the curve until he was already well into it and the shifting of the load that led to the truck flipping.
Our first concern was cell phone usage while driving. We looked into the problem and found that 14 states and numerous countries have pending legislation regarding the use of cell phones in moving vehicles. Developing a policy preventing the use of cellular telephones by the driver of a moving vehicle is not a popular idea on the North Slope or elsewhere. Rather than fix this problem, there are those who would much rather simply blame the driver, dismiss him, and get back to business as usual. But this wouldn’t solve the problem. So we are going to move ahead with a recommendation to not allow the use of cell phones by the driver of a moving vehicle and to raise the awareness of this hazard (as is the Alaska Truckers Association).
Our second concern was the improperly secured load. Our roads on the North Slope are non-DOT regulated. We found that the drivers had no guidance or formal training for securing loads on our type of roads. Therefore many loads were not “properly” secured because the guidelines for properly securing a load had not been developed. Therefore we are going to develop guidance for properly securing loads on the North Slope’s non-DOT regulated roads.

Results
Was this incident simple human error? Our answer is that there was much more to it than that.
On the North Slope vehicle accidents have been the leading cause of fatalities. Investigations that look for correctable causes (like inappropriate cell phone usage and improperly secured loads) and get corrective action implemented will help us reduce hazards and improve our vehicle safety record.
As for the driver, he was not fired. His employer recognizes that he is a valuable asset to his company. And he is one of the people in his organization that is helping raise the awareness of the hazards of cell phone usage by drivers.

Using TapRooT to Improve Root Cause Analysis & Safety at Intel

March 15th, 2011 by

Challenge
We experienced a rather severe incident early in 1995 and recognized the need for better root cause analysis to improve our accident investigations. Our challenge was to find a better system, apply it, and thereby improve safety at our facility.

Action
We held our first on-site TapRooT Training in mid-1995. Shortly after the training we had another incident that allowed me to use the skills I had learned at the TapRooT Course. It was evident to everyone participating in the investigation that the TapRooT® System was a really useful tool to help us identify the causal factors and ultimately the root causes and corrections. Our management was impressed enough with the results of the system to send two of us to a 5-day TapRooT Team Leader Class.
When we returned from training we performed several investigations using TapRooT to help us identify fixable root causes. Our investigation work and the results we were getting came to the attention of other groups. The decision was made for our facility to obtain a TapRooT License so that we could conduct our own on-site courses using the TapRooT training material. We could then spread the techniques to a large number of employees.

Results
We held our first on-site course taught by Intel instructors in May of 1997. Within 18 months we had trained 132 employees. How did the classes go? We get frequent comments like:
“This is the best training I’ve ever had.” and
“Great class – this should have been provided years ago.”
But positive comments on course critiques is not the reason we chose to use TapRooT. We decided to use TapRooT® to improve our root cause analysis and improve safety at our plant. And we think that the results we’ve achieved show that we made a wise decision.
First, we are frequently asked to help with investigations. The most impressive part of these investigations are the results we’ve accomplished. When we investigate an incident using the TapRooT® System and get the corrective actions applied, the incident does not repeat.
Second, it has become common for management to ask key TapRooT trained investigators to review other investigations (that didn’t use TapRooT) so that they would be assured that the real root causes were identified. This is a pretty impressive indicator all by itself!
Third, TapRooT has been so successful helping us improve safety that we are now using it to investigate other types of incidents: yield loss, misprocessing, and audit findings.
So how successful have we been in improving performance using TapRooT? Naturally, I can’t give TapRooT credit for all the improvement we’ve experienced, but it is a part of some key programs that produced the following results:

Plan Safety Indicators

1995 1996 1997 1998 1999 2000 2001
Lost Day Case Rate 1.88 0.44 0.33 0.08 0 0.08 0
Recordable Injury Rate 5.33 2.47 1.17 0.61 0.27 0.16 0.08
Safety Bulletin Incidents 1 0 0 0 0 0 0

I think that these results speak for themselves.
Thanks for the great system.
John Carpenter
Safety/ERT/Microcontamination Manager (retired)
Intel Corporation

Using TapRooT to Improve Process Reliability

March 15th, 2011 by

Challenge
Our Acrylates Area Oxidation Reactor was experiencing frequent unplanned shutdowns (trips) that were causing losses of large fractions of our plant capacity. Previous corrective actions seemed to have little lasting impact. Our challenge was to form a team of operators, mechanics, and an engineer and come up with ways to reduce and eventually eliminate these unnecessary shutdowns.

