Category: TapRooT

Get TapRooT® Trained in Hartford

May 23rd, 2018 by

In two days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet at the Hilton Garden Inn Hartford North/Bradley Int’l Airport for the 2-Day Root Cause Analysis Training course.

Register here to take the TapRooT® course in Hartford. 

 

Experience Hartford
Connecticut’s capital, Hartford, is home to beautiful parks, a choice of unique museums, attractions, performing arts and restaurants. See the stunning Connecticut State Capitol, visit the Wadsworth Atheneum, one of the oldest art museums in the U.S., and stroll through the Rose Garden in Elizabeth Park. Best things to do in Hartford include the Connecticut Science Center, the Mark Twain House & Museum and the carousel in Bushnell Park.

Connecticut State Capitol: At 210 Capitol Ave., the marble and granite state capitol building dates from 1871 and is a U.S. National Historic Landmark.

Mark Twain House & Museum: This Victorian Gothic house on Farmington Avenue has 19 rooms and is where Samuel Longhorne Clemens wrote The Adventures of Huckleberry Finn and The Adventures of Tom Sawyer, and where he raised his family.

Wadsworth Atheneum Museum of Art, 600 Main St., was founded in 1842 and opened in 1844, one of the oldest art museums in the U.S. You’ll see French and American Impressionist collections, works by contemporary and modernist artists, landscapes by members of the Hudson River School, American decorative arts, and furniture. The Wadsworth Atheneum is the largest art museum in Connecticut and is listed on the U.S. National Register of Historic Places.

Lincoln Financial Sculpture Walk: Created to honor Abraham Lincoln, the walk includes sculpture installations, murals, and artwork. Noted historian and biographer Doris Kearns Goodwin was instrumental in the launch of the mobile tour, and is the narrator.

Connecticut Science Center: At 250 Columbus Blvd., the Connecticut Science Center is a nine-story science museum with 40,000 square feet of interactive exhibits.

A city park on Asylum Avenue, 102-acre Elizabeth Park is the oldest municipal rose garden in the U.S., with 15,000 rose bushes representing 800 varieties. The Park is also home to an outdoor concert series in the summer, and contains greenhouses, lawns, pathways, a pond, and tennis courts.

Bushnell Park, 30 Arbor St., has its own summer concert series. The park also offers visitors a tour of the Soldiers and Sailors Memorial Arch or a historical tour.

Hartford eateries 
At Bushnell Park (see above), you will find food trucks at the park year round with fare such as the bacon marmalade grilled cheese from Whey Station.

Salute, 100 Trumbull St., in downtown Hartford, is a great “meet and eat” spot, with a robust bar and a creative menu.

BBQ Bear’s Smokehouse, 25 Front St., smokes meats Kansas City-style and boasts “the best ribs in Connecticut,” along with its delicious sides and desserts.

The Capital Grille, 44 Front St., is a great steakhouse with classic American fare in an upscale setting.

The Trumbull Kitchen, 150 Trumbull St., is a stylish eatery featuring a inventive menu—from tasters and tapas to soothing comfort food.

Firebox Restaurant, 539 Broad St., is set in a renovated forge, with an upscale-casual atmosphere and a farm-to-table New American menu.

Sarah’s Coffee House, 257 Asylum St., is farm-to-table and a local charity supporter along with having terrific coffees, teas, smoothies, and pastries.

Homemade doughnuts, breakfast sandwiches, coffee, and more—Tastease, 70 New Park Ave.—is a local favorite.

Family-owned Tangiers, 550 Farmington Ave., is a restaurant and a grocery, specializing in Middle Eastern and Mediterranean fare, such as spicy falafel, chicken gyro, tabbouleh, baklava.

Mozzicato DePasquale Bakery and Pastry Shop, 329 Franklin Ave., is ideal for cocktails, an espresso, a pastry.

Sample a German-Polish smokehouse/deli, Adolf’s Meats & Sausage Kitchen, 35 New Britain Ave., for brats, hams, Canadian bacon, kielbasa, and more.

Stop in at Spigot Cafe, 468 Prospect Ave., for ice-cold brews from around the world. Cash only. Feel free to bring food in to have with your beer!

Discover more to explore from our Hartford Pinterest board and begin planning your TapRooT® trip to Connecticut today.

Why is TapRooT® Root Cause Analysis Software the Best Choice?

May 23rd, 2018 by

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If you are looking for the best root cause analysis software, here are some things to consider:

  1. How the software works is important, but the root cause analysis system that the software uses is probably THE MOST IMPORTANT part of picking your software. No matter how well a bad root cause tool is implemented in software … it is still a bad root cause analysis tool. Therefore, you should look for a world-class root cause analysis tool.
  2. It’s all in the cloud, baby! The days of software just working on one operating system are over. Now your software should be cloud-based and available on a multitude of devices. Mac or PC, laptop or tablet, even phones should be supported.
  3. Able to connect with other software. Does the software play well with others? The root cause analysis software should be able to connect with other ESHQ (Environment, Safety, Health, Quality), human resource, or performance monitoring systems.
  4. Custom reports. Reports the way that you and your management want them. Easy to develop and save. No special software required.
  5. Trends. Advanced trending techniques that help you measure and predict performance.

Sounds great. But where can you find these features? The TapRooT® Version VI Software (of course).

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First, the TapRooT® VI Software is based on the world-class TapRooT® Root Cause Analysis System. If you don’t know why TapRooT® stands head and shoulders above other root cause systems, you should attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and find out. Learn to use SnapCharT® to investigate what happened and organize your evidence. Use Equifactor® to troubleshoot equipment failures. Use Safeguard Analysis to find all the Causal Factors. Use the Root Cause Tree® to find the real, fixable causes of human performance and equipment issues. and use the Corrective Action Helper® Module to develop effective fixes.

