Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…
… your own actions.
… your understanding of other peoples actions.
… your past corrective or preventative actions.
Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.
To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.
To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit
If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw
On January 15, 1919, the North end of Boston was one of the most congested neighborhoods in the entire world. There were about 40,000 people in a one mile square of geographic space. When a large molasses tank burst and a huge wave of molasses rushed through the streets at approximately 35 mph, 150 people were injured and 21 were killed.
Theories ensued after the disaster. Some said the tanks were intentionally set to explode by anarchists, and others believed the fermenting of the molasses led to the explosion. In the end, it was discovered the person who oversaw the construction of the tank wasn’t an engineer or an architect. He couldn’t even read a blueprint!
According to folklore, residents claim that on a hot summer day, the area still smells of molasses.
What is your blueprint for investigating incidents and finding and fixing root causes, and can everyone read it? Our 2-day TapRooT® Course provides all the essentials and is designed for everyone, from beginner to expert. (Learn more.)
Or you could take the Creative Corrective Actions Course prior to the 2015 TapRooT® Summit.
Summit attendee, Dan Avery, discusses what he loved the most about our Global TapRooT® Summit.
Don’t have time to listen to the whole video? Read the dialogue below.
What is your favorite part about the Summit?
“So far, you have had some interesting speakers. One of the speakers was really funny. I always enjoy coming to these.”
Well, thank you for coming this year and we hope to see you next year!
“Absolutely be at Las Vegas!”
Interested in joining us at the Summit in June 2015 in Las Vegas? Click here for more information.
Rome is a great place for a spring vacation. The sights, the food, and the shopping are amazing!
And when you can combine the trip with some great TapRooT® Training (a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course), you are getting two great experiences at once!
The 2-Day TapRooT® Course is a great value. In two days you will learn how to apply the standard TapRooT® Tools (SnapCharT®, Safeguards Analysis, the Root Cause Tree®, the Corrective Action Helper®, and SMARTER) to find and fix the root causes of problems.
What kind of problems can you solve using TapRooT®?
- Major safety accidents
- Drug/medical device quality issues
- Medical sentinel events
- Process safety accidents/incidents
- Equipment reliability issues
- Neat-miss accidents
- Production issues
- Cost overruns
- Schedule slippage issues
- Customer complaints
- Security issues
- Product waste issues
- Hardware/software failures
And that’s just to name a few!
And the instructors scheduled to teach the course are Mark Paradies and Linda Unger – the inventors of TapRooT®!
The course is being held at a great hotel in the center of Rome. Watch this video for a bird’s eye view of the location…
Here’s the hotel’s web site:
As you can see, the hotel is just a couple of blocks from the Pantheon. And near many of Rome’s tourist attractions.
You probably won’t get an opportunity like this again. Because this course is so special, you should register today for the March 18-19, 2015 course to make sure you save your spot! Also, get your hotel reservation set. You don’t want to miss this great training in a great location.
Take a look at this video testimonial of Billy Hendricks who attended our 2014 Global TapRooT® Summit in Horseshoe Bay, Texas. He discusses some important information he took back to work with him from our great summit sessions.
Don’t have a chance to listen to the whole video? Read the dialogue below.
Billy, what did you think about the Summit Session, OSHA: Be Prepared for Sweeping Workplace Safety Changes?
“The former leader of OSHA under the Bush administration put an emphasis on safety of how important it was to you and me and to our company’s, and how we need to get passionate about being safe. Everything we do, every single day, not only in our workplace but at home, is so important to do it safely so that we can continue on.”
What were other sessions you enjoyed, as well?
“We just got done with the session on Body Language and how to interpret someone’s body language. It’s not just the interviewing and getting the answers but also finding out what their body is telling you when doing an interview. It is an important part in an interview investigation to find a root cause of something.”
Absolutely! Very helpful and important information in Barb’s session.
Want more information on the Summit and the sessions offered in the upcoming one in June? Click Here.
Registration for our June 2015 Global TapRooT® Summit will be available on December 30. Stay tuned!
Still lot’s more to go!
Root Cause Analysis Tip: What is a corrective action worth? – A Gambler’s View of Corrective Actions (A Best of Article from the Root Cause Network™ Newsletter)December 3rd, 2014 by Mark Paradies
Adapted from the January 1995 Root Cause Network™ Newsletter, Copyright © 1995. Reprinted by permission. Some modifications have been made to update the article.
A GAMBLER’S VIEW OF CORRECTIVE ACTIONS
WHEN TO BET/WHEN TO FOLD
A winning gambler knows the odds. He knows that in the long run, he can beat the odds. Therefore, he looks for opportunities to bet more when the odds are in his favor. And when the odds are against him, he folds and waits for a better hand.
Preventing accidents is a numbers game. The pyramid blow provides a typical example of the ratio of accidents to incidents to near-misses to unsafe conditions.
In this pyramid, every incident must have the potential under slightly different circumstances to become the major accident at the top of the pyramid. Also, every near miss must have the potential to become an incident that could have become the top level accident. Finally, every unsafe condition could have caused a near-miss that could have become an incident that could have become the top level accident.
Thus, every unsafe act included at the bottom level of the pyramid must have the potential with the right set of circumstances to “cause” the top level accident.
The ratio above might not be exact. Your facility might be different. But we will use the ration of 1000 unsafe acts for every major accident as a starting point for out calculation of odds that we describe below.
The point is that every corrective action that fixes an unsafe condition has some odds of being the corrective action that could be preventing a major accident. Thus, we should try to understand the value NOT ONLY of the benefits that the corrective action immediately brings, BUT ALSO the reduction in the odds of a major accident that this corrective action provides.
THE COST OF A MAJOR ACCIDENT
To calculate the value of preventing a major accident, we need to calculate the potential cost of a major accident at your facility.
Of course, we don’t know the exact cost of the biggest accident (or even a typical major accident) that you face at your company. After all, they still don’t know what the cost of the Deepwater Horizon accident will be even after years of litigation. So, we have to make an educated guess that can be scaled to show how the cost could change.
For example, we might say that the cost a typical major accident would be $1,000,000,000.
Then, if you think your accident might be ten times worse (or ten times less), you can multiple or divide the results we calculate by 10.
ASSESSING THE ODDS
Why do we have to use “odds” to perform this calculation? Because you can’t tell exactly which unsafe condition will be related to your next major accident. We don’t know what corrective action that we implement today will prevent the next Deepwater Horizon, Three Mile Island, or Exxon Valdez type accident that costs billions of dollars. No one is that prescient. That’s why preventing major accidents is a numbers game. To prevent the next major accident you must reduce thousands of unsafe conditions.
Because the exact odds of any one unsafe act being a key factor in the next accident is unknowable, we assign equal potential to every unsafe condition that has potential to cause a major accident.
If the pyramid above represents your accident pyramid, then for every major accident, there are 1000 unsafe conditions that could contribute to it. Or another way to think about it is that we can’t predict the exact combination of factors that will cause the next major accident but if we do 1000 things to fix problems that could be involved in a major accident, we will stop one major accident.
Thus the odds that any one corrective action will stop a major accident is 1000 to 1.
CALCULATING THE VALUE OF A CORRECTIVE ACTION
I’ve seen people value corrective actions by using the value of the incident they would prevent.
For example, if the failure of a machine caused a delay that lost the company $100,000, the value of the corrective actions to prevent future failures would be $100,000. It’s never clear to me if this value should be divided between all of the corrective actions (for example, if there are 10 corrective actions, each would be worth, $10,000) or if each corrective action is worth $100,000. But the idea is that the corrective actions can be valued by the costs that will be saved from future similar incidents prevented.
What this equation leaves out is the value of an even worse accident that could also be prevented by the corrective actions.
Thus to calculate the value of a corrective action, you not only need to calculate the direct benefit, but also the amount that that corrective action contributed to the prevention of a major accident (if, indeed the corrective actions could help prevent a major accident).
But let’s stop here to correct misconceptions. A corrective action meant to stop paper cuts probably have very little value in preventing major accidents. Thus, we are not assigning severe accident risk to every corrective action. We would only assign the value to corrective actions that could help prevent major accidents.
The, the value of a corrective action is the direct cost that the corrective action saves us PLUS the value of the unknown major accident that it could prevent divided by the odds.
For example, if a corrective action saved us $10,000 in direct costs for a similar incident and if the value of a major accident at your facility is $1,000,000,000 and if we estimate that it will take correcting 1,000 unsafe acts to prevent the next accident, the value of our corrective action is…
VALUE = $10,000 + ($1,000,000,000/1000)
VALUE = $10,000 + $1,000,000
VALUE = $1,010,000
Thus valuing corrective action at their benefit for preventing a similar incident is UNDERVALUING the corrective actions.
And I believe we frequently undervaluing corrective actions.
Because we aren’t considering the value that a gambler sees. We are folding when we should be betting!
We should be investing much more in effective corrective actions thereby win by preventing the next major accident.
YOU CAN IMPROVE THE ODDS
There is even better news that can help you make the corrective actions you implement even more valuable (effective).
The TapRooT® Root Cause Analysis System can help you do a better job of analyzing potential problems and developing even more effective corrective actions for the root causes you uncover.
Think of TapRooT® as a luck rabbit’s foot that increases your odds of winning.
Of course, TapRooT® is much better than a lucky rabbit’s foot because instead of being built upon superstition, it is built upon proven human performance and equipment reliability technology that makes your investigators much more effective.
So don’t wait. Stop undervaluing your corrective actions and if you haven’t already started using TapRooT®, see our upcoming courses list, click on your continent, and get signed up for a course near you (or in a spot that you would like to visit).
Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.
For more information regarding our Public and Onsite TapRooT® Courses, click here.
Want to join us at the Global TapRooT® Summit? Click here for more information and registration.
Was this tip helpful? Check out more short videos in our series:
Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)
What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)
TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)
Steve Lerner shares what he will be taking back to his workplace to improve his organization after attending his very first TapRooT® Summit. Check it out:
Don’t have time to watch the video? Read the dialogue below.
What do you think about the Summit?
“I think the Summit is absolutely awesome. I had a great time. Learned quite a bit of stuff. Networking with hundreds of different people with what they do and what works for them and what’s not working for them and finding out that our problems are not just our problems. Most everybody is going through some of the same things.”
So, what would you say to your co-workers about the Summit?
“Yes, we need to come to the Summit more often since this is my first one.”
Have you learned any best practices that you’ll be taking back?
“Yes, we had a couple of really good ideas, actually. The best practices that we created over the last couple of months, we are going to add going into corrective actions and digging deeper into tracking corrective actions. Not just talking about TapRooT® itself, but how effective are our corrective actions that we’re coming up with?”
Well, we’re glad that you came and got to see how great our Summit is and we hope that you will be back next year.
For more information regarding the upcoming Global TapRooT® Summit in June, 2015, click here.
Gard Clark attended the 2014 Global TapRooT® Summit and shared what he enjoyed the most about the Summit and how he can use it back home.
If you don’t have access audio or don’t have time to watch it, here is what Gard had to say:
What is your favorite part about the Summit?
“My favorite part this year was how all the presentations worked together to build a theme and, for me, that was team work and getting your corrective actions done and using the TapRooT® method to figure out what you were doing.”
Great, well we look forward to seeing you next year. Thank you!
For more information regarding the 2015 Global TapRooT® Summit coming up in June, click here.