Category: TapRooT

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

May 16th, 2017 by

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

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

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Don’t start with the answer.

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

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

What should you do?

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

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

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

This system gets you to think beyond your current knowledge!

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

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

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

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

May 10th, 2017 by

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

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

Improve Employee Safety and reduce injuries

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

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

Opportunity to Improve Vision

May 9th, 2017 by

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

The Opportunity to Improve Vision

What does the Opportunity to Improve vision look like?

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

As W. Edwards Deming said:

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

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

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

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

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

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

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

TapRooT® Around the World

May 2nd, 2017 by

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

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

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

Crisis, Crisis Everywhere…

May 1st, 2017 by

The Crisis Management Vision

Has your management ever said:

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

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

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

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

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

Are you tired of crisis management?

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

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

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

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

 

Technically Speaking – Help Desk Humor

April 27th, 2017 by

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

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

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

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

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

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

Trapped in the Blame Vision

April 20th, 2017 by

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

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

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They were trapped in the Blame Vision.

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

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

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

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

Why be fair when you can be arbitrary?

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

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

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

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

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

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

April 19th, 2017 by

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

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

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

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

See you then!

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

April 11th, 2017 by

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

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

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

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

How do you change your vision?

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

TapRooT® Root Cause Analysis Leadership Lessons

 

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What’s in the new book?

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

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

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

 

Why Does TapRooT® Exist?

March 28th, 2017 by

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

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

And we are accomplishing our mission around the world.

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

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

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

Case Study: Using Dye Packs to Locate Leaks

March 16th, 2017 by

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

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

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

Here are the 11 tenants they suggest:

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

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

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

Do you believe that ignorance is bliss?

March 6th, 2017 by

Ignorance is Bliss

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

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

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

Is this the way you treat your root cause analysis?

Would you rather have a simple BUT WRONG answer?

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

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

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

Have you read the new book yet?

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

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

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

Simple Root Cause Analysis (Don’t Settle!)

February 23rd, 2017 by

 

RCA, Root Cause analysis, 5-why, 5-whys
OK, show of hands:

How many companies are using TapRooT® for their “hard,” “high-risk” incident analyses and using something like 5-Whys for the “simple” stuff?  Yep, I thought so.  A lot of companies are doing this for various reasons. I’ll get into that more in a minute.

Now, another poll:

How many of you are performing effective root cause analyses on your “important,” “high-consequence” investigations, and performing nearly useless analyses on the “easy” stuff?  Of course, you know this is really exactly the same question, but you’re not as comfortable raising your hand the second time, are you?

Those of you that follow this blog have already read why using inferior RCA methods don’t work well, but let me recap.  I’m going to talk about 5-Whys specifically, but you can probably insert any of your other, less-robust analysis techniques here:

5-Whys

  • It does not use an expert system.  It relies on the investigator to know what questions to ask.
  • Because of this, it allows for investigator bias.  If you are a training person, you will (amazingly enough) end up with “training” root causes.
  • The process does not rely on human performance expertise.  Again, it relies on the skill of the investigator.  Yes, I know, we’re all EXCELLENT investigators!
  • It does not produce consistent results.  If I give the same investigation to 3 different teams, I always get 3 different sets of answers.
  • There is no assistance in developing effective corrective action.  When 80% of your corrective actions fall into the “Training” “Procedures” and “Discipline” categories, you are not really expecting any new results, are you?

So, knowing this to be true, why are we doing this?  Why are we allowing ourselves to knowingly get poor results?

  • These are low risk problems, anyway.  It doesn’t matter if we get good answers (Why bother, then?)
  • It’s quick.  (Of course, quickly getting poor results just doesn’t seem to be an effective use of your time.)
  • It’s easy (to get poor results).
  • TapRooT® takes too long.  Finally, an answer that, while not true, at least makes sense.

So what you’re really telling me is that if TapRooT® were just easier to use, you would be able to ditch those other less robust methods, and use TapRooT® for the “easy” stuff, too.

Guess what?  We’ve now made TapRooT® even easier to use!  The 7-step TapRooT® process can now be shortened for those “easy” investigations, and still get the excellent results you’re used to getting.