Action
A team was formed to study the problem. We decided that we needed better data (not conjecture) to study the reasons for the plant unreliability. We had heard about the TapRooT System and so the whole team attended an open 2-day course.
We went back and started performing a root cause analysis of each reactor trip. Using the root cause information, we developed solid corrective actions for each problem. We also collected statistics (a rolling three month average) about the causes of the shutdowns and looked into the generic (systemic) causes for the top three causes and developed additional systemic corrective actions for these.

Results
In less than 12 months we saw a constant, dramatic improvement in our plant reliability. Due to the reduction of the number of shutdowns and the estimated capacity available with the improved reliability, in the past two years we saved about 40 million dollars. These savings will continue to accumulate so the total saved will be even more.
Besides saving money, our team received the highest corporate award possible for these improvement efforts. It easy to see why we believe that learning and using the TapRooT® System is an excellent investment.

Improving Investigations to Provide Management with the Information They Need to Support Corrective Actions

March 15th, 2011 by

Challenge
The Bi-State Development Agency is a progressive rail and bus transit system whose service area includes metropolitan St. Louis, Missouri and expands over the Mississippi River into St. Clair County, Illinois.
In December of 1998 I became the Manager for Bus and Rail Safety. In discussions with the new Executive Director one of my challenges became clear. I needed to improve the investigation and reporting of accidents so that management would have the information they needed to improve performance and support effective corrective actions.
Before my arrival, a member of the Safety Department would go to the scene of an accident and, within four hours, write a “Fact Sheet” (a boilerplate consisting of the events leading up to the accident and the response efforts). Management recognized that this method of investigation just was not providing the information needed to develop effective corrective actions.

Action
Fortunately, I already had a plan. I had previously used TapRooT to improve investigations and I knew how fast it could work to improve investigations and corrective actions. So I introduced TapRooT as the Safety Department’s investigative tool and sent our investigators to TapRooT Training.

Result
Within weeks of instituting TapRooT as the investigative tool, we had dramatically improved the investigation of accidents. The Safety Department drew Events and Causal Factors Charts as part of the investigation and used the charts to explain what happened to management. We also used the TapRooT Root Cause Tree to consistently identify the accidents’ root causes. These two techniques helped us understand the details of what happened and look much deeper into the system causes that needed to be corrected.
Of course, this was much more difficult than just blaming the driver. But the effort is very worthwhile. The Safety Department can now answer questions as to why human error or mechanical failure occurred.
Upper management was pleased with the wealth of knowledge gleaned from the TapRooT System. People that I hardly knew were stopping me to say that the reports were much more informative and that now they now understood Safety?s role in accident investigations. Using TapRooT, our department provides an unbiased resource to dig into the factors that caused the accident, find the system causes, and recommend effective corrective actions.
Since implementing TapRooT, the Executive Director praises our accident reports saying that they ?now add value in terms of reducing accidents and improving the way Bi-State does things.
Our next challenge is to ensure that the corrective actions are implemented quickly and documented when completed. But with upper management?s support for problem investigation and rapid implementation of corrective actions, I?m sure our efforts will be successful and that we will have even more impressive successes to report in the future.

Improving Investigations and Root Cause Analysis

March 15th, 2011 by

Challenge
As the Supervisor of Health and Safety at Enmax Corporation (a municipal electric utility), I reviewed all incident reports. My observations were that quality of the reports varied greatly depending on the training, experience, and diligence of the investigator. There was little consistency in format and content from one report to the next. And the investigators tended to identify immediate causes (actions that went wrong) rather than root causes (the causes for the actions that went wrong).
Perhaps these problems were related to the investigation system we were using. It was time consuming and not very user friendly. And it didn’t provide us with a tool to clearly explain what happened and why it happened. Nor did it effectively track the status of corrective actions.
To me the challenge was obvious. If we wanted to learn more from the dear bought experience derived from accidents and incidents, then we needed to improve our investigation and root cause analysis.

