Category: TapRooT

TapRooT® Around the World: Uruguay

December 14th, 2017 by

Another successful course in Uruguay! TapRooT® instructor, Hernando Godoy Garzón, sent these course photos in from ANDRITZ – Fray Bentos. Contact us at info@taproot.com to schedule a course at your facility. We have instructors who are proficient in both Spanish and Portuguese languages.

 

 

 

 

 

 

 

 

 

 

 

TapRooT® Around the World: Uruguay

December 14th, 2017 by

TapRooT® Instructor, Hernando Godoy Garzón sent us these great photos from his course at ANDRITZ URUGUAY S.A. | Colonia.

Contact us at info@taproot.com to bring a course to your site. We deliver training around the globe.

 

TapRooT® Around the World: Jeanette PA

December 14th, 2017 by

TapRooT® Instructor, Heidi Reed sent us these course photos from an onsite course at Elliott Group. If you’d like to host a TapRooT® course for employees at your facility, contact us at info@taproot.com.

 

What are the favorite blog posts from this year and from all time?

December 12th, 2017 by

The end of the year is coming and sometimes it is good to look back and see whats been trending for people who read this blog. Let’s look at the articles posted in 2017 and see what’s been trending …

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5. How Far Away is Death? (October – above)

4. Friday Joke: An Old Nuke Navy Joke… (October)

3. US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald (August)

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

1. What is the Root Cause of the USS Fitzgerald Collision? (July)

And then let’s look back to the past to see the top five most popular articles of all time:

5. Root Cause Tip: What’s a Causal Factor? (2012)

4. 7 Secretos / secretos del análisis de Causa raíz (2011)

3. Live Your Core Values: 10 Minute Exercise to Increase Your Success (2013)

2. 7 Secrets of Root Cause Analysis (2011)

1. An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts… (2007)

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

I first heard of 5-Why’s over 20 years ago when I got my first job in Quality. I had no experience of any kind, I got the job because I worked with the Quality Manager’s wife in another department and she told him I was a good guy. True story…but that’s how things worked back then!

When I was first exposed to the 5-Why concept, it did not really make any sense to me; I could not understand how it actually could work, as it seemed like the only thing it revealed was the obvious. So, if it is obvious, why do I need it? That is a pretty good question from someone who did not know much at the time.

I dived into Quality and got all the certifications, went to all the classes and conferences, and helped my company build an industry leading program from the ground up. A recurring concept in the study and materials I was exposed to was 5-Why. I learned the “correct” way to do it. Now I understood it, but I still never thought it was a good way to find root causes.

I transferred to another division of the company to run their safety program. I did not know how to run a safety program – I did know all the rules, as I had been auditing them for years, but I really did not know how to run the program. But I did know quality, and those concepts helped me instill an improvement mindset in the leaders which we successfully applied to safety.

The first thing I did when I took the job was to look at the safety policies and procedures, and there it was; when you have an incident, “ask Why 5 times” to get your root cause! That was the extent of the guidance. So whatever random thought was your fifth Why would be the root cause on the report! The people using it had absolutely no idea how the concept worked or how to do it. And my review of old reports validated this. Since then I have realized this is a common theme with 5-Why’s; there is a very wide variation in the way it is used. I don’t believe it works particularly well even when used correctly, but it usually isn’t in my experience.

Since retiring from my career and coming to work with TapRooT®, I’ve had literally hundreds of conversations with colleagues, clients, and potential clients about 5-Why’s. I used to be somewhat soft when criticizing 5-Why’s and just try to help people understand why TapRooT® gets better results. Recently, I’ve started to take a more militant approach. Why? Because most of the people I talk to already know that 5-Why’s does not work well, but they still use it anyway (easier/cheaper/quicker)!

So it is time to take the gloves off; let’s not dance around this any longer. To quote Mark Paradies:
“5-Why’s is Root Cause Malpractice!”

To those that are still dug in and take offense, I do apologize! I can only share my experience.

For more information, here are some previous blog articles:

What’s Wrong With Cause-and-Effect, 5-Why’s, & Fault Trees

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Fake News or Real?

December 6th, 2017 by

FakeNews

That’s the headline. Here is the link:

http://www.abcnews-us.com/2017/12/05/morgue-employee-cremated-by-mistake-while-taking-a-nap/

Could it really be true? I guess the funeral home industry needs TapRooT®!

