Throwback to 2009 in Chile. Chile is just one of the many places where you can receive training and hands on experience with a certified TapRooT® instructor.
Thinking about signing up for a TapRooT® Training class? Click here to find out what courses are available near you.
What was your favorite moment at a TapRooT® course? Please leave comments below.
Look over recent FDA Warning Letters (http://www.fda.gov/iceci/enforcementactions/WarningLetters/default.htm) to medical device manufacturers, and you will see that about a third of them are issued because of failures of CAPA (Corrective and Preventive Action programs).
The FDA expects medical device manufacturers and drug makers to find the root causes of quality issues, effectively fix them, and monitor them to make sure that the fixes worked.
A key part of a CAPA program is effective root cause analysis. Without effective root cause analysis, problems tend to repeat – and the FDA definitely doesn’t like repeat problems.
What makes effective root cause analysis? That’s a question we’ve been dedicated to answering for over 25 years. We designed the TapRooT® System to include tools to help guide investigators to the root causes of human performance and equipment reliability issues and find effective corrective actions to stop repeat problems from occurring.
Want to see how TapRooT® can help your company find and fix the root causes of quality issues? Then I would recommend attending one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. See the upcoming public course schedule by CLICKING HERE.
Don’t be afraid that the TapRooT® System won’t work at your company. Our training is guaranteed:
Attend this course, go back to work, and use what you have learned
to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and if you and your management
don’t agree that the corrective actions that you recommend are much more effective,
just return your course materials/software and we will refund the entire course fee.
It’s that simple. We know TapRooT® will work for you because we’ve seen it work at so many companies in so many industries including pharmaceutical and medical device manufacturers. See success stories from multiple industries at:
But don’t wait. You can’t afford a major finding adverse to quality and a warning letter. And you don’t want to have the course you want to attend fill up before your register (seats are limited in each class). Register today and start applying TapRooT® to improve performance and avoid quality incidents.
The US Bureau of Labor Statistics release some interesting information about workplace fatalities in a recent press release.
It would be interesting to see these statistics graphed on an XmR Chart … as we teach in our Advanced Trending Techniques Course. If you are interested in learning advanced trending techniques, you missed our 2014 course. But we are planning to offer the course again on June 1-2, 2015 prior to the 2015 TapRooT® Summit (June 3-5, Las Vegas, NV). I know that’s a long ways ahead to start planning but you probably can’t say that your schedule is already full.
One more note, if you have a bunch of folks at your company who need to learn advanced trending techniques, we can come to your site to present the course. If you are interested, CLICK HERE to contact us.
Pictures from Day 2 of the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in New OrleansMay 21st, 2014 by Mark Paradies
Day two is finished and it was another great course! Here is Linda teaching the class…
Later, the class members are woking in teams to apply what they have learned to one of their own incidents …
And then each team selects someone to present to the class what they have found by applying TapRooT®.
That’s it! The end of another great class! If you would like to attend TapRooT® Training, see our courses at:
Oops – lost one on the left side of the class! I’ll try to get some “action shots” tomorrow.
If you need information about TapRooT® Root Cause Analysis Training, CLICK HERE.
Root Cause Analysis Tip: TapRooT® is more than a Root Cause Analysis Tool – TapRooT® is Your Performance Improvement Partner!April 16th, 2014 by Mark Paradies
If you are reading this you probably already know about TapRooT® as a root cause analysis system. If you don’t, watch this:
But we want to do more for our clients than helping them fix problems once and for all. We want to help them get a great return on investment from their improvement efforts.
Therefore, we don’t stop by just making TapRooT® the best root cause analysis system that we can invent. We continuously try to find new ideas, new methods, new ways for our clients to be more effective and efficient in their improvement efforts. And we also try to keep them passionate about their improvement efforts so their work can be sustained through the difficulties that people encounter when they try to may positive change occur.
But how do we get this information to the people who need it? Those out their on the factory floor, the oil rig, or even in the corporate boardroom? By several methods.
First, we publish most of what we learn on the Root Cause Analysis Blog.
From these root cause analysis tips, to recent news about accidents, to articles about career development, to course pictures, to Summit information, to TapRooT® software update information, to job openings for TapRooT® users, to our Friday jokes (yes, you can have a sense of humor about improvement), we try to make what we write interesting, short, and to the point so that we communicate things that you may need to know without wasting a bunch of your time.
Because many folks don’t have the time to jump on-line and read the blog every day, we take the information shared on the blog and condense it into a weekly newsletter. We are still experimenting to find the best format for this information to make it readable (or maybe “scannable” is a better word) so that you can pick out what is important to you and learn quickly.
