Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
Just before starting the exercise …
Teams working on their incidents …
Instructions just prior to the presentations …
Teams presenting …
For more information about TapRooT® Root Cause Analysis Courses, see:
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.
Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…
Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:
Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis CourseAugust 6th, 2014 by Mark Paradies
Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…
Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at:
Pictures from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course at Lake TahoeAugust 5th, 2014 by Mark Paradies
The students below are hard at work reading the Root Cause Tree® Dictionary to discover why someone would break a rule. Ever wonder why people break the rules? Then maybe you should attend one of our 2-Day or 5-Day TapRooT® Courses!
View more photos from Tahoe here: http://www.taproot.com/archives/45935
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.