Do You Have the Newest Editions of the TapRooT® Root Cause Dictionary, Root Cause Tree and Corrective Action Helper?May 20th, 2015 by Barb Phillips
A new revision of the TapRooT® Root Cause Dictionary, TapRooT® Root Cause Tree, and TapRooT® Corrective Action Helper Guide was released on May 1, 2015. This revised 3-piece set is available for purchase to anyone who has attended a TapRooT® course.
Root Cause Tree: One new root cause and 3 updated root causes.
Root Cause Dictionary: Updates to definitions to cover root cause changes and current industry best practices.
Corrective Action Helper Guide: Updates for new root causes and updated references.
The updated materials are currently available in English only.
Go here to order: http://www.taproot.com/store/2015-DUOCAH.html
**If you attended a course in 2015, contact email@example.com for a special discount.
When a major accident happens, look out. The tradition is for “heads to roll.”
That’s right, people get fired.
Who get’s fired? Those that are seen as “part of the problem.”
You need to be part of the solution.
Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.
Then you are part of the answer … Not part of the problem.
Or you could just sit around and wait to get fired.
The choice is yours.
Get trained to use TapRooT® root cause analysis to solve problems. See:
On August 3, 2015, join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training public course in Cochin, Ernakulam, India for the ONLY time in 2015. This course is filled with excellent industry training and material that is well worth the investment for you and your company.
Cochin, also referred to as Kochi or Ernakulam, is known as the Queen of the Arabian Sea due to its spice trading on the west coast. Cochin is also the second largest and highest populated city in the area making it the home of major chemical and electrical industries, the Indian Naval Headquarters and offshore refineries (pictured below).
It’s a great trip for everyone! Bring the whole team for Root Cause Analysis Training and bring the whole family to enjoy the attractions and rich culture that Cochin, India has to offer.
Don’t forget, this is the only time this year that you can attend TapRooT® training in this region, so register today before the seats fill up.
Want more information on the TapRooT® 5-Day course? Click here.
Ready to register and take advantage of this incredible opportunity? Click here.
Haven’t registered for the Global TapRooT® Summit yet? Register here
I was at a conference yesterday and one of the talks was about advanced root cause analysis. The presenter’s company had their own “home grown” root cause analysis system and they discovered that they were not getting consistent results. Improvement was needed!
They studied their system and discovered something that was missing – management system causes. In the TapRooT® System we have called these “Generic Causes” since we copyrighted the first TapRooT® manual in 1991.
It made me think … Why did they wait 24 years to discover something we’ve known about since before 1991?
Next, I talked with an engineer who had been trained in a common cause and effect system. He wasn’t too pleased with the results he was getting. He wanted to know how TapRooT® could help. Was it different?
I shared how TapRooT® works (see this LINK for the explanation) and it took quite a bit of effort to get beyond the cause and effect model that he thoroughly understood so that he could understand why he was missing things. He was really smart. He asked very insightful questions. He latched onto the reasons that the less systematic cause and effect analysis led to inconsistent results. He saw how TapRooT® could help investigators go beyond their paradigm and get consistent results.
By the end of this second conversation I started thinking … How did we get so far ahead of common root cause systems?
I think I know the answer.
It starts with the Human Factors training that I received at the University of Illinois. It really showed me how to think about human centered design – including designing a root cause analysis system that people could use consistently.
Second, I was fortunate enough to work in the Nuclear Navy where there was an excellent process safety culture and for Du Pont where there was an excellent industrial safety culture. This helped me see how management systems made a difference to performance. (My boss and I at Du Pont actually coined the phrase “Management System” that is now commonly used throughout industry.)
Third, I was well trained by my mentor at the University of Illinois, Dr. Charles O. Hopkins, how to do applied research. So the research I did studying root cause analysis in the mid-1980’s and early 1990’s really paid off when we created the TapRooT® System.
Fourth, we had a really good team that brought out the best in each other during the early development.
Next, we were lucky to have some excellent clients in the nuclear, oil, and aviation industries that were great early adopters and provided excellent feedback that we used to quickly improve TapRooT® root cause analysis in the early and mid-1990’s.
