Category: Video

Summit Attendee Shares His Favorite Aspect from the 2014 Global TapRooT® Summit

December 11th, 2014 by

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. 

Plan a Trip to Roma Next Spring … And Get Some Great TapRooT® Training!

December 10th, 2014 by

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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:

http://www.hotelnazionale.it

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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.

Summit Attendees Share Favorite Aspects of 2014 Global TapRooT® Summit

December 5th, 2014 by

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!

Building a Nuclear Plant – 5 Years in 2 Minutes

December 4th, 2014 by

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

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.

Screen Shot 2014 10 06 at 1 48 46 PM

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.

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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.

Why?

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.

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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).

What does a bad day look like?

November 27th, 2014 by

Is your day worse than this?

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Root Cause Analysis Video Tip: TapRooT® Resources That Will Help You Be Proactive.

November 19th, 2014 by

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.

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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.)

 

How Far Away is Death?

November 18th, 2014 by

Watch the sailor almost become toast…

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

November 14th, 2014 by

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. 

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

November 7th, 2014 by

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. 

Root Cause Analysis Video Tips: Equifactor®…Are you using it to prevent equipment failures?

November 5th, 2014 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Ken Reed. He briefly discusses the importance of using Equifactor® proactively in order to prevent equipment failures from ever happening.  Among the many uses of TapRooT®, using it proactively is one of the most important. Keep the investigations to a minimum if you can help it!

For more information on Equifactor® and the courses we offer for it, click here.

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Was this tip helpful? Check out more short videos in our series:

Be Proactive with Dave Janney (Click here to view tip.)

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.)

 

Airplane Crashes: Pilot and People in a Simulator Die

November 4th, 2014 by

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Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.

I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.

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.

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Was this tip helpful? Check out more short videos in our series:

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

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.

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