SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.
Are you using advanced root cause analysis to investigate near-misses and stop major accidents? That a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:
TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.
For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.
Don’t wait! If you have attended TapRooT® Training, get signed up today!
When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.
The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.
This modern definition of a root cause leads to this definition of root cause analysis:
Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring.
Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.
Even though a decade had passed since proposing this new definition, I still have people ask:
“Why did you change the definition? I liked it like it was!“
Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.
The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!
The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.
This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.
The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.
One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.
That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.
Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.
I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:
“If people would just try harder, be more careful, or be more alert, the problems would go away.”
This implies bad people (careless, lazy, and/or dullards) are the issues.
Have you ever met one of these people? Do you work in an organization that thinks this way?
I once had a safety manager at a refinery tell me:
“At our refinery, 5% of the people account for 95% of the lost time injuries.”
He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.
Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.
TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.
Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.
And don’t worry about trying something new. Our courses are guaranteed!
Attend our training, 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.
That’s a strong guarantee because we know that TapRooT® will work for your company.
For more information about TapRooT®, watch the video at:
In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:
“The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.“
Additionally, he said:
“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”
That seems like a “Blame Vision” statement.
That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:
“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”
Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:
We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.
Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:
The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.
To subscribe to the newsletter, provide your contact information at:
Above is the start of an OSHA/EPA Fact Sheet titled: “The Importance of Root Cause Analysis During Incident Investigation.”
OSHA and EPA want companies to go beyond fixing immediate cause (which may eliminate a symptom of a problem) and instead, find and fix the root causes of the problems (the systemic/underlying causes). This is especially important for process safety incidents.
The fact Sheet explains some of the basic of root cause analysis and suggests several tools for root cause analysis.
UNFORTUNATELY, many of the tools suggested by the fact sheet are not really suited to finding and fixing the real root causes of process safety incidents. They don’t help the investigator (or the investigative team) go beyond their current knowledge. Thus, the suggested techniques produce the same ineffective investigations that we have all seen before.
Would you like to learn more about advanced root cause analysis that will help your investigators learn to go beyond their current investigative methods and beyond their current knowledge to discover the real root causes of equipment reliability and human performance related incidents? These are techniques that have been proven to be effective by leading companies around the world.
Yes? Then see: http://www.taproot.com/products-services/about-taproot
And choose one of our upcoming public TapRooT® Courses to learn more about the TapRooT® Root Cause Analysis System. See:
November is a month to be thankful and show your appreciation! Here at System Improvements (TapRooT®), we like to let our co workers know that we appreciate everything they do. Without each person in this office, none of what we do would be possible.
So, to keep the thankful spirit alive all November long, we are recognizing specific members of the SI team different weeks throughout the month. This week we are showing special thanks to the amazing TapRooT® Tech Support guys with Dunkin Donuts!
If you’ve ever had any technical issues, they’re always there to help. If you’ve used TapRooT® software, they put an incredible amount of work into development. If you work in our office and need any assistance whatsoever, they’re there!
Help us give a special shout out to the TapRooT® Tech Support guys!
Here are pictures from the 11 pre-Summit Courses ….
TapRooT® Incident Investigation & Root Cause Analysis Course
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 Process Improvement Facilitator Course
Getting the Most from Your TapRooT® VI Software
TapRooT® for Audits
Effective Interviewing & Evidence Collection Techniques
Understanding and Stopping Human Error
You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?
Is this the best approach to preventing future problems? NO! Not by a long shot.
We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:
- Wacky Willie
- Will Discipline Fix the CTA’s Problems?
- USS Hartford / USS New Orleans Collision & Subsequent Discipline
- Should You Discipline BEFORE an Investigation is Complete?
- What Should Managers Know About Root Cause Analysis?
- Root Cause Analysis – Do it before even thinking about discipline!
Let me sum up what we know …
Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.
In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.
For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses
Here’s a partial list …
- New Zealand
- Saudi Arabia
- United Kingdom
That’s why we call the Summit a GLOBAL Summit. Every continent is represented.
Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:
And find out about all the great sessions and keynote speakers by visiting the Summit web site at:
Who would you like to network with if you were going to share best practices and learn how others have solved problems?
The TapRooT® Summit is a great place to meet industry leaders.