(Editor’s update: After this post was published, Snopes reported this as fake news and the news story was removed. Thank goodness!)

Can Your Company Afford a Second Rate Improvement Program?

November 28th, 2017 by

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Sometimes it seems like management’s only objective is to cut costs. Can you produce excellence and record profits by cost cutting alone? Your company needs a world-class improvement program!

How do you get a world-class improvement program? As George Washington Carver said:

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Start where you are with what you have.
Make something of it and never be satisfied.

Have you become satisfied? Is it time to improve?

If you have never attended TapRooT® Training, start your improvement journey with a 2-Day TapRooT® Root Cause Analysis Course.

But most readers here have already learned the basics. They are ready for more. Perhaps a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It’s a great place to learn to improve your skills to learn to investigate difficult, high-risk incidents.

If you are looking to go beyond just improving your own knowledge and you want to improve your company’s performance improvement initiatives, try reading our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to get your copy.

That’s a great start but there is even more…

Would you like to benchmark with industry leaders and learn from improvement experts from around the world? Attend the 2018 Global TapRooT® Summit. Many Summit attendees have explained that attending the Summit is a great way to learn from others and make your improvement program world-class.

People share their success and learn from others…

Many attend the pre-Summit advanced courses to get even more learning packed into their trip…

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Improvement is a never ending cycle of discovery. What are you doing to move the process forward?

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Is it time to make your improvement program world-class or are you settling for second rate performance?

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Five Trends that Will Impact Companies in Environment, Health and Safety in 2018

November 17th, 2017 by

As we approach 2018, now is a good time to look at some external trends to gauge what is coming down the pike. At System Improvements we recently fired up the crystal balls, and spotted five trends that will impact companies:

  • Proactive Safety Culture,
  • Reporting Capability
  • Focus on Prevention
  • Work force changes
  • Increased Drug Use

Let’s look at each of these.

Proactive Safety Culture: Executives continue to get more involved, safety is seen as an improvement opportunity and something to be managed, rather than a liability driven by chance or “workers unsafe actions”. Preventive methods will be used more, like work site evaluations, audits, functional job analysis, and ergonomics training. Instead of having impossible goals like “Zero Harm”, companies will set improvement KPIs, then investigate, track and trend incidents and near misses and put corrective actions in place

Reporting Capability: User- friendly software like TapRooT® and Enablon is available for capturing data and carrying out analysis. Mobile apps and devices like wearable technology enables rapid collection and dissemination of findings. Training is readily available to make sense of the data collected and empower the front line

Focus on Prevention: Companies take active steps to prevent injuries and promote health and safety. We will see more fitness and wellness initiatives but also focus on “intangible” issues like stress, fatigue and mental health. Companies out of line will face ever- increasing Workers Comp costs

Work Force Changes: The age distribution and values of workers are changing, with millennials entering the workforce. The shortage of skilled workers will get worse, and there will be more contract and temp workers. It will be important to involve all these groups in the EHSQ efforts. There will also be more lone and unsupervised workers, which makes behavior- based safety much more difficult to implement

Increased Use of Illegal and Legalized Drugs:  Serious safety, quality and environmental risk. Executives will have to find ways to manage the opioids cycle where injuries drive prescriptions and workers under the influence of opioids get injured again… In some jurisdictions legalization of marijuana is disqualifying a large share of the worker pool from safely operating vehicles, machinery and equipment. In the Hotels & restaurant industry, research found up to 19% of workers using drugs on a regular basis, a clear risk in e.g. kitchen areas. Alcohol will continue to be an issue, not least in Mining and Construction where up to a fifth of workers are estimated to be affected.

A good way to prepare for these trends is to do effective Root Cause Analysis. The TapRooT® methodology helps companies identify root causes of incidents, and put effective corrective actions in place. The process is also used for proactive audits, where issues can be nipped in the bud. Click here for more information: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

TapRooT® Around the World: AMCHAM Trinidad & Tobago Conference

November 14th, 2017 by

Our Senior Associate, Chris Vallee spoke at the AMCHAM Trinidad & Tobago Conference this week. Looks like a great event!

Is TapRooT® Root Cause Analysis a Tool or the Whole Toolbox?

November 14th, 2017 by

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I had a self-proclaimed root cause analysis expert tell me that investigators needed lots of “tools” in their root cause analysis toolbox. For most people that leads to the question:

How many tools do I need to learn?

