In 2012, a little over 12,000 people were trained to use TapRooT® to find and fix root causes.
That’s a record.
If the first quarter of 2013, course registrations are up. We think 2013 will see even more people in TapRooT® Courses.
That good news for the people who will have their lives saved, see product quality improved, see hospital patient safety improved, and get better equipment reliability at their facility … when TapRooT® is applied as part of a performance improvement program (see success stories by clicking here).
What’s the bad news? The popularity of TapRooT® Training means that sometimes our public courses are filling up early. Sometimes even two months before the course takes place.
Also, our training schedule for on-site courses is filling up.
What does that mean to you? If you are planning to attend a specific public TapRooT® Course – SIGN UP EARLY.
If you want to have a course at your site, get it scheduled NOW! (Contact us by CLICKING HERE.)
The next time someone says they used 5-Whys to investigate an accident, just thing …
5-Whys = Root Cause Analysis Malpractice
Because 5-Whys is almost always root cause analysis malpractice. If you don’t believe it, assign someone who is good at 5-Whys to analyze a problem and someone who is good at using TapRooT® to analyze the same problem. Look at the results and you will see what I’m talking about.
That’s the lesson learned for today.
Course planner Diana Munevar shared these photos with us from our recent course in Bogota, Colombia.
Want to learn how to find and fix the incidents & near misses that are costing your company time and money? Attend a TapRooT® Root Cause Analysis course. Learn more at http://www.taproot.com/courses.
If you’re interested in a South America course, feel free to call Diana Munevar at 57 3203429267.
TapRooT® Users … Did you know there is a place where you can discuss your experience using TapRooT®, your questions, and your best practices with other TapRooT® Users? It’s on LinkedIn at the TapRooT® Root Cause Analysis Users and Friends Group.
Currently there are 1, 771 members but we hope to grow the group to include all those actively using TapRooT® (tens of thousands of people).
To join the group at:
And then participate by posting questions, providing your best practices, and commenting on other’s discussions.
Had an interesting conversation the other day.
Had a student in one of our classes tell me that he worked with someone who was “using TapRooT®” to find root causes but had never been to a TapRooT® Root Cause Analysis Course. In fact, the individual didn’t even have the TapRooT® Book.
He claimed to have learned TapRooT® by reading about it “on-line.”
The student said that he came to our training to learn the real way to use TapRooT® because he couldn’t believe that the guy was using it right.
By the end of the course, he told me the guy wasn’t doing anything like what we taught in the course. The course attendee was going to go back to work and straighten things out.
Another “bad example” was a guy who called me before he started an investigation. He was going to “use TapRooT®” because he was required to use it. What was wrong? He had been to training five years before and had never used it. He called me to ask, “What do I do first?”
Why do I bring up these bad examples here? Because not everyone who claims to use TapRooT® has a real understanding of the magic behind the system. They really are NOT using TapRooT®.
The minimum training that I would accept to call someone a TapRooT® User is our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. However, before I would send someone out to do, or facilitate, a major investigation, I would insist that they have attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.
But that’s not all. That’s just the start. At any facility that says they “use TapRooT®,” I would ask them, “How do you keep TapRooT® Users proficient?” Also, … “How do they make their investigators better over time?”
Three things that I would like to hear in their replies are that they:
1. Attend the TapRooT® Summit every year.
2. Attend advanced/refresher training every year.
3. Have a peer review group for investigations that provides real improvement ideas for investigators.
Before you let people claim they are using TrapRooT® to investigate accidents at your company, make sure they are really trained to use it and that they keep themselves proficient and improving!
Don’t let your investigators be a bad example.
I promised people at the 2013 Global TapRooT® Summit that I would post links to last year’s talk about Admiral Rickover and process safety and a link to his testimony to Congress about nuclear safety and the Nuclear Navy. Here they are…
And here are the slides from the Nuclear Navy and Process Safety talk mentioned above…
Here’s a message that I received this weekend (the Summit was last week) from Gard Clark …
I mentioned to Ken and Ed, that over the last 6 years as a Major Program Manager in the navy I have been a “professional conference attendee” (and presenter).
Out of the 25 conferences I have attended in that period, the TapRooT Summit was the best organized. I commend you and your staff on the excellent thought and effort that went into the Summit preparation.
The choice of keynote speakers, breakout sessions, and pre-summit courses complemented each other to pass on significant and targeted knowledge over the week to meet attendees’ specific needs.
And it was fun!
Please feel free to pass on my thoughts as you see fit.
I’ve been to every Summit (I organize them) and for me, it was the best Summit ever.
The Keynote Speakers were very motivational.
I met new TapRooT® Users with great stories to tell.
I had some really interesting discussions about using TapRooT® to solve problems.
I had many Summit participants stop me to tell me how many practical ideas they were taking home.
