The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.
A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.
Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?
“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.
No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions. On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.
You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:
1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)
2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)
3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!
4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.
Simple… yes? Maybe? Feel free to post your examples and thoughts.
On August 3, 2015, join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training public course in Cochin, Ernakulam, India for the ONLY time in 2015. This course is filled with excellent industry training and material that is well worth the investment for you and your company.
Cochin, also referred to as Kochi or Ernakulam, is known as the Queen of the Arabian Sea due to its spice trading on the west coast. Cochin is also the second largest and highest populated city in the area making it the home of major chemical and electrical industries, the Indian Naval Headquarters and offshore refineries (pictured below).
It’s a great trip for everyone! Bring the whole team for Root Cause Analysis Training and bring the whole family to enjoy the attractions and rich culture that Cochin, India has to offer.
A few fun attractions they have to offer:
Wonderla: From water rides to thrilling rides to kid-friendly rides, this amusement park is a fun attraction for the family.
LuLu Mall: Take a break from the heat and visit this giant mall filled with movies, shopping and food!
Folklore Museum: Step back in time with these anthropology, ethnography and architectural exhibits.
Don’t forget, this is the only time this year that you can attend TapRooT® training in this region, so register today before the seats fill up.
Want more information on the TapRooT® 5-Day course? Click here.
Ready to register and take advantage of this incredible opportunity? Click here
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
Do You Have the Newest Editions of the TapRooT® Root Cause Dictionary, Root Cause Tree and Corrective Action Helper?May 20th, 2015 by Barb Phillips
A new revision of the TapRooT® Root Cause Dictionary, TapRooT® Root Cause Tree, and TapRooT® Corrective Action Helper Guide was released on May 1, 2015. This revised 3-piece set is available for purchase to anyone who has attended a TapRooT® course.
Root Cause Tree: One new root cause and 3 updated root causes.
Root Cause Dictionary: Updates to definitions to cover root cause changes and current industry best practices.
Corrective Action Helper Guide: Updates for new root causes and updated references.
The updated materials are currently available in English only.
Go here to order: http://www.taproot.com/store/2015-DUOCAH.html
**If you attended a course in 2015, contact firstname.lastname@example.org for a special discount.
Risk Assessments are necessary in all safety processes, particularly to move programs beyond Behavior Based Safety (BBS).
At least qualitative Risk Assessments (RA) need to be included during any safety-related discussions or interactions, conversations, and meetings. RA are needed every time any safety-related decision needs to be made; and therefore, to move safety programs beyond traditional BBS principles and practices.
RA in safety processes, including BBS – type programs, improve decision-making by making them less subjective, emotional and biased. Safety decision-making needs to be based on the comparative risk levels of the options under consideration. Any chosen safety decision needs to be the option for which the likelihood and quantum of benefit and gain outweighs the likelihood and quantum of loss and harm more than for any other option.
Which option provides the best chance of gain and benefit at both personal and corporate levels?
One such illustrative example is related to un-demonizing the term “shortcut”.
The original, best definition of a shortcut is very simple, positive and with no emotive undertones:
“a smarter, better way of doing a job”
“the method, procedure that best reduces the time / $ / energy needed to achieve business objectives.”
Can a shortcut ever be an appropriate, lower risk and authorized job method? And how?
In any safety discussions between managers, supervisors and workers, this definition can help clarify the troublesome distinction between “finding a shortcut,” and “taking a shortcut without an authorized risk assessment.” Finding is undeniably “smart.” Taking without RA is patently “dumb.”
Issues of workplace complexity and relationships between managers, supervisors and workers need to be addressed to be able to move safety programs and cultures beyond BBS principles and practices. Workplace relationships are based on trust, respect, credibility, encouragement, and valued appreciation of jointly-found solutions of challenges and issues. RA provides processes needed in relationship-based safety RBS.
Positive relationships include establishing and holding common beliefs that we want everyone to come to work with their brains as well as their brawn, (and hopefully their hearts), because we all recognize that it is in everyone’s interest for everyone to be always challenged to find smarter better ways of doing our jobs. That is what business is about! It is the never-ending goal of finding smarter, more efficient, more effective, more productive and safer (lower risk) ways of doing our work.
However, too often we tell our people we need and want their “shortcut” ideas for more efficiency and productivity, but as soon as they do give them we jump on them and label their suggestions with negative emotive labels such as “violations” or “breaches” of existing rules and describe them in meaningless, undefined terms such as “unsafe acts” or “at-risk behaviors”. Use of these negative, emotion-loaded terms actually discourages searching for the deep underlying root causes of an apparently stupid, careless, and lazy “violation.”
