Upcoming TapRooT® Public Courses:
For more information regarding our public courses around the world, click here.
Rome is a great place for a spring vacation. The sights, the food, and the shopping are amazing!
And when you can combine the trip with some great TapRooT® Training (a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course), you are getting two great experiences at once!
The 2-Day TapRooT® Course is a great value. In two days you will learn how to apply the standard TapRooT® Tools (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, the Corrective Action Helper®, and SMARTER) to find and fix the root causes of problems.
What kind of problems can you solve using TapRooT®?
- Major safety accidents
- Drug/medical device quality issues
- Medical sentinel events
- Process safety accidents/incidents
- Equipment reliability issues
- Neat-miss accidents
- Production issues
- Cost overruns
- Schedule slippage issues
- Customer complaints
- Security issues
- Product waste issues
- Hardware/software failures
And that’s just to name a few!
And the instructors scheduled to teach the course are Mark Paradies and Linda Unger – the inventors of TapRooT®!
The course is being held at a great hotel in the center of Rome. Watch this video for a bird’s eye view of the location…
Here’s the hotel’s web site:
As you can see, the hotel is just a couple of blocks from the Pantheon. And near many of Rome’s tourist attractions.
You probably won’t get an opportunity like this again. Because this course is so special, you should register today for the March 18-19, 2015 course to make sure you save your spot! Also, get your hotel reservation set. You don’t want to miss this great training in a great location.
When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.
Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.
Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.
SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.
Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.
Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.
Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.
Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).
Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.
Generic Cause: A systemic problem that allows a root cause to exist.
But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?
Here are eight examples that could help you decide when to ask for help:
1. LEGAL ISSUES
Could this accident end up in court? If so, you need the help of your company’s attorney.
They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.
2. CUSTOMER DISPUTE
It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.
But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.
3. UNION ISSUE
Ever had an investigation that gets contentious with a union?
This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.
4. COMPLEX ACCIDENTS
TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.
What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.
What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.
5. INDEPENDENT INVESTIGATION / NEW SET OF EYES
Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.
6. CONTROVERSIAL INVESTIGATION
I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.
Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.
Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.
Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.
Still not sure? Contact us at: http://www.taproot.com/contact-us for more information.
For training at your site, you need to call us (865-539-2139) or CLICK HERE to drop us a note. We still have a few dates open in November and December but you need to get your training scheduled soon or all the 2014 training dates will be full.
For our public TapRooT® Courses, you can see the entire worldwide list of courses remaining for 2014 and the first half of 2015 at:
Or you can click on a particular continent to see the courses being held there. Or just click on the continent below that you are interested in:
Don’t wait to register. TapRooT® Courses fill up fast and there may be a waiting list.
Hope to see you at one of the upcoming courses!
TapRooT® is a systematic process for the investigation of problems and root cause analysis of their causes.
If you been to one of our TapRooT® Root Cause Analysis Courses, you know the basis of TapRooT® and how to use it to find the root causes of accidents, incidents, and near-misses. You also know how to use TapRooT® proactively to stop accidents BEFORE they happen.
But for those who HAVE NOT yet attended a TapRooT® Course, here’s a link where you can learn more about how TapRooT® works.
Hope to see you at a course in the future!
We hope you enjoy this new format of our Instructor Root Cause Tips. Today we have Ken Reed, TapRooT®/Equifactor® Instructor and Partner, discussing “What Makes a World Class Root Cause Analysis System?”. Be sure to pay attention to the 7 Strengths of TapRooT® that he discusses.
Click here to learn more about our courses where you can learn root cause analysis and implement in your own workplace.
Was this tip helpful? Check out more short videos in our series:
TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)
Prevent Equipment Failures with Ken Reed (Click here to view tip.)
Be Proactive with Dave Janney (Click here to view tip.)
Thanks to TapRooT® Instructor Marco Flores for these great photos of our September 8-12, 2014 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.
Thanks to Diana Munevar for these great photos of our August 27-29, 2014 course in Bogota, Colombia.
Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 16th, 2014 by Mark Paradies
Final presentations by the teams after performing a root cause analysis on their incident that they brought to the course…
Linda Unger Teaching the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
Teams Working on Their SnapCharT®s at the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
You have to understand what happened before you can understand why it happened. The SnapChart helps you do just that. These folks at the 2-Day class in Dayton are practicing their newly learned skills…
View more photos here.
For the next public TapRooT® Course near you, click on your continent at:
Mark Paradies Teaching a Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, OhioSeptember 15th, 2014 by Mark Paradies
Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
Just before starting the exercise …
Teams working on their incidents …
Instructions just prior to the presentations …
Teams presenting …
For more information about TapRooT® Root Cause Analysis Courses, see:
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.
Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…
Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:
Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis CourseAugust 6th, 2014 by Mark Paradies
Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…
Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at:
Pictures from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course at Lake TahoeAugust 5th, 2014 by Mark Paradies
The students below are hard at work reading the Root Cause Tree® Dictionary to discover why someone would break a rule. Ever wonder why people break the rules? Then maybe you should attend one of our 2-Day or 5-Day TapRooT® Courses!
View more photos from Tahoe here: http://www.taproot.com/archives/45935
Throwback to 2009 in Chile. Chile is just one of the many places where you can receive training and hands on experience with a certified TapRooT® instructor.
Thinking about signing up for a TapRooT® Training class? Click here to find out what courses are available near you.
What was your favorite moment at a TapRooT® course? Please leave comments below.
Look over recent FDA Warning Letters (http://www.fda.gov/iceci/enforcementactions/WarningLetters/default.htm) to medical device manufacturers, and you will see that about a third of them are issued because of failures of CAPA (Corrective and Preventive Action programs).
The FDA expects medical device manufacturers and drug makers to find the root causes of quality issues, effectively fix them, and monitor them to make sure that the fixes worked.
A key part of a CAPA program is effective root cause analysis. Without effective root cause analysis, problems tend to repeat – and the FDA definitely doesn’t like repeat problems.
What makes effective root cause analysis? That’s a question we’ve been dedicated to answering for over 25 years. We designed the TapRooT® System to include tools to help guide investigators to the root causes of human performance and equipment reliability issues and find effective corrective actions to stop repeat problems from occurring.
Want to see how TapRooT® can help your company find and fix the root causes of quality issues? Then I would recommend attending one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. See the upcoming public course schedule by CLICKING HERE.
Don’t be afraid that the TapRooT® System won’t work at your company. Our training is guaranteed:
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.
It’s that simple. We know TapRooT® will work for you because we’ve seen it work at so many companies in so many industries including pharmaceutical and medical device manufacturers. See success stories from multiple industries at:
But don’t wait. You can’t afford a major finding adverse to quality and a warning letter. And you don’t want to have the course you want to attend fill up before your register (seats are limited in each class). Register today and start applying TapRooT® to improve performance and avoid quality incidents.
The US Bureau of Labor Statistics release some interesting information about workplace fatalities in a recent press release.
It would be interesting to see these statistics graphed on an XmR Chart … as we teach in our Advanced Trending Techniques Course. If you are interested in learning advanced trending techniques, you missed our 2014 course. But we are planning to offer the course again on June 1-2, 2015 prior to the 2015 TapRooT® Summit (June 3-5, Las Vegas, NV). I know that’s a long ways ahead to start planning but you probably can’t say that your schedule is already full.
One more note, if you have a bunch of folks at your company who need to learn advanced trending techniques, we can come to your site to present the course. If you are interested, CLICK HERE to contact us.
Pictures from Day 2 of the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in New OrleansMay 21st, 2014 by Mark Paradies
Day two is finished and it was another great course! Here is Linda teaching the class…
Later, the class members are woking in teams to apply what they have learned to one of their own incidents …
And then each team selects someone to present to the class what they have found by applying TapRooT®.
That’s it! The end of another great class! If you would like to attend TapRooT® Training, see our courses at: