Category: Video

What Does a Bad Day Look Like?

April 26th, 2016 by

Certainly was an impressive way to arrive for the prom. But a bad day for the pilot!

Ken Reed Invites You to The Asset Optimization Track at the 2016 Global TapRooT® Summit

April 22nd, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Asset Optimization Track. Come to the Summit and maximize improvement at your company!


Starring Ken Reed. Produced by Benna Dortch.

Learn more about the Summit!

Interested in the Safety Track?  Learn about it here!

Summit Flashback

April 19th, 2016 by

This is a great flashback. Remember when we were this young? It wasn’t all that long ago. And everything we said then is still true today – just even more so!

Don’t miss the 2016 Global TapRooT® Summit in San Antonio, Texas, on August 1-5. See:

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

Improve your root cause analysis.

  • Network
  • Benchmark
  • Learn best practices
  • Refresh your TapRooT® skills
  • Be inspired!
  • Get motivated!

That’s what the Global tapRooT® Summit is all about.

What does a bad day look like?

April 12th, 2016 by

And it could have been much worse!

What Does a Bad Day Look Like?

April 5th, 2016 by

If you are in the Navy … it looks like this!

Notice how happy sailors look when they aren’t to blame! (Bet they don’t look that happy on the bridge.)

Just needs some duct tape for repairs!

Dave Janney invites you to the Safety Track at the 2016 Global TapRooT® Summit

March 30th, 2016 by

The Global TapRooT® Summit offers multiple focused learning tracks for performance improvement. This video introduces the Safety Track. Come to the Summit and maximize improvement at your company!


Starring Dave Janney. Produced by Benna Dortch.

LEARN MORE about the Summit, August 1-5, 2016, San Antonio, Texas.

Interested in Asset Optimization?  Learn about that track here!

Normalization of Excellence – The Rickover Legacy – Responsibility

March 17th, 2016 by

For the previous article, see:

https://www.taproot.com/archives/53085

The second of the “essential” elements for excellence described by Rickover is RESPONSIBILITY.

You probably think you know what this means. You probably think that this is something your company already emphasizes. But read on and you will discover that it may be a missing element of your process safety program, and one reason that your company is not achieving excellence.

In the Nuclear Navy, Admiral Rickover was totally responsible. He was in charge of the design, construction, operations, and maintenance of all the Navy’s nuclear reactors (prototypes, subs, and ships). This single point of responsibility was unique in the Navy and is unique in the civilian world.

And responsibility for safety was (and is) passed down the chain of command to each Commanding Officer, Engineer, Engineering Watch Officer, and Reactor Operator. If you see something unsafe, you are fully authorized and expected to act.

If a Reactor Operator saw some safety parameter go out of spec, s/he was fully authorized and expected to SCRAM (emergency shut down) the reactor. There was no asking permission or waiting for approval.

If a reactor accident (a meltdown) had occurred, Rickover would take full responsibility. And the rest of the chain of command would likewise take responsibility for their actions.

Do you remember the hearings in front of congress after the Deepwater Horizon accident? Each of the executives from BP, Transocean, and Halliburton pointed fingers at the other executives. None would take responsibility for the accident.

An Associated Press Story said:

Executives of the three companies, all scheduled to testify before the Senate
Energy and Natural Resources Committee, are trying to shift responsibility for the
environmental crisis to each other, according to prepared testimony
.”

The Washington Post had to say about the testimony:

“Three major oil industry executives agreed on one thing in a pair of
Senate hearings Tuesday: Someone else was to blame for the drilling rig accident
that triggered the massive oil spill in the Gulf of Mexico.”

Here is some coverage of the testimony that talks about “divided responsibility” …

Watch what it takes to get Tony Hayward to say he was the ultimately in command of safety at BP.

Without Rickover’s unique concept of total accountability/responsibility, people can sidestep responsibility. Without full accountability/responsibility, decisions to:

  • cut budgets,
  • reduce staffing,
  • defer maintenance,
  • opt for cheaper designs,
  • or shortcut company requirements

are easy to make because no one person is responsible. As Philippe Paquet wrote:

When everyone is responsible, no one is responsible.”

Therefore, as Rickover points out, you must have one person at the top clearly responsible for process safety or no one is responsible and you will NOT be able to achieve excellence.

That’s it for this week’s discussion of excellence. Next week’s topic is perhaps the most important concept in excellence and process safety … “Facing the Facts.”

37 Years After TMI – What have we learned?

March 11th, 2016 by

Here’s a short video that doesn’t share much. But nuclear plants are much safer today as a result of learning lessons from accidents and incidents.

Root cause analysis has helped nuclear plants perform at record levels of safety.

Grading Your Investigations

March 10th, 2016 by

How do you grade an incident investigation? Here’s an Excel spreadsheet to use…

RateRootCauseAnalysis03082016.xlsx

How do you use the spreadsheet? Here’s a video from last year’s Summit …

Grading Your Investigation from TapRooT® Root Cause Analysis on Vimeo.

Would you like to learn this and hear about someone who has been using it to improve their company’s investigations? Go to the Grading Your Investigations Breakout Session (Wednesday – 1:30-2:30) at the 2016 Global TapRooT® Summit.

How Can the Summit Help Your Company and Your Career?

March 2nd, 2016 by
San Antonio, Texas

San Antonio, Texas

Should you attend the Global TapRooT® Summit in San Antonio, Texas, August 1 – 5, 2016?  How can it help your company and your career?

Ask yourself these questions:

1. Does your facility/company need to improve in any of these areas:

  • Asset Optimization
  • Human Factors
  • Investigations
  • Reducing Medical Error
  • Quality
  • Safety
  • TapRooT® Software

2. Are you a Certified TapRooT® Instructor that needs to maintain their certification?

3. Do you want to be more motivated to improve performance?

4. Would you like to get a team of people from your facility excited about performance improvement?

5. Do you need knew ideas to take your improvement program to the next level?

6. Do you need to refresh your TapRooT® knowledge?

7. Would you like to visit the world-famous San Antonio River Walk?

8. Would you like to meet a bunch of new valuable contacts that can help you improve performance at your facility and advance your career?

9. Are you interested in benchmarking your improvement efforts against other industry leaders?

10. Are you interested in best practices from other industries that can be applied to improve performance in your industry?

If you said “yes” to any of these questions, that’s how it will help your company and your career!

To register, click here.

For more information, click here.

For the Summit schedule, click here.

What Does a Bad Day Look Like?

March 1st, 2016 by

Coming face-to-face with any of these visions would be a bad day …

What Temp for the Best Night’s Sleep

February 24th, 2016 by

Or click on this link if the video does not play …

http://on.wsj.com/21luzyO

Accident: Collapse of Didcot Power Station

February 24th, 2016 by

Footage of the collapse …

It was being demolished. Here are two news stories …

There is no such thing as “Normalization of Deviation”

February 24th, 2016 by

Yes, I have written and spoken about normalization of deviation before. But today I hope to convince you that normalization of deviation DOES NOT EXIST.

What is “Normalization of Deviation”? (Or sometimes referred to as normalization of deviance.) In an interview, Diane Vaughan, Sociology Professor from Ohio State University, said:

Social normalization of deviance means that people within the organization become so much accustomed to a deviant behaviour that they don’t consider it as deviant, despite the fact that they far exceed their own rules for the elementary safety.

Let’s think about this for a moment. What defines deviation or deviance?

To deviate means to depart from a set path.

In a country, the government’s rules or laws set the path.

In a company, management usually sets the path. Also, management usually conforms to the regulations set by the government.

To say that there is normalization of deviation means that the normal course of doing business is to follow the rules, regulations, and laws.

Let’s look at a simple example: the speed limit.

When Jimmy Carter was President, he convinced Congress to pass a national speed limit of 55 miles per hour. He did this because there was an oil shortage and he declared the conservation of oil to be the “moral equivalent of war.”

What happened?

Violating the speed limit became a national pastime. Can you remember the popular songs? Sammy Hagar sang “I can’t drive 55.”  There was C.W. McCall signing “Convoy.”

And the most famous of all? The movie “Smoky and the Bandit” with Burt Reynolds and Sally Fields …

How many laws did they break?

One might think that this is just a rare example. The rule (55 mph speed limit) was just too strict and people rebelled.

Take a minute to consider what you observe … who breaks the rules?

  • Drivers
  • Teenagers
  • Politicians
  • Executives
  • Pilots
  • Nurses
  • Police
  • Teachers
  • Judges
  • Doctors
  • Clergy

You can probably remember a famous example for each of these classes of people above where rule breaking was found to be common (or at least not so uncommon).

You might ask yourself … Why do people break the rules? If you ask people why they break the rules you will hear the following words used in their replies:

  • Unnecessary
  • Burdensome
  • Just for the inexperienced
  • Just once
  • They were just guidelines
  • Everybody does it

My belief is that rule breaking is part of human nature. We often work the easiest way, the quickest way, the way with the least effort, to get things done.

Thus deviation from strict standards is NOT unusual. Deviation is NORMAL!

This there is no “Normalization of Deviation” … the abnormal state is getting everyone to follow strict rules.

  • To follow the procedure as written
  • To always wear PPE
  • To follow the speed limit
  • To pay every tax
  • To never sleep on the job (to stop nodding off on the back shift or at a boring meeting)

Thus, instead of wondering why “Normalization of Deviation” exists and treating it like an abnormal case, we should see that we have to do something special to get the abnormal state of a high performance organization to exist.

What we now want is an abnormal state of an extremely high performance organization that we try to establish with strict codes of behavior that are outside our normal experience (or human nature).

How do you establish this high performance organization with high compliance with strict standards? That’s a great question and the topic for another article that I will write in the future.

What does a bad day look like?

February 10th, 2016 by

Have you had a snow near-miss this year?

Monday Accident & Lessons Learned: Was “Paying Attention” the Root Cause?

February 8th, 2016 by

Watch this video and see what you think …

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