Category: TapRooT

Now perform your Basic and Major investigations with TapRooT®

June 27th, 2017 by

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

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

 

7 Traits of a Great Root Cause Analysis Facilitator

June 27th, 2017 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That’s about it.

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

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

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

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

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

Where? Have a look at these courses:

http://www.taproot.com/courses

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

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Top 10 Reasons People Don’t Use TapRooT®

June 23rd, 2017 by

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

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

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

7. Their company has no mistakes to investigate.

6. They don’t like tapping noises.

5. They would rather use their massive brainpower.

4. They are trying to get fired.

3. They just say that everything is human error.

2. They don’t grow trees.

1. They use Spin-A-Cause.

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How do you plan your root cause analysis?

June 20th, 2017 by

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General George Patton said:

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

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

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

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

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

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

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

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

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

Order your copy by CLICKING HERE.

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

June 15th, 2017 by

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

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

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

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

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

TapRooT® Optional Root Cause Analysis Tools

June 14th, 2017 by

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

  • Equifactor®
  • CHAP
  • Change Analysis

These optional techniques are usually applied in more complex investigations.

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

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

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

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

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

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

June 6th, 2017 by

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

So here is the question …

Do you have the latest TapRooT® Materials?

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

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

Where can you get the most recent materials?

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

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

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

We recently published two other new books:

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

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

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

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

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

That’s a lot of new information.

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

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

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

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

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

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

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

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

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

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

#TapRooT_RCA #safety

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

May 31st, 2017 by

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

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

Building a Safety Culture

May 26th, 2017 by

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

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

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

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

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

#TapRooT_RCA

Is there an easier way to investigate simple problems?

May 24th, 2017 by

People often ask me:

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

The answer is “YES!”

The simplest method is:

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Of course, some methods may be too simple.

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

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

Or just order a copy by CLICKING HERE.

To Hypothesize or NOT to Hypothesize … that is the Question!

May 16th, 2017 by

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

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

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Opportunity to Improve Vision

May 9th, 2017 by

(Taken from Book 1: TapRooT® Root Cause Analysis Leadership Lessons, used by permission of System Improvements)

The Opportunity to Improve Vision

What does the Opportunity to Improve vision look like?

If there is a problem, the people, either individually or in teams, work to solve the problem. Everyone views this as an opportunity to improve. The team doing the investigation knows better than to just address the symptoms. They are NOT looking for someone to blame. They ARE looking for the root causes. They know that if they find and fix root causes they will prevent the problem’s recurrence.

As W. Edwards Deming said:

“Management’s job is to improve the system.”

This is the Opportunity to Improve Vision. Improving the “system” is the key to improving performance.

But what is the system? The system is equipment, procedures, tools, communication techniques, training, human factors design, supervisory techniques, resources (time), policies, and rules that all impact the ability to achieve the intended goal. These are all things that management can change to improve performance.

The Opportunity to Improve Vision sees each incident as an opportunity. Not an opportunity to find a scapegoat (someone to blame). Not an opportunity to survive yet another crisis. The Opportunity to Improve Vision sees each incident as an opportunity to improve performance by changing the system.

If you are living in the Blame Vision or the Crisis Management Vision, this may seem like a fairy tale. But the Opportunity to Improve Vision exists at many sites using TapRooT® Root Cause Analysis. And TapRooT® helped them achieve the vision when they started finding the real root causes of problems rather than placing blame and using “quick fixes” that really didn’t work.

Would you like to learn more about TapRooT® Root Cause Analysis? Attend one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. See:

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

TapRooT® Around the World

May 2nd, 2017 by

Systems Improvements/TapRooT® was a proud sponsor of Girls, Inc. Knoxville at their fundraising event last Friday.

Girls, Inc. is a national organization dedicated to helping girls realize their potential and exercise their rights. Learn more about them at: http://girlsinctnv.org/

Cirrus Aircraft was one of the sponsors as well. Pictured here is our Chief Financial Officer, Cherie Larson, and her spouse, Paul.

Crisis, Crisis Everywhere…

May 1st, 2017 by

The Crisis Management Vision

Has your management ever said:

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

Then there is a good chance that you are living in a crisis management vision.

What are your three most common corrective actions for any problem?

  • Counsel the operator to be more careful
  • Require more training.
  • Write (or rewrite) the procedure.

Unfortunately, this type of corrective action usually doesn’t work (even though sometimes it may appear to work). The problem happens again. The vicious cycle of crisis and crisis management repeats itself. And everyone complains about having to work too hard because they are always in “crisis mode.” 