Action
Fortunately, I had just been introduced to a system for incident investigation and root cause analysis called “TapRooT.” The action to take seemed clear. I needed to hold training for the people performing investigations so that they could use TapRooT to improve our investigation performance.

Result
The feedback from the participants in the training was that they left the course feeling confident that they had the skills they needed to use TapRooT to find the root causes of our incidents. They now had a new vocabulary of root cause analysis, a clear goal for their investigations, and the tools they needed to reach that goal.
However, the real test would be when they applied the techniques. What would I get? The answer was clear and obvious. I immediately noticed improvement in the quality and thoroughness of investigations and reports. This improvement and consistency meant that all the investigations were well above the minimum that I expected.
The software also helped improve the consistency of the reports and our analysis and the database helps us maintain our incident records. The Corrective Actions Reports are essential in completing the investigation loop by tracking the status of corrective actions and providing documentation that improvements have been implemented.
We are in the process of implementing the improved corrective actions that we are developing thanks to TapRooT. As time passes I’m sure that I will be sending you an additional success story with the statistical data that shows the impact of improved root cause analysis on our already good health and safety record.

Improved Medication Administration By Using FMEA and TapRooT to Proactively Analyze the Process

March 15th, 2011 by

Challenge
Our challenge was to further improve the medication administration process at our facility by proactively analyzing the process using FMEA and TapRooT. Our goal was to find ways to help prevent errors and increase patient safety by identifying error prone points in the system and anticipating what might cause these failures so they could be eliminated or minimized whenever possible. The medication administration process had already been reviewed for ways to decrease medication errors and increase patient safety. Therefore, we were starting with a system that many people thought might not present easy improvement targets.
A practical constraint to our efforts was that because of the fiscal constraints that all healthcare facilities face in these days of tight budgets, we knew it would be difficult to make large capital investments. Therefore, complex or costly systems for automation of the medication administration process were not a possibility.
However, we thought that by the use of systematic evaluation tools – FMEA and TapRooT – we might find ideas for improvement that others had missed.

Action
We formed a core team of nurse managers and pharmacists to analyze the process. As the analysis progressed, others were asked to help where they had more familiarity with or a better working knowledge of the process in a particular area. Each of these team members had been trained in the past in the use of TapRooT (TapRooT has been used at our institution for the last 5 years).
We started by diagramming the process using the SnapCharT Software from the TapRooT System. This helped the team visualize the whole process and break it down into manageable pieces for further analysis.
As we performed the FMEA for various parts of the process, familiarity with the TapRooT System’s Root Cause Tree helped team members ask better questions and identify potential failures that they may not have thought of without the TapRooT Training. The TapRooT Training also increased the team’s awareness of how problems at a particular unit might be generic (applicable to the whole organization).
Once the team had identified problems and their root causes, it was time to develop corrective actions. This is where the training that we had received at the TapRooT Course about developing ?SMARTER? corrective actions came in. As we looked for ways to improve, we considered the caregivers and what it takes to provide that care. We made sure that safeguards that we put in place to improve patient care didn’t actually introduce new types of errors by making the process too complicated or difficult to follow. Therefore, each corrective action was reviewed (the final “R” of SMARTER) to make sure that there were not any unintended negative consequences from the proposed improvement.

Results
How did we improve our medication administration process to improve patient care? Here are some of the ideas that we implemented:

  • Medication carts ordered for the bigger units that will enable medications to be prepared closer to the patient decreasing distractions.
  • Medication references easily accessible at the point of administration and pharmacy phone numbers posted bold and bright encouraging communication and questions.
  • Rearranging of floor stock medications in smaller units where storage is a problem.
  • Changing labels where labeling was not clear in some areas.
  • Chemotherapy administration sequence references made readily available.
  • Standardize transcription on the major units to decrease transcription error potential.