When we started to develop TapRooT® back in the 1980’s, we thought we just needed a tool. We soon learned that we needed a toolbox. So we went to work finding, developing, and refining the best root cause analysis tools and adding them to our root cause analysis toolbox called the TapRooT® Root Cause System.

You might ask:

What’s in the toolbox?

The TapRooT® 7-Step Major Investigation Process from the book, Using TapRooT® Root Cause Analysis for Major Investigations, shows all the major tools in the right column.

SI Chart 7 StepMajorInvestigation

How can you learn these techniques and “fill your toolbox” with tools proven to be successful by TapRooT® Users from around the world? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See the locations and dates for our public courses around the world at:

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

But why should you learn these tools?

First, we spent decades of research and developing choosing, developing, and refining these techniques to make them the most successful root cause analysis toolbox in the world. See our user success stories at:

http://www.taproot.com/archives/category/success-stories?s=

The research and testing we performed showed us the limitations of some common root cause analysis tools that some experts try to teach and have trouble getting their students to achieve consistent results. We based our selection of techniques on human factors principles. This makes our system robust yet easy to use.

We also decided to limit the techniques we chose to those that you would really need. Most people don’t get tremendous amounts of experience performing root cause analyses. Thus, we wanted to minimize the training and practice required to use TapRooT®. We made it so that TapRooT® can be applied to low-risk incidents (simple incidents) or medium to high-risk incidents. In that way people get experience applying TapRooT® to simple incidents so that they are practiced using the techniques when something big happens (God forbid).

Also, we built human factors experts systems (AI) into the TapRooT® System to help investigators find the root causes of human errors and equipment problems.

Finally, do other root cause analysis systems provide this course 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 a powerful guarantee. And we can offer it because of the hundreds of thousands of people we have trained who apply TapRooT® sucessfully. We know you, too, will be successful.

Why not create your own toolbox?

You could duplicate our efforts, spend decades researching and perfecting your own toolbox of root cause analysis tools. Then you could develop training courses to teach what you learned. But guess what … your system still wouldn’t be as good as TapRooT®. Why? Because while you were doing your research, we would be improving. We constantly make the TapRooT® Books, Training, and Software better.

Besides the feedback we get from thousands of users and from classes we hold around the world, we have a TapRooT® Advisory Board that makes suggestions and reviews improvement ideas. This helps us keep making the best even better.

And one last advantage that we have … very talented instructors. We have 50 instructors at various locations around the world that have extensive experience teaching and using the TapRooT® System. And these instructors are constantly sharpening their skills. We have a link on our blog with a few profiles of our instructors but we are way behind on keeping it updated. This gives us something to improve!

If you want to learn more about TapRooT®, attend a class. Or at least see the About TapRooT® page on our web site.

Where is the nearest TapRooT® Training?

November 7th, 2017 by

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We hold public TapRooT® Courses all over the world. See our upcoming courses at:

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

If you have 10 or more people to train, you could probably save money by having an on-site course for your folks. Get a quote by CLICKING HERE.

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KISS and Root Cause Analysis

November 1st, 2017 by

I’ve heard many “experts” claim that you need to apply the KISS principle when it comes to root cause analysis. You may hear this too and I want you to understand where these experts lead many people astray.

First, what is KISS? Keep It Simple Stupid! The acronym implies that simple solutions are better solutions. And when simple solution work (are effective) KISS is a dream come true. But remember Einstein’s quote:

Make things as simple as possible, but not simpler.

So let’s start with some of the reasons that these experts say you need to use simple techniques and debunk or demystify each one. Here’s a list of common expert advice.

  1. It’s a waste of time to use full root cause analysis on every problem.
  2. People can’t understand complex root cause analysis techniques.
  3. Learning simple techniques will get people to start thinking deeper about problems.
  4. Simple is just about as good as those fancy techniques.
  5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.
  6. You can apply those complicated techniques to just the most serious accidents.
  7. The data from the simple investigations will help you identify the more complex issues you need to solve.

I see these arguments all the time. They make me want to scream! Let me debunk each one and then you too can dismiss these “experts” the next time they try one or more of these arguments on your management team.

1. It’s a waste of time to use full root cause analysis on every problem.

I actually sort of agree with this statement. What I don’t agree with is the answer they arrive at. Their answer is that you should apply some “simple” root cause analysis technique (let’s just say 5-Whys as an example) to “solve” these problems that don’t deserve a well thought out answer.

