Category: TapRooT

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

August 16th, 2017 by

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

August 16th, 2017 by

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

ACE – How do you find the root causes?

August 16th, 2017 by

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First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

How Much Do You Believe?

August 1st, 2017 by

I was talking to my kids about things they read (or YouTube videos) on the internet and asked them …

How much of what you see online do you believe?

I told them that less than half of what I see or read online is believable (maybe way less than half).

But the next question I asked was more difficult …

How do you know if something is believable? How would you prove it?

This made them think …

I said that I have a lifetime of experience that I can use to judge if something sounds believable or not. Of course, that isn’t proof … but it does make me suspicious when something sounds too good to be true.

They didn’t have much life experience and therefore find it harder to judge when things are too good to be true.

However, we all need to step back and think … How can I prove something?

What does that have to do about accident and incident investigations?

Do you have a built-in lie detector that helps you judge when someone is making up a story?

I think I’ve seen that experienced investigators develop a sense of when someone is making up a story.

We all need to think about how we collect and VERIFY facts. Do we just accept stories that we are told or can we verify them with physical evidence.

The 1-Day TapRooT® Effective Interviewing & Evidence Collection Course that will be held in Houston on November 8th will help you think about your interviews and evidence collection to make your SnapCharT® fact based. In addition to the 1-Day Interviewing Course you can also sign up for the 2-Day TapRooT® Root Cause Analysis Course being held in Houston on November 6-8 by CLICKING HERE.

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Barb Phillips will be the instructor for the Effective Interviewing & Evidence Collection Course. Don’t miss it!

Is There Just One Root Cause for a Major Accident?

July 26th, 2017 by

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Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

http://www.taproot.com/store/Courses/

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

Get Both Books and Save

July 25th, 2017 by

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There are two new books that explain how to perform TapRooT® root cause analyses.

One is used to investigate low to medium risk incidents. It is titled:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

It is used for fast, simple investigations.

The second is used for major investigations, big fires, oil spills, fatalities, and the such. It is titled:

Using TapRooT® Root Cause Analysis for Major Investigations

It includes all the TapRooT® optional techniques.

Did you know that you can buy both books at the same time and save? To order, CLICK HERE.

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

Mark Paradies and Kathy Ireland on Worldwide Business – It’s a wrap!

July 21st, 2017 by

Here’s a live Facebook cut from the end of shooting. We’ll post the show dates here.

System Improvements,Inc. is now LIVE on the set of Worldwide Business with kathy ireland!

Posted by Worldwide Business with kathy ireland on Wednesday, July 19, 2017

 

Dave Janney Discusses Investigating Near Misses

July 18th, 2017 by

Sometimes we are fortunate enough and avoid an accident, but do we still investigate those close calls? Watch as Dave Janney describes the importance of investigating near misses.

Should You Attend a Public TapRooT® Root Cause Analysis Course or Have a Course at Your Site?

July 12th, 2017 by

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People often ask me …

“Is it best to go to a public TapRooT® Root Cause Analysis Courses
or is it better to have a course at my site?”

I also get asked about the type of course they should attend.

Here are some answers to these frequently asked questions…

PUBLIC OR ON-SITE TapRooT® COURSE

PUBLIC: If you only have a few folks who are checking out the TapRooT® Root Cause Analysis System, I recommend attending one of our public courses. See the upcoming schedule by CLICKING HERE. Of course, we hold our courses all over the world, so you probably can find a course near you or in a location that you would really like to visit. In addition, you will meet people from other companies who use TapRooT® or are considering using TapRooT® and you can discuss your efforts to improve performance with them.

ON-SITE: If you have about 10 or more people at a site who need training, I recommend having on-site training. You will save money and your folks won’t have to travel. To get a quote for a course at your site, CLICK HERE.

WHAT COURSE SHOULD I ATTEND

First, you can see a list of all the courses we offer HERE. I usually recommend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training or the 2-Day TapRooT® Root Cause Analysis Training.

5-DAY TapRooT® TRAINING: The 5-Day Course is the most complete. It teaches techniques for simple investigations and major investigations. You get the most practice using all the TapRooT® techniques (you do a major exercise every day) and you get to practice using the TapRooT® Software (you get a trial subscription with the course).

