Root Cause Analysis Blog

 

What Countries Will Be Represented at the 2016 Global TapRooT® Summit?

Posted: June 23rd, 2016 in Pictures, Summit, TapRooT

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Here’s a partial list …

  • Australia
  • Brazil
  • Canada
  • Colombia
  • Ecuador
  • Iraq
  • Jordan
  • Kenya
  • Mexico
  • New Zealand
  • Philippines
  • Qatar
  • Russia
  • Saudi Arabia
  • Senegal
  • Singapore
  • Trinidad
  • United Kingdom
  • USA

That’s why we call the Summit a GLOBAL Summit. Every continent is represented.

Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:

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

And find out about all the great sessions and keynote speakers by visiting the Summit web site at:

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

Technically Speaking – TapRooT® VI Toggles

Posted: June 23rd, 2016 in Software Updates, Technical Support, Technically Speaking, Video, Video Depot

This week I ‘d like to introduce you to the new toggle system found in the TapRooT® VI software. The toggle system allows you to customize your preferences on how you use the software including:

-Performing a BASIC investigation (for minor incidents) or a MAJOR investigation (for more complex incidents)
-Using the Root Cause Tree® as a QUESTION view or using the classic TREE view.
-Creating Corrective Actions using a SIMPLE method or a SMARTER form.

Watch the video to see how these features make TapRooT® VI a completely flexible, customizable software solution.

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

What is a “Trend”???

Posted: June 22nd, 2016 in Courses, Performance Improvement, Pictures

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Have you ever had an accident and someone in management says …

That looks like a bad trend to me.

And you didn’t think it was but you couldn’t prove him wrong?

Have you ever had a regulator tell you that you have problems that look like an adverse trend and you didn’t know how to respond?

Have you ever wondered if a slight improvement in safety statistics is really significant?

Have you ever wondered how long it will take without a significant accident until you can say that performance really has improved?

Have you ever presented trend data and hoped that nobody asked any real questions because you were just making stuff up?

IF YOU DON’T LIKE YOUR ANSWERS TO ANY OF THESE QUESTIONS, you need to attend the TapRooT® Advanced Trending Techniques Pre-Summit Course in San Antonio, TX, on August 1-2.

We only offer this course once a year and anyone interested in learning how to trend safety statistics should attend.

Register at:

http://www.taproot.com/store/2-Day-TapRooT-R-Advanced-Trending-Techniques-Course.html

Who Could You Network With at the 2016 Global TapRooT® Summit?

Posted: June 22nd, 2016 in Pictures, Summit, TapRooT

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Who would you like to network with if you were going to share best practices and learn how others have solved problems?

The TapRooT® Summit is a great place to meet industry leaders.

Here a partial list of companies that have signed people up for the 2016 Summit:

  • Agrium
  • Air Liquide
  • Arizona Public Service
  • Ashplundh
  • Avangrid Renewables
  • Balitmore Gas & Electric
  • Barrick
  • California Resources
  • Chevron
  • CHS
  • ConocoPhillips
  • Duke Energy
  • Enerplus
  • Exelon
  • Exxon
  • FirstEnergy
  • Formosa Plastics
  • GE
  • Genetech
  • Hallam-ICS
  • Intergen
  • Lawrence Berkeley national Lab
  • Liberty Carton Company
  • Marathon
  • Matrix Services
  • Monsanto
  • Nalco Champion
  • National Grid
  • Northern Star Generation
  • NRG Energy
  • Nuclear Fuel Services
  • Occidental
  • Oceaneering
  • PCS Nitrogen
  • Prarie State Generation
  • Pratt & Whitney
  • PSH JV
  • Red Cedar Gathering
  • Sacramento Municipal Utility District
  • Saudi Aramco
  • Siemens
  • Siltronic
  • SNOLAB
  • Teranga Gold
  • Tuscon Electric
  • US Well Services
  • United Technologies
  • Valspar
  • Vancouver Airport Authority
  • Weatherford
  • Westar Energy
  • Willbros

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What are some of the job titles of people attending the 2016 Summit?

