Picture of One Section of a Two Section Public TapRooT® Root Cause Analysis Course in Houston, TexasPosted: December 9th, 2013 in Courses, Pictures, TapRooT
Pictures of the Presentations from the Final Exercise at the Las Vegas Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis CoursePosted: December 8th, 2013 in Courses, Pictures, TapRooT
Some pictures of the students presenting the results of incidents they analyzed using TapRooT® Root Cause Analysis…
And then there was the prize for being on time. A chance to win $10 million dollars! But … the odds were against us…
No instant millionaires today.
Want to find out more about TapRooT® Training? See:
Have you read your 2008 TapRooT® Book from cover to cover? If you do, you will find there are many topics that can help you improve investigation efficiency. Appendix C specifically calls out these six:
1) A well thought out strategy
2) The use of technology
3) Management understanding
5) Help from people in the field
6) Proper use of a SnapCharT®
Each of these is explained in detail in pages 466 – 471 of the book. If you are interested, crack open your book and get reading! You’ll find there is lots more to learn and use!
If you don’t already have your own copy, get some ideas about what’s in the TapRooT® Book by reviewing the table of contents at:
Order the TapRooT® Book at:
But don’t procrastinate! There’s important information in the book that can help you save lives, time, and money.
Many people begin decorating for the winter holidays the day after Thanksgiving. As you string your lights up and dust off those plastic trees, keep these tips in mind from the Electrical Safety Foundation International.
- Inspect your strands of lights and extension cords for damage.
- Attach them securely, but never nail or staple them.
- Extinguish all candles and unplug all lights when you leave a room or go to bed.
- Never use a hot extension cord.
- Consider battery-operated candles.
- Always purchase electronics from a reputable retailer.
- Always inspect cords for damage before plugging them in.
- Avoid overloading electrical outlets.
- Never connect more than three strands of lights together.
- Always unplug lights before changing a bulb.
- Consider LED lights, they use less energy and run cooler.
- Insert plugs all the way into the wall.
- Don’t run cords through walls or ceilings.
- Extension cords are only for temporary use. Make sure they are rated for the proper use, indoor or outdoor.
- Christmas tree and holiday décor fires result in twice the injuries and five times for fatalities per fire than the average winter holiday fire.
- 5,800 people per year are treated in emergency rooms for falls associated with holiday decorations. Over half are ladder or roof falls.
- Inspect ladders for missing screws, hinges, bolts, and nuts.
- Use wooden or fiberglass ladders, as metal ladders conduct electricity.
- Use the right ladder height, ensuring that your ladder extends at least three feet past the edge of the roof.
- Be sure to tape extension cords down, or refrain from placing them in places where someone could trip on them.
- Over 4,000 injuries per year are associated with extension cords. Half of these are due to tripping over an extension cord.
Tune in next week for Child Safety and Fire Safety tips for the holidays.
CLICK HERE for the article in SHP.
The article says that the ride failed due to a low gearbox oil level. Some would classify that as an equipment failure. But a complete SnapCharT® would consider maintenance and operator checks (should someone check the gearbox oil level periodically?).
How do you analyze the causes of equipment failures?
Perhaps you should condier a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course. See the upcoming course schedule by CLICKING HERE.
Material found in a doughnut, see the initial indications from the KAKE media article below.
A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth.
“There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother.
The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here.
The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened.
Now what? Is this a safety or quality issue or both?
If you were the retailer what would you do?
Would you quarantine the doughnutt and ask for access to the material found in the stomach? Would you be allowed?
If you were the doughnut supplier what would you do?
Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed?
If you were the doughnut manufacturer what would you do?
Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported?
For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts?
Everything just discussed would be part of the analysis/investigation planning stage. The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available.
Our public course schedule
Accident Investigation Training – Incident Investigation Training – Root Cause Analysis Training … They are all related and people often ask my opinion … “What accident investigation (incident or root cause) training should we be doing at our facility?”
When we wrote the TapRooT® Book (published in 2008), we knew people would have that question. That why we included a whole section in Chapter 6 (the implementation chapter) on recommended training and a training matrix:
Each of the titles in the left column are described as well as the reasoning for that level of training.
Some interesting titles to review here are Management, the Improvement Team Leader, and Facilitators.
The first training recommendation to review is management. Some might ask, “Why does management need training.”
My answer? because they are the customer – the user – of what comes from the root cause analysis process. Advanced root cause analysis (TapRooT®) should be an essential part of their management system – a management tool that they rely upon. And because this is an essential management tool, they need to understand their role in applying root cause analysis, how root cause analysis fits into their improvement strategy, and what people in the field need to succeed in their root cause analysis efforts.
