Cook found alive in wreckage three days after ship sinks…
Does your healthcare facility need a reboot when it comes to root cause analysis? Attend our 2014 Global TapRooT® Summit and our Improving Healthcare Quality and Patient Safety best practice track. In this video, Track Leader Ed Skompski gives you a preview of what you’ll learn.
Learn more about our Summit and register today by clicking here.
Remembering an Accident: On December 3, 1984, The Union Carbide Bhopal Chemical Release Kills Over 2,000 – Injuries Over 200,000Posted: December 3rd, 2013 in Accidents, Video
Here is a 10 year anniversary Reuters report …
Here is a video called “The Inside Story” …
There’s lot’s more video out there … some very emotional.
Root Cause Analysis Training for Human Error Reduction and Behavior Change – 2014 Global TapRooT® Summit Video InvitationPosted: December 2nd, 2013 in Summit, Video
Would you like to reduce human error in your facility? Take a look at Mark Paradies’ invitation to attend the 2014 Global TapRooT® Summit in the Human Error Reduction & Behavior Change track.
Mark mentioned in the video “the link to the Summit Schedule.” Click here to see our full Summit Schedule, then click the “Human Error Reduction and Behavior Change” option on the left sidebar menu.
At the 2013 Global TapRooT® Summit, we met so many wonderful clients and friends. They couldn’t stop talking about how much they enjoyed the Summit! We got a few of those conversations on camera for you, so you know what you’ll get when you attend the 2014 Global TapRooT® Summit in Horseshoe Bay, Texas!
In this video, we talk with Tom DiGiacomo of Saudi Aramco.
Carl Dixon will be playing & singing at our reception again this year. Click here for more reception information.
For Certified Instructors like Tom, click here to view our Summit Schedule. Choose the Certified instructors track on the left, and learn more about each session.
Tom mentions Process Safety, and our need for increasing it. Click here and choose the Process Quality & Corrective Actions track on the left hand side for more info on our Process Safety session.
Interested in our 2014 Summit? Click here to learn more.
Root Cause Analysis Training in Texas – TapRooT® Certified Instructor Training at the 2014 Global TapRooT® SummitPosted: November 25th, 2013 in Summit, Video
Calling all Certified Instructors! It’s required that you attend the Summit and some additional training once every two years. For many of you, this is your year. Below, Michelle Wishoun invites you to register for our Certified Instructors Track.
I’m hoping that my shots (and cart driving) is better than these examples…
For Tournament and Summit info, CLICK HERE.
We offer advanced trending courses that can help you really understand performance at your facility.
See information about the course here:
Trending is NOT too hard. Watch what these kids are doing…
Press Release from the US Chemical Safety Board: CSB Releases Safety Video on 2009 Fatal Blast at NDK Crystal – Animation Depicts Stress Corrosion Cracking; Vessels Were Not Inspected or TestedPosted: November 19th, 2013 in Accidents, Current Events, Investigations, Video
Do you need to learn to prevent serious injuries and fatalities at your facility? Join us at the 2014 Global TapRooT® Summit! In this video, track leader and TapRooT® Instructor Dave Janney lets you in on what you can expect to learn when you register for the Safety Improvement and Serious Injuries/Fatalities Prevention track.
Watch the video below:
Learn more about the best practice sessions that Dave mentions by visiting our Summit Schedule. Click here, then choose the Safety Improvement and Serious Injuries/Fatalities Prevention option on the left sidebar to see the sessions.
Dave also mentions the golf tournament, reception, and keynote speakers. Click here to learn more about these and so much more at our 2014 Global TapRooT® Summit in Horseshoe Bay, Texas!
I guess that you need to address one problem at a time, but which is the most important?
(click to play – Windows Media/.wmv format)
Do you people understand hazard recognition? We have a pre-Summit course that might help. See the Hazard Recognition Course details at:
And see all the 2014 Global TapRooT® Summit information at:
© Copyright 2013 By System Improvements Inc. Used by Permission.
WHAT IS YOUR PURPOSE?
Have you thought about why you do root cause analysis? What is your purpose? I ask because many people go through the motions of root cause analysis without asking this essential question.