I know that everyone is busy but I think improvement information is important so that I hope you take the few minutes required to skim the weekly e-mail to see if there is anything important that you need to read and, if you can’t get to it right then, that you print it out for your professional reading stack.
The main way we get the bulk of the details about new improvement ideas out to TapRooT® Users is the annual Global TapRooT® Summit. If you were at the 2014 Summit, you know the value of the best practice sharing and advanced improvement knowledge that goes on at the Summit. You also know that we have excellent keynote speakers to pass along great information and keep you motivated to make improvement happen. To find out more about the Summit, see the Summit web site:
We like to think of ourselves as you performance improvement partners. And now you know how we try to get the latest information to you to help you develop the most effective performance improvement program possible.
What does it look like attending one of the 13 pre-Summit courses? Have a look at these pictures. People are actively learning…
I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…
Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.
Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!
Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.
What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.
As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.
The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.
Learn more about TapRooT® Training at: http://www.taproot.com/courses
One worker was killed and two were injured aboard a nuclear submarine under construction in India.
Was it some high tech nuclear accident? No. I was a simple pressure test of a hydraulic tank.
This accident once again shows that failure to control simple energy is often the cause of fatalities.
See the whole story here: http://www.dawn.com/news/1091836/accident-at-indian-nuclear-submarine-centre-kills-one-worker
Could this accident have been prevented? Yes. How? Find out at the Proactive Use of TapRooT® Course being held on April 7-8.
If you don’t have time to check the Root Cause Analysis Blog every week, you could be missing career changing updates! Subscribe to our weekly eNewsletter and don’t miss a thing. Here is yesterday’s edition:
Have you attended TapRooT® training or our Global TapRooT® Summit?
Are you on LinkedIn?
If so, you have a chance to win a cool TapRooT® t-shirt!
- Log in to LinkedIn: http://www.linkedin.com/company/system-improvements-inc. (If it doesn’t open our Company Page, search for “System Improvements | TapRooT®” in the LinkedIn search box.)
- Follow us on LinkedIn (by clicking the yellow “Follow” button on the top right).
- Then click the “Services” tab on the top left (under our company name, next to “Home”)
- Select the name of the training you attended or the Summit, and leave a recommendation.
That’s it – leave a brief recommendation and follow us on LinkedIn, and you’ll be entered to win our monthly drawing for a new shirt. Ready, set, GO!
Root Cause Analysis Training in Texas – 2014 Global TapRooT® Summit Annual Charity Golf Tournament at Award-Winning Horseshoe Bay Golf Course (VIDEO)February 3rd, 2014 by Megan Craig
Calling all golfers! Whether you’re a novice or a golf enthusiast, you’ll love playing in our Annual Charity Golf Tournament at the 2014 Global TapRooT® Summit April 7-11. Join us on Friday April 11th around 11:30am for lunch and a scramble-style tournament at the award-winning Horseshoe Bay Resort Golf Course. All proceeds go to the Oasis of Love Women’s Shelter in Clinton, Tennessee.
We’ll let our Tournament Coordinator, Benna Dortch, tell you the rest. Check our her video below.
Watch two children explain their morning routine using a process flow chart and a control chart.
If you do not have a knowledgeable kindergartner hanging around to help you, I would recommend attending the following this April during our TapRooT® Summit Week:
Advanced Trending Techniques
TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training http://www.taproot.com/taproot-summit/pre-summit-courses#TapRooTSixSigma
Process Quality and Corrective Action Programs
A license to use the TapRooT® Enterprise Software is an investment in improved root cause analysis. To realize the most from that investment requires thought and support for the software installation and maintenance.
Who is the software guru at your site? Have they been trained in the software administrator features of the TapRooT® Enterprise Software? Are they utilizing all of the power to get things done that’s offered through our software?
Once a year, the TapRooT® Software Program Manager – Dan Verlinde – teaches a course to help TapRooT® Software Administrators and Program Managers get the most from their software investment.
To get the most from your TapRooT® Enterprise Software you need an administrator who understands all the built in features. They need to know how to:
- Install the software for best performance.
- Set-up custom fields and lists.
- Link the software to other databases.
- Answer users’ common questions.
- Explain the basics of using the software.
This course is an intensive review of the TapRooT® Version 5 Web Software system administration. Topics including: installation, configuration, data migration (from Version 4), best practices, and future releases. System Administrators and TapRooT® Super Users will learn all the capabilities built into this amazing software. Don’t get just 10-20% from your software investment. Learn the full power of your TapRooT® Software!
