Category: Video

6,600,000 Preventable Deaths

October 24th, 2014 by

What is the key intervention for preventing 6,600,000 death? You may be surprised by this solution, which is also the key intervention for reducing Ebola outbreak. It is the simple act of handwashing with soap. Invest 12 minutes of your time viewing this video and learn about the power of handwashing.

Did you know that TapRooT® is recognized worldwide as a premier “knowledge broker”? Stay in the know with relevant root cause analysis tips by joining our weekly email list:

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

Some recent tips include:

Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry: (View video.)

Missed Opportunities: (Read post.)

What Makes a World Class Root Cause Analysis System? (View video.)

2014 Global TapRooT® Summit Attendees Share Favorite Aspects from the Summit

October 17th, 2014 by

Rich Horan from PPL Electric Utilities shared some of his favorite aspects of the 2014 Global TapRooT® Summit in Horseshoe Bay, TX. Listen to what content he enjoyed most and what he will be taking back to his workplace to implement some of the Best Practices shared at the Summit.

Don’t have time for the whole video? Read below some questions we asked him and what he had to say.

How did you like the Summit? 

“I loved it! Very well organized. It was my first Summit and from the beginning right up to the end today it was very enjoyable and very nice to meet a lot of the people looking for the same experience and networking.”

What was your favorite session? 

“I would have to say the Best Practices and Learning. It was very interactive but there was a lot we walked away with, that I walked away with that get to take back to my work place and apply some of those lessons learned. So, I would have to say that was the better session of all of them.”

Can you think of any of those Best Practices that you’d like to share with us?

“The corrective actions and the effectiveness reviews. So the quality of the investigation is important but most important is the corrective actions and the effectiveness review as far as a follow up to see if there is some quality in those investigations.”

Did you attend the reception? How did you enjoy that? 

“Well, it was absolutely wonderful. It was a good way to break away and meet some people. There was beautiful weather, good music, and probably one of the better receptions I’ve been to in some of the conferences over the years, so, well done!”

How was the networking and the people that you met here? 

“I think that networking is very important and from that, learning what others are doing and sharing what I have done in the past two years as a TapRooT® instructor. So, very valuable to meet other people and continue that networking after the conference.”

For more information regarding the upcoming 2015 Global TapRooT® Summit in June, click here.

Root Cause Analysis Video Tips: How TapRooT® Can Help with The Joint Commission Requirements

October 15th, 2014 by

This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.

Click here for more information regarding our TapRooT® courses around the world.

And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.

 

2014 Global TapRooT® Summit Attendees Share Favorite Aspects of the Summit

October 10th, 2014 by

Juan Silva attended the 2014 Global TapRooT® Summit this past April in Horseshoe Bay, Texas and shared with us his favorite aspects, best practices and sessions in Spanish.

Click here to learn more about the upcoming Global TapRooT® Summit in Las Vegas June 1-5.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (KBR)

October 8th, 2014 by

John Hodges from KBR (Kellogg, Brown & Root) shared his TapRooT® Best Practice with us at the 2014 Global TapRooT® Summit during our Users Share Best Practices session. Watch his video below to hear more about how his team at KBR implements TapRooT® into their product line and various other areas of the company.

If you don’t have time to watch the video, here is his Best Practice tip:

“One of the things that we feel like is a best practice is that we have several product lines that not only investigate injuries or serious incidents, we also drop it down to a level of Near-Miss incidents and investigate those as well because those are the things that are going to lead to a serious incident in the future. The other thing we do is that any of our people that go through TapRooT® training, have to attend a refresher every two years. The third thing that we do, that I feel like is significant, is offer all the people that we train on their first several TapRooT® analyses to send them in to us and we give them some coaching on what they need to do.”

Want to know more about the upcoming 2015 Global TapRooT® Summit in Las Vegas in June?

Click here!

Root Cause Analysis Video Tips: What Makes a World Class Root Cause Analysis System?

October 6th, 2014 by

We hope you enjoy this new format of our Instructor Root Cause Tips. Today we have Ken Reed, TapRooT®/Equifactor® Instructor and Partner, discussing “What Makes a World Class Root Cause Analysis System?”. Be sure to pay attention to the 7 Strengths of TapRooT® that he discusses.

Click here to learn more about our courses where you can learn root cause analysis and implement in your own workplace.

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Or check out our other videos in the series, like How To Get The Most From Your Sentinel Event Investigation:

http://www.taproot.com/archives/47036

Remembering an Accident: Ajka Alumina Sludge Spill

October 4th, 2014 by

On October 4, 2010, toxic sludge leaked from a metal refinery in Hungary. Over 100 people were injured, many suffering burns, and at least ten deaths were attributed to the disaster. The company was fined $647 million for environmental damage (Read article and view dramatic photos on The Guardian).

Learn how TapRooT® Root Cause Analysis can help you avoid injuries, deaths and costly fines. (Click here to learn more.)