  • Airside Safety Officer
  • Area HSE Manager
  • Compliance Specialist
  • Corporate ESH Director
  • Corporate HSE Manager
  • Corrective Action Program Manager
  • Director of Corporate Safety
  • EHS Engineer
  • Electrical Engineer
  • Emergency Management Manager
  • Engineering Superintendant
  • Environmental Steward
  • Facility Manager
  • Global H&S Advidor
  • HSE Regional Leader
  • HSE Director
  • HSE Specialist
  • HSE Supervisor
  • Human Performance Specialist
  • Industrial Hygienist
  • Industrial Operations manager
  • Issue Management Program Leader
  • Lead Production Supervisor
  • Loss Prevention System Advisor
  • Manager, H&S
  • Mechanical Engineer
  • Operational Excellence Manager
  • Operations Staff
  • PDM Coordinator
  • Process Safety Manager
  • PSM Specialist
  • QHSE Leader
  • Quality Auditor
  • Quality Manager
  • Quality Systems Auditor
  • RCA Leader
  • RCA Manager
  • Refining Consultant
  • Reliability Specialist
  • Results Supervisor
  • Risk Manager
  • Safety & Training Specialist
  • Safety Associate
  • Safety Specialist
  • SHE Supervisor
  • SHEQ Divisional Manager
  • Site CAP Manager
  • Sr. Director, Serious Injury & Fatality Prevention
  • Sr. Safety Analyst
  • Staff Compliance Specialist
  • Supervisor Training
  • Team Leader H&S
  • Training Director
  • Training Specialist
  • Upstream HSE Team Lead
  • Vice President, HSE
  • VP & Regional Manager
  • VP HSE
  • WMS Advisor
  • Work Week Coordinator

And those are just partial lists!

Imagine the things you could learn and the contacts you could make.

Add your company and your job title to the list by registering at:

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

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How Far Away is Death?

Posted: June 22nd, 2016 in Accidents, How Far Away Is Death?, Video

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Special thanks to TapRooT® Instructor, Jim Whiting for sending in the video.

Have a Plan! Using the TapRooT® Tools to Plan Your Investigation

Posted: June 22nd, 2016 in Investigations, Root Cause Analysis Tips, TapRooT

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Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?

Unfortunately, most systems kind of leave you hanging.  They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt.  Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!

Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process.  We have recently tweaked this guidance to make it even easier to quickly progress through the investigation.  Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.

Some of these tools are required for every investigation; some are optional data-gathering tools.  Let’s first take a look at the required tools.

Mandatory Tools

SnapCharT®:

One of the first things you need to do is get a good understanding of exactly what happened.  Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred.  By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out.  It helps you figure out what questions to ask and who to ask.  Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason.  There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask.  It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.

Root Cause Tree®:

Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process.  However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®.  In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation.  You’ll need the answers to these questions once you get to the root cause analysis phase.  Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?

The tools I listed above are used during EVERY investigation.  However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®.  Let’s look at the non-required tools.

Optional Tools

Change Analysis:  This is a great tool to use to help you ask thought-provoking questions.  It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances.  The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident.  It is actually an extremely easy tool to use, and yet it is very powerful.  I find this to be my most-used optional tool.  The results of this analysis are now added to your SnapCharT® for later root cause analysis.

Critical Human Action Profile (CHAP):  Sometimes, you need help understanding those “dumb” mistakes.  How can someone be walking down the stairs and just plain fall down?  The person must just be clumsy!  This is a great time to use CHAP.  It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task.  What tools were they using (and supposed to be using)?  How did we expect them to perform the individual steps in the task?  This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing.  The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.

Equifactor®:  If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure.  You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem.  For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring.  Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration.  The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure.  These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure.  Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.

The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with.  The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations.  If you need some help getting started, the TapRooT® tools will get you going!  Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.

Weekly Wisdom: Be Proactive!

Posted: June 21st, 2016 in Wisdom Quote

ounce of prevention

“An ounce of prevention is worth a pound of cure.” -Henry de Bracton

Handwriting and RCA

Posted: June 20th, 2016 in Medical/Healthcare, Root Cause Analysis Tips

Today’s article is meant to create a discussion. We all know that Electronic Medical Records (EMR) are taking the place of written orders in healthcare (providing their own set of issues), so where does the written word fall on the Root Cause Tree®?

The cartoon below illustrates the issue we are discussing:

Handwriting
Back in the day doctors and nurses always used written records, or prescriptions. Today the reliance on this form of communication is less than in the past but can still cause issues. One question to ask yourself is, “Is the burden of understanding written communication on the writer or the reader?”  What is your opinion on this? Mine is that it is most certainly on the writer. We should not provide communications of any kind that have to be interpreted to be understood. Going back that is why many acronyms have been removed from healthcare…they simply created confusion.

So thinking about written communication, if we have a Causal Factor dealing with a nurse or physician did something wrong due to a misunderstanding of a written communication…where would we go under the “Human Performance Difficulty” section?

One question that would most likely be a yes is the second question under the Team Performance Section: Did failure to agree about the who/what/when/where of performing the job play a role in this problem?. This leads us to Training, Communications, and Work Direction but does that really match?

For this week please provide your insight into where you believe this issue would fit. Thank you for reading and for providing your insight! I will write about our results in next week’s article! Have a great week……

(P.S. Don’t forget to sign up for my Medical track at the 2016 Global TapRooT® Summit, San Antonio, August 3-5, 2016.)