And I had great fun at the Wednesday night reception with Carl Dixon (great Canadian rocker) and at the Friday afternoon Charity Golf Tournament (where we came in last but had great fun with my team).
I’ve been exhausted this weekend but I’m headed back to work to start planning the 2014 Global TapRooT® Summit that will be held the week of April 7-11 near Austin, Texas. Put the dates on your calendar and plan to be there!
Alright … What about the rest of the Summit participants? What did you think? Click on the comments link below and tell me what you thought of your Summit experience?
Those you see in these pictures are learning valable new skills to improve safety, equipment reliability, operations, and quality. If you aren’t in these pictures, you are missing a valuable chance to make your facility a better place to work.
2-DAY TapRooT® INCIDENT INVESTIGATION & ROOT CAUSE ANALYSIS
SLIPS, TRIPS, & FALLS
ADVANCED TapRooT® (CAUSAL FACTORS)
Sorry if you missed this year’s Pre-Summit Courses.
Now is the time to start planning to attend the 2014 Pre-Summit Courses on April 7-8 of 2014. Set aside the dates and make a request for the travel and training budgets. Then watch this blog for more news.
The Agency for Healthcare Research and Quality did a study looking for proven methods of improving patient safety and healthcare outcomes. In that study, results of root cause analyses were used to find targets for improvement, look for effective techniques (proof of improvement), and provide potential areas for developing corrective actions (improvement initiatives).
The report defined root cause analysis several different ways, including:
Page 290: “Root cause analysis (RCA) is a structured analysis technique originally developed for human factors and systems engineering to retrospectively determine the interrelationship of component elements in causing an observed malfunction or accident. It has been adapted for use in medical and health care systems.”
Page 412: “…an in-depth examination of the data to identify factors in the care process that contribute to the errors…”
One comment in the report was:
“Wu examined the use of RCAs in medicine generally, and noted a very wide range of skill in performing RCAs accurately, a lack of best practices in reporting and followup, and the absence of peer-reviewed evidence of the effectiveness of RCAs or their cost-benefits tradeoffs.”
(Wu AW, Lipshutz AK, Pronovost PJ. Effectiveness and efficiency of root cause analysis in medicine. JAMA. 2008;299(6):685-7. PMID: 18270357)
That made me worry.
Were conclusions drawn in the report that were based on faulty root cause analysis?
After all, we have all seen poor root cause analysis done before. 5-Whys that lead to a preconceived result. Fault Trees built to prove a hypothesis (and missing other possibilities). People jumping to conclusions and not considering causes that they don’t understand.
I wondered … “What if the healthcare industry really adopted an effective root cause tool (TapRooT®) and then actually implemented it effectively? … What would happen?”
There’s more to TapRooT® than just sending people to a 2-Day Course.
To get the full benefits from TapRooT®, management must integrate it into their improvement efforts and manage it’s implementation and use.
That’s why we wrote Chapter 6 of the TapRooT® Book. To guide people to what an effective TapRooT® implementation looks like.
Implementation that includes a vision for improvement with a written plan that includes a sponsor, an improvement leader, and trained facilitators and peer reviewers. A plan that includes effective measurement and continuous improvement. A plan that includes management reviews and rewards for investigations and measured improvement success.
Work is required to make root cause analysis successful. If you are in the healthcare industry (or any other industry for that matter) read Chapter 6 and take the challenge to implement TapRooT® effectively at your facility. You’ll then be able to prove that TapRooT® was effective in helping you improve patient safety.
I just finished our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Dubai. What a great group we had. Here is the class picture:
Our next courses in the region will be in April, the 5 Day in Doha and 2 Day in Dubai. Both courses are already half full, so if you want to attend, you should register right away. DOHA OR DUBAI REGISTRATION CLICK HERE
Mark & Ed were in London this week sharing how TapRooT® could help people improve safety and prevent fatalities by finding about fixing the root causes of safety issues.
They talked to people who weren’t familiar with TapRooT® but left thinking about implementing a new, effective technology.
They also talked to current TapRooT® Users to discuss their success and share ways to make TapRooT® implementation even more effective.
As always, Spin-A-Cause™ was a big hit!
To all that stopped by, were trained on Spin-A-Cause™, had a laugh, had a beer with us, or went to dinner … Thanks!
We had a great time and hope that you will take away ideas to make your company safer.
I’ve had so many people ask me, “How can I find the root causes of the problem?” that I’ve decided to put my experience (or at least some of it) and links to others’ suggestions (even though some of the suggestions are bad) in one location – THIS ARTICLE – about how to find root causes.
I’m going to start with a “simple” root cause analysis technique. A technique that I do NOT recommend but that I will share because it is frequently recommended by others. If you choose to use this simple technique, don’t blame me when the “root cause” you find and fix doesn’t seem to improve performance and you keep having the same accidents happen over and over again.