The training matrix says that managers should take the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course. But the book explains this in more detail.
First, I would prefer that senior managers take the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as part of their management development career training. A major oil company had all their senior project managers (those managing multi-million dollar projects) attend the 5-Day Training and every manager I trained was impressed with the usable information they learned that they could apply a senior managers. These were things that they previously had not learned in their management careers.
However, getting senior managers to sit down for five days of training is next to impossible (even if the training is needed). In this case it took the President of the big oil company requiring his project managers to have the training or they could not receive their annual bonuses. (He really knew how to get their attention.)
Why would a big oil company President require the training? because he was tired of hearing excuses for fatalities. He knew these senior managers had to understand what was causing fatal accidents or they would never be successful in preventing them. And he knew that TapRooT® was the explanation for the causes of the fatal accidents. Thus TapRooT® Training became the requirement.
For those who don’t have the company president’s support for management training, I would suggest a custom course focussed on the basics of TapRooT® and what management needs to to to make sure their improvement program effectively applies root cause analysis. That’s the minimum needed for management root cause analysis training.
IMPROVEMENT TEAM LEADERS & FACILITATORS
Improvement Team Leaders and Facilitators have the same basic training requirements – the 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course. Those who will also be investigating equipment issues should take the additional day of Equifactor® Training (that can be customized into an on-site 5-Day Course).
To continually improve their skills and keep up with the latest in performance improvement technology, we also recommend attending the Global TapRooT® Summit and a pre-Summit advanced course every year.
Two additional courses that Improvement Team Leaders should take are the Advanced Trending Techniques and the Getting the Most from Your TapRooT® Software courses. Trending and using the TapRooT® software are integral parts of any improvement team leader’s job so these courses are a must for them.
Have any questions about these training recommendations? We would be happy to discuss our recommendations with you. just give us a call at 865-539-2139. Or drop us a note by CLICKING HERE.
I know, it is too early for Friday’s Joke of the Day, but I could not help it. I saw this posted recently and had to share.
As you are laughing, look into your tool cabinet and tell me that you do not have these 2 items in it.
Now if you want to know how to troubleshoot equipment the right why and want an Individual TapRooT® Software License (comes with the course), then join us at one of our Equifactor® courses.
Here is the current schedule: http://www.taproot.com/store/3-Day-Courses/
I’ll bring my WD-40 and Duct Tape for the classroom equipment.
What are the risks of setting a circuit breaker without knowing why it opened?
I just saw this local news article about a father teaching his daughter about the circuit breaker panel in their house after a ceiling fan stopped working. End result….. House on fire. Read more here.
With eighteen years in aviation and having worked on the C-141 Aircraft, this incident brought to mind the wrong pump replaced and reseting the circuit breaker during testing explosion. Read more here.
There are additional ways to gain equipment troubleshooting experience without starting a fire. The easiest way is to attend one of our upcoming Equifactor® Course coming up in your local area. See the schedule here: http://www.taproot.com/store/3-Day-Courses/
With community protests after losing school aged loved ones, the Indian Government is closing in on suspected causes to include suspects. But is this a sign of Systemic Food Quality Control or as TapRooT® calls them “Generic Causes”? Will the nature of the investigations detour looking for Generic Causes by looking for blame instead?
Read below and ask, how would this be investigated or analyzed if it were in your hometown? What would be the response of the lunch cafeterias and Food on Wheels programs for the elderly and sick?
In a months time…..
23 students in the southwestern coastal state of Goa were treated at a hospital after they got sick at lunch
23 students died and 25 people were hospitalized from food poisoning after a school lunch in northern India’s Bihar state
Schoolchildren falling sick after drinking contaminated water from hand pumps continued for the third consecutive day on Saturday with at least 35 more students taken ill in different parts of Bihar.
Arrests made in two of incidents with possible cause being insecticide poisoning; the water pump incident possibly criminal intent and the Bahir lunch room incident due to possible negligence. The Goa incident not so clear in details yet.
Due to fear, large lunch producers temporarily shut down their lunch kitchens resulting in children not getting their mandated free lunches during school.
See more at this link:
Great final exercises. Here’s pictures of the teams working and presenting their results …
To get signed up for a TapRooT® Root Cause Analysis Course in the future, CLICK HERE!
Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)Posted: August 1st, 2013 in Pictures, Root Cause Analysis Tips, TapRooT
Find the Root Cause
Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, used this example – a robot failure – to teach others the 5-Why technique at Toyota:
1. Why did the robot stop?
- The circuit has overloaded, causing a blown fuse.