For most people, the purpose of root cause analysis is to learn to stop major accidents by finding the root causes of accidents and fixing them. Obviously, we must analyze the root causes of fatalities and serious injuries. But waiting for a serious accident to prevent a fatality or serious injury is like shutting the barn door after the cow has escaped.
Instead of waiting for a major accident, we need to learn from smaller incidents that warn us about a big accident just around the corner. Thus, root cause analysis of these significant warning events is a great idea.
The same philosophy applies to other types of adverse events that you want to prevent. Quality issues, equipment failures, production upsets, or environmental releases. You want to use root cause analysis to learn from the minor events to prevent the major ones.
This seems obvious. But why do so many companies seem to wait to learn from major accidents? And why do so many others waste tremendous time and money investigating incidents that don’t have the potential to cause a serious loss? Read on for ideas…
WAITING FOR BIG ACCIDENTS
Many companies seem to wait for big accidents before they decide to make serious change to the way they manage safety. They think they are doing everything needed to be safe. They may even have evidence (like decreasing lost time injury/medical treatment rates) that they are improving. But, when a major accident happens, the investigation reveals multiple opportunities that were missed before the major accident to have learned from minor incidents. That makes me wonder … Why aren’t they learning?
I’ve seen eight reasons why major companies to fail to learn. These reasons can occur separately or rolled up together as a “culture issue.” They include:
Near-Misses Not Reported
If you don’t find out about small problems, you will wait until big problems happen to react. Often people don’t report near-misses because they are unofficially discouraged to do so. This can include being punished for self-reporting a mistake or being assigned to fix a problem when it is reported. Even the failure to act when a problem is reported can be seen as demotivating.
Hazards Not Recognized
Another reason that near-misses/hazards are not reported (and therefore not learned from) is that they aren’t even recognized as a reportable problem. I remember an operator explaining that he didn’t see an overflow of a diesel fuel tank as a near-miss, rather, he saw it as a “big mess.” No report means that no one learned until the diesel caught fire after a subsequent spill (a big accident).
Shortcuts Become a Way of Life (standards not enforced)
This is sometimes called the “normalization of deviation.” If shortcuts (breaking the rules) become normal, people won’t see shortcuts as reportable near-misses. Thus, the bad habits continue until a big accident occurs.
Process Safety Not Understood
We’ve built a whole course around this cause of big accidents (The 2-Day Best Practices for Reducing Serious Injuries & Fatalities Using TapRooT® Course). When management doesn’t understand the keys to process safety, they reward the wrong management behavior only to suffer the consequences later.
Ineffective Root Cause Analysis
If a problem is reported but is inadequately analyzed, odds are that the corrective actions won’t stop the problem’s recurrence. This leaves the door open to future big accidents.
Inadequate Corrective Actions
I’ve seen it before … Good root cause analysis and poor corrective action. That’s why we wrote the Corrective Action Helper® module for the TapRooT® Software. Do you use it?
Corrective Actions Not Implemented
Yes. People do propose good corrective actions only to see them languish – never to be implemented. And the incidents continue to repeat until a big accident happens.
Trends Not Identified
If you aren’t solving problems, the evidence should be in the incident statistics. But you will only see it if you use advanced trending tools. We teach these once a year at the pre-Summit 2-Day Advanced Trending Techniques Course.
INVESTIGATING PAPER CUTS
Another problem that I’ve seen is companies overreacting. Instead of ignoring problems (waiting for the big accident), they become hyperactive. They try to prevent even minor incidents that never could become fatalities or serious injuries. I call this the “Investigating Paper Cuts” syndrome.
Why is overreacting bad? Because you waste resources trying to prevent problems that aren’t worth preventing. This usually leads to a backlog of corrective actions, many of which have very little return on investment potential. Plus you risk losing the few critical improve-ments that are worthwhile in “the sea of backlog.” Thus, an improvement program that isn’t properly focused can be a problem.
WHAT SHOULD YOU DO?
You need to truly understand the risks presented by your facility and focus your safety program on the industrial and process safety efforts that could prevent fatalities and serious injuries. Don’t overlook problems or make the mistake of trying to prevent every minor issue. Focus proactively on your major risks and reactively on incidents that could have become major accidents. Leave the rest to trending.
“An ounce of prevention is worth a pound of cure.”