None of these changes look like a radical departure from our old practices. None of the changes were extremely expensive. But people involved in the analysis believe that the changes address issues that could have caused errors and had previously been overlooked in our improvement efforts. Therefore the analysis was both useful and worthwhile.
Our institution has a strong commitment to continuous improvement of patient safety and the quality of care. Use of systematic tools – like TapRooT and FMEA – helps us recognize the potential opportunities for improvement proactively.
As a healthcare professional I feel that this proactive approach (instead of waiting for accidents and analyzing the failures after the fact) allows us to manage our processes and provide better care. We aren’t victims of the system with no control to change or improve things. We can systematically analyze, manage, and improve our processes. And TapRooT is a key part of that proactive analysis and improvement process.

Improved Investigations and Enhanced Management Interest and Acceptance by Using TapRooT

March 15th, 2011 by

Challenge
We wanted to improve our incident investigations, root cause analysis, and corrective actions.

Action
In 2002, we decided that to reduce accidents, prevent injuries, and ultimately save money, we needed to do a better job investigating accidents. We investigated various improvement options and decided to try using the TapRooT System for investigation and root cause analysis.
Several of our staff attended System Improvements’ 5-day Advanced TapRooT Investigation Team Leader Training and received an individual user version of the TapRooT Software as part of the course. After the course we returned to apply the tools that we had learned to investigate bus and rail accidents, employee safety incidents, and safety issues.

Results
We immediately noticed improvements in our investigations.
The SnapCharT diagram drawn using the SnapCharT Software helped us understand the circumstances surrounding an incident.
The Root Cause Tree part of the TapRooT Software helped us analyze the root causes to a much greater level of detail. This better analysis and the Corrective Action Helper® Module of the Software helped us develop more effective corrective actions.
An unexpected but very valuable side benefit of our efforts has been the effect the TapRooT System has had on the interest of management in our investigations and their acceptance and support of the investigations and corrective actions.
Management has a much better understanding of what happened when we use the SnapCharT technique to present the incident to them. The presentation of the Safeguards (found using Safeguards Analysis) helps them understand how many or how few things had to fail to cause the incident. And management has commented that they now see corrective actions that they believe will be much more effective than before we started using TapRooT.
Because management support to pay for and assign resources to implement corrective actions is so important (because without implementation of corrective actions, your analysis effort is wasted) the new enhanced support by management may be the most important benefit that we have seen.
In summary, by using TapRooT we have achieved our goal of improved investigations, root cause analysis, and corrective actions. We also achieved a perhaps even more important benefit of enhanced management interest and acceptance of investigations and greater support for implementation of our corrective actions. This is helping us improve transit safety and operations and will eventually lead to cost savings.

Using TapRooT to Improve Root Cause Analysis, Cut Our Incident Rate, and Our Workers’ Compensation Costs

March 15th, 2011 by

Challenge

At our phosphate mining and chemical plants located in White Springs, Florida, we had been improving our safety processes throughout the 80’s and into the 90’s. We had recognized a need for improved consistency in our root cause analysis. With this in mind I attended a 2-day TapRooT Course in October of 1995 and was convinced that the TapRooT System offered us the mechanism for improving our incident investigation system and ultimately achieving our goals in safety excellence.

Action

We began in 1996 by having System Improvements conduct two on-site 2-day TapRooT Courses for 50 people (including frontline Supervisors, Superintendents, Safety Specialists, and our four Chief Shop Stewards from the union who serve as Safety Committee Chairmen). In addition, we held a four hour overview class for our upper management including our Vice President of Operations.
We started by applying TapRooT to analyze the root causes of our OSHA/MSHA recordable injuries and significant near-misses. As our confidence and experience with the system grew, root cause analysis and TapRooT became “household words” for our employees and were used for a variety of analysis and improvement efforts. The techniques were highly valued by management and employees. The acceptance of the TapRooT System by our bargaining unit was an unanticipated benefit. This was at least partially due to the Chief Shop Stewards attending the same training as our Superintendents so that both groups had a clear understanding of the process and both could easily see that in TapRooT there are no hidden agendas.
In 1997 and 1998 we have increased our skill in applying TapRooT and increased the scope of the investigations in which we apply TapRooT. We now consistently apply TapRooT to all incidents including near-misses and first aid incidents. Looking for and fixing root causes for these smaller problems represents a paradigm shift for line management and employees alike. It also provides many more opportunities for our employees to hone their skills in the use of TapRooT.