Next, I’ll cover more complex techniques. Some of these are souped-up versions of the simple technique. However, the complex techniques – while being more complex – still have the same inherent problems as the simple technique. Therefore, I can’t recommend these more complex techniques for serious root cause analysis of important safety, quality, maintenance, service, or production issues.
Finally, I’ll talk about the technique you should be using. A technique that was developed to avoid the problems presented by the previously mentioned simple and complex techniques. A technique that was intelligently designed to take you beyond your current knowledge. A technique that users praise for it’s repeatability, thoroughness, and effectiveness.
SIMPLE TECHNIQUE: 5-Whys
I’ve probably heard more “experts” talk about 5-Whys than any other root cause tool. Why? Because it is simple. Simple to teach and simple to use. All you have to do to find root causes is ask “Why?” five times.
Here’s an example of the technique from the technique’s creator, Tailchi Ohno:
1. “Why did the robot stop?”
The circuit has overloaded, causing a fuse to blow.
2. “Why is the circuit overloaded?”
There was insufficient lubrication on the bearings, so they locked up.
3. “Why was there insufficient lubrication on the bearings?”
The oil pump on the robot is not circulating sufficient oil.
4. “Why is the pump not circulating sufficient oil?”
The pump intake is clogged with metal shavings.
5. “Why is the intake clogged with metal shavings?”
Because there is no filter on the pump.
What do you think? Is “NO FILTER ON THE PUMP” a root cause? I think this example is a perfect example of what is WRONG with 5-Whys (and most unguided cause-and-effect analysis).
First, they missed a whole line of questioning. Why didn’t the loss of lube oil pressure trigger an alarm or an automatic shutdown?
Another line of questioning that was missed was “Where did the metal shavings come from?” After all, metal shavings are not normally found in a well-maintained machine.
And finally,”Why was there no filter on the pump?” Did maintenance forget to install it? Did the designer fail to include it? Was it removed because it kept getting clogged?
All of these questions need to be answered but the ultimate expert, Tailchi Ohno, didn’t ask them because he thought he already had the answer.
Watch this 5-Why training video and see if you can poke more holes in their example …
OK, so according to the video, you might need to ask why more or less than five times. And in other 5-Why training they try to teach techniques to determine when you have asked enough “whys” to call the result a “root cause.” So simple might not be so simple after all.
Just watch this 5-Why example and see if you can tell when a root cause has been reached …
Five, six, ten, twenty “Whys”? Or was a root cause ever mentioned in all those why question answers?
MORE COMPLEX TECHNIQUES
Many root cause analysis tools start with the idea of cause and effect. Every effect is caused. If you follow the cause and effect chain back far enough, you will reach the root cause.
Most of the techniques realize that the unguided 5-Why process fails to produce adequate results. Therefore, they modify the process by putting rules or structure around the asking of why (developing the cause and effect chain). They think rules or more extensive training can solve the basic defects inherent in cause and effect.
Here’s an article I wrote for Quality Progress (a quality oriented professional society journal) that outlines most of the problems with cause and effect:
Here’s the root cause analysis example that I criticize in the Quality Progress article “Under Scrutiny” … the bug example.
Here is a You-Tube training video about a common cause-and-effect technique – a Fishbone Diagram …
Here’s what Dilbert has to say about Fishbone Diagrams …
Another technique commonly included as a cause-and-effect analysis tool is Fault Tree Analysis. Here is a presentation oriented toward engineers about Fault Tree Analysis …
Still another version of cause-and-effect mainly used as a design evaluation tool (rather than a root cause analysis tool) is Failure Modes and Effects Analysis (or FMEA). Here is a video about FMEA …
Once again, each example presented in the above references provides proof of why the technique should NOT be used for root cause analysis. All the examples show that the techniques display the analysis teams current knowledge. The technique does NOT get beyond what the team knows. If the team doesn’t know about human factors, they won’t solve human factors problems. And worse yet, the investigators don’t even know that they don’t know. And that’s a real problem when analyzing accidents by finding the accidents’ root causes.
THE ROOT CAUSE ANALYSIS SYSTEM YOU SHOULD BE USING
Back in 1985, I started looking for a way that people in the field could be taught to find the root causes of human error and equipment failure related incidents. Because of my human factors training, I often saw causes that others couldn’t see. I knew the answer wasn’t for me to do every investigation (the ultimate root cause guru) or to put everyone through the same training and experience that I had. Instead, the answer was to develop a system that would help people be able to troubleshoot, understand, and fix problems by leading them to root causes that they previously would have overlooked.
The work over the next six years eventually lead to the development of the TapRooT® Root Cause Analysis System. And that initial development work was just the start. We, with the help of tens of thousands of users, have continuously improved TapRooT® for over 20 years.