It is more appropriate to use non-emotive descriptors such as “variations,” “adaptations,” “departures,” or very simply “work-arounds.”
All day-to-day safety meetings, discussions, and personal risk taking behavioral choices involve BBS questions such as:
- Which procedure or method is safer (lower risk) than another?
- Which is the safer tool, plant, equipment for this job?
- Which risk control option is better than the others?
- Which route should be taken?
- Which control panel design is less error-provoking than the other?
- Which roster is best for managing fatigue?
- What is the appropriate time that we need to allocate to this incident investigation?
- What to say and how to interact / converse with my peers, supervisors and managers?
These real examples of safety optioneering processes make a compelling argument for doing at least a qualitative (but preferably a Semi – Quantitative) Risk Assessment.
In fact, Risk Assessments will be recognized as definitely needed every time any safety-related decision needs to be made and therefore can move safety programs beyond traditional BBS principles and practices often confused and undermined by subjective beliefs, biases and perceptions.
How can you improve your confidence in the accuracy, reliability, consistency of Risk Assessments?
Learn Best Practices in the training courses being offered as below.
May 20-21, (Weds-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505HOUS20.html
May 27-28, (Wed-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505CALG27.html
Las Vegas, Nevada
June 1-2 (Mon-Tues before the TapRooT® Summit)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1506LASV01-RISKMGMT.html
IN-HOUSE Courses are also available. Contact us for a quote.
Jim Whiting, an international expert in risk management and root cause analysis will be conducting the courses detailed above. The courses are the updated versions of a highly successful course that he has been offering for a number of years to over 200 attendees at Pre-Summit courses at past TapRooT® Summits. Due to increasing requests for more offerings of the course, the TapRooT® folks and Jim have decided to offer three RAMBP PUBLIC Courses in North America in 2015.
Jim was on Committees developing the Risk Management Standard AS/ISO 31000 which has been adopted word for word by US standard bodies as ANSI Z690.2 and Canadian bodies as CAN/CSA/ISO 31000. He has developed Risk Assessment unique tools and processes for maximizing the confidence of the results of assessments need to make all safety-related decision-making such as – what is a tolerable risk ?
I was in Las Vegas teaching a TapRooT® Course when I realized … We are the only no-lose game in town!
What do I mean? TapRooT® Training is GUARANTEED.
Here’s the 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.
It’s that simple.
But there’s more.
On June 1-5, System Improvements is holding the only GUARANTEED conference that I know about. The 2015 Global TapRooT® Summit. If you need to learn best practices from around the world that will help you improve performance, you need to be in attendance!
Here’s the Summit 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.
Another great guarantee because we know you will love the Summit.
On November 17, 2014, TapRooT® will be hosting a 5-Day Advanced Root Cause Analysis Team Leader Training Public Course in Johannesburg, South Africa. Will you be joining us? Johannesburg, or JoBurg as locals call it, has quite interesting and intriguing facts, history and landmarks that pull people in. It is said to be the world’s largest city not located directly on a water source, however, it is located on mineral rich land where the city’s source of gold and diamonds come from. It is known as Africa’s economic powerhouse due to it being the largest economy of any metropolitan area in Sub-Saharan Africa. There is so much offered in this massive city that you’re sure enjoy inside and outside of our course.
Mugg & Bean Cafe: This delicious little cafe offers a little of everything from barbeque and quesadillas to cupcakes and soups.
The GrillHouse Rosebank: Enjoy a fabulous steak dinner in a warm atmosphere with live music here at The GrillHouse.
SalvationCafe: If you love gourmet flavors and branching out from the everyday menu, check out this quaint cafe.
Gold Reef City: Fun on every corner! Theme parks, dining, theaters, etc await you as you stroll through and take it all in.
Apartheid Museum: History museums are always an educational, impacting experience for anyone!
Peacemakers Museum: What an inspirational and interesting exhibit full of the history of all Nobel Peace Laureates. You’re sure to learn something new and leave encouraged by all the incredible men and women all across the globe.
Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
Root Cause Analysis Training in Texas – 2014 Global TapRooT® Summit Annual Charity Golf Tournament at Award-Winning Horseshoe Bay Golf Course (VIDEO)February 3rd, 2014 by Barb Phillips
Calling all golfers! Whether you’re a novice or a golf enthusiast, you’ll love playing in our Annual Charity Golf Tournament at the 2014 Global TapRooT® Summit April 7-11. Join us on Friday April 11th around 11:30am for lunch and a scramble-style tournament at the award-winning Horseshoe Bay Resort Golf Course. All proceeds go to the Oasis of Love Women’s Shelter in Clinton, Tennessee.
We’ll let our Tournament Coordinator, Benna Dortch, tell you the rest. Check our her video below.
Material found in a doughnut, see the initial indications from the KAKE media article below. A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth. “There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother. The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here. The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened. Now what? Is this a safety or quality issue or both? If you were the retailer what would you do? Would you quarantine the doughnutt and ask for access to the material found in the stomach? Would you be allowed? If you were the doughnut supplier what would you do? Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed? If you were the doughnut manufacturer what would you do? Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported? For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts? Everything just discussed would be part of the analysis/investigation planning stage. The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available. What is Root Cause Analysis? Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results) Our public course schedule
I know, it is too early for Friday’s Joke of the Day, but I could not help it. I saw this posted recently and had to share.
As you are laughing, look into your tool cabinet and tell me that you do not have these 2 items in it.
Now if you want to know how to troubleshoot equipment the right way to find the right what’s and why’s and want an Individual TapRooT® Software License (comes with the course), then join us at one of our Equifactor® courses.
Here is the current schedule: http://www.taproot.com/store/3-Day-Courses/
I’ll bring my WD-40 and Duct Tape for the classroom equipment.
What are the risks of setting a circuit breaker without knowing why it opened?
I just saw this local news article about a father teaching his daughter about the circuit breaker panel in their house after a ceiling fan stopped working. End result….. House on fire. Read more here.
With eighteen years in aviation and having worked on the C-141 Aircraft, this incident brought to mind the wrong pump replaced and reseting the circuit breaker during testing explosion. Read more here.
There are additional ways to gain equipment troubleshooting experience without starting a fire. The easiest way is to attend one of our upcoming Equifactor® Course coming up in your local area. See the schedule here: http://www.taproot.com/store/3-Day-Courses/
Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.
Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.
Often FDA findings are found by an external audit. To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction? Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?
I suggest Enforcement needs improvement is not the only problem. To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators. Here is our upcoming courses link: http://www.taproot.com/store/Courses/
To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit. http://www.taproot.com/content/wp-content/uploads/2012/02/RileyandGorman.pdf
Then check out the quality track in the upcoming 2014 Summit in April. http://www.taproot.com/products-services/summit
Pictures from the Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Monterrey, MexicoFebruary 1st, 2013 by Mark Paradies
Need TapRooT® Training in Spanish? We have qualified instructors! Get a quote by CLICKING HERE.
Based on client’s request, we have scheduled our ONLY Public India 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training for April 22 – April 26.
For those not familiar with the course, it includes the TapRooT® single user software (unless attendee’s company has a network software license), TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.
Course Fee which includes a software individual license for each student is only $2,395 USD. Here is the registration link: Register
Please register 30 days prior to the course if you need a quote first to send to your billing department. Anything within 30 days or less must be paid for during registration. All course seats must be paid for prior to the course to hold the seat and attend the course.
We look forward to seeing our repeat clients and new clients in our only 5-Day public India course for 2013.
TapRooT® Instructor Harry Thorburn sent these photos our way, of a current 5-Day course in Bratislava, Slovakia. Enjoy!
Would you like to attend a course? Visit our Courses Page to learn more.
Already attended a course, but want to hone your root cause analysis skills? Join us at our 2013 Global TapRooT® Summit!
This week, we’ve got courses from three different continents to share! If you’ve already attended a course, but want to sharpen your root cause analysis expertise, we invite you to attend our 2013 Global TapRooT® Summit next March 18-22. Learn more about our Summit here: Global TapRooT® Summit Page
2-Day TapRooT® Incident Investigation and Root Cause Analysis
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Dec 3-4, 2012
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Sao Paulo, Brazil
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Jan 28-29, 2013
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3-Day TapRooT®/ Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis
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5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
Jan 21-25, 2013
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Looking for a different location? View our Courses Page for more.
With many industries and natural resources located in Trinidad, System Improvements, Inc. teaches many onsite TapRooT® Root Cause Analysis Courses. In fact, I will be teaching a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis this November with contract instructor, Mark Olson. I will be scheduling another 5 Day Course in Trinidad this the summer of 2013.
We get so busy sometimes in performing root cause analysis facilitations, courses and just plain business, that it is nice to see a reminder about why we want to make all industries safer. Pictured above is Safraz Ali, a student from the Trinidad Course, whom I had the opportunity to meet with his family.
Family, friends and the community are why we love what we do when we get it right!
Join us in South America, Africa, or the good old Midwest for some fantastic root cause analysis training:
Looking for a different course? Click here to visit our course page.