This year the course is being held just prior to the Summit, April 7 – 8, 2014 in Horseshoe Bay Texas.
To get more information about the Summit and this course, see:
One more note. If you are attending the TapRooT® Summit, you get a $200 discount off the course fee of $1095.
To register for the course and the Summit, see:
Picture of One Section of a Two Section Public TapRooT® Root Cause Analysis Course in Houston, TexasDecember 9th, 2013 by Mark Paradies
Pictures of the Presentations from the Final Exercise at the Las Vegas Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis CourseDecember 8th, 2013 by Mark Paradies
Some pictures of the students presenting the results of incidents they analyzed using TapRooT® Root Cause Analysis…
And then there was the prize for being on time. A chance to win $10 million dollars! But … the odds were against us…
No instant millionaires today.
Want to find out more about TapRooT® Training? See:
Have you read your 2008 TapRooT® Book from cover to cover? If you do, you will find there are many topics that can help you improve investigation efficiency. Appendix C specifically calls out these six:
1) A well thought out strategy
2) The use of technology
3) Management understanding
5) Help from people in the field
6) Proper use of a SnapCharT®
Each of these is explained in detail in pages 466 – 471 of the book. If you are interested, crack open your book and get reading! You’ll find there is lots more to learn and use!
If you don’t already have your own copy, get some ideas about what’s in the TapRooT® Book by reviewing the table of contents at:
Order the TapRooT® Book at:
But don’t procrastinate! There’s important information in the book that can help you save lives, time, and money.
Many people begin decorating for the winter holidays the day after Thanksgiving. As you string your lights up and dust off those plastic trees, keep these tips in mind from the Electrical Safety Foundation International.
- Inspect your strands of lights and extension cords for damage.
- Attach them securely, but never nail or staple them.
- Extinguish all candles and unplug all lights when you leave a room or go to bed.
- Never use a hot extension cord.
- Consider battery-operated candles.
- Always purchase electronics from a reputable retailer.
- Always inspect cords for damage before plugging them in.
- Avoid overloading electrical outlets.
- Never connect more than three strands of lights together.
- Always unplug lights before changing a bulb.
- Consider LED lights, they use less energy and run cooler.
- Insert plugs all the way into the wall.
- Don’t run cords through walls or ceilings.
- Extension cords are only for temporary use. Make sure they are rated for the proper use, indoor or outdoor.
- Christmas tree and holiday décor fires result in twice the injuries and five times for fatalities per fire than the average winter holiday fire.
- 5,800 people per year are treated in emergency rooms for falls associated with holiday decorations. Over half are ladder or roof falls.
- Inspect ladders for missing screws, hinges, bolts, and nuts.
- Use wooden or fiberglass ladders, as metal ladders conduct electricity.
- Use the right ladder height, ensuring that your ladder extends at least three feet past the edge of the roof.
- Be sure to tape extension cords down, or refrain from placing them in places where someone could trip on them.
- Over 4,000 injuries per year are associated with extension cords. Half of these are due to tripping over an extension cord.
Tune in next week for Child Safety and Fire Safety tips for the holidays.
CLICK HERE for the article in SHP.
The article says that the ride failed due to a low gearbox oil level. Some would classify that as an equipment failure. But a complete SnapCharT® would consider maintenance and operator checks (should someone check the gearbox oil level periodically?).
How do you analyze the causes of equipment failures?
Perhaps you should condier a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course. See the upcoming course schedule by CLICKING HERE.
Material found in a doughnut, see the initial indications from the KAKE media article below.
A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth.
“There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother.
The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here.
The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened.
Now what? Is this a safety or quality issue or both?
If you were the retailer what would you do?
Would you quarantine the doughnutt and ask for access to the material found in the stomach? Would you be allowed?
If you were the doughnut supplier what would you do?
Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed?
If you were the doughnut manufacturer what would you do?
Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported?
For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts?
Everything just discussed would be part of the analysis/investigation planning stage. The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available.
Our public course schedule
Accident Investigation Training – Incident Investigation Training – Root Cause Analysis Training … They are all related and people often ask my opinion … “What accident investigation (incident or root cause) training should we be doing at our facility?”
When we wrote the TapRooT® Book (published in 2008), we knew people would have that question. That why we included a whole section in Chapter 6 (the implementation chapter) on recommended training and a training matrix:
Each of the titles in the left column are described as well as the reasoning for that level of training.
Some interesting titles to review here are Management, the Improvement Team Leader, and Facilitators.
The first training recommendation to review is management. Some might ask, “Why does management need training.”
