Category: Video

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

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

August 13th, 2014 by

Darlene Normand of Entergy Services shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch her video below to learn how she got everyone engaged and having fun while teaching them TapRooT®:

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

“Hello my name is Darlene Normand. I’m with Entergy Services, fossil section. We’re building a new plant. We had a conference last year and I was tasked with teaching everyone a little bit about TapRooT®. We cover four states and they heard about TapRooT® because they were getting these corrective actions to put in place, but they didn’t know what it was. So how do you teach 1000 people about TapRooT® and make it fun? Well, I came up with a game, and called it the TapRooT® scramble. (I think I called Ken Reed and said “Hey, you got anything for me?”) I made a SnapCharT®. I used the pothole story from the 5-day class and I made puzzle pieces from the SnapCharT®. I had them all scrambled. I think I did 20 groups. I would give them the story, put them in teams, and their goal was to put the SnapCharT® in the sequence that it went. It went over well; the VPs and the directors got a little taste of it, and some people even took it back to their plants and started changed some of their ways with TapRooT®. It got the message across. It was fun.”

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

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

Root Cause Analysis Tip: Conduct Real-Time Peer Reviews

August 6th, 2014 by

Welcome to our first week of video root cause analysis tips. Today, TapRooT® Co-Creator Mark Paradies shares the some best practices for conducting peer reviews. Watch it above, and print out the notes below for future reference:

You don’t want to wait until you’ve finished your investigation to conduct a peer review. We’ve seen a lot of resistance to change at this point, since so much work has already gone into the investigation. Instead, conduct peer reviews at various stages of the investigation.

Here are four stages that are great times to evaluate investigators, and some guidelines on what to look for:

1. After Creating Summer SnapCharT® – Is the SnapCharT® thorough enough or do we need more interviews & data?

2. After Defining Causal Factors – Are they at the right end of the cause-and-effect chain? – Was a Safeguards Analysis conducted? – Were all the failed safeguards identified as causal factors?

3. After RCA and Generic Cause Analysis – Did they use their tools (Root Cause Tree®, Root Cause Tree® Dictionary, etc.)? – Did they find good root causes? – Did they find generic causes? – Did they have evidence for each root cause?

4. After Developing Corrective Actions – Use corrective action helper to determine effectiveness of corrective actions.

You may not want to conduct these peer reviews during every investigation, because it can become time-consuming. Ask these questions for new investigators and during major investigations. Another pro tip: Use your most experienced investigators to conduct peer reviews. In addition to improving the quality of your investigation step-by-step, you also gain the opportunity to sharpen the investigation skills of the investigators and the reviewers.

Join us in two weeks for another Root Cause Tip video, this time from TapRooT® Instructor Dave Janney.

Click here to learn more about the TapRooT® System.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Arizona Public Service)

July 24th, 2014 by

Teresa Berry of Arizona Public Service shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch her video below to learn how she fixed her company’s poorly written reports by finding the root cause of the bad writing:

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

I’m Teresa Berry. I’m from Arizona Public Service and we’ve been using TapRooT® for probably three or three and a half years now on the process side of our industry and what we’ve found is that every now and then we’ll come up with a report that is not written very well. It doesn’t have facts to back up the root causes that were chosen. That is a symptom of a much bigger problem. The problem we found, that we had to go fix, is that people were not using all of the processes that we’re taught to use in TapRooT®; “the rules,” I call them when I teach. These are your rules. You must use the process as it’s laid out or it doesn’t work as well as you’d hoped. And along with that there are also assumptions. Make sure you turn those assumptions into questions so that you know you’ve got to go and answer that question. It’s not a fact until you prove that it’s a fact.

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

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

Corrective Action for Natural Disaster Category on the Root Cause Tree®

July 24th, 2014 by

Are you prepared for a tornado at your facility?

Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …

Things to Do in Seattle

July 23rd, 2014 by

MarkTeach

I am one of the instructors for the upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Traning in Seattle and I thought I’d pass along some of the great things to do in your spare time (after hours) while attending the course. 

Seattle is a great place to eat, shop, and have fun so I’ve listed my favorite places to eat and visit below with links to more information. I’ve also listed a few ideas for the weekend before or after for those who want to get outside of Seattle and see the impressive natural wonders nearby. 

Food

Wild Ginger – If you like asian food, try this.

Metropolitan Grill – Best steaks in the USA

The Brooklyn Seafood, Steaks, & Oysters – I recommend getting the oyster sampler.

Ivar’s Acres of Clams – I love their clam chowder and prices are reasonable.

The Cheesecake Factory – Always one of my favorites no matter where I go.

Kells Irish Pub – Love the atmosphere, beer, and the food is good (and a ghost).

Fun Activities

Space Needle and World’s Fair Park

Seattle Aquarium

Seattle Mariners – In town playing the Toronto Blue Jays on Monday, Tuesday, and Wednesday (night games) of the course. 

Seattle Art Museaum

Seattle Underground

Seattle Ferries

Tillicum Village Cruise and Samon Dinner

Shopping

REI Co-Op

Nordstroms

Pike Place Market

The Weekend Before/After Ideas

Olympic Peninsula

Mount Raineer

 

 

Remembering an Accident: Val di Stava Dam Collapse

July 19th, 2014 by

The Val di Stava dam collapsed on July 19, 1985 when two tailings dams used for sedimenting the mud from a nearby mine failed. The subsequent mudflow caused one of Northern Italy’s worst disasters – 268 lives were lost and 63 buildings and eight bridges were destroyed.

What happened?

According to The History of Geology:

“An investigation into the disaster found that the dams were poorly maintained and the margin of safe operation was very small. As last trigger of the failure is considered a leak of water, caused by a pipe in the upper dam, used to drain water, which had been bent by the weight of sediments. The increasing water pressure of the bunged up dam, in combination with the water saturation weakening the sediments of the dam wall, caused probably the collapse.”

See more at:  http://historyofgeology.fieldofscience.com/2010/07/july-19-1985-val-di-stava-dam-collapse.html

National Hazards and Earth System Sciences published a report indicating that effective regulation may have prevented this disaster.

Read report:

http://www.nat-hazards-earth-syst-sci.net/12/1029/2012/nhess-12-1029-2012.pdf

What do you think? Leave your comments below.

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Encana Oil & Gas)

July 17th, 2014 by

Devin Johnston of Encana Oil & Gas 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 streamlined the way his facility performed TapRooT® investigations to make each one more efficient than ever:

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

Hi I’m Devin Johnston, with Encana Oil & Gas, from Denver, Colorado. One of the issues with had with TapRooT® is when we would have an incident we would want everyone to be involved. … Everyone would come in the room, we’d lock the doors, we’d run through the whole TapRooT® process, and bang it all out. At the end of the day, everyone was so tired of going through the process and arguing on each little point, that the corrective action part of it at the end was just, they’d take whatever. You’d give them a corrective action and they’d take it, and they weren’t always quality corrective actions. So the thing we fixed at our company is that we made it a more iterate process where we would investigate it, have SnapCharT®s built out already before we went into that meeting, then we selected who actually attended that meeting. If it was contractors, we made sure it wasn’t the whole EHS team, just the guys that things happened to out there. We’d pick the people that were in the investigation at the end to make it simpler, to come to an agreement better, and to improve our process on how we did those TapRooT®s.

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 (US Army Medical Command)

July 10th, 2014 by

Dana Rocha of US Army Medical Command shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during out Users Share Best Practices session. Watch her video below to learn how she has tailored her TapRooT® investigations so that they are the absolute most thorough they can be:

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

Hello, my name is Dana Rocha, I work for US Army Medical Command. With the help of the navy and the air force we in the army have put together a couple of different documents for people who haven’t been through the training to prepare them for facilitating an RCA as well as sitting on a RCA team. And what we did is we put together a couple of documents for “just in time training” for TapRooT® to help them facilitate and what your roles and responsibilities are on the team. We also put together an RCA trifold and what this is, is a root cause analysis for what event you’re looking at whether its an adverse outcome or sentinel event, near misses or you’re looking at something proactively. It doesn’t matter what you’re looking at, so we use it in different realms. We also put together some checklists. When you do your SnapCharT®, have you considered this? Have you considered that? Check the dates, check the times. Talk to people, and things like that and we found this to be very helpful. And we have done checklists for certain types of events that we find occur more frequently than others. When I say this, don’t freak, but wrong site surgeries do occur, we have retained foreign objects, all kinds of things that do happen, unanticipated deaths, so certain types of events we put together the most common things and asking the questions to make sure that we do a real thorough job when we do the analysis and the investigation so we found that to be very helpful.

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 (Tesco Corp)

July 3rd, 2014 by

At our Users Share Best Practices session at the 2014 Global TapRooT® Summit, Simon Blackwood shared a great tip from his facility. Watch his video below to learn how his company is now “speaking the same language” when it comes to root cause analysis investigations:

Don’t have a minute to watch the video? Here’s his tip:

My name is Simon Blackwood, I work for Tesco Corporation in Houston, Texas and we transferred our terminology of generic causes and root causes over to our compliance report system for HSE and quality incidents so now we’re actually trending for actually all incidents we sill use the TapRooT® software but we have to admit our software is a little bit of work (although in truth it can trend proactively) now we’re getting ahead of the game, we’re using it for project management now but now certainly we’re speaking the same language in our company so it’s been great.

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

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

Career Development: A Conference Call in Real Life

July 2nd, 2014 by

This video is a hilarious because it highlights everything that can (and often does) go wrong on a conference call. Are conference calls productive? What do you think?

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