We’re offering our 2-day course right before the Global TapRooT® Summit! Take the course and then stay for the 3-day Summit. LEARN MORE!
I’m so excited to be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit with Alan Smith. If you want to learn a little about Alan, click here. With Alan’s background as a former Detective Superintendent with the Grampian Police in Scotland, and my background in psychology and legal (preparing accident/injury cases for court), we will leave no stone unturned. I guarantee there is no other course like this anywhere. Register today!
The Nuclear Energy Institute published a white paper titled:
To summarize what is said, the nuclear industry went overboard putting everything including the kitchen sink into their Corrective Action Program, made things too complex, and tried to fix things that should never have been investigated.
How far overboard did they go? Well, in some cases if you were late to training, a condition report was filed.
For many years we’ve been preaching to our nuclear industry clients to TARGET root cause analysis to actual incidents that could cause real safety or process safety consequences worth stopping. We actually recommend expanding the number of real root cause analyses performed while simplifying the way that root cause analyses were conducted.
Also, we recommended STOPPING wasting time performing worthless apparent cause analyses and generating time wasting corrective actions for problems that really didn’t deserve a fix. They should just be categorized and trended (see out Trending Course if you need to learn more about real trending).
We also wrote a whole new book to help simplify the root cause analysis of low-to-medium risk incidents. It is titled:
Those who have read the book say that it makes TapRooT® MUCH EASIER for simple investigations. It keeps the advantages of the complete TapRooT® System without the complexity needed for major investigations.
What’s in the new book? Here’s the Table of Contents:
Chapter 1: When is a Basic Investigation Good Enough?
Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System
- Find Out What Happened & Draw a SnapCharT®
- Decision: Stop or More to Learn?
- Find Causal Factors Using Safeguard Analysis
- Find Root Causes Using the Root Cause Tree® Diagram
- Develop Fixes Using the Corrective Action Helper Module
- Optional Step: Find and Fix Generic Causes
- What is Left Out of a Basic Investigation to Make it Easy?
Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation
Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation
The TapRooT® Process for simple incidents is just 5 steps and is covered in 50 pages in the book.
If you are looking for a robust techniques that is usable on your simple incidents and for major investigations, LOOK NO FURTHER. The TapRooT® System is the answer.
If you are in the nuclear industry, use TapRooT® to simplify the investigations of low-to-moderate risk incidents.
If you are in some other industry, TapRooT® will help you achieve great results investigating both minor incidents and major accidents with techniques that will help you no matter what level of complexity your investigation requires.
One more question that you might have for us ,,,
How does TapRooT® stay one (or more) steps ahead of the industry?
- We work across almost every industry in every continent around the world.
- We spend time thinking about all the problems (opportunities for improvement) that we see.
- We work with some really smart TapRooT® Users around the world that are part of our TapRooT® Advisory Board.
- We organize and attend the annual Global TapRooT® Summit and collect best practices from around the world.
We then put all this knowledge to work to find ways to keep TapRooT® and our clients at the leading edge of root cause analysis and performance improvement excellence. We work hard, think hard, and each year keep making the TapRooT® Root Cause Analysis System better and easier to use.
If you want to reduce the cumulative impact of your corrective action program, get the latest TapRooT® Book and attend our new 2-Day TapRooT® Root Cause Analysis Course. You will be glad to get great results while saving time and effort.
Shout out to TapRooT® instructor, Heidi Reed, for sending in these great course photos from Las Vegas.
You have just one more chance to take TapRooT® training in Vegas in 2016 at that is December 5.
I know it’s far out but time flies. Mark your calendar and make plans to end the year on a high note!
Special thanks to TapRooT® instructor, Derek Rutherford, who sent in these great pictures from a recent onsite TapRooT® course in Athens, Greece.
Want to find out how our training can be a perfect fit for your company’s needs? Contact us and request a quote or licensing information from our Implementation Specialists. We can come to your site and train.
If it is written down, it must be followed. This means it must be correct… right?
Lack of compliance discussion triggers that I see often are:
- Defective products or services
- Audit findings
- Rework and scrap
So the next questions that I often ask when compliance is “apparent” are:
- Do these defects happen when standard, policies and administrative controls are in place and followed?
- What were the root causes for the audit findings?
- What were the root causes for the rework and scrap?
In a purely compliance driven company, I often here these answers:
- It was a complacency issue
- The employees were transferred…. Sometimes right out the door
- Employee was retrained and the other employees were reminded on why it is important to do the job as required.
So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.
Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.
What are some options to removing the blinders of pure compliance?
GOAL (Go Out And Look)
- Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
- Don’t just check off the audit checklist fro compliance’s sake, GOAL
- Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
- Learn how to evaluate your own process without the pure Compliance Glasses on.
If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.
“The actor, Harrison Ford, was struck by a hydraulic metal door on the Pinewood set of the Millennium Falcon in June 2014.”
“The Health And Safety Executive has brought four criminal charges against Foodles Production (UK) Ltd – a subsidiary of Disney.”
“Foodles Production said it was “disappointed” by the HSE’s decision.”
Read more here
Are you a Certified Instructor that is NOT planning to attend the 2016 TapRooT® Summit because you don’t need to be recertified until 2017? Please keep reading for important information regarding 2017.
Did you know that the TapRooT® Summit is held every 14-16 months? If you look back at the past few Summits, they have been in April 2014, June 2015 and now August 2016. There is a strategic rotating schedule that TapRooT® uses to choose the best time for the Summit.
Due to this rotation schedule, once in a while there is a gap year. A year with no Summit. This detail requires some extra planning on our Certified Instructor’s part since each instructor is required to go through recertification every two years.
What does this rotating schedule mean for 2017? It means that 2017 will be our next gap year. To clarify, there will NOT be a TapRooT® Summit in 2017. We are aware that some of our instructors will be due for recertification in 2017 making this a potential hiccup in their future plans.
Those of you who attended our 2015 Summit might remember Mark announcing the upcoming changes here at TapRooT®. There have been significant improvements and modernization to our 2-Day course that would be beneficial for all Certified Instructors to attend and see in person. The 2016 Summit this August will provide all Certified Instructors with the new 2-Day course materials and look into the new layout. Stay tuned for more details on these improvements in a later post!
What does TapRooT® recommend? We highly recommend that each instructor look at their schedule for this year and plan to attend the 2016 Summit in San Antonio this August 1-5. You will be able to go through recertification early, to continue teaching in 2017, not need recertification until 2018, and get a first-look at the new 2-Day course. Besides, you don’t want to miss the 2016 Summit and all that we have in store for you!
If you have questions or concerns regarding your recertification, please contact Michelle Wishoun (email@example.com) or Linda Unger (firstname.lastname@example.org) or call our office (865) 539-2139 for assistance.
Do you like quick, simple tips that add value to the way you work? Do you like articles that increase your happiness? How about a joke or something to brighten your day? Of course you do! Or you wouldn’t be reading this post. But the real question is, do you want MORE than all of the useful information we provide on this blog? That’s okay – we’ll allow you to be greedy!
A lot of people don’t know we have a company page on LinkedIn that also shares all those things and more. Follow us by clicking the image below that directs to our company page, and then clicking “Follow.”
We also have a training page where we share tips about career/personal development as well as course photos and information about upcoming courses. If you are planning to attend a TapRooT® course or want a job for candidates with root cause analysis skills, click the image below that directs to our training page and then click “Follow.”
Thank you for being part of the global TapRooT® community!
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 email@example.com 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