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First, what do I have against their ideas of simple root cause analysis? If you’ve been reading this blog for a while you know what I’m going the explain, so just skip ahead. For those who don’t know what’s wrong with most “simple” root cause analysis techniques, I would suggest start reading from the top of the links below until you are convinced that most expert advice about “simple” root cause analysis is root cause analysis malpractice. If you haven’t been convinced by the end of the links … perhaps you are one of the experts I’m talking about. Here’s the list of links:

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

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

What’s Wrong with 5-Whys??? – Complete Article 

What’s Fundamentally Wrong with 5-Whys?

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

I believe that one of the biggest root cause analysis problems that companies face is that they are performing “root cause analysis” on problems that don’t need to be analyzed.  YES – I said it. Not every problem deserves a root cause analysis.

What problems don’t need to be analyzed? Problems that aren’t going to teach you anything significant. I call these “paper cut problems.” You don’t need to investigate paper cuts.

But some people would say that you do need to investigate every loss time injury and medical treatment case. Maybe … maybe not.

You do need to investigate an incident if it could have caused an outcome that you are trying to prevent and there are worthy lessons learned. Some medical treatment cases fall into this category. They got a cut finger but they could have lost their whole arm.

Two similar examples are provided in the book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. One is a sprained ankle and one is a sprained wrist. Both came from falling down. One was judged worthy of a full but simple root cause analysis using the essential features of the TapRooT® Root Cause Analysis System. One was judged not worthy of a full investigation after a simple SnapCharT® was developed. Interested in how this works? Read the book. It’s only 100 pages long and seeing how to judge if a root cause analysis is worthwhile is worth it. (And you will learn how to apply TapRooT® simply to low-to-medium risk incidents.)

Once you know how to do a real “simple” investigation with an effective technique, you won’t need to do bad root cause analysis with an ineffective technique.

2. People can’t understand complex root cause analysis techniques.

I don’t know every “complex” root cause analysis technique but I do know that this statement does NOT apply to TapRooT®. Why? Because we’ve tested it.

One “test” was at a refinery. The Operation Manager (a good guy) thought that TapRooT® was a good system but wasn’t sure that his operators would understand it. We decided to run a test. We decided to teach a basic class to all his union stewards. Then refinery management did a focus group with the shop stewards.

I was one of the instructors and from the course examples that they analyzed, I knew that they were really enjoying finding real root causes rather than placing blame.

They did the focus group (with us in another room). I could hear what was going on. The first question the facilitator asked was: “Did you understand the TapRooT® Root Cause Analysis Technique?” One of the shop stewards said …

“If I can run a Cat Cracker I can certainly understand this! After all, it’s not rocket science!”

And that’s one of the great parts about TapRooT®. We’ve added expert systems for analysis of equipment and human performance problems, but we’ve kept the system understandable and made it easy to use. Making it seem like it isn’t rocket science (even though there is a whole bunch of science embedded in it) is the secret sauce of TapRooT®.

3. Learning simple techniques will get people to start thinking deeper about problems.

Learning to count is required before you learn calculus BUT counting over and over again does not teach you calculus.

If you don’t understand the causes of human performance problems, you won’t find the causes of the problems by asking why. And I don’t care how many times you ask why … it still won’t work.

For years we did a basic poll at the start of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. We asked:

“How many of you have had any formal training in human factors or the causes of human error?”

Only about 2% of the attendees had ANY training on the causes of human error. But almost everybody that attended our training said that they had previously been assigned to find the causes of human errors. I wonder how well that went? (I can tell you from the student feedback, they said that they really DID NOT address the real root causes in their previous investigations.)

So, NO. Learning simple techniques DOES NOT get people to “think deeper” about problems.

4. Simple is just about as good as those fancy techniques.

NO WAY.

First, I’ve never seen a good example of 5-Whys. I’ve seen hundreds of bad examples that 5-Why experts thought were good examples. One “good example” that I remember was published in Quality Progress, the magazine from the American Society for Quality (ASQ). I couldn’t stand it. I had to write a reply. When I sent the letter to the editor, they asked me to write a whole article … so I did. To see the example and my article that was published in Quality Progress, see page 32 of the link below:

Under Scrutiny: A Critical Look at Root Cause Analysis.

