Root Cause Analysis Tip – Heinz Block Writes: “Maintain proficiency in root-cause-failure analysis” in Hydrocarbon Processing MagazinePosted: November 7th, 2013 in Uncategorized
Heinz Block, contributor to the Equifactor® technique and speaker at the 2014 Global TapRooT® Summit, wrote an article about maintaining root cause failure analysis proficiency. See the article at:
Jonathan Ellgass and I are teaching the 5 day course here in Dallas this week. Here are some pictures of the day one activities:
Why not join us for the next course? You can see the schedule and register HERE
“Do not look where you fell, but where you slipped.” ~ African Proverb
Bob Koonce and I are in San Antonio this week teaching our two day course. Here are some pictures of Bob teaching and the students working on their group exercises:
If you missed us on this one, join us for another course soon. This course filled up several weeks in advance so we apologize for not being able to accommodate everyone. Many of our courses this summer have filled up very early, so if you plan to attend a course, you should register as soon as possible. You can see the course schedule HERE.
Often when teaching Onsite TapRooT® Root Cause Analysis Courses, we get to teach two different companies in back to back courses. Doing this actually saves our clients on instructor airplane travel costs. Last week in Trinidad, I had the opportunity to work with IPSL (pictured above) and Tucker Energy (pictured below).
Just some of the Testimonials after the final exercise:
“Very engaging, eye opening! Be neutral!” (bias kills an investigation every time the students learn)
“Today’s session was detailed and gave a clear idea on how to investigate an incident totally and fair.”
“The course highlighted that we used the wrong approach for incident investigations in the past.” (They found conflicting evidence that had not been verified yet)
“Very good hands on approach; assistance from the facilitators (instructors) was very helpful throughout the course.”
It is easier to do a job right than to explain why you didn’t. ~ Martin Van Buren
I am a sucker for a 1948 Indian Chief motorcycle. So I thought … what a great opportunity to talk about Human Factors Design and show off a little nostalgia. The topic of today is the Suicide Shifter.
The Suicide Shifter is located on the left side of the fuel tank and was used to shift gears while riding. Called a Suicide Shifter because you had to take your left hand off the handle bar grip to shift it.
So the question for you today is how many equipment control designs used today at your work area are not placed in the safest area to use while operating?
In the human factors world there is an acronym, HCI. This stands for Human Computer Interaction. A subset of the human factors field, HCI is where computer software programers meet the computer user’s needs by design BEFORE they sell it. So…… have you seen the marketing and pre-beta download for Windows 8?
- Will the new version frustrate new or experienced window users? or both?
- Will Microsoft help experienced users transition?
- How will Microsoft help experience users transition (if they do) to the new version?
- Will software developers who have software used on Microsoft help transition their existing customers?
Windows 8 Developer Preview is available for you to try now: http://msdn.microsoft.com/en-us/windows/apps/br229516
Watch the chimpanzee vs. human child in a learning experiment.
Here is the video link: http://youtu.be/nHuagL7x5Wc
We are all trained, or learn, by trial and error on how to use equipment or how to use it “properly”. What happens when you get a better “understanding” of how the equipment works? Here are some of the choices that we could make:
1. Ignore the previous training and just get the prize (work done faster, like the chimpanzee)
2. Continue the rules that you learned or were trained to do (at least in front of the bosses like the children).
3. Stop and ask what’s up?
4. Stop using the tool all together and do not tell anyone.
Often the previous training and experience overrides the new operation steps needed … ever been totally frustrated every time someone changes your computer’s Microsoft Windows version? And no, training by itself does not override experience, practice and repetition does!
I had a discussion not too long ago that OSHA forklift training requirements were met when people were retrained after changing forklifts. Unfortunately, the controls worked exactly opposite on the new forklift and the quick review did nothing to override the past knowledge and muscle motor memory.
Just something to think about when you think “Great Human Factors.”
Last week we shared some quick tips and staggering stats on Fall Safety and Electrical Safety during the holiday season. Here are a few tips from The Electrical Safety Foundation International to keep you and your children safe when displaying your decorations.
- Make sure your Christmas tree is fresh, and keep it hydrated by refilling the stand. It will pose less of a fire hazard this way.
- With artificial trees, look for a fire resistant one.
- Don’t use electrical ornaments or lights on trees with metallic leaves or tinsel in them.
- Place your tree at least 3 feet away form heat sources, including fireplaces, radiators, and heaters.
- 45% of home décor fires start with candles.
- An average of 260 homes fires begin with Christmas trees each year, resulting in 12 deaths, 24 injuries, and $16.4 million in damage.
Check out this Fire safety video comparing the flammability of a poorly watered tree and properly watered tree: Click Here
- Keep children supervised around candles and electrical lights.
- Never allow them to use garlands, tree lights, and cords as playthings – they pose a strangulation hazard.
- All small, fragile ornaments and decorations should be placed out of children’s reach, as children may break them and get hurt, or simply put them in their mouth.
- Cover all unused outlet with electrical tape or plastic covers.
Happy Holidays and stay safe, from all of us at TapRooT®!
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Phasellus mollis ultricies vehicula. Nunc vel augue nulla. Vivamus tortor est, bibendum nec congue id, lacinia eget ante. Mauris quis mollis ligula. Curabitur interdum eleifend libero, non vulputate purus vulputate eu. Aenean est leo; bibendum id consectetur ut, pellentesque ut arcu. Aliquam enim risus, aliquet quis volutpat vitae, auctor at risus. Curabitur et eros justo. Ut fringilla vehicula ligula et fermentum. In hac habitasse platea dictumst. Nulla nisl enim, aliquet at pretium elementum, bibendum et libero. Etiam vel semper tortor. Proin sodales blandit ipsum, et consectetur elit lobortis at. Sed diam mi, consequat non commodo sit amet; semper nec leo. Vestibulum nec nisi eget neque sodales fermentum sed sed erat. Nulla risus sapien, gravida eget posuere eu, accumsan nec orci.
After an intensive but fun two days of work invested already in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (as seen in the photos above), the students needed a duck break at the Peabody Hotel in Orlando.
Expert TapRooT® instructor Sanjay Gandhi provided these photos from our most recent TapRooT® 5-Day Incident Investigation and Root Cause Analysis course in Phalaborwa, South Africa.
Have you ever seen such a colorful venue?
If you enjoyed these photos and want to learn more about our TapRooT® courses around the world, visit us at our 5-Day TapRooT® Course Info page.
We look forward to working with you.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
March 14-18, 2011
Learn all the TapRooT® tools and advanced skills that a Team Leader needs to collect information, analyze root causes, and develop effective fixes that will help your company improve performance. Find Out More.
Nairobi, the capital of Kenya, was founded as a swampy supply depot for the Uganda Railway. Far from these humble roots, it blossomed into a political and financial hub of Eastern Africa. Buzzing with residents of African, English, and Middle Eastern descent, Nairobi is home to over 3 million people.
The Maasai name Ewaso Nyirobi, meaning ‘cool waters,’ inspired the city’s name. Nairobi boasts a comfortable climate, with temperatures ranging from 10-25°C. Look out from Nairobi on a clear day and you’ll see Mount Kenya and Mount Kilamanjaro rising royally in the distance.
Uhuru Gardens – Rest here with a picnic lunch or explore its historic significance: Uhuru Park houses a monument honoring Jomo Kenyatta, the first Kenyan president.
Nairobi National Museum – Travel 10 minutes away from Nairobi’s city center and learn about Kenya’s nature, culture, and history. This recently renovated museum will reveal to you the beauty and richness of Kenya!
Nairobi Safari Walk – Experience Kenya’s native wildlife. Don’t know much about the area? A tour guide will happily lead you along to see animals like the bongo, white rhino, albino zebra, wild cats, antelopes, and various primates.
Nairobi City Market – No trip to Nairobi is complete unless you come home laden with beautifully handcrafted Maasai masks, jewelry, or textiles! Snag your souvenirs and enjoy the buzz of the city market.
Yaya Centre – Treat yourself to Yaya’s high-end shopping mall and delectable dining options.
Bamboo – Perfect for casual or formal dining, enjoy this elegantly decorated Pan-Asian restaurant specializing in sushi, salad, and soup.
Le Rustique – Come eat on the breezy patio, or dine indoors. This stylish Mediterranean restaurant creates a new menu each week, making each meal with fresh ingredients and ambiance. Inside, local artists contribute to a rotating display of artwork, so “no two meals at Le Rustique are the same.” -Le Rustique
Nairobi Java House – Sit down and relax with friends after the TapRooT® course, or grab your much-needed morning cup o’ joe. Kenya produces delicious coffees and teas, and Nairobi Java House serves them with style.
Carnivore – At ‘Africa’s Greatest Eating Experience’, “meat is roasted over charcoal and carved at your table. Delicious side dishes and an exceptional array of sauces complement this fixed price feast that also includes soup, a selection of desserts, and Kenyan coffee. Set in attractive tropical gardens, the service and the décor are outstanding.”
“The pulsating rhythms of Africa combine to ensure an exciting ambiance.” -The Tamarind Group
Travel to Nairobi! Experience its refreshing natural beauty and vivacious cultural buzz, all while attending our 5-Day TapRooT® Team Leader Training!
A boiler explosion is a bad way to end the career of an aging cruise ship. But thats what happened to the SS Norway in 2003.
I have received several requests from our San Antonio Summit attendees for a copy of our ‘What’s New In The TapRooT® Software?” breakout session. So without further ado, here it is…Click Here
23 Survivors found out of at least 47 people on board.
The Summit is rapidly approaching (October 27-29). See the 2010 Summit info at:
I think this fits in the Natural Phenomenon / Sabotage category …