Category: TapRooT

What Pre-Summit Course Should I Attend?

January 23rd, 2018 by

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That’s a tough question…

Here is more course info: http://www.taproot.com/taproot-summit/pre-summit-courses

Attending the 2018 Global TapRooT® Summit and a Pre-Summit course is a great way to learn more AND get a discount of $200 off the course.

And if you bring a team to the Summit, you can get discounts up to $600 off per person!

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CLICK HERE to REGISTER!

Safety Fines Double in One Year in UK

January 18th, 2018 by

In the UK, fines related to safety doubled from 2016 to 2017. Here is a video from Safety & Health Practitioner (SHP) that provides more details…

Perhaps now is the time to invest in improved root cause analysis as part of your safety improvement efforts?

CLICK HERE for more information about TapRooT® Root Cause Analysis or CLICK HERE for information about TapRooT® Training.

CLICK HERE to see a list of public TapRooT® Courses in Europe.

CLICK HERE to contact us for information about training at your site.

Why do people try to make root cause analysis so difficult?

January 17th, 2018 by

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I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

January 17th, 2018 by

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About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

January 17th, 2018 by

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The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

Time for some advanced root cause analysis?

January 15th, 2018 by

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What do you think? Does someone in the Hawaii government need to attend TapRooT® Training?

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

January 10th, 2018 by

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Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.

REASONS TO ATTEND THE SUMMIT

1. SAVE MONEY

You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.

2. GET A PROMOTION

What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.

3. GET FIRED UP!

Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.

4. HAVE FUN

What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.

ONE MORE IDEA…

Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.

GUARANTEE

We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

Why Should I get the New TapRooT® Books?

January 9th, 2018 by

When someone calls me for help with an investigation, I often ask them what color TapRooT® Book they have. Sometimes they want to know..

What difference does it make what color my book is?

The answer is that it let’s me know how long ago they took TapRooT® Training and what version of the TapRooT® System they are using.  It is always sad to see people struggling with an issue we solved by improving TapRoot® and they just don’t know about the improvement.

Over the almost three decades that we have been developing TapRooT®, we have made major improvements. If you are still using the system that came in three-ring binders, you are back in the 1996 version of the system.

You might think that NOBODY would be using that outdated a version of the system but someone sent me a review of TapRooT® that they read and … sure enough … the review was of the 1996 book. So to people still using the three-ring binders: Update your documentation to the newest version and you will be shocked.

If you have the green book, you are working from the 2000 revision. You are working from a system from the same millennia. Update to the new version and you will jump ahead 16 years.

If you have the thick black book, you are working from the 2008 version. You too will be pleasantly surprised by what we have learned in the last eight years and how we have improved the usefulness of the TapRooT® Books.

And what is the latest version? These books are also black but there are  smaller and there are eight of them (currently book five and eight are still in production).

What do these books look like and how are they an improvement over the older 2008 book?

BOOKS 3 & 4

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Above is the Investigation book set. It includes:

These are the books that cover using TapRooT® to find the root causes of everything from small/minor incidents to major accidents.

How are they an improvement over the older 2008 TapRooT® Book? Well … we took everything we have learned in the last eight years and used it to improve our documentation. And the first things we learned is … LESS IS MORE. That’s why we broke the books up into separate topics. You can just read what is applicable to what you are doing. But how specifically is the investigation set improved over the old book?

  • The set includes the latest Root Cause Tree® and Dictionary that make the system even better with improved definitions in the Dictionary and an new category (language) in the Communication Basic Cause Category.
  • The Essentials Book is a an easy read (only 100 pages long). It guides you through a new 5 step process that makes TapRooT® easy to use for simple investigations. This improves your simple investigations while saving time.
  • The Major Investigations Book explains the whole TapRooT® System and includes the traditional 7-Step Investigation Process. The book includes improved TapRooT® Techniques, detailed examples of each technique, and even better ideas to help you identify your Causal Factors before you start analyzing their root causes.
  • The set also references the latest TapRooT® Software (Version VI).

The ideas we have for improving low-to-medium risk investigations alone are worth buying the new set.

Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is included in the 2-Day TapRooT® Root Cause Analysis Training. The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training include Book 4: Using TapRooT® Root Cause Analysis for Major Investigations, and Book 3.

But that’s just two (Books 3 & 4) of the new books. What else is there and what new information is in the other six books? Read on…

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BOOK 1

Until Book 1: TapRooT® Root Cause Analysis Leadership Lessons was written, we really didn’t have a book that explained the concepts of TapRooT® Root Cause Analysis to management. Now we have produced a concept book that is just 70 pages long (think of it as a bedtime story for management). When management asks what they need to know about TapRooT®, Book 1 is the place to start.

Of course, we would like leaders to learn much more about a tool that should be in their leadership tool kit but Book 1 is a starting point to get management to understand the basis for TapRooT® and how it will help them improve safety, quality, productivity, and environmental compliance.

To learn more about this book, CLICK HERE, or order your copy at: http://www.taproot.com/store/TapRooT-R-Philosophy.html.

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BOOK 2

Book 2: TapRooT® Root Cause Analysis Implementation, is for those in charge of an improvement program. It explains how TapRooT® can be used to improve an already existing program or part of a completely new improvement effort.

Making this a separate book (89 pages long) helps the right people get the right information to make their improvement program much more effective.

What’s in the book?

  • The “Just Do It!” method of getting started.
  • How to add TapRooT® Root Cause analysis to an existing 6 Sigma, Lean, 8-D, Process Safety, Behavior-Based Safety, or other improvement initiative.
  • Building a best-in-class improvement initiative.
  • A checklist to evaluate your improvement efforts.

If you are serious about improvement and in charge of a program to make improvement happen … this book is for you. Order it HERE.

Book 5

This book is close enough to finished that I can explain what you will find in it when it comes out. If you are interested in equipment troubleshooting and root cause analysis, this is the book for you.

Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability, explains how to use TapRooT® and Equifactor® to solve equipment problems. The new book explains the techniques and includes a paper version of the equipment troubleshooting tables from the TapRooT® VI Software all in one book. That makes this a much handier reference.

We expect this book to be available in the 1st half of 2018. Watch our newsletter for more information.

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Book 6

Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, explains how to build TapRooT® root cause analysis into your audits and proactive improvement efforts. It’s only 57 pages long and is a great compliment to books 3 and 4.

It describes the 7-step process for using TapRoot® in an audit and how to build TapRooT® techniques into your proactive improvement efforts.

When you order the book HERE, you will also get the latest:

  • TapRooT® Root Cause Tree®
  • TapRooT® Root Cause Tree® Dictionary
  • TapRooT® Corrective Action Helper® Guide

What’ new about book 6? It is the latest information about using TapRooT® to audit performance. It can be used for safety or quality audits. It’s a very fast read.

This book is included in the course materials for the pre-Summit TapRooT® for Audits Course.

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Book 7

Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills, is all about information collection. We’ve never had a book specifically about this topic. In the past you had to find some of the information provided here buried in the steps of the old 2008 TapRooT® Book.

But this book is more than just a rehash of the information about interviewing and evidence collection. In  addition to information about planning your evidence collection, emergency response and scene management, and the TapRooT® investigation process, it includes:

  • The 3 P’s and an R of evidence collection. (People, Paper, Physical, and Recordings)
  • The TapRooT® 12-Step Interview Process (Cognitive Interviewing)
  • Decoding non verbal behavior
  • Building your investigation kit
  • An initial observation form
  • An interview preparation form
  • An evidence log
  • How to use Change Analysis and CHAP as part of an interview/evidence collection process

That’s a lot to pack into a 93 page book! Buy this book by CLICKING HERE.

Book 8

This book is also still in production but is also expected in the first half of 2018. Book 8: TapRooT® Performance Measures and Trending for Safety, Quality, and Business Management, explains the state-of-the-art in performance measurement and trending.

If you have ever wondered how you can prove that you have improved or if a “negative” trend is actually significant, this is the book for you.

In addition, the book explains what management should know about trends. This information can keep them from being misled by false trends and how to use trends to manage improvement initiative.

The math involved isn’t complicated, but it is beyond some of the common “trending” graphs that you may be using now.

This book is included in the pre-Summit Advanced Trending Techniques Course. Watch our newsletter for more information on when the book will be available.

KEEP UP TO DATE! If you don’t have the latest TapRooT® Books that apply to your work, order them today!

Resolve to Improve!

January 2nd, 2018 by

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On New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:

  1. Get healthy.
  2. Get organized.
  3. Live life to the fullest.
  4. Learn new hobbies.
  5. Spend less/save more.
  6. Travel.
  7. Read more.

Are you surprised by any of the above? Nothing earth shattering there.  Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.

Here are some work-related resolutions to consider…

  • Eliminate the blame environment when someone makes a mistake.
  • Stop problems from happening over and over again.
  • Save time and get better results when you perform an incident investigation.
  • Learn best practices to make your workplace safer and more productive.
  • Become better at your job by applying state-of-the-art root cause analysis.

How do you do these things?

TapRooT®

Start by attending TapRooT® Training. See our upcoming courses here:

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

Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:

http://www.taproot.com/taproot-summit/summit-schedule

And register here:

http://www.taproot.com/taproot-summit/register-for-summit

The knowledge you will gain will help you make 2018 the best year ever.

Sign up now for the February 2018 Global TapRooT® Summit Quality Track

December 19th, 2017 by

 

Need a jumpstart on your Quality Management System’s improvements to better utilize your company’s product realization? Sign up for the Quality Track during the Global TapRooT® Summit, Knoxville, Tennessee, February 26 – March 2, 2018

Improve Your Resource Usage Management by attending:

Mark Paradies (the creator of TapRooT®)

How to Replace 5 Whys with TapRooT® for Better Results

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

 

Kevin McManus– Great Systems!

Stop Daily Goofs for Good

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job.

Using Wearables to Minimize Daily Human Errors

Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

 

Barb Carr – System Improvements, Inc.

Top 7 Secrets of a Great Investigation Interview

Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.

 

Improve Your Management Responsibility by attending:

 John Boyle

Making Audits an Integral Part of a Proactive Improvement Program –

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job. Kevin McManus

 Jonathan Kennedy

Influencing Change

Nothing happens without change. Nothing happens without support of change. Learn techniques to increase the ability to change with full management support.

 

Improve Your Analysis and Improvements by attending:

Christopher Vallee – System Improvements, Inc.

What is a Trend and How Can You Find Trends in the TapRooT® Data?

You have invested in TapRooT® and have root cause data, but do you know what the data tells you? Do you know if what you are measuring has changed for the good or the bad? Do you know how to access your trend-able data in your VI Software? Learn what to look for, what needs to be acted on and how to access the data on VI Software.

Performance Improvement Gap Analysis

Put together everything that you learned this week in your Summit Tracks and from your peers, then develop your action plan to hit the ground running.

REGISTER NOW or

Learn more!

TapRooT® Around the World: Uruguay

December 14th, 2017 by

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

 

 

 

 

 

 

 

 

 

 

 

TapRooT® Around the World: Uruguay

December 14th, 2017 by

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

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

 

TapRooT® Around the World: Jeanette PA

December 14th, 2017 by

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

 

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

December 12th, 2017 by

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

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

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

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

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

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

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

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

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

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

2. 7 Secrets of Root Cause Analysis (2011)

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

My 20+ Year Relationship with 5-Why’s

December 11th, 2017 by

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

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

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

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

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

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

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

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

For more information, here are some previous blog articles:

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

Comparing TapRooT® to Other Root Cause Tools

What’s Fundamentally Wrong with 5-Whys?

Fake News or Real?

December 6th, 2017 by

FakeNews

That’s the headline. Here is the link:

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

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

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

Can Your Company Afford a Second Rate Improvement Program?

November 28th, 2017 by

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

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

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

Have you become satisfied? Is it time to improve?

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

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

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

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

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CLICK HERE to get your copy.

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

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

People share their success and learn from others…

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

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

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

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

November 17th, 2017 by

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

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

Let’s look at each of these.

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

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

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

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

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

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

TapRooT® Around the World: AMCHAM Trinidad & Tobago Conference

November 14th, 2017 by

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

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

November 14th, 2017 by

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

How many tools do I need to learn?

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

You might ask:

What’s in the toolbox?

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

SI Chart 7 StepMajorInvestigation

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

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

But why should you learn these tools?

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

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

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

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

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

Finally, do other root cause analysis systems provide this course guarantee:

Attend this course, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software
and we will refund the entire course fee.

That’s a powerful guarantee. And we can offer it because of the hundreds of thousands of people we have trained who apply TapRooT® sucessfully. We know you, too, will be successful.

Why not create your own toolbox?

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

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

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

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

Where is the nearest TapRooT® Training?

November 7th, 2017 by

Iraq

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

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

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

Italy

KISS and Root Cause Analysis

November 1st, 2017 by

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

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

Make things as simple as possible, but not simpler.

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

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

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

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

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

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

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

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

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

What’s Fundamentally Wrong with 5-Whys?

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

NO WAY.

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

Under Scrutiny: A Critical Look at Root Cause Analysis.

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

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

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

Once again, I’m reminding of a saying:

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Advanced Trending Techniques

As W. Edwards Deming said:

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

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

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

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

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

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1. Read the book:

TapRooT® Root Cause Analysis Leadership Lessons

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

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2. Read the book:

TapRooT® Root Cause Analysis Implementation

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

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

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

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

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

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

October 31st, 2017 by

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

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

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

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

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

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

December 4: Edmonton, AB

December 11: Houston Texas

TapRooT® Road Trip!

October 25th, 2017 by

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

 

Click image to view featured courses.

 

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

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

What causes the implementation to vary? Try these factors …

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

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

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

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CLICK HERE to order your copy.

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

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

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

Then attend the Summit on Wednesday – Friday.

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

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

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

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

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

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Investigation Detects Lack of Experience in Experienced Personnel And Leads To Job Simulation To Improve Performance Submitted by: Errol De Freitas Rojas, SHE Coordinator Company: ExxonMobil, Caracus, Venezuela Challenge We investigated a Marine incident where an anchor cable picked up tension during maneuvers and caused a job to be stopped. We needed to find the …

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