Register today and join us in San Antonio, Texas, August 3-5, 2016.
The Global TapRooT® Summit offers multiple focused learning tracks. This video introduces the Medical track for healthcare professionals. Come to the Summit and maximize improvement at your company!
REGISTER for the 2016 Global TapRooT® Summit.
Interested in the Investigation Track? Learn about it here!
Interested in the Asset Optimization Track? Learn about it here!
Interested in the Safety Track? Learn about it here!
Interested in the Quality Track? Learn about it here!
That’s why we make the Summit FUN!
Don’t miss it! August 1-5, 2016.
More info here:
Did you know… TapRooT® has a block of rooms at the Westin Riverwalk hotel in San Antonio for attendees to get a discounted rate? Not only is the Westin hotel ideally located on the historic and beautiful Riverwalk, it is also the venue for the 2016 Summit. With these perks plus a discount, why would you not book your room today?
The deadline for booking your room with the TapRooT® room block is July 15. Hurry now before they all fill up!
Click here for all the information you need to book and prepare for your trip to San Antonio.
There is also still time to register for the TapRooT® Summit. Follow the links below to find all the reasons why you need to be in San Antonio for the 2016 Summit.
Words that I hate to hear when asked to help with an investigation: “I am surprised this incident did not happen earlier!” Rarely have I seen an incident where there is not a history of the same problems occurring. Think of it like a math equation:
X + Y (A) = The Incident
A company’s issues are just waiting for the right math equation to occur at the right time. What are some of the common factors that populate the equation above?
- Audit Findings (risk or compliance)
- Near Misses (or some cases, Near Hits)
- OSHA Non-Recordable(s)
- Defects (caught before the defect reached the customer)
- Project Delays
- Procurement Issues
- Behavior Based Safety Entries
This list of variables is infinite and dependent on the industry and service or product that your company provides. Should you be required to perform a full root cause analysis on each and every write-up or issue listed above to prevent an Incident? Not, necessarily.
Instead, I recommend that you start looking at what would be a risk to employees, customers, environment, product/service or future company success if you combined any of your issues in the same timeline or process of transactions (in TapRooT® our timeline is called a SnapCharT®). For example, take the 3 issues listed below that have a higher potential of incident occurrence when combined in the right equation.
Issue 1: Audit finding for outdated procedures found in a laboratory for testing blood samples.
Issue 2: Behavior Based Safety Write-up entered for cracked and faded face shields
Issue 3: Older Blood Analyzer has open equipment work orders for service issues.
Combining the 3 items above could cause a contaminated blood sample, exposure of contaminated blood to the lab worker or a failed test sample to the patient.
If the cautions about your future combination of known issues are not heeded then please do not acted surprised after the future Incident occurs.
Want to learn about causal factors? It’s not too late to sign up for our Advanced Causal Factor Development Course, August 1-2, 2016, San Antonio, Texas.
I just went through the attendance list for the 2016 Global TapRooT® Summit and I was impressed. What a great bunch of people we are having come together in San Antonio!
For me, as President of System Improvements and one of the creators of the TapRooT® Root Cause Analysis System, the Summit always seems like old home week or a high school reunion. I get to see some of our clients that have been working hard to save lives, improve quality, and keep their companies from getting a black eye.
We’ve been doing these Summits since 1994 and you might not believe it but, I’ve been learning new and valuable stuff at the Summit every year.
So for all of you coming to the 2016 Global Summit,
I CAN’T WAIT TO SAY “HOWDY!”
And get caught up on what you have been doing to make the world a better place.
And for those who haven’t signed up yet,
What? You don’t know why you should attend? You need the knowledge shared at the Summit to …
SAVE YOUR COMPANY $$$
Those are business critical topics that you need to make your company best in class.
See the Summit brochure at:
See the Summit agenda at:
If you need more convincing, let me plead with you to attend. Watch this video…
Can command and control improve safety?
According to this ABC article, Chinese government has “ordered” improvements in safety. Yet 11 people died in an accident at an Aluminum Corp. of China aluminum plant when equipment they were dismantling fell on them. The article also mentions the chemical explosion that killed 173 people in the port city of Tianjin last year.
What are you doing to improve safety?
Can you or your management “order” improvements?
Perhaps you need to learn root cause analysis and best practices and skills to make your safety program world class?
If you want next year to be better than this year, sign up for the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5.
Pick the advanced course that will help you learn the skills you need to to improve your company’s performance.
Then pick the best practice sharing sessions at the Summit that will help you meet the biggest challenges that face your company.
Learn from your peers from around the world (see the LIST here).
Learn from people in your industry and other industries (see the LIST here).
And don’t forget our Summit GUARANTEE:
Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
Dave Janney invites you to TapRooT® for Audits, a special 2-day course for auditors to help them find and fix the root cause of problems as well as use TapRooT® Root Cause Analysis proactively.
Here’s a partial list …
- New Zealand
- Saudi Arabia
- United Kingdom
That’s why we call the Summit a GLOBAL Summit. Every continent is represented.
Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:
And find out about all the great sessions and keynote speakers by visiting the Summit web site at:
Who would you like to network with if you were going to share best practices and learn how others have solved problems?
The TapRooT® Summit is a great place to meet industry leaders.
Here a partial list of companies that have signed people up for the 2016 Summit:
- Air Liquide
- Arizona Public Service
- Avangrid Renewables
- Balitmore Gas & Electric
- California Resources
- Duke Energy
- Formosa Plastics
- Lawrence Berkeley national Lab
- Liberty Carton Company
- Matrix Services
- Nalco Champion
- National Grid
- Northern Star Generation
- NRG Energy
- Nuclear Fuel Services
- PCS Nitrogen
- Prarie State Generation
- Pratt & Whitney
- PSH JV
- Red Cedar Gathering
- Sacramento Municipal Utility District
- Saudi Aramco
- Teranga Gold
- Tuscon Electric
- US Well Services
- United Technologies
- Vancouver Airport Authority
- Westar Energy
What are some of the job titles of people attending the 2016 Summit?
- Airside Safety Officer
- Area HSE Manager
- Compliance Specialist
- Corporate ESH Director
- Corporate HSE Manager
- Corrective Action Program Manager
- Director of Corporate Safety
- EHS Engineer
- Electrical Engineer
- Emergency Management Manager
- Engineering Superintendant
- Environmental Steward
- Facility Manager
- Global H&S Advidor
- HSE Regional Leader
- HSE Director
- HSE Specialist
- HSE Supervisor
- Human Performance Specialist
- Industrial Hygienist
- Industrial Operations manager
- Issue Management Program Leader
- Lead Production Supervisor
- Loss Prevention System Advisor
- Manager, H&S
- Mechanical Engineer
- Operational Excellence Manager
- Operations Staff
- PDM Coordinator
- Process Safety Manager
- PSM Specialist
- QHSE Leader
- Quality Auditor
- Quality Manager
- Quality Systems Auditor
- RCA Leader
- RCA Manager
- Refining Consultant
- Reliability Specialist
- Results Supervisor
- Risk Manager
- Safety & Training Specialist
- Safety Associate
- Safety Specialist
- SHE Supervisor
- SHEQ Divisional Manager
- Site CAP Manager
- Sr. Director, Serious Injury & Fatality Prevention
- Sr. Safety Analyst
- Staff Compliance Specialist
- Supervisor Training
- Team Leader H&S
- Training Director
- Training Specialist
- Upstream HSE Team Lead
- Vice President, HSE
- VP & Regional Manager
- VP HSE
- WMS Advisor
- Work Week Coordinator
And those are just partial lists!
Imagine the things you could learn and the contacts you could make.
Add your company and your job title to the list by registering at:
Our Global TapRooT® Summit attendees help one another by sharing best practices. We’d love to hear from you this year! Learn more about joining us in San Antonio the first week of August at the Summit website!
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Today, I was talking to someone in an industry that has had a major price reduction in the commodity that they produce.
They said that they couldn’t attend the 2016 Global TapRooT® Summit (August 1-5, San Antonio, TX) because there was a corporate travel ban. Only “business critical” travel was allowed.
That got me thinking … What is business critical travel?
If your travel would:
- save someone’s life,
- stop a major accident that would ruin your company’s reputation,
- save your company big $$$$ (at least 10X more than the cost of travel),
- keep one of your biggest client’s happy by preventing a quality issue, or
- stop critical equipment from failing,
Would that be business critical?
I understand the need to meet budgets and cut costs in times of economic difficulties.
What I don’t understand is being “penny wise and pound foolish.”
I hope your company isn’t making a mistake by stopping critical improvements from being made. Critical improvements that would have been learned at the 2016 Global TapRooT® Summit BUT won’t be because someone was afraid to ask to attend because only business critical travel is being allowed.
Want to learn about the sessions and lessons that will be shared at the 2016 Global TapRooT® Summit? See the complete Summit schedule at:
Then register for the Summit at:
In these videos (Part One and Part Two above), Alan Smith introduces fascinating case studies of serious incidents he has been involved in and lessons learned. He is the former Head of Major Crime Operations – Grampian Police, Scotland. As a career detective, he was the lead investigator in numerous homicide investigations. He is a Certified TapRooT® Instructor/Facilitator and has in-depth experience in numerous offshore tragedies including Piper Alpha and the MV Bourbon Dolphin. He is an Accredited Senior Investigator in Counter Terrorism and Kidnap and Ransom. Alan is the former Chair of the Scottish Senior Investigating Officer’s Conference.
Alan will be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit, August 1 & 2, San Antonio. He will also be leading a special session you don’t want to miss: Risk Assessing the Perfect Murder.
It’s not too late to register for the 2016 Global TapRooT® Summit!