Here a partial list of companies that have signed people up for the 2016 Summit:
- Air Liquide
- Arizona Public Service
- Avangrid Renewables
- Balitmore Gas & Electric
- California Resources
- Duke Energy
- Formosa Plastics
- Lawrence Berkeley national Lab
- Liberty Carton Company
- Matrix Services
- Nalco Champion
- National Grid
- Northern Star Generation
- NRG Energy
- Nuclear Fuel Services
- PCS Nitrogen
- Prarie State Generation
- Pratt & Whitney
- PSH JV
- Red Cedar Gathering
- Sacramento Municipal Utility District
- Saudi Aramco
- Teranga Gold
- Tuscon Electric
- US Well Services
- United Technologies
- Vancouver Airport Authority
- Westar Energy
What are some of the job titles of people attending the 2016 Summit?
- Airside Safety Officer
- Area HSE Manager
- Compliance Specialist
- Corporate ESH Director
- Corporate HSE Manager
- Corrective Action Program Manager
- Director of Corporate Safety
- EHS Engineer
- Electrical Engineer
- Emergency Management Manager
- Engineering Superintendant
- Environmental Steward
- Facility Manager
- Global H&S Advidor
- HSE Regional Leader
- HSE Director
- HSE Specialist
- HSE Supervisor
- Human Performance Specialist
- Industrial Hygienist
- Industrial Operations manager
- Issue Management Program Leader
- Lead Production Supervisor
- Loss Prevention System Advisor
- Manager, H&S
- Mechanical Engineer
- Operational Excellence Manager
- Operations Staff
- PDM Coordinator
- Process Safety Manager
- PSM Specialist
- QHSE Leader
- Quality Auditor
- Quality Manager
- Quality Systems Auditor
- RCA Leader
- RCA Manager
- Refining Consultant
- Reliability Specialist
- Results Supervisor
- Risk Manager
- Safety & Training Specialist
- Safety Associate
- Safety Specialist
- SHE Supervisor
- SHEQ Divisional Manager
- Site CAP Manager
- Sr. Director, Serious Injury & Fatality Prevention
- Sr. Safety Analyst
- Staff Compliance Specialist
- Supervisor Training
- Team Leader H&S
- Training Director
- Training Specialist
- Upstream HSE Team Lead
- Vice President, HSE
- VP & Regional Manager
- VP HSE
- WMS Advisor
- Work Week Coordinator
And those are just partial lists!
Imagine the things you could learn and the contacts you could make.
Add your company and your job title to the list by registering at:
Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?
Unfortunately, most systems kind of leave you hanging. They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt. Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!
Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process. We have recently tweaked this guidance to make it even easier to quickly progress through the investigation. Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.
Some of these tools are required for every investigation; some are optional data-gathering tools. Let’s first take a look at the required tools.
One of the first things you need to do is get a good understanding of exactly what happened. Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred. By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out. It helps you figure out what questions to ask and who to ask. Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason. There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask. It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.
Root Cause Tree®:
Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process. However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®. In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation. You’ll need the answers to these questions once you get to the root cause analysis phase. Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?
The tools I listed above are used during EVERY investigation. However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®. Let’s look at the non-required tools.
Change Analysis: This is a great tool to use to help you ask thought-provoking questions. It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances. The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident. It is actually an extremely easy tool to use, and yet it is very powerful. I find this to be my most-used optional tool. The results of this analysis are now added to your SnapCharT® for later root cause analysis.
Critical Human Action Profile (CHAP): Sometimes, you need help understanding those “dumb” mistakes. How can someone be walking down the stairs and just plain fall down? The person must just be clumsy! This is a great time to use CHAP. It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task. What tools were they using (and supposed to be using)? How did we expect them to perform the individual steps in the task? This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing. The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.
Equifactor®: If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure. You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem. For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring. Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration. The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure. These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure. Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.
The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with. The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations. If you need some help getting started, the TapRooT® tools will get you going! Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.
Many years ago when I was in the Navy, I was writing an application to become an Assistant Professor at the University of Illinois. My boss was reviewing what I wrote and we got into a long discussion over whether a problem we had had was an event or an incident. A couple of years later, while I was doing my Master’s Degree research, I got into a very similar discussion over whether a significant problem at a nuclear plant was an accident or an incident.
OK, let’s look at the dictionary definitions… (from the Merriam-Webster on-line Dictionary)
- an unforeseen and unplanned event or circumstance
- lack of intention or necessity : chance <met by accident rather than by design>
- an unfortunate event resulting especially from carelessness or ignorance
- an unexpected and medically important bodily event especially when injurious <a cerebrovascular accident>
- an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought
- used euphemistically to refer to an involuntary act or instance of urination or defecation
- a nonessential property or quality of an entity or circumstance <the accident of nationality>
- something dependent on or subordinate to something else of greater or principal importance
- an occurrence of an action or situation that is a separate unit of experience : happening
- an accompanying minor occurrence or condition : concomitant
- an action likely to lead to grave consequences especially in diplomatic matters <a serious border incident>
- outcomeb : the final outcome or determination of a legal actionc :
- a postulated outcome, condition, or eventuality <in the event that I am not there, call the house>
- something that happens : occurrence
- a noteworthy happeningc : a social occasion or activity
- an adverse or damaging medical occurrence <a heart attack or other cardiac event>
- any of the contests in a program of sports
- the fundamental entity of observed physical reality represented by a point designated by three coordinates of place and one of time in the space-time continuum postulated by the theory of relativity
- a subset of the possible outcomes of an experiment
So let’s make this simple …
In safety terminology, an EVENT is something that happens.
An INCIDENT is a minor accident.
An ACCIDENT is something that has serious human consequences (injury or fatality).
Thus we probably talk about:
- lost time accidents
- near-miss incidents
- events that led to a near-miss
In the TapRooT® System, an Event is an action step in the sequence of events on the SnapCharT®. The Incident is the worst thing that happened in the SnapCharT® sequence of events. Thus, and Incident is a special kind of Event. Plus, if the SnapCharT® is describing a serious injury, the Incident describes the Accident. Thus an Event could be an Incident that describes an Accident!
Do you define these terms at your facility?
If so, please add your definitions as a comment here.
We’re offering our 2-day course right before the Global TapRooT® Summit! Take the course and then stay for the 3-day Summit. LEARN MORE!
What can you learn about planning a high risk business activity from the planning for a high risk criminal activity?
Probably much more than you might think!
The Global TapRooT® Summit is all about learning from other industries and disciplines and it certainly is different learning from criminal activities and criminal investigations. This talk is based on Alan’s first hand experience with a murder investigation that will keep you riveted to his every word. Don’t miss it.
We have just scheduled a new talk in the Safety Track at the 2016 Global TapRooT® Summit. “Risk Assessing the Perfect Murder” will be held on Thursday, August 4, 2016 from 12:45 p.m. to 1:35 p.m.
Alan Smith, a former Detective Superintendant with the Grampian Police in Scotland, is now a TapRooT® Instructor and a Director of Matrix Risk Control in Aberdeen, Scotland and is leading this intriguing course.
See the complete 2016 Global TapRooT® Summit schedule by CLICKING HERE.
Register for the Safety Track at the 2016 Global TapRooT® Summit (August 1-5 in San Antonio, Texas) by CLICKING HERE. Or add Alan’s talk to another track to customize your Summit experience.
Each year Mark Paradies, President of System Improvements, picks courses to hold prior to the TapRooT® Summit. He chooses the courses to help TapRooT® Users learn even more about root cause analysis and performance improvement… lessons that go beyond the standard 2-Day and 5-Day TapRooT® Courses.
What are the courses scheduled for August 1-2?
- TapRooT® for Audits (New)
- Effective Interviewing and Evidence Collection Techniques (New)
- TapRooT® Quality Process Improvement Facilitator Course (New)
- TapRooT® Advanced Trending Techniques
- Advanced Causal Factor Development Course
- Analyzing and Fixing Safety Culture Issues
- Risk Assessment and Management Best Practices
- Getting the Most from Your TapRooT® VI Software
- Understanding and Stopping Human Error
- 2-Day TapRooT® Root Cause Analysis Training (The revised course)
- TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis
WHICH COURSE IS RIGHT YOU?
I’ll provide some background on each course so that you can choose the course that will provide the knowledge you need to help your facility reach the next level in improving safety, quality, patient safety, root cause analysis, trending, or equipment reliability.
Are you responsible for equipment troubleshooting and root cause analysis?
Do you need to improve your plant’s equipment reliability?
This course has been completely redeveloped and focused on solving equipment problems. Ken Reed, Vice President at System Improvements and lead for Equifactor® will be one of the instructors.
The course is equipment focused, but you don’t have to be an engineer to attend. Anyone who looks into the causes of equipment failures as part of:
- equipment troubleshooting
- safety investigations
- environmental releases
- quality issues
can benefit from this systematic approach to discovering why equipment failures occur.
The course teaches techniques for equipment troubleshooting developed by equipment expert Heinz Bloch. It combines those techniques with the world-renowned TapRooT® Root Cause Analysis System to make a best-of-class system for finding the causes of equipment troubles.
The text for this course is the new book: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
2-Day TapRooT® Root Cause Analysis Training (The revised course)
The 2-day TapRooT® Course has been around for over 20 years. This year we decided to go back to the basics and focus the course on performing investigations of low-to-medium risk incidents. We developed a new 50 page book (Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents) that goes with the course.
The course teaches the essential TapRooT® Techniques in an easy to use new simplified 5-Step Investigation Process. You will learn to:
- Use the SnapCharT® Diagram to collect and organize information and understand what happened.
- Identify Causal Factors using the new, simplified three question method
- Use Safeguard Analysis to help quickly identify Causal Factors.
- Find root causes using the latest TapRooT® Root Cause Tree® and Dictionary.
- Develop effective but simple fixes to improve performance.
- Identify Generic Causes if you want to go beyond the simple process.
You will practice each of these skills to become proficient. In this new course you get more practice than you did in the old course. And each team will take one of their own incidents through the process to find root causes and develop effective fixes.
If you want to learn to use a state-of-the-art root cause analysis process to perform quick investigations of low-to-moderate risk incidents, THIS COURSE IS FOR YOU.
If you are a Certified TapRooT® Instructor, you may want to attend this course to see all the new things you will be teaching (including new animated examples).
Dr. Joel Haight, a TapRooT® User since 1991 and a Professor at the University of Pittsburgh, will teach you to analyze and understand human error. This course teaches many of the techniques covered in a university human factors course in a modified short course format.
Topics covered in the course include:
- Basic understanding of visual, auditory, tactile and vestibular senses.
- Understanding reaction time and decision making.
- Understanding physical human performance (ergonomics).
- Factors that influence human error (stress, fatigue, equipment design,/automation, training, and social factors)
- Nuclear industry human performance tools (attention to detail, questioning attitude, and error traps/precursors, peer checking, 3-way communication, procedure use, peacekeeping, pre-job brief/SAFER, post-job brief, observation/coaching, STAR, and time out)
- Practical questions for incident investigators
- Quantitative/Qualitative methods (THERPS, MAPPS, OAT, and FTA)
If you are interested in an overview of techniques focused on human error to augment your standard incident investigations, this course is for you.
To continue to the other course descriptions click on the link MORE below.
TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.
The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.
But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.
One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.
The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.
For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).
For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):
- Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
- Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
- Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?
If you get a “Yes” then you have a problem to solve.
How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.
The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.
The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.
Are you using a tool or a system?
If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:
2-Day TapRooT® Root Cause Analysis Training
2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Training
For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.
To hold a course at your site, contact us by CLICKING HERE.
(Note: Copyrighted material shown above is used by permission of System Improvements.)
We had some great final presentations at the Dayton 2-Day TapRooT® Root Cause Analysis Course. Here’s a few pictures…
Linda Unger teaching at the 2-Day TapRooT® Root Cause Analysis Course in Dayton, Ohio.
Do you need an advanced system to find and fix the root causes of safety, quality, equipment reliability, and production problems? See out public courses at: http://www.taproot.com/courses
Another happy class learning how to find the root causes of incidents, quality issues, and other problems. Do you need advanced root cause analysis training? See our courses at:
The Nuclear Energy Institute published a white paper titled:
To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated.
How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.
For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.
Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).
We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:
Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations.
What’s in the new book? Here’s the Table of Contents:
Chapter 1: When is a Basic Investigation Good Enough?
Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System
- Find Out What Happened & Draw a SnapCharT®
- Decision: Stop or More to Learn?
- Find Causal Factors Using Safeguard Analysis
- Find Root Causes Using the Root Cause Tree® Diagram
- Develop Fixes Using the Corrective Action Helper Module
- Optional Step: Find and Fix Generic Causes
- What is Left Out of a Basic Investigation to Make it Easy?
Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation
Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation
The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.
If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.
If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.
If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.
One more question that you might have for us ,,,
How does TapRooT® stay one (or more) steps ahead of the industry?
- We work across almost every industry in every continent around the world.
- We spend time thinking about all the problems (opportunities for improvement) that we see.
- We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board.
- We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.
We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.
If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.
This is a great flashback. Remember when we were this young? It wasn’t all that long ago. And everything we said then is still true today – just even more so!
Don’t miss the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. See:
Improve your root cause analysis.
- Learn best practices
- Refresh your TapRooT® skills
- Be inspired!
- Get motivated!
That’s what the Global tapRooT® Summit is all about.
Normalization of Excellence – The Rickover Legacy – 18 Other Elements of Rickover’s Approach to Process SafetyMarch 31st, 2016 by Mark Paradies
The previous three articles discusses Rickover’s “key elements” to achieving safety in the Navy’s nuclear program. They are:
In addition to these three keys that Rickover testified to Congress about, he had 18 other elements that he said were also indispensable. I won’t describe them in detail, but I will list them here:
- Conservatism of Design
- Robust Systems (design to avoid accidents and emergency system activation)
- Redundancy of Equipment (to avoid shutdowns and emergency actions)
- Inherently Stable Plant
- Full Testing of Plant (prior to operation)
- Detailed Prevent/Predictive Maintenance Schedules Strictly Adhered To
- Detailed Operating Procedures Developed by Operators, Improved with Experience, and Approved by Technical Experts
- Formal Design Documentation and Management of Change
- Strict Control of Vendor Provided Equipment (QA Inspections)
- Formal Reporting of Incidents and Sharing of Operational Experience
- Frequent Detailed Audits/Inspections by Independent, Highly Trained/Experienced Personnel that Report to Top Management
- Independent Safety Review by Government Authorities
- Personal Selection of Leaders (looking for exceptional technical knowledge and good judgment)
- One Year of Specialized Technical Training/Hands-On Experience Prior to 1st Assignment
- Advanced Training for Higher Leadership Positions
- Extensive Continuing Training and Requalification for All Personnel
- Strict Enforcement of Standards & Disqualification for Violations
- Frequent Internal Self-Assessments
Would like to review what Rickover had to say about them? See his testimony here:
Now after the description of the excellence of Rickover’s program, you might think there was nothing to be improved. However, I think the program had three key weaknesses. They are:
- Blame Orientation (Lack of Praise)
- Needed for Advanced Root Cause Analysis
Let me talk about each briefly.
The dark side of a high degree of responsibility was a tendency to blame the individual when something went wrong. Also, success wasn’t celebrated, it was expected. The result was burnout and attitude problems. This led to fairly high turnover rate among the junior leaders and enlisted sailors.
Want to work long hours? Join the Nuclear Navy! Eighteen hour days, seven days a week, were normal when at sea. In port, three section duty (a 24 hour day every third day) was normal. This meant that you NEVER got a full weekend. Many errors were made due to fatigue. I remember a sailor was almost killed performing electrical work because of actions that just didn’t make sense. He had no explanation for his errors (they were multiple) and he knew better because he was the person that trained everyone else. But he had been working over 45 days straight with a minimum of 12 hours per day. Was he fatigued? It never showed up in the incident investigation.
ADVANCED ROOT CAUSE ANALYSIS
Root Cause Analysis in the Nuclear Navy is basic. Assign smart people and they will find good “permanent fixes” to problems. And this works … sometimes. The problem? The Nuke Navy doesn’t train sailors and officers how to investigate human errors. That’s where advanced root cause analysis comes in. TapRooT® has an expert system that helps people find the root causes of human error and produce fixes that stop the problems. Whenever I hire a Navy Nuke to work at System Improvements, they always tell me they already know about root cause analysis because they did that “on the boat.” But when they take one of our courses, they realize that they really had so much to learn.
Read Part 7: Statement of Admiral Rickover in front of the Subcommittee on Energy Research and Production of the Committee on Science and Technology of the US House of Representatives – May 24, 1979
If you would like to learn more about advanced root cause analysis, see our course offerings:
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We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.
TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.
Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.
TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:
TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Corrective Actions and Exercise
The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise
Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”
We hope to see you in the course! To register:
REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).
REGISTER for this 2-day course only (August 1 – 2, 2016).
We are busy preparing for this year’s summit, which will be held August 3-5 (with pre-summit courses on August 1-2) in San Antonio, Texas.
I’m very excited about the lineup for this year’s Safety Track. We have some great speakers and topics:
7 Deadly Sins of Human Performance – Mark Paradies, Creator of TapRooT®
Weatherford’s Global Journey to HSE and Quality Improvement with TapRooT® – Mitch Miller, David Smith, Shawn Holden
Proactive Use of TapRooT® – Dave Janney
Interviewing Behaviors & Body Language – Barb Phillips
Marathon Galveston Bay – Ken Bloch
Arc Flash Loss Prevention – Scott King and Terry Butler
TapRooT® in What If Analysis – Joel Solomon
In addition to the speakers in the safety track, all tracks with attend the keynote sessions each morning and afternoon, with top-notch speakers. We also have the famous Wednesday night reception with great food and drinks and featuring live entertainment from Carl Dixon (of the Guess Who, April Wine, and Coney Hatch). And the best part of the summit? Getting to meet other like-minded professionals; we hear every year from attendees that the Global TapRooT® Summit is the best networking opportunity of the year.
So please join us for the Safety Track at this yea’s summit. For more information and to register, go HERE
See you in San Antonio!