Finally, I made friends with and/or listened to many industry gurus who were experts in safety, process safety, quality, and equipment reliability. Their influence was built into TapRooT® and helped it be a world-class system even in it’s early stages. These experts included:
- Jerry Ledderer, aviation safety pioneer
- Dr. Charles O. Hopkins, human factors pioneer
- Smoke Price, human factors expert
- Larry Minnick, nuclear safety expert
- Rod Satterfield, nuclear safety expert
- Dr. Alan Swain, human reliability expert
- Heinz Bloch, equipment reliability expert
- Admiral Hyman Rickover, father of the Nuclear Navy and process safety expert
- Dr. Christopher Wickens, human factors expert
- Dr. Jens Rassmussen, system reliability and human factors expert
- W. Edwards Deming, quality management guru
- Admiral Dennis Wilkerson, first CO of the Nautilus and first CEO of INPO
That’s quite a list and I was lucky to be influenced by each of these great men. Their influence made TapRooT® root cause analysis far ahead of any other root cause tool.
So that’s why I shouldn’t be surprised that others are finally catching on to things that we knew 25 years ago. Perhaps in a century, they will catch up with the improvements we are making to TapRooT® today (with the help of thousands of users from around the world).
If you would like to learn the state-of-the-art of root cause analysis and not wait 25 to 100 years to catch up, perhaps you should attend a TapRooT® Course in the next month or two. See our course schedule for upcoming public courses at:
And get information about all the courses we offer at:
And if you would like to learn about the state of the art of performance improvement, attend the 2015 TapRooT® Summit coming up on June 1-5 in Las Vegas. Get more information and download the brochure at:
But don’t wait. Every day you wait you will be another day behind the state-of-the-art in root cause analysis and performance improvement. Don’t be left behind!
TapRooT® Root Cause Analysis
Changing the Way the World Solves Problems
Grading Your Investigations – Summit Best Practice Session 2 at the 2015 Global TapRooT® Summit in Las VegasApril 23rd, 2015 by Mark Paradies
Mark Paradies is organizing the “Grading Your Investigations” session at the 2015 Global TapRooT® Summit.
At this session participants will use an Excel spreadsheet (download your copy below) to grade a typical incident investigation from your facility.
All participants attending this session are asked to bring an investigation report from your facility and the Excel spreadsheet available below preloaded onto a device so that you can participate in the exercise that will teach attendees to grade their company’s investigations using the spreadsheet.
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:
Attending the 5-Day Advanced Root Cause Analysis Course in Hamburg, Germany will be a great experience because the training is exceptional. But you may also be interested in attending the Miniature Wonderland. Watch the following video for more info …
See the article by Heinz Bloch at:
And then attend the Equipment Reliability and Troubleshooting Track at the 2015 Global TapRooT® Summit and hear Heinz speak about the business end of equipment reliability and the foundations of Equifactor®. See the complete Summit schedule at:
TapRooT® Instructor, Marco Flores, sent in this great class photo from Lima.
We have some awesome training opportunities coming up, including 15 exclusive 2-day courses on every subject from interviewing to stopping human error. If you missed the recent post, check them out here: http://www.taproot.com/archives/49008
1. Where was the first TapRooT® Summit (then called the TapRooT® Conference) held?
c) San Antonio
2. How many TapRooT® Summits have been held since the first Summit?
3. In what year was the first TapRooT® Summit Held?
4. Who was presented with the “Most Beloved Speaker” Award?
a) Ed Skompski
b) Mark Paradies
c) Beverly Chiodo
d) ED Hill
5. Counting this year, how many times has the Global TapRooT® Summit been held in Las Vegas?
6. Where was the largest (by attendance) Global TapRooT® Summit ever held?
d) Las Vegas
7. How was JR Ewing connected to the Global TapRooT® Summit?
a) He invented it.
b) People from his oil company always attend.
c) He was involved in a TapRooT® investigation.
d) A JR look alike attended the TapRooT® Summit reception in 1998 at the Southfork Ranch.
8. How many Summit Best Practice Tracks are there at this year’s Global TapRoot® Summit?
9. You can customize your Summit schedule by picking topics from different Best Practice Tracks.
10. Last years Global TapRooT® Summit was held in?
a) Las Vegas
Check the comments field below for the answers!
And don’t miss the 2015 Global TapRoot® Summit. For more information see:
There are 15 potential Pre-Summit Courses to choose from in June and five of the courses are new. That’s probably why so many people are asking which course would be best for them. Therefore, I thought I’d share my thoughts to help people make the best choice.
First, the 15 Courses are:
- 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
- Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis
- Advanced Causal Factor Development Course
- Advanced Trending Techniques
- TapRooT® Analyzing and Fixing Safety Culture Issues
- Risk Assessment and Management Best Practices
- TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training
- Getting the Most from Your TapRooT® Software
- Hazard Recognition
- Proactive Use of TapRooT®
- NEW Interviewing & Investigation Basics
- NEW Combating Fatigue
- NEW Understanding and Stopping Human Error
- NEW Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement
- NEW Creative Corrective Actions
Next, let me say that I like all these courses. I’ve hand-picked them to be included before the Summit because I think they will help you solve some of your biggest problems. But I understand that you can only attend one of these courses and that you want to pick the best one, so I’ll offer some advice.
If you haven’t attended a TapRooT® Root Cause Analysis Course before, then you should consider attending the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. This is the basic/starter TapRooT® Course that all investigators/root cause analysts should take. It will make the Summit much more valuable if you understand how the TapRooT® Root Cause Analysis System works. And it will help you perform much better investigations of safety, quality, and production issues. This course (like all Pre-Summit Courses) is completely guaranteed. We know that you and your management will agree that you will find root causes that you previously would have missed and develop much more effective corrective actions.
Need to improve equipment reliability and apply advanced equipment troubleshooting techniques? Then the Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course is for you. You will learn to apply Heinz Bloch’s advanced troubleshooting techniques to understand how equipment failures occurred. You will then learn to take that information, organize it in a SnapCharT®, identify the Causal Factors, and find each Causal Factors root causes using the TapRooT® Root Cause Tree®. Even equipment troubleshooting experts that have attended this course have commented on the helpfulness of the Heinz Bloch troubleshooting tables and the TapRooT® Root Cause Analysis System.
Want to improve your TapRoot® Skills, especially your ability to identify Causal Factors? Then the Advanced Causal Factor Development Course is for you. Ken Turnbull teaches this course using recent examples of accidents, incidents, and near-misses – some straight from the press. You will get lot’s of hands-on exercise practice and instructor feedback.
Do you need to learn to trend your safety and performance data? Especially data from infrequently occurring accident statistics? Would you like to prove that you have improved performance? Or do you need to mathematically demonstrate that a “trend” really isn’t a trend, but rather, is just normal process variation? That’s what the Advanced Trending Techniques Course is all about. I developed after I saw a client’s advanced trending best practices that blew me away. This was trending that really worked and showed when a trend was real and when it was just normal process variation. It was based on advanced lean/six sigma techniques that were specially modified for low frequency accident data. But the same techniques can be applied to all your data. It truly is a one size fits all trending program that will help your management focus their improvement initiative. In the course you will learn how to draw advanced graphs and practice your skills so that you can apply the techniques to your data back home. The course is taught by Kevin McManus, a quality/safety guru, and I know that you will find it enlightening and very useful.
The topic of Safety Culture is a hot button in the nuclear, oil, and aviation industry. If you would like to analyze and improve your safety culture, then the TapRooT® Analyzing and Fixing Safety Culture Issues Course is for you. Brian Tink and Brian Tink (Jr & Sr) will show you how to use TapRooT® Tools along with culture analysis tools to analyze and fix safety culture issues. Part of this course is a practice safety culture analysis for your company. If safety culture is a hot button topic at your company, don’t miss this course.
Interested in risk assessment and management? Want to learn about the latest international standards and how they can help keep your management out of trouble? Then you need to listen to risk management guru Jim Whiting in his course: Risk Assessment and Management Best Practices. Jim shares all the latest risk management techniques and tons of documentation that you will use when you return to work
Interested in applying advanced root cause analysis techniques in a Lean, Six Sigma, or Quality program? Then attend the TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training taught by Chris Vallee. Chris is a Six Sigma Black Belt. He will show you how to use TapRooT® Techniques to analyze and fix quality problems, lean waste issues, and problems discovered using Six Sigma techniques.
Do you provide technical support for the TapRooT® Software? Are you a TapRooT® Software “Power Users” who wants to learn the latest tricks and see the latest software updates? Are you interested in the changes coming in Version 6 of the TapRooT® Software. Are you responsible for setting up the TapRoot® Software and preparing the trending fields and linking the software to other databases? Then you want to attend the Getting the Most from Your TapRooT® Software Course taught by Dan VerLinde, VP for Software Development at SI. You will be amazed how much you learn and how much better your software usage will be.
What is a hazard? Do you see them before they can cause an accident? If you are interested in Hazard recognition and elimination, then the Hazard Recognition Course is for you. Peter Berkholtz, a TapRoot® Instructor from Australia with 25 years of mining and industrial experience, will teach this practical course. Don’t let hazards sneak up on you. Recognize and eliminate them!
Did you know you could use the TapRooT® System to solve problems before they cause a crisis? If you want to stop problems BEFORE they happen, then the Proactive Use of TapRooT® Course is for you! Dave Janney developed this course after realizing that people would rather stop fatalities before they happen rather than investigate fatalities after they happen. He explains how TapRooT® can be applied to improve auditing, observations and BBS, and pre-job hazard assessments. Learn new ways to apply the TapRoot® System to proactively improve performance at your facility.
And now for the new courses …
Interviewing and Investigation Basics: We’ve taught this course before but after we had so many positive comments about Barbara Phillips talk on Body language and interviewing at last year’s TapRooT® Summit, we decided to completely revise the course adding new material on interviewing, I think you will find this course to be engaging, useful, practical, and a good use of your time if you are interested in effective cognitive interview and non-verbal techniques and the tools and practices needed to collect information for an effective root cause analysis.
Combating Fatigue: fatigue in the workplace (and while driving) is one of the most frequent, and least investigated, causes of accidents. Studies of actual auto accidents that were video tapped inside the car for later analysis showed that actual fatigue and sleeping was often NEVER reported but was the cause of the accident. What can you do to fight fatigue at your company? Get great ideas from fatigue expert Bill Sirois. Learn to understand the risks of fatigue. Learn the five levels of defense against fatigue. Learn to build and improve a Fatigue Risk Management System (required in several industries). Understand specific methods to handle fatigue in high hazard industries. This course has been completely updated since it was last given before the 2012 Summit and we see it as completely new.
Understanding and Stopping Human Error: Mark Paradies, President of System Improvements and Joel Haight, Professor of Industrial Engineering at the University of Pittsburg, will bring their considerable knowledge of the practical application of human factors engineering to this newly developed course. The course will cover the human abilities and limitations that lead to human error, how to understand error likely situations and error causing designs, and how to apply error reducing techniques that work and to understand why some error reducing techniques that are frequently suggested are of little practical value. If you are interested in human performance and stopping human error (or at least reducing it as far as practical), then don’t miss this course.
Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement: Ed Skompski, Vice President at System Improvements, has created a 2-Day TapRooT® Course especially for the healthcare community that focuses on the analysis of the root causes of sentinell events and healthcare quality issues. The course is built around real clinical events and uses the TapRooT® System, a recognized good practice in the healthcare industry and that the terminology is recognized by The Joint Commission.
Creative Corrective Actions: You may remember this course from the past. Michele Lindsay was a TapRooT® Instructor for over a decade. But she now is a performance improvement coach at a healthcare facility. But this year she will be coming back to the TapRooT® Summit and is presenting a new course on creative corrective actions using Dr. Edward de Bono’s Six Thinking Hats™ techniques.
That’s a lot of training to choose from! But don’t wait too long to register. Seats are limited in these courses and we want you to get your first choice!
Additionally, you get a $200 discount on the training when you also attend the 2015 Global TapRooT® Summit. For more Summit info, see:
And if you have any questions about the Pre-Summit Courses or the Summit, please call us at 865-539-2139. Or CLICK HERE to drop us a note with your question.
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Rome, ItalyMarch 19th, 2015 by Mark Paradies
The students at the Rome 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course show off what they have learned as they analyze an incident from their own company as the final exercise at the course. They then present their work for critique by the rest of the class participants.
Working on their analysis…
If you want to experience the magic of the TaoRooT® Root Cause Analysis System – of how it can help you discover causes that you previously would have missed and develop much more effective corrective actions, then select a course to attend from this upcoming course list:
Or have a course at your facility by contacting us at:
Come learn the TapRooT® process with other healthcare professionals and understand why the TJC recognizes our terminology and understands the quality of what TapRooT® provides in healthcare. Ed Skompski will lead this 2-day course offered June 1 and 2, 2015 in Las Vegas, Nevada — right before the 3-day Global TapRooT® Summit.
Ed Skompski,Vice President
This course provides the basic building blocks of performing both a reactive TapRooT® investigation as well as the use of the TapRooT® tools for Proactive analyses.
With clinical examples and healthcare experts teaching, this learning experience will provide you with the best RCA tools on the market and the knowledge to use them. Tools include:
- SnapCharT® for organizing and understanding the data you collect;
- Root Cause Tree® and Dictionary for finding consistent, real root causes that you can communicate to your organization; and
- Corrective Action Helper® and SMARTER tools to help you define detailed, measurable corrective actions to prevent future events.
All of this adds up to a great training session that you will find to be not only valuable but also practical and useable.
REGISTER for this course and the Improving Healthcare Quality & Patient Safety track at the Summit:
REGISTER for this course alone: http://www.taproot.com/store/2-Day-RCA-Sentinel-Events-1506LASV01.html
LEARN MORE about the 2015 Global TapRooT® Summit: http://www.taproot.com/taproot-summit
Brisbane, Queensland, Australia
Upcoming TapRooT® Public Courses:
New South Whales:
Papua New Guinea:
For more information regarding our public courses around the world, click here.
Linda Unger, VP at SI, sent these pictures of Ken Turnbull, one of our contract instructors, teaching a bunch of great students.
Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…
… your own actions.
… your understanding of other peoples actions.
… your past corrective or preventative actions.
Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.
To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.
To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit
If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw
TapRooT® hosts public courses all over the world, including New Zealand. Come out to New Plymouth, New Zealand on February 16, 2015 for a 5-Day Advanced Root Cause Analysis Team Leader Training to learn how you can be proactive and perform better investigations. New Plymouth is a coastal city on the west coast of New Zealand that has been named a “model community” because of its beautiful infrastructure. The small population walks and cycles along the coastal walkway (pictured above) and enjoys the each other’s company and the view. Talk about a great place to visit and take a TapRooT® course!
Table Restaurant: Placed within the Nice Hotel, this gourmet, award winning restaurant ensures you will enjoy food, wine and friends.
The Mayfair: Want a burger, fries, salads, pizzas or snacks? The Mayfair has it all and some drinks to go with it.
Cow Ree: This small vintage cottage set right on the beach makes for a fun, enjoyable evening out for a great meal.
Pukekura Park: You’ve never experienced a local park with such beautiful scenery and events-including a lights show you won’t forget!
Coastal Walkway: Enjoy a nice walk along the coast with a perfect view of the mountains.
Taranaki Aviation Transport and Technology Museum: If you’re interested in all things to do with aviation and technological transportation, then this museum is for you.
REGISTER HERE for this Public Course today
Today, Schlumberger announced it was planning on laying off 9,000 employees worldwide. The rapid drop in oil prices is having a negative employment impact.
If any TapRooT® Users find themselves unemployed, I’d like to remind them to watch for job opportunities here:
We post new job openings every week for people that have TapRooT® Root Cause Analysis Skills.
What? You haven’t attended a TapRooT® Root Cause Analysis Course?
NOW is the time BEFORE you need a new job that requires TapRooT® Root Cause Analysis Training.
See our course schedule around the world and click on your continent to see local courses at:
I was in Las Vegas teaching a TapRooT® Course when I realized … We are the only no-lose game in town!
What do I mean? TapRooT® Training is GUARANTEED.
Here’s the guarantee:
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.
But there’s more.
On June 1-5, System Improvements is holding the only GUARANTEED conference that I know about. The 2015 Global TapRooT® Summit. If you need to learn best practices from around the world that will help you improve performance, you need to be in attendance!
Here’s the 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.
Another great guarantee because we know you will love the Summit.
One of our TapRooT® Users in Europe is interested in having 2 or 3 people trained in a course conducted in Spanish. Would anyone else be interested?
If we get enough response, we’ll get the course scheduled for later this year in Spain.
Leave your response as a comment here.
Rome is a great place for a spring vacation. The sights, the food, and the shopping are amazing!
And when you can combine the trip with some great TapRooT® Training (a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course), you are getting two great experiences at once!
The 2-Day TapRooT® Course is a great value. In two days you will learn how to apply the standard TapRooT® Tools (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, the Corrective Action Helper®, and SMARTER) to find and fix the root causes of problems.
What kind of problems can you solve using TapRooT®?
- Major safety accidents
- Drug/medical device quality issues
- Medical sentinel events
- Process safety accidents/incidents
- Equipment reliability issues
- Neat-miss accidents
- Production issues
- Cost overruns
- Schedule slippage issues
- Customer complaints
- Security issues
- Product waste issues
- Hardware/software failures
And that’s just to name a few!
And the instructors scheduled to teach the course are Mark Paradies and Linda Unger – the inventors of TapRooT®!
The course is being held at a great hotel in the center of Rome. Watch this video for a bird’s eye view of the location…
Here’s the hotel’s web site:
As you can see, the hotel is just a couple of blocks from the Pantheon. And near many of Rome’s tourist attractions.
You probably won’t get an opportunity like this again. Because this course is so special, you should register today for the March 18-19, 2015 course to make sure you save your spot! Also, get your hotel reservation set. You don’t want to miss this great training in a great location.
When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.
Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.
Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.
SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.
Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.
Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.
Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.
Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).
Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.
Generic Cause: A systemic problem that allows a root cause to exist.