Results

Improvement in a single element of a safety process will normally not bring success for the total program. Also, increasing the number and scope of root cause investigations is only worthwhile if you can see results that justify the effort. However, we have seen a direct link between the improvements we have made to our incident investigation process by using TapRooT® and our total safety process results.
First we have seen two improvements in our injury incident rate. Before implementing TapRooT our injury incident rate was 2.66. By 1997 it had declined to 1.75. After increasing our use of TapRooT to analyze near-misses and first aid incidents, our injury rate was cut in half (from our 1996 rate) to 1.27 for the first three quarters of 1998.
During the same period we have achieved two safe work milestones for our site by working 1 million and 2 million hours consecutively without a lost time accident.
These incident rate records have also led to financial rewards in the form of decreased workers’ compensation premiums that have more than paid for the cost of the training.

Path Forward

Perhaps the best way to judge our belief in the effectiveness of the TapRooT System is to observe that we are have licensed the use of TapRooT System and Software for our entire company.

Finding Root Causes Without Blame

March 15th, 2011 by

Challenge
Perform an investigation of an incident under our new “non-punitive environment policy” to focus on real, fixable root causes rather than focusing on blame.

Action

The healthcare industry has recognized that improved root cause analysis of quality incidents and healthcare sentinel events is required to improve patient care and reduce patient risk. But one obstacle to improved root cause analysis is a long history of blame oriented investigations and tort actions that cause individuals to be reluctant to share information about mistakes. Therefore, our hospital decided to institute a new “non-punitive environment policy.”
Part of this “non-punitive environment” policy for investigations was using the TapRooT System to investigate the incident, find root causes, and develop corrective actions. One of the reasons that TapRooT was chosen was that it provided a robust systematic approach to root cause analysis without pointing fingers and placing blame. This was not the first time we had used TapRooT, but it was the first time we used TapRooT in a “non-punitive environment” investigation.

Results
The first incident we chose to investigate was one that, in the past, would probably have been very blame oriented. A wrong patient was given the wrong drug intravenously.
This is a violation of our “5 Rights” policy that is standard practice throughout the medical industry.
However, by using TapRooT we found causes beyond the normal “policy was violated” causes that we had expected. We found that:

  • The IV bag design had changed and now it was the same size as other bags.
  • The font and type used to label the bags was small and could easily be misread.
  • The nurses hurried because of unnecessary, repetitive paperwork that could be reduced to allow more time with patients and in administering medications.
  • That IV bags were being hung unnecessarily high which made them hard to read for short nurses (especially if the nurse wore bifocals).

The increased information obtained led to a better understanding of the contributors to the errors and helped the investigation team develop corrective actions that previously would not have been considered. These included:

  • Increasing the type size that is printed on the label of the IV bags.
  • Putting the patient’s name in BOLD type to make it easier to find on the label.
  • Lowering the height of the IV bags for IV’s being delivered by IV or PCA pumps.

Implementing these corrective actions did not reduce the importance of the “5 Rights” policy. The corrective actions highlighted that hospital management was taking action to ensure that the “5 Rights” policy could be implemented more effectively. This reinforces to our staff the importance of the policy and their compliance with it.
Because of this management effort to make the policy easier to comply with, the staff is even more committed to use the “5 Rights” policy consistently and accurately.
We therefore see this investigation as a very successful first application of our “non-punitive environment policy” for investigations.
The staff was more willing to openly share mistakes that they had made.
The investigation team identified causes that they previously would have missed.
The hospital implemented corrective actions that will improve performance and improve compliance with a policy without blame or disciplinary action.
The entire staff (investigation team, those who made the mistakes, and hospital management) was impressed with the process and how TapRooT helped people focus on what happened and what could be done to improve performance rather than focusing on who to blame.