Simple is not “almost as good” as real root cause analysis (TapRooT®). If you would like another example, see Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation in the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

That’s it – Case Closed. Those “simple” techniques are NOT just about as good as TapRooT® Root Cause Analysis.

5. Managers don’t have time to do fancy root cause analysis and they already know what is wrong.

Once again, I’m reminding of a saying:

Why is there never enough time to do it right,
but there is always enough time to do it over? 

How many times have I seen managers misdiagnose problems because they didn’t find the root causes and then have bigger accidents because they didn’t fix the near-misses and small accidents?

The percentage of managers trained in the causes of human error is very similar to the statistics I previously provided (2%). This means that managers need an effective root cause analysis technique … just like investigators need an effective technique. That’s why the standard corrective actions they use don’t solve the problems and we have accidents that happen over and over again.

So if you don’t have time, don’t worry. You will make time to do it over and over again.

That reminds me of a quote from a plant manager I knew…

“If we investigated every incident, we’d do nothing but investigate incidents!”

6. You can apply those complicated techniques to just the most serious accidents.

I’ve seen companies saving their “best” root cause analysis for their big accidents. Here are the two problems I see with that.

FIRST, they have the big accidents BECAUSE they didn’t solve the precursor incidents. Why? because they didn’t do good root cause analysis on the precursor incidents. Thus, applying poor root cause analysis to the lessor incidents CAUSES the big accidents.

SECOND, their investigators don’t get practice using their “best” root cause analysis techniques because the “most serious” incidents are infrequent. Therefore, their investigators get rusty or they never really develop the skills they need by using the techniques on smaller incidents that could give them practice.

The key here is to learn to use TapRooT® Root Cause Analysis to investigate smaller problems. And that’s why we wrote a book about using TapRooT® for simple incidents: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Don’t wait for big accidents to find and fix the causes of your biggest risks. Find and fix them when they give you warnings (the precursor incidents).

7. The data from the simple investigations will help you identify the more complex issues you need to solve.

Why do people think that analyzing lots of bad data will yield good results? I think it is the misconception about mathematics. A good formula doesn’t provide knowledge from bad data.

If you don’t really know how to analyze data, you should attend our pre-Summit course:

Advanced Trending Techniques

As W. Edwards Deming said:

“Without data, you’re just another person with an opinion.”

And if you know much about Deming, you know that he was very interested in the accuracy of the data.

If you aren’t finding the real root causes, data about your BAD ANALYSIS only tells you what you were doing wrong. You now have data about what was NOT the causes of your problems. Go analyze that!

So data from BAD simple investigations DOES NOT help you solve your more complex issues. All it does is mislead your management.

THAT’S IT. All the bad advice debunked. Now, what do you need to do?

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

You will learn the theory behind performance improvement and you will be well on your way to understanding what management needs to do to really improve safety, quality, equipment reliability, and operational/financial performance.

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

You will know how to implement a real, effective root cause analysis system for low-to-medium risk incidents as well as major accidents.

3. If you haven’t done it already, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the list of our upcoming public 5-Day TapRooT® Courses held around the world at this link:

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

And don’t take any more bad advice from experts who don’t know what they are talking about!

PS: If you have questions or want to discuss what you read in the books, contact me (Mark Paradies) at 865-539-2139 or by e-mail by clicking HERE.

Finish strong! Register for 5-day Advanced Root Cause Analysis Team Leader Training

October 31st, 2017 by

What do people say about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training?

“Excellent material. Motivated me to go back and make sure preparations are put into place.” ~ R. Shank

“TapRooT® has already proven very useful to our organization but the 5-day gives us the extra depth to make it better.” – J. Spraul

“Perfect combination of class material and exercises / practice.” ~ J. Stiles

What are you waiting for? Finish the year on a strong note and go into the New Year with new skills! Register for one of our upcoming 5-day Advanced Root Cause Analysis Team Leader Trainings!

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

December 4: Edmonton, AB

December 11: Houston Texas

TapRooT® Road Trip!

October 25th, 2017 by

Travel is one of the most rewarding things you can do in life but it gets expensive and hard to fit in the schedule sometimes. Why not take an opportunity to increase your skills and travel to a new destination? Just don’t hole up in your hotel room eating, working and watching TV after you get there. Get out and see a little of what our featured cities have to offer. Click the image below to learn about our upcoming host cities.