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Champion Technologies)

September 24th, 2014 by

Trevor Archibald of Champion Technologies shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he keeps his investigation teams’ skills fresh and up-to-date:

If you’re at work and don’t have time to watch the video, here’s his tip:

“My name’s Trevor Archibald. I work with Champion in Canada. It was written into my performance contract this year to improve the quality of our investigations. And one of my activities in meeting that goal is holding three workshops a year. We’ve got two dozen folks trained in TapRooT® – [we'll be] bringing them back in here three times a year, putting them through a smaller 1-day workshop, giving them some investigations, doing it all over again. In addition to that I’ve written about a dozen things you all have said here so I’ll be adding that in as well.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

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

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Marathon Petroleum)

September 10th, 2014 by

Pete Reynolds of Marathon Petroleum Company shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he uses peer groups to improve investigations:

If you’re at work and don’t have time to watch the video, here’s his tip:

We have a peer group that is kind of a silo buster. We all get together and talk about the TapRooT® Process and getting the investigation done.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

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

How Far Away is Death?

September 9th, 2014 by

One broken hydraulic hose…

Remembering an Accident: Imperial Foods Processing Plant Fire

September 3rd, 2014 by

On September 3, 1991, a fire broke out at Imperial Foods Processing Plant in Hamlet, North Carolina after a repaired hydraulic line burst.

Heating gas plumes from a cooking vat ignited hydraulic fluid spreading heavy black smoke throughout the plant within a couple of minutes. Twenty-five workers lost their lives including a route salesman who had been filling food machines in the break room. Fifty-four people were injured.

It was determined that the deaths were caused by smoke inhalation when the workers could not exit the building due to blocked or locked exits. According to the Fire & Rescue Journal, “Hydrocarbon-charged smoke, particularly as heavy as this, is extremely debilitating to the human body and can disable a person with one or two breaths.”

Imperial Food’s owner pleaded guilty to involuntary manslaughter and was sentenced to 19 years 11 months in prison. The victims received a $16.1 settlement. (New York Times.)

In the following video, a visitor films the memorial for all the workers whose lives were lost.

It’s devastating when a workplace becomes a memorial to workers who perished there. Learn best practices to find and fix root causes so this never happens at your facility:

http://www.taproot.com/products-services/getting-started#investigators

 

Root Cause Analysis Tips – Doing Better Investigations (Part 2)

August 27th, 2014 by

Last week we discussed how to improve your investigation by preparing well. This week we’ll dive into evidence collection.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart.

We teach several evidence collection techniques in our courses….

The 3 P’s and the R:
• People
• Plant
• Paper
• Recordings

Interviewing (TapRooT® book, Chapter 3)

Optional techniques:
• Equifactor® (for equipment problems) – TapRooT® book, Chapter 9
• Change Analysis (what has changed or what is different) TapRooT® book, Chapter 11
• CHAP (critical human action profile) TapRooT® book, Chapter 12

Trust me, if you have a good comprehensive SnapCharT® your analysis will be easy and you will find all the root causes. Without that, you will miss something, your corrective actions will be lacking, and your incidents will recur.

Once you have your chart complete, your causal factors identified, and have completed your root cause analysis, it is time for the output of your investigation – corrective actions. Don’t forget our SMARTER technique and use the Corrective Action Helper® for good ideas. Safeguards Analysis is also a great tool for developing corrective actions.

I could go on all day about this, but the key thing I want to bring out here is you MUST have a good SnapCharT®. If you focus on that the rest should fall into place nicely.

Click here to view Part 1.

How Far Away is Death?

August 26th, 2014 by

Compilation of aviation crashes … some fatal, some not.

Root Cause Analysis Tips – Doing Better Investigations (Part 1)

August 20th, 2014 by

Hello and welcome to this week’s root cause analysis tip. This week the topic is doing better investigations.

The most important thing you can do for better investigations is to use TapRooT®! But assuming you already do that, here are some more tips that I hope will help.

The first thing to think about is preparation – does your company have an investigation policy and does everyone know their roles and responsibilities? In other words, do you have a plan? The time to develop your plan is not after you have had a major incident! You can refer to Appendix A of the TapRooT® book for a sample plan; however, I would imagine most of you already have a plan at your company, so your preparation is simple – read the plan and understand it.

Think about Notification – Who, and under what circumstances? Let senior management know someone’s working on the investigation.  You can share the preliminary information as well. Set expectation that it may take some time. They’ll often back off and let you do your job if you tell them these things.

Plan your investigation – what kind of photos, documents, equipment reliability data do you need? Plan what data to collect and how you’re going to collect that data.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart. Interviewing is an important part of evidence collection. Follow our 14-Step interview process, it’s in the book. The best way to interview is to let the person tell their story, they may answer your questions without you even needing to ask. If you only ask questions, you’ll only get the answers to your questions and nothing else.

View Part 2 of Dave’s tip on Performing Better Investigations!

 

How Far Away is Death?

August 19th, 2014 by

Don’t stand under a load (or nearly under a load)! Click this video link below to watch…

WatchtheLoad.mp4

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