Here in the TapRooT® office, we thoroughly enjoy your all’s clever captions during our caption contests. This month, we decided to make it TapRooT® Summit themed since our trip to San Antonio is coming up soon! Take a look at the picture of one of our Tech guys, Garrett, from the 2014 TapRooT® Summit, and come up with the most clever caption you can in 5 words or less to enter to win.
1. Create your caption in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by June 29th.
3. If you haven’t already, subscribe to the TapRooT® Friends & Experts e-newsletter to find out if you won.
(Email the Editor at firstname.lastname@example.org with subject “Subscribe to Win”)
Our in-house instructors will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on June 30th.
Prize! The winner will receive a Big Texas Prize inspired by the upcoming Summit to thank you for joining TapRooT® in changing the way the world solves problems.
We’re so impressed with how a large retail pharmacy approached a problem and their corrective actions not only improved their processes but also earned an impressive award! What can you proactively improve at your facility? How can we help?
If you’d like to learn more about how to be proactive in healthcare, check out our Medical Track at the 2016 Global TapRooT® Summit, August 3-5, San Antonio, Texas.
We are giving away an Fitbit Blaze Smart Fitness Watch to the 2016 Global TapRooT® Summit early bird prize drawing winner and you still have a chance to win but it’s the LAST WEEK to get a ticket in the drawing.
Here’s how it works: Register on or before June 15 and receive ONE ticket in the drawing.
The early registration drawing will be held at the Kickoff Session, Wednesday, August 3, 2016 at 8:00 a.m. at The Westin Riverwalk (You must be present to win!). This drawing is in addition to the other prize giveaways we have planned for the 2016 Summit.
If you are planning to register for the Summit, don’t delay!
REGISTER NOW for the 2016 Global TapRooT® Summit!
Electrical energy helps us in many ways, but when it is misused and an arc flash occurs … perhaps this video will help people get the message that arc flash precautions are important!
WARNING – GRAPHIC CONTENT AT VARIOUS POINTS – DON’T WATCH IF YOU WILL BE UPSET
Want to learn more about arc flash safety? We have a session about it at the 2016 Global TapRooT® Summit. The session titled “Arc Flash Prevention” is from 1:40-2:50 on Thursday in the Safety Best Practices Track.
Scott King and Terry Butler will present Employee and contractor protection utilizing general electrical principles as referenced by OSHA and NFPA 70E 2015 guidelines and qualified low voltage safety training.
Learning Objectives for this session include:
- Provide an overview of the importance of Arc Flash Safety
- Understanding Electrical Hazards
- Safe Work Practices
- Incident Energy Exposure Levels
- Risk Assessment Analysis
- Personal Protective Equipment (PPE)
- Safety Training
See the complete 2106 Global TapRooT® Summit schedule at:
And register for the Summit at:
We’re offering our 2-day course right before the Global TapRooT® Summit! Take the course and then stay for the 3-day Summit. LEARN MORE!
Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.
One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…
First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.
So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):
• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations
If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.
Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:
A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.
The data for the yearly compliance is presented on a Pareto Chart below.
The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:
Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.
I hate to use clichés, but WORK SMARTER NOT HARDER!
Want to learn more? I have a couple of opportunities that might interest you:
If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on August 1-2.
If you are not there yet and want to learn how to collect data and trend, consider the Advanced Trending Techniques Course, also on August 1-2.
Thanks for taking the time to read the blog, and happy investigating/auditing.
The results are in, and apparently many of you know your TapRooT® Summit history. Way to go!
We asked, “In what year did Mark Paradies organize the first TapRooT® Summit?”
Although many answered correctly, I’m sure those of you who didn’t get to play are dying to know… 1994! Can you believe the TapRooT® Summit began in Gatlinburg, TN with just 33 attendees 23 years ago? We hope this gets you excited for the 2016 Global TapRooT® Summit in San Antonio in August!
We had many responses, over half of them being correct, but there can only be one winner. After removing the incorrect responses and shuffling the correct ones, the winner of the May Contest is…
Charles Fowler – congratulations!
Thank you all for playing! Stay tuned for more contests this summer.
Don’t forget, registration for the 2016 Global TapRooT® Summit is OPEN. Click here to register today.
Here is a video with lessons learned about a fatal accident involving equipment (a scissor lift).
But there is an additional lesson that we can learn.
Every worksite should have a supervisor perform a quick Safeguard Analysis before people start work.
In this case, power lines were an obvious hazard (high voltage). And getting equipment with booms or lifts near them would cause the natural Safeguard (distance) to fail. If this Safeguard Analysis had been performed proactively, the worker could have been warned OR the actions (visually warnings and signage) could have been implemented to prevent the fatality.
Don’t wait for a fatality. Use TapRooT® to proactively prevent fatalities.
Would you like to learn to use TapRooT® to look for problems before accident, quality problems, and other failures happen? Then you should attend the upcoming TapRooT® for Audits Course on August 1-2 in San Antonio, Texas (just before the 2016 Global TapRooT® Summit on August 3-5). Register here: