Category: TapRooT

Summit Flashback

April 19th, 2016 by

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:

http://www.taproot.com/taproot-summit

Improve your root cause analysis.

  • Network
  • Benchmark
  • 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 Safety

March 31st, 2016 by

NewImage

The previous three articles discusses Rickover’s “key elements” to achieving safety in the Navy’s nuclear program. They are:

  1. Technical Competence
  2. Total Responsibility
  3. Facing the Facts

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:

  1. Conservatism of Design
  2. Robust Systems (design to avoid accidents and emergency system activation)
  3. Redundancy of Equipment (to avoid shutdowns and emergency actions)
  4. Inherently Stable Plant
  5. Full Testing of Plant (prior to operation)
  6. Detailed Prevent/Predictive Maintenance Schedules Strictly Adhered To
  7. Detailed Operating Procedures Developed by Operators, Improved with Experience, and Approved by Technical Experts
  8. Formal Design Documentation and Management of Change
  9. Strict Control of Vendor Provided Equipment (QA Inspections)
  10. Formal Reporting of Incidents and Sharing of Operational Experience
  11. Frequent Detailed Audits/Inspections by Independent, Highly Trained/Experienced Personnel that Report to Top Management
  12. Independent Safety Review by Government Authorities
  13. Personal Selection of Leaders (looking for exceptional technical knowledge and good judgment)
  14. One Year of Specialized Technical Training/Hands-On Experience Prior to 1st Assignment
  15. Advanced Training for Higher Leadership Positions
  16. Extensive Continuing Training and Requalification for All Personnel 
  17. Strict Enforcement of Standards & Disqualification for Violations
  18. Frequent Internal Self-Assessments

Would like to review what Rickover had to say about them? See his testimony here:

Rickover Testimony

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:

  1. Blame Orientation (Lack of Praise)
  2. Fatigue
  3. Needed for Advanced Root Cause Analysis

Let me talk about each briefly.

BLAME ORIENTATION

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.

FATIGUE

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. 

If you would like to learn more about advanced root cause analysis, see our course offerings:

COURSES 

And sign up for our weekly newsletter:

NEWSLETTER

New TapRooT® for Audits course to debut August 1-2, 2016

March 21st, 2016 by

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:

DAY ONE

TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Generic Causes
Corrective Actions and Exercise

DAY TWO

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).

Safety Track at the 2016 Global TapRooT® Summit

March 21st, 2016 by

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!

2016-global-taproot-summit-brochure-1-638

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

book_graphic_1511

If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

Monday Accident & Lessons Learned: Button Pushed “Accidentally” Shuts Down Refinery

March 7th, 2016 by

Screen Shot 2016 02 29 at 11 29 09 AM

Here’s the press report about an incident at a west coast refinery …

http://ww2.kqed.org/news/2016/02/26/martinez-refinery-incident-triggered-when-someone-hit-the-wrong-button

They think that someone working in the area accidentally hit a button that shut down fuel to a boiler. That caused a major portion of the refinery to shut down.

 At least one Causal Factor for this incident would be “Worker accidentally hits button with elbow.”

If you were analyzing this Causal Factor using the Root Cause Tree®, where would you go?

Of course, it would be a Human Performance Difficulty.

When you reviewed The Human Performance Troubleshooting Guide, you would answer “Yes” to question 5:

“Were displays, alarms, controls, tools, or equipment identified or operated improperly?”

 That would lead you do evaluating the equipment’s Human Engineering.

Under the Human-Nachine Interface Basic Cause Category, you would identify the “controls need improvement” root cause because you would answer “Yes” to the Root Cause Tree® Dictionary question:

“Did controls need mistake-proofing to prevent unintentional or incorrect actuation?”

That’s just one root cause for one Causal Factor. How many other Causal Factors were there? It’s hard to tell with the level of detail provided by the article. I would guess there was at least one more, and maybe several (there usually should be for an incident of this magnitude). 

At least one of the corrective actions by the refinery management was to initially put a guard on the button. Later, the button was removed to eliminate the chance for human error. 

Are there more human-machine interface problems at this refinery? Are they checking for them to look for Generic Causes? You can’t tell from the article.

Would you like to learn more about understanding human errors and advanced root cause analysis? Then you should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See public course dates at:

http://www.taproot.com/store/5-Day-Courses/

And click on the link for the continent where you would like to attend the training.

Would Ronald Reagan Endorse the New TapRooT® Book for Low-to-Moderate Incident Investigations?

February 25th, 2016 by

NewImage

Ronald Reagan said:

They say the world has become too complex for simple answers. They are wrong.”

That’s why I think Reagan would like the new TapRooT® Book …

NewImage

It makes using TapRooT® simple for analyzing simple incidents.

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

Where can you get the new book? CLICK HERE!

 

Using the Essential TapRooT® Techniques to Perform Apparent Cause Analysis

February 17th, 2016 by

If you are in the nuclear industry you have probably read my rant on apparent cause analysis. I said that apparent cause analysis was a curse.

The curse as been lifted!

We published a book that describes how to use TapRooT® for low-to-moderate risk incidents. And this new way of using TapRoot® is perfect for apparent cause analysis!

EssentialsBook

What’s in the 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

WHEN CAN YOU BUY THIS NEW BOOK??? NOW!!!

See this link: 

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

Are You Being Held Back Because You Think You Know Everything???

February 16th, 2016 by

Those who are humble learn from others.

This saves the humble learner the difficulty of experiencing the pain of learning by trial and error (or in other words, the pain of mistakes).

As Sam Levenson said:

You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.

But have you met folks who are so sure of themselves that they must believe that they know it all?

Just imagine the smartest person in history. Then imagine how little of the total knowledge of the universe that that person actually knew. How can anyone think that they know it all?

I was thinking about this because I run into people that can’t learn from others because when they walk into a room, they think they are the smartest person in the room. They pontificate. They expect everyone to listen to their stories and learn. But they don’t  listen to others and learn.

I hope I’m not talking about you … or your boss. Learning from others is really important.

Where can you learn from others?

One of the best places is the TapRooT® Summit.

Have a look at the Summit Schedule.

 Look at all the topics in all the sessions.

One of my favorite sessions is the TapRooT® Users Share Best Practices session.

As one of the attendees told me last year …

You sit at a table with people from leading companies from around the world.
The people you are talking to are really smart.
And they share their best ideas. You share yours.
And everybody gets even smarter. It is amazing
.”

 Another way to meet and discuss topics at the Global TapRooT® Summit is to participate in the opening session. 

Most conferences start off slow. NOT the Global TapRooT® Summit.

We start off with a description of the improvements we’ve made to TapRooT® in the past 12 months and what you can learn at the Summit. Then we immediately go to the networking activity where you will meet someone from your industry, someone from a different industry, and an expert. That’s three new contacts in the first hour of the Summit. AND you get rewarded for your work.

Don’t miss out on the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. You know you don’t know everything and you will enjoy meeting really smart people and sharing best practices that will help your company be even better in 2017!

The “Force” was with HSE this time in Star Wars Accident

February 11th, 2016 by

“The actor, Harrison Ford, was struck by a hydraulic metal door on the Pinewood set of the Millennium Falcon in June 2014.”

“The Health And Safety Executive has brought four criminal charges against Foodles Production (UK) Ltd – a subsidiary of Disney.”

“Foodles Production said it was “disappointed” by the HSE’s decision.”

Read more here

 

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

February 10th, 2016 by

In 2008 we wrote the book TapRooT® – Changing the Way the World Solves Problems. In one book we stuffed in all the information we thought was needed for anyone from a beginner to an expert trying to improve their root cause analysis program. It was a great book – very complete.

As the years went on, I realized that everybody didn’t need everything. In fact, everything might even seem confusing to those who were just getting started. They just wanted to be able to apply the proven essential TapRooT® Techniques too investigate low-to-moderate risk incidents.

Finally I understood. For a majority of users, the big book was overkill. They wanted something simpler. Something that was easy to understand and as easy as possible to use and get consistent, high-quality results. They wanted to use TapRooT® but didn’t care about trending, investigating fatalities, advanced interviewing techniques, or optional techniques that they would not be applying.

Therefore, I spent months deciding was were the bare essentials and how they could be applied as simply as possible while still being effective. Then Linda Unger and I spent more months writing an easy to read 50 page book that explained it all. (Yes … it takes more work to write something simply.)

 

EssentialsBook

Book 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

By April, the new book and philosophy will be incorporated into our 2-Day TapRooT® Root Cause Analysis Course. But you can buy the new book (that comes with the latest Dictionary, Root Cause Tree®, and TapRooT® Corrective Action Helper® Guide) from our web site NOW. See:

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

I think you will find the book invaluable because it has just what you need to get everything you need for root cause analysis of low-to-medium risk incidents in just 10% of the old book’s pages.

Eventually, we are developing another eight books and the whole set will take the place of the old 2008 TapRooT® Book. You will be able to buy the books separately or in a boxed set. Watch for us to release each of them as they are finished and the final box set when everything is complete. 

Times are Tough … How Can TapRooT® Root Cause Analysis Help?

February 4th, 2016 by

NewImage

Many industries have dropped into a recession or a downright depression.

Oil, coal, iron ore, gas, and many other commodity prices are at near term (or all time) lows.

When the economy goes bad, the natural tendency is for companies to cut costs (and lay people off). Of course, we’ve seen this in many industries and the repercussion have been felt around the world.

Since many of our clients are in the effected industries, we think about how we could help. 

If you could use some help … read on!

FIRST

I think the first way we can help is to remind TapRooT® Users and management at companies that use TapRooT® that in hard times, it is easy for employees to hear they wrong message.

What is the wrong message?

Workers and supervisors think that because of the tough economic times, they need to cut corners to save money. Therefore, they shortcut safety requirements.

For example:

  • A mechanic might save time by not locking out a piece of equipment while making an adjustment. 
  • An operator might take shortcuts when using a procedure to save time. 
  • Pre-job hazard analyses or pre-job brief might be skipped to save time.
  • Facility management might cut operating staff or maintenance personnel below the level needed to operate and maintain a facility safely.
  • Supervisors may have to use excessive overtime to make up for short staffing after layoffs.
  • Maintenance may be delayed way past the point of being safe because funds weren’t available.

These changes might seem OK at first. When shortcuts are taken and no immediate problems are seen, the decision to take the shortcut seems justified. This starts a culture shift. More shortcuts are deemed acceptable. 

In facilities that have multiple Safeguards (often true in the oil, mining, and other industries that ascribe to process safety management), the failure of a single Safeguard or even multiple Safeguards may go unnoticed because there is still one Safeguard left that is preventing a disaster. But every Safeguard has weaknesses and when the final Safeguard fails … BOOM!

This phenomenon of shortcuts becoming normal has a PhD term … Normalization of Deviation

NewImage

The result of normalization of deviation? Usually a major accident that causes extensive damage, kills multiple people, and ruins a company’s reputation.

So, the first thing that we at System Improvements can do to help you through tough times is to say …

WATCH OUT!

This could be happening to your operators, your mechanics, or your local management and supervision. 

When times are bad you MUST double up on safety audits and management walk arounds to make sure that supervisors and workers know that bad times are not the time to take shortcuts. Certain costs can’t be cut. There are requirements that can’t be eliminated because times are tough and the economy is bad. 

SECOND

When times are tough you need the very BEST performance just to get by.

When times are tough, you need to make sure that your incident investigation programs and trending are catching problems and keeping performance at the highest levels to assure that major accidents don’t happen.

Your incident investigation system and your audit programs should produce KPI’s (key performance indicators) that help management see if the problems mentioned above are happening (or are being prevented).

If you aren’t positive if your systems are working 100%, give us a call (865-539-2139) and we would be happy to discuss your concerns and provide ideas to get your site back on the right track. For industries that are in tough times, we will even provide a free assessment to help you decide if you need to request additional resources before something bad happens. 

Believe me, you don’t want a major accident to be your wake up call that your cost cutting gone too far.

NewImage

THIRD

How would you like to save time and effort and still have effective root cause analysis of small problems (to prevent big problems from happening)? 

For years I’ve had users request “TapRooT®-Lite” for less severe incidents and near-misses. I’ve tried to help people by explaining what needed to be done but we didn’t have explicit instructions.

Last summer I started working on a new book about using TapRooT® to find the root causes of low-to-medium risk incidents. And the book is now finished and back from the printers.

NewImage

Good news:

  • The book is only 50 pages long.
  • It makes using TapRooT® easy.
  • It provides the tools needed to produce excellent quality investigations with the minimum effort.
  • It will become the basis for our 2-Day TapRooT® Root Cause Analysis Course.

When can you get the book? NOW! Our IT guys have a NEW LINK to the new book on our store.

By April, we should have our 2-Day TapRooT® Course modified and everything should be interlinked with our new TapRooT® Version VI Software.

In hard economic times, getting a boost in productivity and effectiveness in a mission critical activity (like root cause analysis) is a great helping hand for our clients.

The new book is the first of eight new books that we will be publishing this year. Watch for our new releases and take advantage of the latest improvements in root cause analysis to help your facility improve safety, quality, and efficiency even when your industry is in tough economic times. For more information on the first of the new books, see:

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

FINALLY

If you need help, give us a call. (865-539-2139)

NewImage

Are you having a backlog of investigations because of staff cuts? We can get you someone to help perform investigations on a short term basis.

Need to get people trained to investigate low-to-medium risk incidents effectively (and quickly)? We can quote a new 2-Day TapRooT® Root Cause Analysis Course t to be held at your site.

Need a job because of downsizing at your company? Watch the postings at the Root Cause Analysis Blog. We pass along job notices that require TapRooT® Root Cause Analysis skills.

This isn’t the first time that commodity prices have plummeted. Do you remember the bad times in the oil patch back in 1998? We helped our clients then and we stand by to help you today! We can’t afford to stop improvement efforts! Nobody wants to see people die to maintain a profit margin or a stock’s price. Let’s keep things going and avoid major accidents while we wait for the next economic boom.

Are Your Corrective Actions Designed to Prevent Future Incidents?

October 14th, 2015 by

I had a great conversation with one of our clients today. He mentioned that, with the price of oil below $50/barrel, his company is being proactive and looking at ways to improve their processes.  One thing that they’re doing is reviewing old incidents and seeing where the commonalities lie.  One item of interest that they found:  They have discovered several instances of repeat problems.  They found root causes, but they seem to pop up again.

What they are doing is what we call a Generic Cause analysis.  They are looking deeper at their data and finding opportunities for improvement.

A review of the corrective actions found quite a few that seemed to be more akin to immediate actions than corrective actions.  For example, if there was a production shutdown that was caused by a failed valve, the corrective action was, “Remove and repair the faulty valve.”  Now, I’m not saying that this is necessarily a bad idea.  However, is this corrective action aimed at preventing future recurrence of the incident?  This corrective action, by itself, is designed more to restore plant operation, not prevent future issues.

Remarkably, this turned out to be more a terminology issue than a failure of their system.  When asked about this, the Corrective Action team said, “Oh, you want actions that will prevent the incident in the future?  Then you aren’t asking for ‘corrective actions’; you are asking for ‘preventative actions.’  You have to be clear what you want.”

TapRooT® does not really distinguish between these types of fixes.  We expect all of these actions to be developed.  We find that the “corrective actions” noted above are designed to fix the Causal Factor (“Valve failed to open.  Therefore, repair the valve.”).  This is as far as most other “root cause analysis” systems go, since they normally only get to the causal factor level.

pablo(28)

While you DO need to fix these issues, we also want you to continue to assign corrective actions to actual root causes.  If the valve failed because the repair procedure specified the incorrect part (in TapRooT®, this root cause would be “facts wrong”), and you would therefore put a corrective action in place to fix this human-performance problem (“Update repair standard to indicate the correct gasket part number 885-33425″).  This will fix not just this particular valve, but any valves in the future that are repaired using this same repair procedure.  Without this corrective action, you will see this same issue pop up again as we continue to improperly repair valve failures.

Make sure you and your investigation teams are all on the same page.  We use the term “Corrective Action” to indicate any and all actions that are designed to fix problems.  Corrective Actions include those actions that fix the general issue (failed valve), and those that are designed to prevent the issue from occurring again in the future (procedure wrong).  Take a look at your systems and make sure you are fixing both types of problems.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

Get More from TapRooT®: Follow our Pages on LinkedIn

August 13th, 2015 by

Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness?  How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post.  But the real question is, do you want MORE than all of the useful information we provide on this blog?  That’s okay – we’ll allow you to be greedy!

A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more.  Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”

linkedinheader

We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses.  If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”

training page

Thank you for being part of the global TapRooT® community!

Final presentations at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

July 24th, 2015 by

Great work by all participants! Here’s one of the presentations and the audience …

IMG 5511

IMG 5507

 

We Train Great Leaders

July 21st, 2015 by

Click the light gray box near the bottom right corner to view larger slideshow.

The more things change the more they stay the same…

July 21st, 2015 by

I overheard a senior executive talking about the problems his company was facing:

  • Prices for their commodity were down, yet costs for production were up.
  • Cost overruns and schedule slippages were too common.
  • HSE performance was stagnant despite improvement goals.
  • They had several recent quality issues that had caused customer complaints.
  • They were cutting “unnecessary” spending like training and travel to make up for revenue shortfalls. 

I thought to myself … 

“How many times have I heard this story?”

I felt like interrupting him and explaining how he could stop at least some of his PAIN. 

I can’t do anything about low commodity prices. The price of oil, copper, gold, coal, or iron ore is beyond my control. And he can’t control these either.

 But he was doing things that were making his problems (pain) worse. 

For example, if you want to stop cost overruns, you need to analyze and fix the root causes of cost overruns.

How do you do that? With TapRooT®.

And how would people learn about TapRooT®? By going to training.

And what had he eliminated? The training budget!

How about the stagnant HSE performance?

To improve performance his company needs to do something different. They need to learn best practices from other industry leaders from their industry AND from other industries.

Where could his folks learn this stuff? At the TapRooT® Summit.

His folks didn’t attend because they didn’t have a training or travel budget!

And the quality issues? He could have his people use the same advanced root cause analysis tools (TapRooT®) to attack them that they were already using for cost, schedule, and HSE incidents. Oh, wait. His people don’t know about TapRooT®. They didn’t attend training.

This reminds me of a VP at a company that at the end of a presentation about a major accident that cost his company big $$$$ and could have caused multiple fatalities (but they were lucky that day). The accident had causes that were directly linked to a cost cutting/downsizing initiative that the VP had initiated for his division. The cost cutting initiative had been suggested by consultants to make the company more competitive in a down economy with low commodity prices. At the end of the presentation he said:

“If anybody would have told me the impacts of these cuts, I wouldn’t have made them!”

Yup. Imaging that. Those bad people didn’t tell him he was causing bad performance by cutting the people and budget they needed to make the place work. 

That accident and quote occurred almost 20 years ago.

Yes, this isn’t the first time we have faced a poor economy, dropping commodity prices, or performance issues. The more things change, the more they stay the same!

But what can you do?

Share this story!

And let your management know how TapRooT® Root Cause Analysis can help them alleviate their PAIN!

Once they understand how TapRooT®’s systematic problem solving can help them improve performance even in a down economy, they will realize that the small investment required is well worth it compared to the headaches they will avoid and the performance improvement they can achieve.

Because in bad times it is especially true that:

“You can stop spending bad money
or start spending good money
fast enough!”

NewImage

People Hard at Work at the 5-Day Advanced Root Cause Analysis Team Leader Course in Seattle

July 20th, 2015 by

It’s day one of the 5-Day Advanced Root Cause Analysis Team Leader Course in Seattle and folks are hard at work in their first exercise using the Root Cause Tree® Diagram to find the root causes of an incident.

IMG 5505

IMG 5503

IMG 5502

IMG 5501

 

IMG 5500

 

VIEW MORE PHOTOS of this course: http://www.taproot.com/archives/50746

Do you need advanced root cause analysis training? See out worldwide public 5-Day TapRooT® Course schedule at: 

http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training

IT/Computer Problems and Root Cause Analysis

July 8th, 2015 by

United grounds all of their flights for two hours due to “computer problems” (see the CNBC story). 

The NYSE stops trading for over three hours due to an “internal technical issue” (see the CNBC story).

Computer issues can cost companies big bucks and cause public relations headaches. Do you think they should be applying state of the art root cause analysis tools both reactively and proactively to prevent and avoid future problems?

TapRooT® has been used to improve computer reliability and security by performing root cause analysis of computer/IT related events and developing effective corrective actions. The first TapRooT® uses for computer/high reliability network problems where banking and communication service providers that started using TapRooT® in the late 1990’s. The first computer security application of TapRooT® that we knew about was in the early 2000s. 

Need to improve your root cause analysis of computer and IT issues? Attend one of our TapRooT® Root Cause Analysis Courses. See the upcoming course schedule at:

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

Robot Made a Human Error and a Worker was Killed

July 8th, 2015 by


_83994885_getty_robot_pic

The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.

A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.

Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?

http://www.bbc.co.uk/newsbeat/article/33359005/man-crushed-to-death-by-robot-at-car-factory

 

TapRooT® in Chile

July 8th, 2015 by

Marco Flores

 

chile flag

Chile Wins Cup!

TapRooT® Instructor Marco Flores sent us this great photo from a recent course in Chile and reported that Chile recently won the America Cup in soccer for the first time in 105 years!

Congratulations to our Chilean friends!

.

.

Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

Public TapRooT® Course in India

June 25th, 2015 by

1280px-Marine_Drive_Kochi_Night_View_DSWOn August 3, 2015, join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training public course in Cochin, Ernakulam, India for the ONLY time in 2015. This course is filled with excellent industry training and material that is well worth the investment for you and your company.

Cochin, also referred to as Kochi or Ernakulam, is known as the Queen of the Arabian Sea due to its spice trading on the west coast. Cochin is also the second largest and highest populated city in the area making it the home of major chemical and electrical industries, the Indian Naval Headquarters and offshore refineries (pictured below).

SBM01

It’s a great trip for everyone! Bring the whole team for Root Cause Analysis Training and bring the whole family to enjoy the attractions and rich culture that Cochin, India has to offer.

A few fun attractions they have to offer:

Wonderla: From water rides to thrilling rides to kid-friendly rides, this amusement park is a fun attraction for the family.

LuLu Mall: Take a break from the heat and visit this giant mall filled with movies, shopping and food!

Folklore Museum: Step back in time with these anthropology, ethnography and architectural exhibits.

Don’t forget, this is the only time this year that you can attend TapRooT® training in this region, so register today before the seats fill up.

Want more information on the TapRooT® 5-Day course? Click here.

Ready to register and take advantage of this incredible opportunity? Click here

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

Do You Have the Newest Editions of the TapRooT® Root Cause Dictionary, Root Cause Tree and Corrective Action Helper?

May 20th, 2015 by

2015 DuoCahA new revision of the TapRooT® Root Cause Dictionary, TapRooT® Root Cause Tree, and TapRooT® Corrective Action Helper Guide was released on May 1, 2015.  This revised 3-piece set is available for purchase to anyone who has attended a TapRooT® course.

Revisions include:

Root Cause Tree: One new root cause and 3 updated root causes.

Root Cause Dictionary: Updates to definitions to cover root cause changes and current industry best practices.

Corrective Action Helper Guide: Updates for new root causes and updated references.

The updated materials are currently available in English only.

Go here to order: http://www.taproot.com/store/2015-DUOCAH.html

**If you attended a course in 2015, contact info@taproot.com for a special discount.

***If you are attending the 2015 Global TapRooT® Summit, you can purchase all at the Summit at a special discount as well! Contact info@taproot.com for more information

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski

Medical

Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed

Equifactor®

Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

Alaska Airlines adopted System Safety and incorporated TapRooT® into the process to find the root causes…

Alaska Airlines
Contact Us