How does TapRooT® work? Here are two links that explain the workings of the TapRooT® Root Cause Analysis System:
The first link includes a TV interview I did about root cause analysis. The second link is a white paper that describes how the TapRooT® Root Cause Analysis System works.
For those that lead difficult investigations, I would recommend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
I hope this article helped you understand some of the techniques that are available and the limitations of the common or “simple” techniques.
Please be careful when you decide “How to find root causes.” Picking the wrong technique can lead to poor analysis and corrective actions that don’t solve the real root causes. That’s why we developed TapRooT® and recommend it … because we know you really need to find and fix the root causes of serious safety, quality, production, service, or maintenance issues.
Snapped this photo of Harry teaching about Critical Human Action Profile.
For more information about our 5-Day Courses, CLICK HERE.
Need help developing your incident investigation and corrective action program? We can help.
Need help facilitating a difficult investigation? We can help.
Need help analyzing the trends in your accident data? We can help.
Our TapRooT® Instructors are all experienced improvement professionals (many retired from senior leadership positions before they started a second career helping others improve).
You can get their advice by hiring them to provide TapRooT® Consulting Services.
Call 865-539-2139 to discuss the options and get a quote!
Pictures from the Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Monterrey, MexicoPosted: February 1st, 2013 in Courses, Pictures, TapRooT, Training
Need TapRooT® Training in Spanish? We have qualified instructors! Get a quote by CLICKING HERE.
That’s a great question.
We keep track of the people we teach in public and on-site TapRooT® Root Cause Analysis Training. We also know how many sets of training materials are ordered by Certified TapRooT® Instructors at Licensed TapRooT® companies. So, we know that in 2012 about 12,000 people were trained to use TapRooT® to solve problems by finding and fixing their root causes.
In 2011, there were about 11,000 people trained to use TapRooT®.
From 2001-2010, we averaged about 10,000 people per year.
Our estimate that since we wrote the first TapRooT® Book and held the first TapRooT® Course in 1991, we have trained over 150,000 people to find root causes (rather than jumping to conclusions, blaming the worker, and treating symptoms).
These problem solvers are on every continent around the world. They work in all types of industries and governmental agencies. They solve safety, quality, production, maintenance, and software issues.
Need to get your problem solvers trained in the techniques that are “Changing the Way the World Solves Problems”? CLICK HERE to get a quote or call us at 865-539-2139
This week, we bring you a few in the USA.
Next week, we’ll highlight some from the other side of the world – Australia and Asia!
2-Day TapRooT® Incident Investigation & Root Cause Analysis
Houston, Texas | Feb 20-21, 2013
Corpus Christi, Texas | March 14-15, 2013
Denver, Colorado | March 25-26
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis
Houston, Texas | Feb 20-22, 2013
5-Day TapRooT® Advanced Root CAuse Analysis Team Leader Training
San Antonio, Texas | Feb 25 – March 1
Not the course you’re looking for?
Based on client’s request, we have scheduled our ONLY Public India 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training for April 22 – April 26.
For those not familiar with the course, it includes the TapRooT® single user software (unless attendee’s company has a network software license), TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.
Course Fee which includes a software individual license for each student is only $2,395 USD. Here is the registration link: Register
Please register 30 days prior to the course if you need a quote first to send to your billing department. Anything within 30 days or less must be paid for during registration. All course seats must be paid for prior to the course to hold the seat and attend the course.
We look forward to seeing our repeat clients and new clients in our only 5-Day public India course for 2013.
How much do you know about TapRooT® Instructors? Take this quiz and find out.
1. Who taught the first root cause analysis course for System Improvements?
2. Who is the tallest TapRooT® Instructor:
a) Chris Vallee
b) Dave Janney
c) Jim Whiting
d) Mark Paradies
3. What TapRooT® Instructor(s) were born in Tennessee (the greenest state in the land of the free)?
4. What instructor did a round-the-world tour helping Rio Tinto implement TapRooT®?
5. Who taught the first TapRooT® Course in Australia?
6. How many countries are home to TapRooT® Instructors? How many continents?
7. What TapRooT® instructor has the highest level university degree?
8. Name the first three female TapRooT® instructors.
9. What TapRooT® Instructor graduated from MIT?
10. What TapRooT® Instructor went swimming in the Beaufort Sea?
For the answers, click on the comments link.
Take 2 minutes from your afternoon to learn from TapRooT® Instructor/ Six Sigma expert Chris Vallee. He’ll highlight what you’ll learn when you attend the Human Performance & Behavior Change track at the 2013 Global TapRooT® Summit.
Are you interested in attending our Summit? Register today!
Visit our 2013 Global TapRooT® Summit page for more information.