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Second, TapRooT® VI Software is cloud-based. You can subscribe as an individual; you can host the TapRooT® VI Software on your network; or we can host the software for your whole company. TapRooT® VI is device independent. Mac, tablet, smartphone. No problem. CONTACT US for more information.

Third, TapRooT® VI Software has an API. This allows easy connections to other software. Talk to our IT guys to find out more. Call 865-357-0080 or CLICK HERE.

Fourth, need a custom report? No problem when you are using TapRooT® VI Software. Have a look at this link to get some ideas … http://www.taproot.com/?s=custom+report.

Fifth, we have been teaching advanced trending techniques for 20 years and they are built into the TapRooT® VI Software. Here’s a short video on exporting trending data to Excel.

But there is more to consider when picking your root cause analysis software. Consider this:

How good is the training?

How good is the software support?

TapRooT® Training is highly rated by students around the world. See samples of what they have to say HERE.

What abut our software support? Outstanding! Our knowledgeable support staff is happy to help you figure things out.

Want more information about TapRooT® VI Software? Let’s do an online demo. CONTACT US to learn more.

Connect with TapRooT® in Hamburg

May 22nd, 2018 by

In five days with TapRooT®, you can learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Courtyard by Marriott Hamburg Airport on June 11. You may want to make plans to explore your host city while you’re there. See our travel tips below.

Register here for the course.

Hamburg—Germany’s second-largest city and seaport—offers you lots to explore. Walk along the harbor, see the sights, and plot your Hamburg game plan.

Hamburg highlights
Visit the port. See Hamburg and feel its maritime vibes on a boat tour. View the fish market, pass contemporary seaside architecture and the Elbe beach, touring across the port and back.

Honored as a Historic Landmark of Civil Engineering in Germany, the Old Elbe Tunnel was the first river tunnel on the European continent. Access the entry point from the harbor, walking to Steinwerder and back to St. Pauli in a few minutes.

Marvel at the Museum Ships—such as Rickmer Rickmers and Cap San Diego—Hamburg’s heralded historical ships, moored by the harbor.

If you’re a fan of model ships, U-boats and military history, visit International Maritimes Museum Hamburg, with the world’s largest private collection of maritime treasures, in historic Speicherstadt.

Appreciate the art and architecture of the oldest parish church in Hamburg, St. Peter’s Church, just a few blocks from Town Hall. Bronze lion-head door handles grace the west portal and date from 1342. A gothic mural that dates from 1460 is in the north portion of the church. The bell tower is up 544 steps and offers a grand view over Rathausmarkt, the Town Hall market, and Alster Lake.

Impressive sandstone Town Hall, also called Rathaus or City Hall, houses the senate and parliament among its 647 rooms. Note the staircase made of Sardinian marble, a commentary on the course of human life.

Check out Miniatur Wunderland, the largest model railway in the world. Close to the miniature wonderland, the canal of Nikolaifleet is one of the oldest spots in Hamburg, where you can see well-preserved Old Hamburg townhouses.

St. Pauli is a unique quarter in Hamburg, a great place to walk around and absorb the street art, get a drink, and shop.

Fun fact: Hamburg has more bridges than Venice.

Hop on a double-decker bus for a fun city tour. Take in the Landungsbrücken, the breathtaking harbor, historical Speicherstadt, modern HafenCity, famous Reeperbahn, the ‘Michel,” the Alster, Town Hall, museums, and villas.

Want more action? Take a beach walk on the Elbstrand, bike by Alster Lake, and kayak Hamburg’s canals.

Relax in the Rissen district, by the Elbe River on the Wittenberg shore. Nearby, explore the Wittenberg lighthouse.

Relish the views from the bistro and the collections in noted art museum, Hamburger Kunsthalle.

Taste Hamburg
Nosh at Barefood Deli. This bright, cozy atmosphere was introduced by a famous German actor and is family-owned. Homemade beer and wine, Sunday brunch, DJs in the evening—food and fun for everyone.

Dine with a view of Hamburg harbor at Fischereihafen, where fish dishes rule the day.

Another great fish eatery is Schabi’s Fischimbiss, where you can pick your own fish, eat inside or out, and enjoy the experience.

Insider tip: If you’re more interested in exploring than sitting down to dine, pop into a Hamburg grocery store for cheap-and-go items. Groceries often give out generous samples, so keep your eyes open!

You can see it from the Elbe bridges: Entenwerder 1. What a view from this pontoon eatery! Public Coffee Roasters is next door, so the cappuccino, espresso and coffee are amazing.

In a former pharmacy, the Brooklyn Burger Bar’s offerings are fresh and homemade.

Taste chocolate at Chocoversum. Learn about the process and create your own chocolate bar.

Enjoy Luicella’s Ice Cream in the St. Georg or St. Pauli locations.

Taste Scandinavia at Karlsons, where the Norwegian apple pancake is but one of the offerings you’ll long remember.

Klimperkiste is a bar and an eatery, so you don’t have to choose. Good for all night or a nightcap.

Discover more to explore from our Hamburg Pinterest board and begin planning your TapRooT® trip to Germany today. Download the handy, free Hamburg app here.

Avoid Big Problems By Paying Attention to the Small Stuff

May 16th, 2018 by

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

TapRooT® Around the World: Bogota, Colombia

May 15th, 2018 by

Many thanks to Diana Munevar for these TapRooT® training photos from a three-day TapRooT® training course led by Hernando Godoy and Piedad Colmenares in Bogota, Colombia! Looks like they are having fun and learning a lot!