Simple RCA, TapRooT, root cause analysisWe now teach the normal 7-Step method for major incidents, where you need the optional data-collection tools.  However, we are now showing you how to use TapRooT® in low to medium-risk investigations.  You are still using the tools that make TapRooT® a great root cause analysis tool.  However, we show you how to shorten the time it takes to perform these less-complex analyses.

The 2-Day TapRooT® Incident Investigation Course concentrates on these low to medium-risk investigations.  The 5-Day TapRooT® Advanced Team Leader Course teaches both the simple method, but also teaches the full suite of TapRooT® tools.

Don’t settle for poor investigations, knowing the results are not what you need.  Take a look at the new TapRooT® courses and see how to use the system for all of your investigations.  You can register for one of these courses here.

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.

As Bart Simpson says:

“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”

Blame is so common that people take it for granted.

Somebody makes a mistake and what do we do? Discipline them.

If they are a contractor, we fire them. No questions asked.

And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.

Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?

But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.

Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution. 

How do you stop blame and get people to cooperate with investigations? Here are two best practices.

A. Start Small …

If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous. 

Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.

B. Use a SnapCharT® to facilitate your investigation and report to management.

We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.

Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame. 

What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:

TapRooT® Training

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2. FIRST ASK WHAT NOT WHY

Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.

Why?

Because they should have started by asking what before they asked why.

Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem. 

How do you get people to ask what instead of why?

Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.

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3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE

Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.

What happens when an investigator starts an investigation by jumping to conclusions?

They ignore evidence that is counter to their hypothesis. This problem is called a:

Confirmation Bias

It has been proven in many scientific studies.

But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.

What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?

Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.

How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.

THAT’S IT…

The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.

If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.

If your organization faces:

  • Quality Issues
  • Safety Incidents
  • Repeat Equipment Failures
  • Sentinel Events
  • Environmental Incidents
  • Cost Overruns
  • Missed Schedules
  • Plant Downtime

You need to be apply the best root cause analysis system: TapRooT®.

Learn more at: 

http://www.taproot.com/products-services/about-taproot

And find the dates and locations for our public TapRooT® Training at:

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

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Have You Planned Your TapRooT® Training for 2017?

January 10th, 2017 by

 Are you sending people to our Public TapRooT® Training?

 

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Or are you having a TapRooT® Course at your site?

 

Class picture

 

And arranging TapRooT® Training at one or more of your facilities around the world?

 

KualaLumpur

 

If you want to choose your dates, now is the time to get your onsite courses scheduled.

And if you want to choose a particular public course, now is the time to get your folks registered!

Monday Accident & Lessons Learned: Ammonia leak kills 1 at Carlsberg brewery in UK

December 5th, 2016 by

SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.

Are you using advanced root cause analysis to investigate near-misses and stop major accidents? Major accidents can be avoided.  That’s a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:

Upcoming TapRooT® Public Courses

TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.

For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.

Don’t wait! If you have attended TapRooT® Training, get signed up today!

Old Fashioned Definition of Root Cause vs. Modern Definition of Root Cause

November 29th, 2016 by

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When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:

Root Cause
The most basic cause (or causes)
that can reasonably be identified 
that management has control to fix
and, when fixed, will prevent 
(or significantly reduce the likelihood of)
the problem’s recurrence.

The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:

Root Cause
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.

 This modern definition of a root cause leads to this definition of root cause analysis:

Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring

Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.

Even though a decade had passed since proposing this new definition, I still have people ask:

Why did you change the definition? I liked it like it was!

Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.

The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!

The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.

This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.

The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.

One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.

That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.

Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.

To Improve You Must Change

November 17th, 2016 by

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I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:

“If people would just try harder, be more careful, or be more alert, the problems would go away.”

This implies bad people (careless, lazy, and/or dullards) are the issues.

Have you ever met one of these people? Do you work in an organization that thinks this way?

I once had a safety manager at a refinery tell me:

“At our refinery, 5% of the people account for 95% of the lost time injuries.”

He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.

Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.

TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.

Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.

And don’t worry about trying something new. Our courses are guaranteed!

GUARANTEE:
Attend our training, 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 strong guarantee because we know that TapRooT® will work for your company.

For more information about TapRooT®, watch the video at:

http://www.taproot.com/products-services/about-taproot

Navy Root Cause Analysis Focused on Blame Vision, Crisis Vision, or Opportunity to Improve Vision?

November 3rd, 2016 by

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In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:

The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.

Additionally, he said:

“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”

That seems like a “Blame Vision” statement.

That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:

“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”

Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:

We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.

Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:

The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems

It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.

To subscribe to the newsletter, provide your contact information at:

http://www.taproot.com/contact-us#newsletter

OSHA/EPA “Fact Sheet” About Root Cause Analysis & Incident Investigation

November 1st, 2016 by

Screen Shot 2016 11 01 at 1 49 05 PM

Above is the start of an OSHA/EPA Fact Sheet titled: “The Importance of Root Cause Analysis During Incident Investigation.”

OSHA and EPA want companies to go beyond fixing immediate cause (which may eliminate a symptom of a problem) and instead, find and fix the root causes of the problems (the systemic/underlying causes). This is especially important for process safety incidents. 

The fact Sheet explains some of the basic of root cause analysis and suggests several tools for root cause analysis. 

UNFORTUNATELY, many of the tools suggested by the fact sheet are not really suited to finding and fixing the real root causes of process safety incidents. They don’t help the investigator (or the investigative team) go beyond their current knowledge. Thus, the suggested techniques produce the same ineffective investigations that we have all seen before.

Would you like to learn more about advanced root cause analysis that will help your investigators learn to go beyond their current investigative methods and beyond their current knowledge to discover the real root causes of equipment reliability and human performance related incidents? These are techniques that have been proven to be effective by leading companies around the world. 

Yes? Then see: http://www.taproot.com/products-services/about-taproot

And choose one of our upcoming public TapRooT® Courses to learn more about the TapRooT® Root Cause Analysis System. See:

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

 

 

System Improvements Appreciation Days!

October 31st, 2016 by

November is a month to be thankful and show your appreciation! Here at System Improvements (TapRooT®), we like to let our co workers know that we appreciate everything they do. Without each person in this office, none of what we do would be possible.

So, to keep the thankful spirit alive all November long, we are recognizing specific members of the SI team different weeks throughout the month. This week we are showing special thanks to the amazing TapRooT® Tech Support guys with Dunkin Donuts!

If you’ve ever had any technical issues, they’re always there to help. If you’ve used TapRooT® software, they put an incredible amount of work into development. If you work in our office and need any assistance whatsoever, they’re there!

Help us give a special shout out to the TapRooT® Tech Support guys!

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Pictures from the Summit – The Courses #taprootsummit

August 1st, 2016 by

Here are pictures from the 11 pre-Summit Courses ….

TapRooT® Incident Investigation & Root Cause Analysis Course

IMG 6437

 

Equifactor® Equipment Troubleshooting and Root Cause Analysis

IMG 6461

 

Advanced Causal Factor Development Course

IMG 6453

 

Advanced Trending Techniques

IMG 6465

 

TapRooT® Analyzing and Fixing Safety Culture Issues

IMG 6448

 

Risk Assessment and Management Best Practices

IMG 6458

 

TapRooT® Quality Process Improvement Facilitator Course

IMG 6469

 

Getting the Most from Your TapRooT® VI Software

IMG 6472

 

TapRooT® for Audits

IMG 6452

 

Effective Interviewing & Evidence Collection Techniques

IMG 6443

 

Understanding and Stopping Human Error

IMG 6465

Is Discipline All That Is Needed?

July 6th, 2016 by

You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?

Is this the best approach to preventing future problems? NO! Not by a long shot. 

We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:

Let me sum up what we know …

Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.

In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.

For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses

 

What Countries Will Be Represented at the 2016 Global TapRooT® Summit?

June 23rd, 2016 by

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Here’s a partial list …

  • Australia
  • Brazil
  • Canada
  • Colombia
  • Ecuador
  • Iraq
  • Jordan
  • Kenya
  • Mexico
  • New Zealand
  • Philippines
  • Qatar
  • Russia
  • Saudi Arabia
  • Senegal
  • Singapore
  • Trinidad
  • United Kingdom
  • USA

That’s why we call the Summit a GLOBAL Summit. Every continent is represented.

Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:

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

And find out about all the great sessions and keynote speakers by visiting the Summit web site at:

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

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