 

Click image to view featured courses.

 

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

TapRooT® provides world-class root cause analysis. But did you know that your results can vary depending upon the goodness of your implementation of the TapRooT® System?

What causes the implementation to vary? Try these factors …

  • Need to improve clearly defined.
  • Senior management support achieved.
  • Written program plan approved by senior management.
  • Proactive improvements drive improvement success.
  • Use advanced root cause analysis for both reactive and proactive investigations.
  • Improvement accomplishments being communicated successfully.
  • Adequate budget/staffing for the improvement organization.
  • Training plan implemented.
  • Employees, supervisors, managers, and contractors/suppliers willingly participate in the program.
  • Software selected, customized, and implemented.
  • Performance measures and advanced trending techniques used by management to guide the program.
  • Organizational learning occurring by effective sharing of lessons learned.
  • Plan for continuous improvement of the program is followed.
  • Leadership succession plan established.
  • Rewards program being used effectively.

This list is provided as a checklist and explained in more detail in Chapter 3 of our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to order your copy.

One more idea you might want to pursue to improve your performance improvement program. Attend the 2018 TapRooT® Global Summit in Knoxville, TN, on February 26 – March 2! It’s a great place to keep up with the state of the art in performance improvement and network with industry leaders.

Start by attending one of our advanced courses on Monday & Tuesday:

  • TapRooT® Root Cause Analysis Training
  • Equifactor® Equipment Troubleshooting and Root Cause Analysis
  • Advanced Causal Factor Development Course
  • Advanced Trending Techniques
  • TapRooT® Analyzing and Fixing Safety Culture Issues
  • Risk Assessment and Management Best Practices
  • Getting the Most from Your TapRooT® VI Software
  • TapRooT® for AuditsTapRooT®
  • Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
  • Understanding and Stopping Human Error

Then attend the Summit on Wednesday – Friday.

What’s on the agenda for the 2018 Global TapRooT® Summit? First, there are five keynote speakers:

  • Inquois “Inky” Johnson – Honor and Legacy
  • Vincent Ivan Phillips – How to Communicate Successfully
  • Dr. Carol Gunn – When Failure Becomes Personal
  • Mark Paradies – How Good is Your TapRooT® Implementation?
  • Mike Williams – Deepwater Horizon

Then there are nine different tracks that include 8 breakout sessions each. These tracks include:

  • Safety
  • Quality
  • Human Factors
  • Asset Optimization
  • Investigator
  • Patient Safety
  • TapRooT® Software
  • TapRooT® Instructor Recertification
  • Alternatives

See the Summit schedule at: http://www.taproot.com/taproot-summit/summit-schedule.

Book 2 in the New TapRooT® Series is Out. Do You Have Your Copy?

October 24th, 2017 by

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Would you like to improve your implementation of TapRooT®? Or are you just getting started and you are trying to decide where to start implementing TapRooT® to improve your root cause analysis?

You should read our new implementation book. CLICK HERE to order yours.

Safety Track at the 2018 Global TapRooT® Summit

October 23rd, 2017 by

It is almost here! The 2018 Summit! Join us in our hometown of Knoxville, TN on February 28-March 2 (Pre-summit courses on February 26-27).

As the coordinator for the Safety Track, I wanted to give you a preview of the speakers we have lined up for this track:

How to Replace 5 Whys with TapRooT® for Better Results – Mark Paradies (the creator of TapRooT®!)

People argue that 5-Whys is a “good enough” root cause analysis tool. They say it’s simple to ask “why” five times and that people in the field can “understand it.” Well, the time has come to put that argument to bed… 5-Whys is inadequate. It has fundamental flaws that make it inadequate. This session will demonstrate how replacing 5-Whys with TapRooT® provides better results.

Making Audits an Integral Part of a Proactive Improvement Program – John Boyle

Do you face resistance when asking for audit funding and resources? Does management not see the benefits of conducting audits? Do the people you audit consider audits a waste of their time and resources? We will explore how to shift your improvement emphasis from reactive to proactive by properly planning and executing audits and turning audit findings into meaningful improvement recommendations.

TapRooT®: The One Stop Solution to Managing Risk – Nancy Hitchins

World-class organizations have utilized TapRooT® for years to identify root causes of safety, environmental, and quality incidents, in order to generate and implement effective corrective actions.

The requirement to identify causes of non-conformities, and implementation of effective corrective actions is not new to the OHSAS/ISO management system standards. Utilization of TapRooT® in the investigation of non-conformities has been successfully utilized for this purpose for many years.

The 2015 management system standards emphasize a process approach, rather than element, to assist in understanding the inter-relationships of an organization’s processes, incorporating the P-D-C-A cycle and risk-based thinking. The TapRooT® SnapChart® is a perfect solution for documenting processes, and identifying where, in each process, risks exist. ISO requires that controls be put in place to minimize negative effect of these risks. The TapRooT® Root Cause Analysis of Causal Factors (Risk) facilitates meeting this requirement, leading to effective controls based upon cause of risk.

During this hour, these ISO requirements will be further discussed, including a demonstration of utilization of TapRooT® to support risk management for your organization.

The Psychology of Failing Fixes – Kevin McManus

This session focuses on how failing to find systemic root causes and/or continuing to see human error as a root cause will lead to a very high percentage of fixes being written that have a high likelihood of failing.

Clarifying Common Misuses of Safety Risk Language – Jim Whiting

This session covers how the welcome and necessary shift of HSE management from absolute safety to risk based safety can be adversely affected by common misuses of HSE risk terminology and language.

Examples of clarification of common misuses of risk language will include:

• how to clearly distinguish between the 3 risk terms: potential, possible and probable
• clarifying descriptive and predictive interpretations of the traditional incident / risk triangles and icebergs in general and in particular the supposed 20% of low severity incidents having a high but poorly defined SIF potential rate. (SIF = Serious Injury / Fatality)
• the futility of using pseudo risk terms such as most likely consequence and maximum reasonable severity in decision-making of what kind of incidents require what level of investigation
• unnecessary replacement of the term risk factor by incident precursor
• recognition that many incident / risk scenarios cannot always be described with linear 1 dimensional Swiss cheese-type models / event trees
• confusion between Zero Harm and Zero Risk
• how the expression “Journey to Zero Harm” can be a HSE Culture Carcinogen

How to Communicate Successfully – Vincent Phipps

In this session, you’ll learn how to listen, negotiate, build teams, gain rapport and increase trust. Identify your communication strengths and weaknesses and take your communication skills to a dynamic new level.

Pike River: The Human Story – Karl Berendt

Pike river was the worst workplace disaster in recent New Zealand history.

On November 19, 2010, 29 miners lost their lives when a methane gas explosion tore through the isolated mine located on rugged West Coast of the South Island.

Even though there were warning signs that things were going wrong in the day-to-day running of the mine, Pike River was a classic accident waiting to happen.

Over the last 12 months, Karl has spoken with those closely linked to this disaster. The insights from families, workers and survivors paints a picture about the importance of good corrective actions, communication and what happens when we get it wrong.

And of course, all tracks attend the KEYNOTE TALKS

We hope to see you there! To register for the Summit, go HERE

How Many Industries and How Many Countries is Your Root Cause Analysis System Used In?

October 17th, 2017 by

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I was talking to someone in the medical industry recently and they asked: “How many people in the medical industry use TapRooT®?”

I gave them several examples of major healthcare systems that use TapRooT® (including perhaps the world’s largest) but I thought … they asked the WRONG question.

The true value of a root cause analysis system is how many different places it is being used SUCCESSFULLY.

Note that this is not the same as if the system is used in a particular industry. It must be used successfully. And if it is used successfully in many other industries and many countries, that proves even more that the system is useful and will probably be useful when applied at your company.

Where is TapRooT® Root Cause Analysis applied successfully?

All over the world. On every continent but Antartica (we’ve never done a course there yet).

In what kind of industries? Try these:

  • Oil & Gas Exploration & Production
  • Refining
  • Chemical Manufacturing
  • Healthcare (Hospitals)
  • Pharmaceutical Manufacturing
  • Nuclear Power / Nuclear Fuels
  • Utilities
  • Auto Manufacturing
  • Aggregates
  • Mining (Iron, Gold, Diamonds, Copper, Coal, …)
  • Aluminum
  • Aviation (airlines and helicopters)
  • Shipping
  • Cosmetics
  • Construction
  • Data Security
  • Nuclear Weapons
  • Research Laboratories
  • Mass Transit
  • Regulatory Agencies
  • Prisons
  • Pulp & Paper
  • Engineering
  • Food & Drinks
  • Alchohol
  • Security
  • Recycling
  • Aerospace Manufacturing
  • Space Exploration
  • Pipelines
  • Agricultural Commodities
  • Steel
  • Forestry
  • City Government
  • General Manufacturing
  • Telecommunications
  • Airport Management

And that’s only a partial list.