Put yourself in this picture. Advance your career and your development through TapRooT® training!

We are global to meet your needs. Register today for a TapRooT® Training course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.

July 16 – Auckland, New Zealand, 2-Day TapRooT® Root Cause Analysis Training

July 17 – Milwaukee, Wisconsin, 2-Day TapRooT® Root Cause Analysis Training

July 25 – Lake Tahoe, Nevada, 2-Day Root Cause Analysis Training

August 08 –  Sao Paulo, Brazil, 2-Day TapRooT® Root Cause Analysis Training

August 13 – Nashville, Tennessee, 2-Day TapRooT® Root Cause Analysis Training

August 27 – Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Training

September 12 – Newcastle, Australia, 2-Day TapRooT® Root Cause Analysis Training

September 26 – Amsterdam, Netherlands, 2-Day TapRooT® Root Cause Analysis Training

October 14 – Dubai, UAE, 5-Day Advanced Root Cause Analysis Training

 If you’re interested in pursuing a TapRooT® course that is near you or for a specific date, look further via these two links:

2-Day TapRooT® Root Cause Analysis Training

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Learn TapRooT® in Denver

May 14th, 2018 by

Expand your skills in Denver!

In less than a week, you can learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Westin Denver Downtown on June 11. You may want to make plans to explore your host city while you’re there.

Register here for the course.

Soak up Denver

Denver is packed with must-do thrills: Stand exactly one mile high on the west steps of the state capitol and see 200 mountains from its dome. Set your eyes on the world’s greatest collection of Native American art at an architectural wonder, the Denver Art Museum. Check out Old West history in a trendy downtown at Golden, Colorado’s first capital, where you can sip a beer while kayakers paddle by.

The Mile High City is a paradise for outdoor adventure and pro sports. The choices are wide-ranging: walking trails, urban hikes, parks, sporting events, and more Denver adventures.

Colorado’s landscape is awe-inspiring. Take Garden of the Gods in Colorado Springs, little more than a hour from Denver. You can go front range climbing, take a jeep or segway tour, or tour via bike or electric bike. If you’re a photography buff, this is a natural for you.

Go brewery touring and get a closeup taste of the culture Denver’s famous for.

Denver’s historic district, or Lower Downtown, is called LoDo. Amid 28 square blocks, you can enjoy excellent restaurants, live music, and fun brewpubs. Walk, sightsee, window shop in downtown Larimer Square among a vibrant district of Victorian buildings restored to hip shops and restaurants.

The creative community of Denver shows up in galleries, studios, and cultural attractions across seven art districts.

Visit Red Rock Canyon Park & Amphitheatre for hiking, walking, and biking trails, or dine at Red Rock’s Ship Rock Grille and admire the view.

Check out Union Station, a transportation hub, historic landmark, and cool space for noshing–such as Mercantile Dining & Provision–gathering, and shopping.

At El Taco De Mexico, 714 Santa Fe Dr., it’s all about being the authentic taqueria.

Try breakfast or lunch at Maria Empanada, a great bakery and cafe offering a taste of Argentina.

At the vintage-inspired ice cream shop Little Man, people line up around the block on 16th Street for homemade flavors like peach cobbler, oatmeal cookie, salted Oreo, and creme fraiche.

Discover more to explore from our Denver Pinterest board and begin planning your TapRooT® trip to Colorado today.

We hope to see you at the IHI/NPSF Patient Safety Conference!

May 14th, 2018 by

If you plan to attend the 2018 IHI/NPSF Patient Safety Conference in Boston, MA on May 23 -25, stop by and say “hello.” Per Ohstrom, Anne Roberts, and Barb Carr (pictured left to right) will be at Booth #316 in Exhibit Hall C discussing how TapRooT® can help you and answer any questions you might have.

We will be at Booth #316 during these times:

Wednesday: 3:30pm – 5:30pm

Thursday: 12:00pm – 1:30pm & 4:30pm – 6:30pm

Friday: 7:00am – 8:30am

The first 500 visitors will receive a special prize, so do not miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Hope to see you there!

“It was such a simple mistake!”

May 14th, 2018 by

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When you have a major incident (fire, environmental release, etc.), your investigation will most likely identify several causal factors (CF) that, if they had not occurred, we probably would not have had the incident.  They are often relatively straight forward, and TapRooT® does a great job identifying those CFs and subsequent root causes.

Sometimes, the simplest problems can be the most frustrating to analyze and fix.  We think to ourselves, “How could the employee have made such a simple mistake?  He just needs to be more careful!”  Luckily, TapRooT® can help even with these “simple” mistakes.

Let’s look at an example.  Let’s say you are out on a ship at sea.  The vessel takes a bit of a roll, and a door goes shut on one of your employees.  His finger is caught in the door as it shuts, causing an injury.  Simple problem, right?  Maybe the employee should just be more aware of where he is putting his hands!  We will probably need more effective fixes if we really want to prevent this in the future.

How can we use TapRooT® to figure this out?  First of all, it is important to fully document the accident using a SnapCharT®.  Don’t skip this just because you think that the problem is simple.  The SnapCharT® forces you to ask good questions and makes sure you aren’t missing anything.  The simple problem may have aspects that you would have missed without fully using this technique.  In this example, maybe you find that this door is different than other doors, which have latches to hold them open, or handles to make it easier to open the door.  Imagine that this door might have been a bathroom stall door.  It would probably be set up differently than doors / hatches in other parts of the ship.

So, what are your Causal Factors?  First, I probably would not consider the sudden movement of the ship as a CF.  Remember, the definition of a CF states that it is a mistake or an error that directly leads to the incident. In this case, I think that it is expected that a ship will pitch or roll while underway; therefore, this would not be a CF. It is just a fact. This would be similar to the case where, in Alaska, someone slipped on a snow-covered sidewalk. I would not list that “it was snowing” as a CF.  This is an expected event in Alaska. It would not be under Natural Disaster / Sabotage, either, since snow is something I should be able to reasonably protect against by design.

In this case, I would consider the pitch / roll of the vessel as a normal occurrence.  There is really nothing wrong with the vessel rolling. The only time this would be a problem is if we made some mistake that caused an excessive roll of the vessel, causing the door to unexpectedly slam shut in spite of our normal precautions. If that were the case, I might consider the rolling of the ship to be a CF.  That isn’t the case in this example.

You would probably want to look at 2 other items that come to mind:

1.  Why did the door go shut, in spite of the vessel operating normally?
If we are on a vessel that is expected to move, our doors should probably not be allowed to swing open and shut on their own. There should be latches / shock absorbers / catches that hold the door in position when not being operated. Also, while the door is actually being operated, there should be a mechanism that does not depend on the operator to hold it steady while using the door. I remember on my Navy vessel all of our large hatches had catches and mechanisms that held the doors in place, EXCEPT FOR ONE HEAVY HATCH. We used to tell everyone to “be careful with that hatch, because it could crush you if we take a roll.” We had several injuries to people going through that hatch in rough seas. Looking back on that, telling people to “be careful” was probably not a very strong safeguard.

Depending on what you find here, the root causes for this could possibly be found under Human Engineering, maybe “arrangement/placement”, “tools/instruments NI”, excessive lifting/force”, “controls NI”, etc.

2. Why did the employee have his hand in a place that could cause the door to catch his hand?
We should also take a look to understand why the employee had his hand on the door frame, allowing the door to catch his finger.  I am not advocating, “Tell the employee to be careful and do not put your hand in possible pinch points.” That will not work too well. However, you should take a look and see if we have sufficient ways of holding the door (does it have a conventional door knob? Is it like a conventional toilet stall, with no handle or method of holding the door, except on the edge?). We might also want to check to see if we had a slippery floor, causing the employee to hold on to the edge of the door / frame for support. Lots of possibilities here.

Another suggestion: Whenever I have what I consider a “simple” mistake that I just can’t seem to understand (“How did the worker just fall down the stairs!?”), I find that performing a Critical Human Action Profile (CHAP) can be helpful.  This tool helps me fully understand EXACTLY what was going on when the employee made a very simple yet significant mistake.

TapRooT® works really well when you are trying to understand “simple” mistakes.  It gets you beyond telling the employee to be more careful next time, and allows you to focus on more human performance-based root causes and corrective actions that are much more likely to prevent problems in the future.

Career Opportunities for Candidates with TapRooT® Skills

May 14th, 2018 by

When you become TapRooT® trained, you can rely on your expertise to communicate how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer across the desk from you. If you have invested yourself in TapRooT® training and skills, explore professional advancement through one of these global opportunities.

Patient Safety Analyst Nurse

Field Service Manager – Wireline & Perforating

HSEQ Manager

Chemical Manufacturing

Environment, Quality and Safety Coordinator –  Collections Division

HES Operations Specialist

Maintenance Manager

Reliability Engineer I

Manager – EHS/Quality

Associate-Senior Engineer Nuclear (Electrical) 

Safety & Health Specialist (Remote)

Patient Safety Program Coordinator

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, May 28, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Perth, Australia, May 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139 or 865.357.0080.

Monday Accidents & Lessons Learned: Airplane Mode

May 14th, 2018 by

When you hear the words “mode” and “aviation,” many of us who are frequent flyers may quickly intuit the discussion is heading toward the digital disconnection of our cellular voice and data connection in a device, or airplane mode. Webster defines “mode” as “a particular functioning arrangement or condition,” and an aircraft’s system’s operating mode is characterized by a particular list of active functions for a named condition, or “mode.” Multiple modes of operation are employed by most aircraft systems—each with distinct functions—to accommodate the broad range of needs that exist in the current operating environment.

With ever-increasing aviation mode complexities, pilots must be thoroughly familiar with scores of operating modes and functions. No matter which aircraft system is being operated, when a pilot is operating automation that controls an aircraft, the mode awareness, mode selection, and mode expectation are all capable of presenting hazards that require know-how and management. Sure, these hazards may be obvious, but they are also often complex and difficult to grasp.

NASA’s Aviation Safety Reporting System (ASRS) receives reports that suggest pilots are uninformed or unaware of a current operating mode, or what functions are available in a specific mode. At this juncture, the pilots experience the “What is it doing now?” syndrome. Often, the aircraft is transitioning to, or in, a mode the pilot didn’t select. Further, the pilot may not recognize that a transition has occurred. The aircraft then does something autonomously and unanticipated by the pilot, typically causing confusion and increasing the potential for hazard.

The following report gives us insight into the problems involving aircraft automation that pilots experience with mode awareness, mode selection, and mode expectation.

“On departure, an Air Carrier Captain selected the required navigation mode, but it did not engage. He immediately attempted to correct the condition and subsequently experienced how fast a situation can deteriorate when navigating in the wrong mode.

“I was the Captain of the flight from Ronald Reagan Washington National Airport (DCA). During our departure briefing at the gate, we specifically noted that the winds were 170 at 6, and traffic was departing Runway 1. Although the winds favored Runway 19, we acknowledged that they were within our limits for a tailwind takeoff on Runway 1. We also noted that windshear advisories were in effect, and we followed required procedure using a no–flex, maximum thrust takeoff. We also briefed the special single engine procedure and the location of [prohibited airspace] P-56. Given the visual [meteorological] conditions of 10 miles visibility, few clouds at 2,000 feet, and scattered clouds at 16,000 feet, our method of compliance was visual reference, and we briefed, “to stay over the river, and at no time cross east of the river.

“Taxi out was normal, and we were issued a takeoff clearance [that included the JDUBB One Departure] from Runway 1. At 400 feet AGL, the FO was the Pilot Flying and incorrectly called for HEADING MODE. I was the Pilot Monitoring and responded correctly with “NAV MODE” and selected NAV MODE on the Flight Control Panel. The two lights adjacent to the NAV MODE button illuminated. I referenced my PFD and noticed that the airplane was still in HEADING MODE and that NAV MODE was not armed. Our ground speed was higher than normal due to the tailwind, and we were rapidly approaching the departure course. Again, I reached up and selected NAV MODE, with the same result. I referenced our location on the Multi-Function Display (MFD), and we were exactly over the intended departure course; however, we were still following the flight director incorrectly on runway heading. I said, “Turn left,” and shouted, “IMMEDIATELY!” The FO banked into a left turn. I observed the river from the Captain’s side window, and we were directly over the river and clear of P-56. I spun the heading bug directly to the first fix, ADAXE, and we proceeded toward ADAXE.

“Upon reaching ADAXE, we incorrectly overflew it, and I insisted the FO turn right to rejoin the departure. He turned right, and I said, “You have to follow the white needle,” specifically referencing our FMS/GPS navigation. He responded, “I don’t have a white needle.” He then reached down and turned the Navigation Selector Knob to FMS 2, which gave him proper FMS/GPS navigation. We were able to engage the autopilot at this point and complete the remainder of the JDUBB One Departure. I missed the hand–off to Departure Control, and Tower asked me again to call them, which I did. Before the hand–off to Center, the Departure Controller gave me a phone number to call because of a possible entry into P-56.”

We thank ASRS for this report, and for helping to underscore TapRooT®’s raison d’être.

We encourage you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Remembering An Accident: Enschede Fireworks Disaster

May 13th, 2018 by

On May 13, 2000 in the eastern Dutch city of Enschede a fireworks warehouse caught fire and lead to an enormous explosion. The explosion caused 22 deaths, with 4 fire-fighters among the causalities, another 974 individual were injured, and 500 homes and businesses were severely damaged and/or destroyed during the blast. After the dust had settled a 13 meter diameter, 1.3 meter deep crater could be observed where concrete round cells C9 and C11 – C 15 once stood. To create a crater that size it would take a TNT equivalent between 4 and 5 tonnes. The largest blast was felt up to 30 kilometers away (19 miles).

  

What makes this incident so interesting is the fact that whatever started the fire was never really discovered. Two possibilities seem to be the likely cause. One possibility discussed was arson. The Dutch police made several arrest, but none of whom had been arrested were convicted of arson for the Enschede Fireworks Disaster. The other theory comes from the fire department stating that accidental ignition via an electrical short circuit could have also been the cause of the fire.

Because of the incident and investigation results the fireworks disaster lead to stronger safety regulations in the Netherlands concerning the sales, storage, and distribution of fireworks. Since the catastrophe three illegal firework warehouses were closed down and the Roombeek area that was destroyed by the explosion has been rebuilt.

  

To read the full detailed report click here.

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

 

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training

May 11th, 2018 by

Last week on TapRooT® TV, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® and the positive impact it can have on your professional career. We pack a lot into our blog!

Among our blog features are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

We always look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Every Wednesday

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Catch up on the conversation with Michelle and Benna  via Vimeo:

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

If you want to chime in the conversation, or have a question or comment, feel free to shout out here and we’ll get right back to you. Thank you for watching TapRoot® TV!

Acquire TapRooT® Training in Aberdeen

May 11th, 2018 by

Meet us in Scotland for TapRooT® training!

Two days. That’s the amount of time it will take for you to learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® Techniques are designed for everyone. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques learned include: SnapCharT®, Root Cause Tree®, & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet and begin the 2-Day TapRooT® Root Cause Analysis Training at the Holiday Inn Aberdeen, West, on June 6. Register here for the course and count on seeing a bit of your host city while you’re there.

Experience Aberdeen, the Granite City
Aberdeen’s rich history began as two separate towns on the North Sea. Along the Don River were Old Aberdeen and the cathedral and university; New Aberdeen, on the Dee River, was the hub for trading and the fishing village. Today, Aberdeen is Britain’s largest granite-exporting industry and the chief seaport of northern Scotland. Stop in at Aberdeen Maritime Museum on Shiprow, overlooking the busy harbor. Learn about the city’s legendary relationship with the sea through collections spanning shipbuilding, fast sailing ships, fishing, and port history. The museum is the UK’s sole location with displays on the North Sea’s gas and oil industry. Catch more seafaring history at Fooddee (pronounced “FIT-ee” locally), an old fishing village straight from a postcard. You may see dolphins leaping up at the harbor mouth!

Aberdeen and Aberdeenshire make up part of Scotland’s castle country, as in more than 300 castles. Listen to the sound of the traditional Scots language, a local Doric, while you’re drinking up the atmosphere here. Play a round of golf at Royal Aberdeen Golf Club, founded in 1780, while you take in North Sea coastal views. Enjoy the rugged cliffs and sandy bays at St. Cyrus National Nature Reserve, or explore mountains, lochs, wildlife, and distilleries at Cairngorms National Park.

History and architecture
Get to know a bit of Aberdeen history beginning with St. Machar’s Cathedral, (1424) and Provost Skene’s House (c. 1545). Visit the Union Street parish church of St. Nicholas, divided into two parts: the West Church (built in 1755) is separate from the East Church (built in 1838), divided by the original 13th-century transept and 19th-century steeple. Compare two medieval bridges, the Brig o’ Balgownie (1320), which spans the Don, and the Old Bridge of Dee (1527). You’ll notice a mix of styles, from the Neoclassical-style Music Hall (1822) to Broad Street’s Marischal College (1844), the latter said to be the largest granite building in the world. Founded in 1845, King’s College, now the University of Aberdeen and home of five Nobel Laureates, is known for its famous crown spire and Renaissance style.

Fun fact: Yes, the jaw-dropping architecture is gray granite and there’s a lot of it. Look closely and you’ll see the buildings take on a silver sparkle in sunlight due to their high mica content.

Eateries and entertainment
Books & Beans, 22 Belmont St: Coffee + WiFi

Foodstory, 13-15 Thistle St: Soups, salads, scones, lasagna, great coffee, and fun folks

The Lemon Tree, 5 West North St: Cool beverages and music

The Sanddollar Cafe & Bistro, 2 Beach Esplanade: Delicious dinners, ample wine list, and jazz nights

Ross Bakery, 44 Chapel St: Pies, breads and scones, burgers and sandwiches, cakes

Moonfish, 9 Correction Wynd: Modern British cuisine, generous gin list, set amid medieval streets of Aberdeen’s merchant quarter with views of the 12th-century St. Nicholas church

Maggie’s Grill, 242 Holburn Street:  Angus steaks; locally sourced hickory-smoked pulled pork; pastrami; locally sourced cheeses, vegetables, breads, beer, and coffee; all served with the motto,“Field to fork and made with soul!”

The Silver Darling, North Pier, Pocra Quay: Dine with panoramic views of the water.  Here’s a sample of the scrumptious fare: brown crab, prawns and pan-fried sea trout with carrot & cardamom purée

Almondine, 39 – 43 Thistle Street: Macarons of every description, afternoon tea, and a French bakery

Discover more of Scotland to explore from our Aberdeen Pinterest page and begin planning your TapRooT® trip to Aberdeen today.

High road or low road, we hope to see you in Scotland!

Auditing: A better way to approach investigations on problems and losses

May 10th, 2018 by

This Wednesday, for our Facebook Live discussion, TapRooT® professionals Benna Dortch and Dave Janney tackled why companies are not proactive in addressing and solving recurring problems and the key differences between incident investigation root cause analysis and the root cause analysis of audit findings. Within this conversation, we touched on inadequate or ineffective audits and why it is those fall short of yielding improvements.

Dave’s book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, is part of the TapRooT® for Audits set that fleshes out the topic of audits into seven steps. Feel free to order the set and call on us for further discussion or a training course.

Watch the discussion via Vimeo

Why are Auditing and Proactive Improvement so important? from TapRooT® Root Cause Analysis on Vimeo.

Tune in for our Wednesday Facebook Live next week. We look forward to being with you on Wednesdays! Here’s how to connect with us for next week’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When?  Wednesday, May 16

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

 

Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)

May 9th, 2018 by

Find the Root Cause

I hear people say that 5-Whys is a good root cause analysis system for “simple” incidents. So, I thought I would show a simple incident that was provided as an example by a very experienced 5-Why user and compare it to the analysis that would be performed using TapRooT®.

Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, is the source of the example – a robot failure. He used the example to teach employees the 5-Why technique while he was at Toyota. Here is the example as he described it…

1.    Why did the robot stop?

–    The circuit has overloaded, causing a blown fuse.

2.    Why did the circuit overload?

–    There was insufficient lubrication on the bearings, so they locked up.

3.    Why was there insufficient lubrication on the bearings?

–    The oil pump on the robot is not circulating sufficient oil.

4.    Why is the pump not circulating sufficient oil?

–    The pump intake is clogged with metal shavings.

5.    Why is the intake clogged with metal shavings?

–    Because there is no filter on the pump.

For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.

Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.

TapRooT® Root Cause Analysis

TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with either the TapRooT® 5-Step Process for low-to-medium risk incidents or the the TapRooT® 7-Step Process for major investigations. The 5-Step Process is shown below…

To start investigating the problem, one gathers evidence and draws a SnapCharT® (shown below being drawn by a team in a TapRooT® 2-Day Root Cause Analysis Course).

Notice that the 5-Whys that Mr. Ohno asked in the example above turned out to be mainly the sequence of events leading up to the failure in the  SnapCharT® (shown below).

The SnapCharT® makes the example event easier to understand than the 5-Why example above. Plus, the SnapCharT® goes beyond the 5-Whys by indicating that there was no low oil pressure alarm.

In TapRooT®, if the investigator decides that there is more to learn, the investigator continues to collect evidence (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.

First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?

Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?

The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.

Notice that in TapRooT®, we complete the collection of evidence about what caused the metal filings and what caused the filter to be missing. These were significant issues that were left out of the 5-Why analysis. This type of omission is common in 5-Why analyses – even when experts apply 5-Whys. Thus the problem isn’t with the investigator or their training – it is embedded in the 5-Why system.

Causal Factors

Once one understands what happened, the third step is to identify the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. A simple technique called Safeguard Analysis is used to do this. The four Causal Factors for the Robot Stops incident were identified as:

  1. Mechanic A uses cloth to cover openings in system.
  2. Mechanic A does not report metal shaving contamination.
  3. Mechanic B does not install oil filter.
  4. Operator does not know oil pressure is low.

Where Mr. Ohno only had one root cause, TapRooT® has already identified four Causal Factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys: that it usually focuses on a single cause and misses additional causes (and the needed corrective actions for those root causes that aren’t identified).

TapRooT® Root Causes

In fourth step of the TapRooT® 5-Step Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).

For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend  attending a 2-Day or 5-Day TapRooT® Course.

However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”

This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.

Copyright © 2015 by System Improvements, Inc.
Used by permission. Duplication prohibited.

In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).

Thus, it was determined that if the operator needed an oil pressure display/alarm (displays NI root cause) to make the detection of a problem possible (errors not detectable root cause). If the display/alarm had been present, then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.

The corrective action for these two root causes would be to install a bearing lube oil pressure indicator and a low bearing lube oil pressure alarm to notify the operator of impending equipment problems before the bearing would lock up.

After analyzing just one Causal Factor using the TapRooT® Root Cause Tree® we have found that even an expert like Taiichi Ohno could miss important root causes when using 5-Whys. But there is more. There are still three more Causal Factors to analyze (and then Generic Causes – an optional technique in the 5-Step Process).

Why would you use a root cause tool with known, proven weaknesses? Why would you risk lives, your corporate reputation, and large sums of money on an inferior approach to problem solving? If something is worth fixing, it is worth fixing it right! Learn and apply TapRooT® Advanced Root Cause Analysis to find the real root causes of problems and effectively fix them. Attend an upcoming course to learn more.

Admiral Rickover’s 7 Rules

May 9th, 2018 by

Hyman Rickover 1955

Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

Are you using advanced root cause analysis to learn from past mistakes? Learn more about advanced root cause analysis by CLICKING HERE.

Hazards and Targets

May 7th, 2018 by

Most of us probably would not think of this as a on the job Hazard … a giraffe.

Screen Shot 2018 05 07 at 9 40 49 AM

But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

Screen Shot 2018 05 07 at 9 42 38 AM

 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

TapRooT® Root Cause Analysis is Heading to Portland, OR

May 4th, 2018 by

Mark your calendars and pack your bags we are heading to Portland, OR to teach a 5-Day TapRooT® Advance Training Course on July 16, 2018. You will learn to find and fix the root causes of incidents, accidents, quatlity problems, operational errors, hospital sentinel events, precursor incidents, and much more! You will also learn how to use the Root Cause Tree®, Corrective Action Helper®, and SnapCharT®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. Once attendees complete the course they will receive a training certificate and a 90-day subscription to TapRooT® VI.  Whether you’re a TapRooT® expert or a beginner there is always something new and exciting to learn at our 5-Day course.

Make sure to bring a safety incident or quality issue when you attend the course. The reports may be a written report or you have extensive knowledge of an incident without a written report. We will divide into teams of 2-4 people, with each team analyzing a different problem.

Experience Portland:

Portland, OR is situated below the constantly snow capped Mount Hood, and is know for its well maintained parks and Eco-friendliness. The cities official nickname is the “City of Roses” due to all of the rose bushes planted in the city. Here you will experience big city excitement with small town charm. Portland is a city you wont soon forget. So, take a break from you course work and enjoy all Portland has to offer.

Dining:

  • Jake’s Famous Crawfish is a historic restaurant that opened in 1892 and is must try while visiting.
  • Huber’s Cafe is another Portland restaurant that has been open for over a 100 years. Here you will find a traditional hearty menu with an old Portland charm dining experience. The restaurant is known for it delicious food, breath taking stain glassed ceiling, and its’ Spanish Coffee that is prepared table side with flare.
  • Looking for something to satisfy your sweet tooth? Then Ruby Jewel is your destination. Here you will find all-natural hand crafted cream and ice cream sandwiches that are made daily.

Entertainment:

  • Pioneer Courthouse Square was once an old run down parking lot, but it has been transformed into a busy urban park. It host over 300 events a year! If you’re not sure what to do just ask one of the green-clad Sidewalk Ambassadors you will find camped out near the park.
  • The Lan Su Chinese Garden is a popular place to visit. It is a walled Chinese garden that’s as big as a full city block. Fun fact, Portland’s sister city is Suzhou, China.
  • Washington Park is full of fun activities all in one easy location! You can visit the Oregon Zoo, Portland Japanese Garden, International Rose Test Garden, and much more.

There is so much do and see I couldn’t possibly write a blog post long enough to cover it all. So check out our Pinterest page to view our Portland board full of exciting things to do and places to eat. Also, watch this informative video on Portland, OR to learn all about this unique and vibrant city.

 

Register here to advance your professional career in Portland, OR.

Can’t make it to Portland? That’s okay click on the links below to view all of our upcoming courses.
2-Day TapRooT® Essentials Training Course
5-Day TapRooT® Advanced Training Course

What is Senior Leadership’s Role in Root Cause Analysis

May 2nd, 2018 by

Screen Shot 2018 04 30 at 3 40 59 PM

Senior leadership wants root cause analysis to uncover the fixable root causes of significant accidents and precursor incidents AND to recommend effective fixes to stop repeat incidents.

But what does senior leadership need to do to make sure the happens? What is their role in effective root cause analysis? Here’s a quick list:

  • Best root cause system
  • Insist that it is used
  • Be involved in reviews
  • Insist on timely implementation of fixes
  • Check status of the implementation of fixes
  • Use trends to manage
  • Steer system to be more proactive

Let’s look at these in slightly more detail.

Best root cause system: Because so much is riding on the effective performance of a root cause system, leaders knows that second best systems aren’t good enough. They don’t want to bet their company’s future on someone asking why five times. That’s why they feel assured when their team uses advanced root cause analysis to find and fix the real root causes of problems. CLICK HERE to find out more about advanced root cause analysis.

Insist that it is used: One common theme in companies that get the most from their performance improvement programs is that senior leaders ASK for investigations. When they see a problem, they insist that the advanced root cause analysis process is used to get to the root causes and develop effective fixes. When middle management and employees see senior leadership asking for investigations and root cause analysis, they want to be involved to help the company improve.

Be involved in the reviews: When senior leaders ask for investigations, it’s only logical that they would want to review the outcome of the investigation they asked for. But it goes beyond being present. Senior management knows what to look for and how to make the review process a positive experience. People often get rewarded for good investigations. When the review process is a positive experience, people want to participate and have pride in their work.

Insist on timely implementation of fixes/Check status of the implementation of fixes: You might not believe this but I’ve seen many examples of companies where they performed root cause analysis, developed fixes, and then were very slow to implement them. So slow that the incident repeated itself, sometimes several times, before any fix was implemented. Good senior leadership insists on prompt implementation of fixes and makes sure they are kept up to date on the progress of implementation.

Use trends to manage: Good root cause analysis efforts produce statistics that can help leaders manage. That’s why senior leadership understands the use of advanced trending techniques and gets reports on the latest root cause trends.

Steer system to be more proactive: Would you rather wait for an accident or incident to find your next improvement opportunity? Or would you rather target and audit or assessment and have them apply advanced root cause analysis to develop effective improvements? The best senior leaders know the right answers to these questions.

That’s it! Senior leaders use proactive improvement and investigations of precursor incidents and major accidents (which rarely happen) to find where improvement needs to happen. They are involved with the system and use it to keep their company ahead of the competition. They are updated about the status of fixes and current trends. They reward those who make the system work.

Does that sound like your facility? Or do you have an improvement opportunity?

Join us for Facebook Live tomorrow: What TapRooT®’s blog can do for you

May 1st, 2018 by

Join TapRooT® professionals Benna Dortch and Michelle Wishoun as they discuss the TapRooT® blog and how its contents can make a significant difference in your professional performance and development.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, May 2

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Among blog features to be discussed are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

Testimonial Tuesday

May 1st, 2018 by

Are you interested in attending one of our TapRooT® courses? Here are some recent comments we received from our clients that have attended a 5-Day or 2-Day TapRooT® Training course.

TapRooT® Root Cause Analysis Training Testimonials for our 2-Day and 5-Day courses:

  • “Very well instructed, great team/group dialogue with industry players.” – Dylan
  • “Excellent way of data analysis.” – Sheeth
  • “I have learned better ways of writing better corrective actions.” – Victor
  • “Interesting examples on how multiple root causes can exist.” – Mike

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location by clicking on the links below.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Technically Speaking – TapRooT®VI Password Security

April 26th, 2018 by

With the latest release of the TapRooT® VI software comes new password security updates. One of the security updates is an account feature lockout where after 5 unsuccessful login attempts. If this happens you will receive a message as in the image below.

If you do receive this message, follow these steps to reset your password.

  • Click “Forgot User Name or Password?”
  • Enter your Email Address

You will then be sent an email with information about your User Name and a link to reset your password. This leads us to the next security update, you cannot reuse your old password.

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, it doesn’t mean it has to be complicated!

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

We hope to see you at the ASQ 2018 World Conference

April 23rd, 2018 by

If you plan to attend the ASQ 2018 World Conference in Seattle, Washington on April 30 – May 2, stop by and say “hello.” Chris Vallee and Dave Janney (pictured left to right) will be at booth #301 discussing how TapRooT® can help you and answer any questions you might have.

 

The first 500 visitors will receive a special prize, so do not miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Hope to see you there!

Monday Accidents & Lessons Learned: Putting Yourself on the Right Side of Survival

April 23rd, 2018 by

While building an embankment to circumvent any material from a water supply, a front end loader operator experienced a close call. On March 13, 2018, the operator backed his front end loader over the top of a roadway berm; the loader and operator slipped down the embankment; and the loader landed turning over onto its roof. Fortunately, the operator was wearing his seat belt. He unfastened the seat belt and escaped the upside-down machine through the broken right-side window of the loader door.

Front end loaders are often involved in accidents due to a shift in the machine’s center of gravity. The U.S. Department of Labor Mine Safety and Health Administration (MSHA) documented this incident and issued the statement and best practices below for operating front end loaders.

The size and weight of front end loaders, combined with the limited visibility from the cab, makes the job of backing a front end loader potentially hazardous. To prevent a mishap when operating a front end loader:
• Load the bucket evenly and avoid overloading (refer to the load limits in the operating manual). Keep the bucket low when operating on hills.
• Construct berms or other restraints of adequate height and strength to prevent overtravel and warn operators of hazardous areas.
• Ensure that objects inside of the cab are secured so they don’t become airborne during an accident.
• ALWAYS wear your seatbelt.
• Maintain control of mobile equipment by traveling safe speeds and not
overloading equipment.

We would add the following best practices for loaders:
• Check the manufacturer’s recommendations and supplement appropriate wheel ballast or counterweight.
• Employ maximum stabilizing factors, such as moving the wheels to the widest setting.
• Ensure everyone within range of the loader location is a safe distance away.
• Operate the loader with its load as close to the ground as possible. Should the rear of the tractor tip, its bucket will hit the ground before the tractor tips.

Use the TapRooT® System to put safety first and to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

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