Closing the Gap – Improving Incident Investigation & Root Cause Analysis

March 15th, 2011 by

Challenge
Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques instructor for our company. I found that many investigators, including myself, had some difficulty (or were inconsistent in) finding the root causes for incidents. We needed some way to consistently find accurate incident root causes to better learn from the incidents. Therefore our challenge was similar to many companies – we needed to consistently find the root causes of incidents.
We needed a tool that we could provide in our training that would guide investigators through root cause analysis without restricting the results. This tool should expedite and add value to investigations. It needed to be simple to use by people who did infrequent investigations, as well as for use in both complex and simple types of incidents.
All these requirements were a tall order.

Action
Fortunately, a colleague of mine had mentioned a system he had seen that might fill the need I had identified. I found out more about the system, called TapRooT, and decided to attend a 5-day course.
Once I saw they system in action, I knew TapRooT would work to help us improve our investigation. But how would we include TapRooT in our training and how would we get people to use the tool in performing investigations?
I decided that I would try TapRooT in several investigations and then share the results. Soon several colleague and my boss agreed it was a valuable addition to our investigation process. Our group decided to buy a license so that we could conduct our own in-house training. I became a certified as a TapRooT instructor and taught TapRooT as part of our companies investigation training.

Results
In the first three months that we offered the training, in excess of 100 people learned how to use TapRooT. The comments from the attendees after they investigated incidents were very favorable. The most important result was that the quality of investigations. My reviews showed that the investigation root cause analysis had improved considerably. The field personnel were using it, producing better, more consistent results. More and more individuals were asking for TapRooT training.
The use of TapRooT was never mandated yet it became the process of choice within our company. Positive comments have been received from employee representatives and managers.
Trying to evaluate the exact dollar cost savings of implementing TapRooT is difficult. Many good initiatives have been implemented as a result of our incident investigation processes. TapRooT has helped these investigation become much more effective. TapRooT helped us develop corrective actions that previously would have been missed. This has helped us prevent many costly incidents and has clearly contributed to our continuing improvement in our safety statistics.
Perhaps the best indicator of TapRooT’s success is its use throughout the company. In the four years since TapRooT was introduced, its use is widespread and requests keep coming for training. Using TapRooT is responsible for the continued improvement of our investigations and corrective actions. And we are now using TapRooT to finding root causes of audit findings.
As Manager of Health, Safety, & Environment, I consider TapRooT an essential part of our safety improvement efforts and our implementation of it a resounding success.

Using TapRooT and System Safety to Improve Aviation Safety

March 15th, 2011 by

Challenge
To improve aviation safety effectively, efficiently, and proactively.

Action
Alaska Airlines adopted System Safety and incorporated TapRooT into the process to find the root causes of problems discover before accidents or incidents could occur.

Results

See the video here to view World Business Review (a TV Show) hosted by General Alexander Haig. David Prewitt (VP of Safety for Alaska Airlines), members of Mr. Prewitt’s staff, and Mark Paradies (President of System Improvements) discuss the use of System Safety and TapRooT® to improve aviation safety.

World Business Review is seen on various cable networks including the Technology Channel and PBS Business.

Using TapRooT to Improve Investigations, Stop Fault Finding, Reduce Injuries, & Cut Workers’ Compensation Costs

January 6th, 2011 by

Challenge
Skyline Mines is an underground coal mining operation with over 350 employees. Our challenge is to go from a company with a better than average lost time injury and reportable injury rate to an injury free workplace.

Action
In January of 1996 our focus shifted from formal investigation and review of just MSHA reportable injuries to investigation and measurement of all incidents. Prevention efforts were then focused on the elimination of these injury causing events. The underlying principle being that the only difference between a Worker?s Comp. injury, MSHA reportable, or lost time accident was severity and that severity had nothing to do with what had caused the incident. We began to focus more and more on the root causes for the injury causing events.

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Angie ComerAngie Comer

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Barb PhillipsBarb Phillips

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Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Gabby MillerGabby Miller

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Garrett BoydGarrett Boyd

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Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

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Mark ParadiesMark Paradies

Creator of TapRooT®

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

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Wayne BrownWayne Brown

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