My answer? because they are the customer – the user – of what comes from the root cause analysis process. Advanced root cause analysis (TapRooT®) should be an essential part of their management system – a management tool that they rely upon. And because this is an essential management tool, they need to understand their role in applying root cause analysis, how root cause analysis fits into their improvement strategy, and what people in the field need to succeed in their root cause analysis efforts.
The training matrix says that managers should take the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course. But the book explains this in more detail.
First, I would prefer that senior managers take the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as part of their management development career training. A major oil company had all their senior project managers (those managing multi-million dollar projects) attend the 5-Day Training and every manager I trained was impressed with the usable information they learned that they could apply a senior managers. These were things that they previously had not learned in their management careers.
However, getting senior managers to sit down for five days of training is next to impossible (even if the training is needed). In this case it took the President of the big oil company requiring his project managers to have the training or they could not receive their annual bonuses. (He really knew how to get their attention.)
Why would a big oil company President require the training? because he was tired of hearing excuses for fatalities. He knew these senior managers had to understand what was causing fatal accidents or they would never be successful in preventing them. And he knew that TapRooT® was the explanation for the causes of the fatal accidents. Thus TapRooT® Training became the requirement.
For those who don’t have the company president’s support for management training, I would suggest a custom course focussed on the basics of TapRooT® and what management needs to to to make sure their improvement program effectively applies root cause analysis. That’s the minimum needed for management root cause analysis training.
IMPROVEMENT TEAM LEADERS & FACILITATORS
Improvement Team Leaders and Facilitators have the same basic training requirements – the 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course. Those who will also be investigating equipment issues should take the additional day of Equifactor® Training (that can be customized into an on-site 5-Day Course).
To continually improve their skills and keep up with the latest in performance improvement technology, we also recommend attending the Global TapRooT® Summit and a pre-Summit advanced course every year.
Two additional courses that Improvement Team Leaders should take are the Advanced Trending Techniques and the Getting the Most from Your TapRooT® Software courses. Trending and using the TapRooT® software are integral parts of any improvement team leader’s job so these courses are a must for them.
Have any questions about these training recommendations? We would be happy to discuss our recommendations with you. just give us a call at 865-539-2139. Or drop us a note by CLICKING HERE.
I know, it is too early for Friday’s Joke of the Day, but I could not help it. I saw this posted recently and had to share.
As you are laughing, look into your tool cabinet and tell me that you do not have these 2 items in it.
Now if you want to know how to troubleshoot equipment the right way to find the right what’s and why’s and want an Individual TapRooT® Software License (comes with the course), then join us at one of our Equifactor® courses.
Here is the current schedule: http://www.taproot.com/store/3-Day-Courses/
I’ll bring my WD-40 and Duct Tape for the classroom equipment.
What are the risks of setting a circuit breaker without knowing why it opened?
I just saw this local news article about a father teaching his daughter about the circuit breaker panel in their house after a ceiling fan stopped working. End result….. House on fire. Read more here.
With eighteen years in aviation and having worked on the C-141 Aircraft, this incident brought to mind the wrong pump replaced and reseting the circuit breaker during testing explosion. Read more here.
There are additional ways to gain equipment troubleshooting experience without starting a fire. The easiest way is to attend one of our upcoming Equifactor® Course coming up in your local area. See the schedule here: http://www.taproot.com/store/3-Day-Courses/
With community protests after losing school aged loved ones, the Indian Government is closing in on suspected causes to include suspects. But is this a sign of Systemic Food Quality Control or as TapRooT® calls them “Generic Causes”? Will the nature of the investigations detour looking for Generic Causes by looking for blame instead?
Read below and ask, how would this be investigated or analyzed if it were in your hometown? What would be the response of the lunch cafeterias and Food on Wheels programs for the elderly and sick?
In a months time…..
23 students in the southwestern coastal state of Goa were treated at a hospital after they got sick at lunch
23 students died and 25 people were hospitalized from food poisoning after a school lunch in northern India’s Bihar state
Schoolchildren falling sick after drinking contaminated water from hand pumps continued for the third consecutive day on Saturday with at least 35 more students taken ill in different parts of Bihar.
Arrests made in two of incidents with possible cause being insecticide poisoning; the water pump incident possibly criminal intent and the Bahir lunch room incident due to possible negligence. The Goa incident not so clear in details yet.
Due to fear, large lunch producers temporarily shut down their lunch kitchens resulting in children not getting their mandated free lunches during school.
See more at this link:
Great final exercises. Here’s pictures of the teams working and presenting their results …
To get signed up for a TapRooT® Root Cause Analysis Course in the future, CLICK HERE!