Where can you read about the successful application of TapRooT® in some of these industries? Try these success stories:

http://www.taproot.com/archives/category/success-stories?s=

You will see examples of companies that saved lives, save money, prevent injuries, improved service, made work more productive, and stopped the cycle of blame and punishment.

The reason that TapRooT® is used by industry leaders is that it works in such a wide variety of industries in such a wide variety of countries.

But don’t just believe the industry leaders. Attend one of our GUARANTEED courses. Guaranteed? That’s right. Here is our guarantee:

  • Attend the 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 and we will refund the entire course fee.

It’s that simple. Try to find a money-back guarantee like that anywhere else. We are so sure of your success that we guarantee it.

Don’t wait. Register for one of our root cause analysis courses today. For a list of upcoming public courses, see:

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

TapRooT® Around the World: Arab Potash

October 9th, 2017 by

TapRooT® instructor, Heidi Reed sent these class photos from 1300 feet below sea level! Looks like a great class!

 

Why is Root Cause Analysis Applied Reactively More Than Proactively?

October 3rd, 2017 by

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

TapRooT® at Enablon SPF Americas 2017

September 26th, 2017 by

The word is out and we are here at SPF Americas 2017 to share our new integration with Enablon’s EHS software.

 

Come stop by our booth in the Innovation Corners starting this afternoon and introduce yourself!

Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

September 26th, 2017 by

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First, let me state that the reason I seem to be carried away by the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much. Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

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What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet. And if you know me, you know that I think they should be using TapRooT® to do this.

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In TapRooT®, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® and see if there is a generic causes using a three step process. The three steps are:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?
  3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these question.

TapRooT® Users know about the Root Cause Tree® and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions. If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

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Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information we can get a hint at the generic causes for these accidents.

Before I list the generic causes we are guessing at and discuss potential fixes, here is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

GENERIC CAUSES

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade if there is the will to invest in a capable fleet. All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

  • Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
  • Conduct the training for all ships on a prioritized basis.
  • Integrate the training into junior officer training courses and department head and perspective XO and CO training.
  • Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staffs.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

  • Develop a standard watch rotation schedule to minimize fatigue.
  • Review underway requirements and prioritize to allow for adequate rest.
  • Allow daytime sleeping to reduce fatigue.
  • Minimize noise during daytime sleeping hours to allow for rest.
  • Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
  • Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
  • Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for CO’s when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

This corrective action is difficult because a through training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented that are not listed above.

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class I learned that it was a 2nd or 3rd order control problem and these types of problems are very difficult for humans to solve. Thus ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

  • A seamanship training program be developed based on best human factors and training practices including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
  • Develop ship handing course for junior officers to complete before they arrive at their first ship to learn and practice common ship handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking and avoidance in restricted waters.
  • Develop an advanced ship handing corse for department heads that refreshes/tests their ship handling skills and teaches them how to coach junior officers to develop their ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance.
  • Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters including when to take control if the ship is in extremis (and practice of this skill).
  • Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship handing and supervisory skills to be passed before reporting to a ship.
  • Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

  • Perform a task analysis of required navigation shipboard duties including new technology duties and duties if technology fails (without shipboard computerized aids).
  • Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

  • Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
  • Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
  • Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

  • Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, number of days at sea under certain levels of high operating tempo, number of days at sea without a port call, staffing levels in key jobs, …
  • Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

  • Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current operating tempo.
  • Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
  • Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
  • Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support current operating tempo and create a better nuclear surface fleet carrier path.
  • Establish a new ship building program to support a modern 400 ship Navy by 2030.
  • Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to adopt and apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources needed to keep our young men and women safe at sea.

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Using TapRooT® Proactively – Behavior Based Safety Observations

September 14th, 2017 by

Here Dave Janney discusses how TapRooT® can be used to make behavior-based safety observations.

Root Cause Analysis for the FDA

September 13th, 2017 by

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

TapRooT® featured on Worldwide Business with kathy ireland®

September 5th, 2017 by

Mark & Kathy discussing root cause analysis and human performance.

Watch the recorded television broadcast below.

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