What is covered in the course? Here is a course outline:

Day One

  • Class Introductions and Background of TapRooT®
  • SnapCharT® Basics
  • SnapCharT® Exercise
  • Define Causal Factors
  • Intro to Root Cause Tree®
  • Root Cause Analysis Exercise 1 – Class Walkthrough
  • Root Cause Analysis Exercise 2 – Team Use of the Root Cause Tree®
  • Developing Corrective Actions
  • Corrective Action Exercise

Day Two

  • Software Tips
  • Generic Causes/Systemic Problems
  • Enhanced Corrective Actions
  • Preparing for Your Investigation
  • Collecting Information
  • Interviewing
  • Interviewing Exercise
  • Interviewing Exercise Root Cause Analysis

Day Three

  • Management System and Changing Behavior
  • Equipment Troubleshooting and Equifactor®
  • Human Engineering
  • CHAP & Exercise
  • Change Analysis
  • Change Analysis Exercise
  • Analyzing Training Problems
  • Putting It All Together
  • Work Direction
  • Aviation Pilot Error Root Cause Analysis Exercise

Day Four

  • Testing Your Human Factors Knowledge
  • Proactive Improvement
  • Auditing Using Safeguard Analysis
  • Trending
  • Analyzing Procedure Issues
  • Operations Root Cause Analysis Exercise
  • Presenting to management
  • Start Final Exercise – SnapCharT®

Day Five

  • Continue Final Exercise
  • Final Exercise Presentations (Class end by 1 PM)

2-DAY TapRooT® TRAINING: The 2-Day TapRooT® Training teaches the essential root cause analysis techniques needed to investigate low to medium risk incidents. The course outline below provides you with the details of the course:

Day One

  • Class Introduction
  • TapRooT® System Overview
  • SnapCharT® Basics – Gathering information
  • SnapCharT® Exercise
  • Define Causal Factors
  • Intro to Root Cause Tree®
  • Root Cause Tree® Exercise
  • Root Cause Team Exercise
  • Developing Fixes
  • Corrective Action Exercise

Day Two

  • Software Overview
  • Generic Causes/Systemic Issues
  • Causal Factors – Additional Practice
  • Reporting/Management Presentation
  • Frequently Asked Questions
  • Final Exercise – Putting What You’ve Learned to Work

OTHER COURSES: These are just two of the courses we offer. For other courses including Trending, Proactive Improvement, and Information Collection and Interviewing, see: http://www.taproot.com/courses

COURSE GUARANTEE: When was the last time you attended training with a money back guarantee? Here is our training guarantee:

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.

That’s it. It’s just that simple. We are confident our training will help you find and fix the causes of your problems and we have hundreds of thousands of users worldwide who have attended our training and agree.

So don’t wait. Sign up for one of our public courses or get a course scheduled at you site to see how much TapRooT® Root Cause Analysis can help your company save lives, stop injuries, improve quality, improve equipment reliability, and boost operations performance. We know you will be pleased.

Can bad advice make improvements more likely?

July 12th, 2017 by

Here is what a consultant recently wrote in a blog article that was republished on LinkedIn:

“The 5 WHY analysis is a simple and very effective technique.”

What do I think about 5 Whys? It is simple but it is NOT effective. Proof of the lack of effectiveness is all over the place. See these articles to find out just some of what I’ve written about the effectiveness of 5 Whys in the past:

 An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

Under Scrutiny (page 32)

If your root cause analysis is having problems, don’t double down on 5 whys by asking more whys. The problem is the root cause analysis system (5 Whys) and not your ability to ask why effectively.

The problem is that the techniques wasn’t designed with human capabilities and limitations in mind.

What system was developed with a human factors perspective? The TapRooT® Root Cause Analysis System. Read more about how TapRooT® was designed here:

http://www.taproot.com/products-services/about-taproot

Or get the book that explains how TapRooT® can help your leadership improve performance:

TapRooT® Root Cause Analysis Leadership Lessons

Are you a member of the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends?

July 11th, 2017 by

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Sometimes people ask me what TapRooT® Users are doing about a particular issue. I recommend they ask the question on the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends.

There are over 3000 group members and it’ a great place to post a question or your opinions.

To join the group, see: https://www.linkedin.com/groups/2164007

 

What happens when root cause analysis becomes too simple? Six problems I’ve observed.

July 5th, 2017 by

I’ve had many people explain to me that they understand that for serious incidents, they need robust root cause analysis (TapRooT®) because … finding effective fixes is essential. But for simple incidents, they just can’t invest the same effort that they use for major investigations.

I get it. And I agree. You can’t put the same level of effort into a simple incident that you put into a major accident. But what happens when the effort you put into a simple incident is too little. What happens when your simple investigation becomes too simple?

Here are the results that I’ve observed when people perform “too simple” investigations.

1. The first story heard is analyzed as fact.

People doing simple investigations often take the first “story” they hear about a simple incident and start looking for “causes”. The shortcut – not verifying what you hear – means that simple investigations are sometimes based on fairy tales. The real facts are never discovered. The real root causes are unknown. And the corrective actions? They are just ideas based on a fantasy world.

The result? The real problems never get fixed and they are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb.

2. Assumptions become facts.

This is somewhat similar to the first issue. However, in this case the investigator fills in holes in the story they heard with assumptions. Because the investigator doesn’t have time to collect much info, these assumptions become facts and become the basis for the root cause analysis and corrective actions.

The result? Just like the first issue, real problems never get fixed. The real, undiscovered problems are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb #2.

3. Skip root cause analysis and go straight to the fixes.

When you don’t have time for the investigation, why not just skip straight to the fixes? After all … we already know what caused the incident … right?

This is a frequent conclusion when people THINK they already know the answers and don’t need to bother with a troublesome investigation and root cause analysis to fix a “simple” problem.

The problems is that without adequate investigation and root cause analysis … you don’t really know if you are addressing the real issues. Do you feel lucky? Well do ya punk? (A little Clint Eastwood imitation.)

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The result? You are depending on your luck. And the problem you may not solve may be more powerful than a .44 magnum … the most powerful handgun in the world.

OK … if you want to watch the scene, here it is …

4. The illusion of progress.

Management often thinks that even though they don’t give people time to do a good investigation, simple investigations are better than nothing … right?

Management is buying into the illusion of progress. They see some action. People scurry around. Fixes are being recommended and maybe even being implemented (more training). So things must be getting better … right?

NO!

As Alfred A. Montapert said:

Do not confuse motion and progress.
A rocking horse keeps moving but does not make any progress
.”

The result? If people aren’t finding the real root causes, you are mistaking the mistake of assuming that motion is progress. Progress isn’t happening and the motion is wasted effort. How much effort does your company have to waste?

5. Complacency – Just another investigation.

When people in the field see investigators make up facts and fixes, they know the real problems aren’t getting fixed. They see problems happening over and over again. They, too, may think they know the answers. Or they may not. But they are sure that nobody really cares about fixing the problems or management would do a better job of investigating them.

The result? Complacency.

If management isn’t worried about the problems … why should I (the worker) be worried?

This contributes to “the normalization of deviation.” See this LINK is you are interested.

6. Bad habits become established practice.

Do people do more simple investigations or major investigations?

If your company is like most, there are tons of simple investigations and very few major investigations. What happens because of this? The practices used in simple investigations become the practices used in major investigations.

Assumptions, shortcuts, made up fixes and more become the standard practice for investigators. The things they learned in a root cause analysis class aren’t what they practice. What gets practiced (the bad practices) becomes the standard way that business is done.

The result? The same poor standards that apply to simple investigations infect major investigations. Major investigation have the same poor root cause analysis and corrective actions seen in the simple investigations.

DON’T LET BAD PRACTICES INFECT YOUR CULTURE.

Would you like to see good practices for performing simple investigations? Here are two options:

1. Attend a TapRooT® 2-Day Root Cause Analysis Course. See the the dates and location of upcoming public courses here:

http://www.taproot.com/store/2-Day-Courses/

2. Read the new book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Now perform your Basic and Major investigations with TapRooT®

June 27th, 2017 by

TapRooT® is a robust root cause analysis system. When you have those major accidents and need an effective and thorough investigation, TapRooT® is the go-to solution. But what about those smaller, simpler, less complex incidents? Is it worth applying such a complex system for such a simple problem? Well, we think all problems are worth a thorough investigation, but we also realize you can only give up so much time on seemingly less serious incidents. Which is why the folks at TapRooT® decided to make a simpler version of our root cause analysis process so that you can still get the best results in less time.

Check out this video of Ken Reed, TapRooT® instructor and expert, to learn more.

 

7 Traits of a Great Root Cause Analysis Facilitator

June 27th, 2017 by

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After decades of teaching TapRooT® and being consulted about many investigations, I’ve met lots of root cause analysis facilitators. Some were good. Some were not so good. Some were really superior. Some were horrible. Therefore, I thought it might be interesting to relate what I see that separates the best from the rest. Here are the seven traits of the BEST.

1. They don’t jump to conclusions. The worst investigators I’ve seen think they know it all. They already have their minds made up BEFORE the first interview. They START the investigation to prove their point. They already know the corrective action they are going to apply … so all they have to do is affirm that the causes they already have assumed ARE the cause they find.

What do the best investigators do? They start by seeing where the evidence leads them. The evidence includes:

  • Physical evidence,
  • Paper evidence (documentations),
  • People evidence (interviews), and
  • Recordings (videos/pictures/tapes/computer records).

They are great at collecting evidence without prejudice. They perform “cognitive interviews” to help the interviewee remember as much as possible. (See the new book TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about cognitive interviews. The book should be released in August. Get the book with the course being held in November in Houston.)

The best investigators may have some technical knowledge, but they know when they need help to understand what the evidence is telling them. Therefore, they get technical experts when they need them.

2. They understand What before Why. The worst investigators start by asking WHY? Why did someone make a mistake? Why did the part fail? Why didn’t the guilty party use the procedure? These “why” questions tend to put people on the defensive. People start justifying what they did rather than sharing what they know.

The best investigators start with what and how. They want to understand what happened and how those involved reacted. What did they see as the problem? What were the indications they were observing? Who did they talk to and what did they say? What was happening and in what order did it happen?

People don’t get defensive about what and how questions. They are much more likely to share information and tell the truth. And these questions help develop an excellent SnapCharT® that helps the root cause analysis facilitator develop a “picture” of what happened.

3. They are not looking for the single root cause. The worst investigators are always looking for THE root cause. The smoking gun. The one thing that caused the problem that can be corrected by a simple corrective action. THE root cause that they are looking for.

The best investigators know that most accidents have multiple things that went wrong. They facilitate their team to understand all the causal factors and how these causal factors came together to cause that particular incident.

These root cause facilitators use their SnapCharT® and Safeguard Analysis to show how the problems came together to cause the incident. This can help show management how latent condition are hidden traps waiting to produce an accident that previously seemed impossible.

4. They dig deeper to find root causes. The worst investigator stop when they identify simple problems. For the worst investigators, HUMAN ERROR is a root cause.

The best investigators know that human error is just a starting point for a root cause analysis. They go beyond equipment failure and beyond human error by using effective investigative techniques that help them go beyond their own knowledge.

For example, if there is an equipment failure they consult the Equifactor® Troubleshooting Tables to find out more about the failure. This helps them get to the bottom of equipment problems. They often find that equipment failures are caused by human error.

For human performance related causal factors they use the Human Performance Troubleshooting Guide of the Root Cause Tree® to help them determine where they need to dig deeper into the causes of human error.

The best investigators don’t accept false stories. They have a good BS detector because false stories seldom make a sensible SnapCharT®.

5. They find root causes that are fixable. The worst investigators find root causes that management really can’t do anything to prevent. For example, telling people to “try harder” not to make a mistake IS NOT an effective corrective action to stop human errors.

The best investigators know that their are many ways to improve human performance. They understand that trying harder is important but that it is not a long-term solution. They look for human factors related fixes that come from human performance best practices. They know that the Root Cause Tree® can help them find problems with:

  • Procedures
  • Training
  • Quality Control
  • Communications
  • Management Systems
  • Human Engineering
  • Work Direction

And that by implementing best practices related to the root causes they identify, they can reduce the probability of future human errors.

6. They recommend effective corrective actions. The worst investigators recommend the three standard corrective actions for almost every problem:

  1. MORE TRAINING
  2. COUNSELING (tell them to be more careful and fire them if they get caught making the mistake again)
  3. If you are desperate, WRITE A PROCEDURE

That’s about it.

The best investigators start by understanding the risk represented by the incident. Higher risk incidents deserve higher order corrective actions. The highest order is to remove the Hazard. Other corrective actions may be related to strengthening the Safeguards by implementing human performance best practices. Sometimes these corrective actions may include training and procedures but that is seldom the only corrective actions recommended.

7. They know what they are doing. The worst investigators don’t really know what they are doing. They haven’t been trained to find root causes or the training they had was superficial at best. (Can you ask “Why?” five times?)

The best investigators are accomplished professionals. They’ve been in advanced root cause analysis training and have practiced what they have learned by performing many simple investigations before they were asked to jump into a major investigation. Even if they have several major investigations under their belt, they continue to practice their root cause analysis skills on simple investigations and on proactive audits and assessments.

Beyond practicing their skills, they attend the only worldwide summit focused on root cause analysis and investigation facilitation – The Global TapRooT® Summit. At the Summit they benchmark their skills with other facilitators from around the world and share best practices. Think of this as steel sharpening steel.

GOOD NEWS. The knowledge and skills that make the best investigators the best … CAN BE LEARNED.

Where? Have a look at these courses:

http://www.taproot.com/courses

And then plan to attend the 2018 Global TapRooT® Summit in Knoxville, Tennessee, on February 26 – March 2 to sharpen your skills (or have those who work for you sharpen their skills).

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Top 10 Reasons People Don’t Use TapRooT®

June 23rd, 2017 by

10. Why do a root cause analysis when you can just discipline people.

9. Job security – they want more incidents to investigate.

8. They learned a system back in the 60’s and why should they try anything new.

7. Their company has no mistakes to investigate.

6. They don’t like tapping noises.

5. They would rather use their massive brainpower.

4. They are trying to get fired.

3. They just say that everything is human error.

2. They don’t grow trees.

1. They use Spin-A-Cause.

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How do you plan your root cause analysis?

June 20th, 2017 by

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General George Patton said:

“A good plan today is better than a perfect plan tomorrow.”

But for many investigations, I might ask … Do you have any plan at all?

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Copyright © 2016 by System Improvements, Inc. Duplication prohibited. Used by permission.

Planning is the first step in the TapRooT® 7-Step Major Investigation Process. We even recommend a simple plan for simple investigations.

You may have read the earlier article about using a SnapCharT® to plan your investigation (see: http://www.taproot.com/archives/58488)

What else can help you plan your investigation? Here’s a list:

  • Have an investigation policy that specifies team make up and other factors that can be predefined.
  • Make sure that people on the scene are trained to preserve evidence and to obtain witness statements.
  • Consider PPE requirements for team members visiting the scene.
  • Collect any recorded evidence (cell phone recordings).
  • Maintain a chain of custody for evidence.
  • Do you need legal or PR assistance for your team?

That’s just a few ideas. There is a whole chapter about planning in the new book: TapRooT® Root Cause Analysis for Major Investigations.

When you order the new book you will also get the latest copies of theRoot Cause Tree®, the Root Cause Tree® Dictionary, and the Corrective Action Helper® Guide – all of which were recently updated.

Order your copy by CLICKING HERE.

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

TapRooT® Optional Root Cause Analysis Tools

June 14th, 2017 by

All TapRooT® Users are familiar with the SnapCharT®, Safeguard Analysis, the Root Cause Tree® and Dictionary, and the Corrective Action Helper® Guide. But do you know about the optional TapRooT® Tools:

  • Equifactor®
  • CHAP
  • Change Analysis

These optional techniques are usually applied in more complex investigations.

Equifactor® is used to troubleshoot equipment problems. We found that many people try to understand the root causes of equipment failures BEFORE they really understand the basic reasons for the failure. That’s why we partnered with Heinz Bloch to develop the Equifactor Troubleshooting Tables and Software. 

CHAP is used for a deep dive on human performance issues. Once again we found that people tended to jump into asking “why” before they understood all the details about a human error. That’s why we developed CHAP to help people collect information about the human action before they start asking why things went wrong.

Change Analysis is an older technique that was derived from the work of Charles Kepner and Benjamin Tregoe. The technique helps identify changes that could have contributed to the equipment failure or human error. 

How can you learn to apply these optional techniques to improve your root cause analysis? Attend one off our 5-Day TapRooT® Root Cause Analysis Team Leader Courses. To see the locations and dates of our public TapRooT® 5-Day Courses being held around the world, CLICK HERE.

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Don’t have time to travel to a course but you do have time for some reading? Then order the TapRooT® Root Cause Analysis for Major Investigations book by CLICKING HERE.

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

Knowing that each year about 900 construction workers do not come home to their families after work, safety on construction work sites must be taken seriously.

AGC, the Associated General Contractors of America recently published a study together with Virginia Tech, “Preventing Fatalities in the Construction Industry”. There are some interesting findings:

  • Dangerous Lunch Hour: construction site fatalities peak at noon, and are much lower on Fridays than Monday through Thursday
  • Small Contractors (less than 9 employees) are overrepresented in the statistics, with a fatality rate of 26 per 100,000 workers
  • Fully 1/3 of fatalities are from falls, and about 29% from Transportation incidents with e.g trucks or pickups
  • More experienced workers are not safer: fatalities start increasing after age 35 and keep growing so that 65 year olds are at the highest risk
  • Industrial projects are the most dangerous, followed by Residential and Heavy construction projects

The consequences of a fatality are devastating. There is a great human cost where families will have to deal with grief as well as financial issues. For the company there may be OSHA fines, law suits and criminal investigations. There really is no excuse for a builder not to have an active safety program, no matter how small the company.

Basic safety activities include providing and checking PPE and fall protection, correct use of scaffolding and ladders, on- going safety training, check- ins and audits. It is also a good idea to actively promote a safety culture, and to use a root cause analysis tool to investigate accidents and near misses, and prevent them from happening again.

The TapRooT® Root Cause Analysis methodology is a proven way of getting to the bottom of incidents, and come up with effective corrective actions. Focus is on human performance, and how workers can be separated from hazards like electricity, falls or moving equipment.

We can organize on- site training, or start by signing up for a public course. We offer the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as well as the introductory 2-Day TapRooT® Root Cause Analysis Training class.

Be proactive, do not let preventable accidents catch up with you… call us today!

#TapRooT_RCA #safety

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

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Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Building a Safety Culture

May 26th, 2017 by

A Safety Culture can be defined as “the sum of what an organization is and does in the pursuit of safety”. Managing company culture is a task of the corner office; top management needs to embrace the safety mindset -that every employee and customer is free from harm.

In the health care field The Joint Commission (an accreditation organization for hospitals) takes patient safety very seriously. Their document, “11 Tenets of a Safety Culture” (https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf) contains a lot of wisdom that can be applied in continuous safety improvement everywhere:

  1. Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions.
  3. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
  4. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop).
  6. Determine an organizational baseline measure on safety culture performance using a validated tool.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
  10. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.

A formal safety culture statement like this is a good start. To avoid it becoming a “flavor of the day” initiative, it is important to put in place a robust root cause analysis method like TapRooT®. This lends immediate support to Tenets 1. and 2. above.  It is also important to empower employees at every level to stop risky behavior.

Every organization benefits from an objective and impersonal way of investigating or auditing safety incidents, that gets to the root causes. Instead of blaming, re-training or firing individuals more effective corrective actions can be implemented, and safety issues dealt with once and for all.

#TapRooT_RCA

Is there an easier way to investigate simple problems?

May 24th, 2017 by

People often ask me:

“Is there an easier way to investigate simple problems?”

The answer is “YES!”

The simplest method is:

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Of course, some methods may be too simple.

That’s why we wrote a book about the simplest, but reliable method to find the root causes of simple incidents. The title? Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Want to learn more? See an outline at: http://www.taproot.com/products-services/taproot-book

Or just order a copy by CLICKING HERE.

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