Are you tired of crisis management?

Would you like to finally solve problems once and for all?

Then it is time you tried TapRooT® Root Cause Analysis. Attend one of our publics courses listed here…

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

This article was derived from Book 1: TapRooT® Root Cause Analysis Leadership Lessons. Copyright 2017 by System Improvements, Inc. Used by permission.

 

Technically Speaking – Help Desk Humor

April 27th, 2017 by

New to the TapRooT® VI software? Don’t fear, Webinar Wednesdays are here! Yes, it’s Thursday BUT it’s always a good practice to plan ahead!

Webinar Wednesday occurs the fourth Wednesday of every month!  If you have been trained in TapRooT®, and want to optimize your investigations, join us. Every month we will be offering a software-specific webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software.

Get the most out of your investment.
 What you need to know: 
  • When: Webinar Wednesdays occur the fourth Wednesday of every month
  • Time: 2:00-3:30pm Eastern Time
  • Length: 90 minutes
  • Price: $195 per seat
  • Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.

Interested? REGISTER HERE FOR WEBINAR WEDNESDAY MAY 24th, 2017.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Trapped in the Blame Vision

April 20th, 2017 by

From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.

The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.

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They were trapped in the Blame Vision.

The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.

The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:

I didn’t do it! 
Nobody saw me do it! 
You can’t prove I did it!

But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:

Why be fair when you can be arbitrary?

A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up. 

One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself. 

The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement. 

Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him. 

If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.

Are you attending the ASQ World Conference on Quality in Charlotte?

April 19th, 2017 by

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

Root Cause Analysis Tip: Does Your Company Vision PREVENT Good Root Cause Analysis?

April 11th, 2017 by

What is your company’s vision? Does your company have a:

  • Blame Vision
  • Crisis Management Vision
  • Opportunity to Improve Vision

The only vision that leads to good root cause analysis is the opportunity to improve vision. 

We’ve been helping people “adjust” their vision since Mark Paradies gave a talk about the opportunity to improve vision at the 1990 Winter American Nuclear Society Meeting. 

How do you change your vision?

That takes more than the few paragraphs of a blog article to describe. But we did write about it in our newest book:

TapRooT® Root Cause Analysis Leadership Lessons

 

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What’s in the new book?

  • A Tale of Two Plants
  • Vision
  • What is a Root Cause and How Was TapRooT® Developed to Help You Find Them?
  • How Leaders Can Apply TapRooT® to Improve Performance
  • What Can TapRooT® Do for You?
  • What TapRooT® Books Do You Need to Read?

The new book is designed for senior managers and leaders of improvement programs to help them understand effective root cause analysis and how it fits into a performance improvement program.

Order your copy of the new book by clicking HERE and make sure your vision supports improved performance!

 

Why Does TapRooT® Exist?

March 28th, 2017 by

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

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

Case Study: Using Dye Packs to Locate Leaks

March 16th, 2017 by

Watch as Brian Tink discusses how his company used dye packs to help them isolate the location of a pipe leak.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

NewImage

To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

Do you believe that ignorance is bliss?

March 6th, 2017 by

Ignorance is Bliss

From many people’s actions, you might believe that they think “ignorance is bliss” is true. We need to ignore the real root causes of problems and just attack the symptoms.

Screen Shot 2017 03 02 at 11 53 09 AM

Even the cartoon, Calvin and Hobbs, commented on it. See the cartoon on my Facebook page …

https://www.facebook.com/ateneobookbench/photos/a.169772396396266.33963.169770589729780/472291752810994/?type=3&theater

Is this the way you treat your root cause analysis?

Would you rather have a simple BUT WRONG answer?

For over a decade, I’ve explained the shortcomings of 5-Whys for root cause analysis but some still believe that easy is better than right.

What if you could find and fix the real root causes of what you think are “simple incidents” with a robust, advanced system (TapRooT®) and not make a career of the investigation? You would put in only the effort required. Your investigation would be as simple as possible without going overboard. And your corrective actions would be effective and stop repeat incidents.

That’s what the new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about.

Have you read the new book yet?

Once you read the book you will want to start implementing TapRooT® for all the “simple” investigations that are worth being done.

Get the book today and find out what you should be doing. Order the book at:

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

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Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

An improvement plan was developed and implemented. Elements of the improvement plan included process…

Exelon Nuclear
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