2. Why did the circuit overload?
- There was insufficient lubrication on the bearings, so they locked up.
3. Why was there insufficient lubrication on the bearings?
- The oil pump on the robot is not circulating sufficient oil.
4. Why is the pump not circulating sufficient oil?
- The pump intake is clogged with metal shavings.
5. Why is the intake clogged with metal shavings?
- Because there is no filter on the pump.
For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.
Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.
Where to Start
TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with the TapRooT® 7-Step Process (picture below of the process being taught in a 2-Day TapRooT® Class).
In the process diagram, the left column contains the steps used to investigate and correct the problem and the right column shows the required (bold text) and optional (plain text) TapRooT® Tools.
To start investigating the problem, one draws a SnapCharT® (shown below).
A Spring SnapCharT® is the start of “growing” a SnapCharT® and helps the investigator understand what happened. In this case we’ve placed everything we know from the previous example on the chart.
Notice that the 5-Whys that Mr. Ohno asked turned out to be mainly the sequence of events leading up to the failure. You might also notice how easy the example is to understand when viewed on a SnapCharT®. One more thing to notice on this simple Spring SnapCharT® is that we’ve already gone beyond the 5-Whys by indicating that there was no low oil pressure alarm.
Next Step – Collect Info
A Spring SnapCharT® is the start of an investigation. Next, the investigator collects info (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.
First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?
Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?
The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.
Once one understands what happened, the next step is to understand why it happened. In TapRooT®, this starts by identifying the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. The four Causal Factors for the Robot Stops incident are shown on the SnapCharT® on page 2 and are indicated by triangles (ᐃ).
Where Mr. Ohno only had one root cause, TapRooT® has already identified four causal factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys – that it usually focuses on a single cause and misses additional causes that also need corrective action.
TapRooT® Root Causes
In Step 4 of the TapRooT® Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).
For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend reading the “How Does TapRooT® Work” article on the Root Cause Analysis Blog (www.taproot.com/blog) or attending a 2-Day or 5-Day TapRooT® Course.
However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”
This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.
In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).
Thus, it was determined that if the operator had some type of oil pressure display/alarm to make the detection of a problem possible (error would be detectable), then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.
There are still three other Causal Factors to analyze; Generic Causes to analyze; and Corrective Actions to develop. There’s more to be learned! However, just this limited analysis shows that, even when used by an expert like Taiichi Ohno, 5-Whys misses important facts and root causes. Perhaps now you will agree that 5-Whys isn’t adequate for analysis of even a simple problem when compared to advanced root cause analysis using TapRooT®. Learn about TapRooT® at an upcoming course.
Another great day yesterday and we are having a great time on day 3! Here are some pictures from day 2…
Want more information about TapRooT® Root Cause Analysis Training? CLICK HERE
Contact us by CLICKING HERE.
Pictures from Day 1 of the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Course in SeattlePosted: July 30th, 2013 in Courses, Pictures, TapRooT
We had a great first day in Seattle with a great class of people learning about using TapRooT® to find the root causes of accident, incidents, quality issues, …
Here’s a couple of pictures of Linda Unger, Vice President of System Improvements, teaching:
And just 1/2 a block from the hotel is a great after class hangout – The Tap House! First we learn TapRooT®, then we relax at the Tap House!
Yes … those are all different kinds of beer.
Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.
Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.
Often FDA findings are found by an external audit. To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction? Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?
I suggest Enforcement needs improvement is not the only problem. To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators. Here is our upcoming courses link: http://www.taproot.com/store/Courses/
To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit. http://www.taproot.com/content/wp-content/uploads/2012/02/RileyandGorman.pdf
Then check out the quality track in the upcoming 2014 Summit in April. http://www.taproot.com/products-services/summit
Ken Turnbull and I are teaching the 2 day course this week in Houston. Here are some pictures of Ken teaching and the students working on their first exercise:
This course filled up, so if you wanted to attend and could not, I’m sorry. Our courses have really been filling up, so if you want to attend a course this year I recommend you enroll as soon as possible. You can see our schedule and enroll HERE
Is your site like most sites? You don’t have major accidents. You occasionally have a lost time injury … but fatalities? … You’ve never see one.
Even though major accidents are rare, you still need to be prepared.
There are many sources of information to help you prepare for serious accidents. The US Department of Health and Human Services has written guidelines for Chemical Hazard Emergency Management. See:
Another source of information to help you prepare for the worst is the TapRooT® Book.
It provides guidance for investigation procedures, for initial response, & evidence collection – all things you need to know.
Some companies have a corporate team to respond to major accidents. The team may include trained accident investigators, lawyers, and PR professionals. They respond quickly to help local management and safety personnel deal with the aftermath of a serious accident and coordinate with government agencies (OSHA, CSB, EPA, MSHA, DOT, NRC, or many others) that descend on the accident site.
Companies may also have pre-negotiated assistance contracts for technical services and investigation facilitation.
Perhaps the best way to prepare is to do everything possible to prevent the major accident from occurring in the first place. As Benjamin Franklin said:
“An ounce of prevention is worth a pound of cure.”
And this is doubly true when it comes to accident prevention.
Chris Vallee sent these photos from our recent 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course held in Calgary, AB, Canada. Enjoy!
Visit http://www.taproot.com/courses to learn more about TapRooT® courses in your area.
In 2012, a little over 12,000 people were trained to use TapRooT® to find and fix root causes.
That’s a record.
If the first quarter of 2013, course registrations are up. We think 2013 will see even more people in TapRooT® Courses.
That good news for the people who will have their lives saved, see product quality improved, see hospital patient safety improved, and get better equipment reliability at their facility … when TapRooT® is applied as part of a performance improvement program (see success stories by clicking here).
What’s the bad news? The popularity of TapRooT® Training means that sometimes our public courses are filling up early. Sometimes even two months before the course takes place.
Also, our training schedule for on-site courses is filling up.
What does that mean to you? If you are planning to attend a specific public TapRooT® Course – SIGN UP EARLY.
If you want to have a course at your site, get it scheduled NOW! (Contact us by CLICKING HERE.)
The next time someone says they used 5-Whys to investigate an accident, just thing …
5-Whys = Root Cause Analysis Malpractice
Because 5-Whys is almost always root cause analysis malpractice. If you don’t believe it, assign someone who is good at 5-Whys to analyze a problem and someone who is good at using TapRooT® to analyze the same problem. Look at the results and you will see what I’m talking about.
That’s the lesson learned for today.
Course planner Diana Munevar shared these photos with us from our recent course in Bogota, Colombia.
Want to learn how to find and fix the incidents & near misses that are costing your company time and money? Attend a TapRooT® Root Cause Analysis course. Learn more at http://www.taproot.com/courses.
If you’re interested in a South America course, feel free to call Diana Munevar at 57 3203429267.
TapRooT® Users … Did you know there is a place where you can discuss your experience using TapRooT®, your questions, and your best practices with other TapRooT® Users? It’s on LinkedIn at the TapRooT® Root Cause Analysis Users and Friends Group.
Currently there are 1, 771 members but we hope to grow the group to include all those actively using TapRooT® (tens of thousands of people).
To join the group at:
And then participate by posting questions, providing your best practices, and commenting on other’s discussions.
Had an interesting conversation the other day.
Had a student in one of our classes tell me that he worked with someone who was “using TapRooT®” to find root causes but had never been to a TapRooT® Root Cause Analysis Course. In fact, the individual didn’t even have the TapRooT® Book.
He claimed to have learned TapRooT® by reading about it “on-line.”
The student said that he came to our training to learn the real way to use TapRooT® because he couldn’t believe that the guy was using it right.
By the end of the course, he told me the guy wasn’t doing anything like what we taught in the course. The course attendee was going to go back to work and straighten things out.
Another “bad example” was a guy who called me before he started an investigation. He was going to “use TapRooT®” because he was required to use it. What was wrong? He had been to training five years before and had never used it. He called me to ask, “What do I do first?”
Why do I bring up these bad examples here? Because not everyone who claims to use TapRooT® has a real understanding of the magic behind the system. They really are NOT using TapRooT®.
The minimum training that I would accept to call someone a TapRooT® User is our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. However, before I would send someone out to do, or facilitate, a major investigation, I would insist that they have attended a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.
But that’s not all. That’s just the start. At any facility that says they “use TapRooT®,” I would ask them, “How do you keep TapRooT® Users proficient?” Also, … “How do they make their investigators better over time?”
Three things that I would like to hear in their replies are that they:
1. Attend the TapRooT® Summit every year.
2. Attend advanced/refresher training every year.
3. Have a peer review group for investigations that provides real improvement ideas for investigators.
Before you let people claim they are using TrapRooT® to investigate accidents at your company, make sure they are really trained to use it and that they keep themselves proficient and improving!
Don’t let your investigators be a bad example.
I promised people at the 2013 Global TapRooT® Summit that I would post links to last year’s talk about Admiral Rickover and process safety and a link to his testimony to Congress about nuclear safety and the Nuclear Navy. Here they are…
And here are the slides from the Nuclear Navy and Process Safety talk mentioned above…