Monday Motivation: Create your legacy

Posted: June 20th, 2016 in Career Development, Career Development Tips, Wisdom Quote

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It doesn’t matter who you are, your time is limited, and your life is finite. Knowing this, if you made a list today of things you would not want to leave undone, what items would be on the list? And what has blocked you from checking these items off? If you are like most people, you wait to act. You wait until something kicks you in the butt and reminds you that maybe you are not living life on your own terms. Maybe you’re living by someone else’s terms … someone you don’t even like.

Identify what’s important (versus what doesn’t really matter). Write your list. Build your legacy. Don’t leave what you’re meant to do here undone.

TapRooT® Users Share Best Practices at the Summit!

Posted: June 20th, 2016 in RCA Tip Videos, Summit, Summit Videos, Video Depot

Our Global TapRooT® Summit attendees help one another by sharing best practices. We’d love to hear from you this year! Learn more about joining us in San Antonio the first week of August at the Summit website!

(Click post title if video is not displaying.)

Monday Accident & Lessons Learned: Collision between a tram and a pedestrian, Manchester

Posted: June 20th, 2016 in Accidents, Current Events, Documents, Investigations, Pictures

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The UK Rail Accident Investigation Branch published a report about a tram hitting a pedestrian in Manchester, UK.

A summary of the report says:

At about 11:13 hrs on Tuesday 12 May 2015, a tram collided with and seriously injured a pedestrian, shortly after leaving Market Street tram stop in central Manchester. The pedestrian had just alighted from the tram and was walking along the track towards Piccadilly.

The accident occurred because the pedestrian did not move out of the path of the tram and because the driver did not apply the tram’s brakes in time to avoid striking the pedestrian.

As a result of this accident, RAIB has made three recommendations. One is made to Metrolink RATP Dev Ltd in conjunction with Transport for Greater Manchester, to review the assessment of risk from tram operations throughout the pedestrianised area in the vicinity of Piccadilly Gardens.

A second is made to UK Tram, to make explicit provision for the assessment of risk, in areas where trams and pedestrians/cyclists share the same space, in its guidance for the design and operation of urban tramways.

A further recommendation is made to Metrolink RATP Dev Ltd, to improve its care of staff involved in an accident.

For the complete report, see:

https://assets.digital.cabinet-office.gov.uk/media/5705107640f0b6038500004d/R062016_160412_Market_Street.pdf

 

Using Safeguards Analysis to Find Root Causes

Posted: June 17th, 2016 in RCA Tip Videos, Summit, Summit Videos, Video Depot

Here is a great best practice tip from TapRooT® User, Jeff Linstedt from our last Global Summit.

https://vimeo.com/157205462

Come to the 2016 Global TapRooT® Summit and learn to solve your most pressing issues!

What’s the BEST way to save MONEY when your industry is under economic pressure?

Posted: June 16th, 2016 in Summit

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Today, I was talking to someone in an industry that has had a major price reduction in the commodity that they produce.

They said that they couldn’t attend the 2016 Global TapRooT® Summit (August 1-5, San Antonio, TX) because there was a corporate travel ban. Only “business critical” travel was allowed.

That got me thinking … What is business critical travel?

If your travel would:
  

  • SAVE SOMEONE’S LIFE,
  • STOP A MAJOR ACCIDENT that would ruin your company’s reputation,
  • SAVE YOUR COMPANY BIG $$$$ (at least 10X more than the cost of travel),
  • KEEP ONE OF YOUR BIGGEST CLIENTS happy by preventing a quality issue,
  • STOP CRITICAL EQUIPMENT FROM FAILING,

Would that be business critical?

I understand the need to meet budgets and cut costs in times of economic difficulties.

What I don’t understand is being “PENNY WISE AND POUND FOOLISH.”

I hope your company isn’t making a mistake by stopping critical improvements from being made. Critical improvements that would have been learned at the 2016 Global TapRooT® Summit BUT won’t be because someone was afraid to ask to attend because only business critical travel is being allowed.

Want to learn about the sessions and lessons that will be shared at the 2016 Global TapRooT® Summit? See the complete Summit schedule at:

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

Then register for the Summit at:

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

Technically Speaking – TapRooT® VI is HERE!

Posted: June 16th, 2016 in Software, Software Updates, Technical Support, Technically Speaking

We are VERY excited to announce the official release of TapRooT® VI, our online software service.

TapRooT® VI is smarter, faster and easier to use. It is supported by most web browsers (Google Chrome, Mozilla Firefox, Internet Explorer, Safari) which makes it compatible with most devices (PC, Mac, Tablet, iPad, Smart Phone, iPhone); and there is no need to download or install, making upgrades a thing of the past.

Experience a whole new design, improved features and lots of enhancements to help guide you through the TapRooT® process.

Here are just some of the exciting new features that you’ll receive with your TapRooT® VI subscription:

  • Full Customization – Create your own custom pick lists, tabs, fields, reports, templates, SnapCharT® defaults and more
  • INCIDENT Management capabilities – Track Incidents, Investigations and Audits all in one place
  • Auto Save function – No need to click the Save Button! TapRooT® VI auto saves your work
  • Redesigned Optional Techniques – Safeguards Analysis, Change Analysis, CHAP and Equifactor® have a new look and improved usability as they interact directly with our SnapCharT®
  • Root Cause Tree® Options – TapRooT® VI now offers both the standard visual TREE View AND the new QUESTION View for an alternative questionnaire format – Track and save your YES and NO responses either way
  • SnapCharT® Enhancements – Apply default shape formatting and the ability to change Events to Conditions (and vice versa) with the simple click of a button
  • Corrective Actions – Use the new step-by-step method to create SMARTER fixes
  • Generic Cause Analysis – Identify, Analyze and create Corrective Actions for GENERIC Causes

TapRooT® VI is also available for new Enterprise customers as well, with a Data Migration release coming shortly for those of you who have Version 5 Enterprise data to preserve.

Get your individual access here today.

If you are a licensed Enterprise customer (or wanting to be), contact us for more information on availability.

Root Cause Analysis is not about Root Causes

Posted: June 15th, 2016 in Root Cause Analysis Tips

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I must be crazy, I teach TapRooT® Root Cause Analysis and say it’s not about the root causes? Yes, it is true. Root Cause Analysis is really about fixing, prevention and improved ability to recover from a problem.

Yes, an objective root cause process is a must, for hints read the 7 Secrets of Root Cause Analysis. However the reason behind the need for and the end intent of the root cause analysis is just as important. Lets start with a new idea for many doing root cause analyses today, “improved ability to recover from a problem.”

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Sometimes the first action to correct a problem on the spot was like pouring water on an oil fire. Didn’t cause the fire but sure did not help the situation, and in some cases it really made the problem. Many problem solvers just look for the root causes that caused a problem and not what also made it worse.

Here are just a few examples of actions or lack of actions that made the initial problem grow larger in extent if not worse at the end of the day:

  1. Flint River Lead Exposure Delayed Response
  2. Firestone Tire Delayed Recall
  3. 1947 Explosion Caused by Incorrect Response to Initial Fire
  4. A case closer to this article writer’s life when the wrong medicine was given for heart failure of loved one: Root Cause Analysis Tip: Patient’s heart stopped twice in the Emergency Room… what was missed?

So why do I say “improved ability to recover from a problem” is a new concept for many doing root cause analyses today? Simple, many start and stay with “why did the problem occur.” Read more on how to improve the use of the more simple “why” tools if you have to use them:  A Look at 3 Popular Quick Idea Based Root Cause Analysis Techniques: 5-Whys, Fishbone Diagrams and Brainstorming.

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The easiest way to improve the ability to respond to a problem is to map out a timeline for actions that occurred before the problem occurred, and the immediate responses to control or correct the problem. If the response made things worse, then perform a root cause analysis on that problem as well.

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The last topic is prevention. The intent of a root cause analysis is not just to find the one “rootiest cause” or even a multitude of root causes. The intent is to find the problems and root causes that caused the problem and the problems that failed to catch/stop the problem AND THEN Eliminate or Mitigate those root causes so that future problems can be prevented or at the minimum, have the probability of the problems occurrence reduced.

Preparedness: Responding To An Accident

Posted: June 15th, 2016 in Accidents, RCA Tip Videos, Summit, Summit Videos, Video Depot

Part One

 

Part Two

In these videos (Part One and Part Two above), Alan Smith introduces fascinating case studies of serious incidents he has been involved in and lessons learned. He is the former Head of Major Crime Operations – Grampian Police, Scotland. As a career detective, he was the lead investigator in numerous homicide investigations. He is a Certified TapRooT® Instructor/Facilitator and has in-depth experience in numerous offshore tragedies including Piper Alpha and the MV Bourbon Dolphin. He is an Accredited Senior Investigator in Counter Terrorism and Kidnap and Ransom. Alan is the former Chair of the Scottish Senior Investigating Officer’s Conference.

Alan will be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit, August 1 & 2, San Antonio. He will also be leading a special session you don’t want to miss: Risk Assessing the Perfect Murder.

It’s not too late to register for the 2016 Global TapRooT® Summit!

How Far Away is Death?

Posted: June 15th, 2016 in Accidents, How Far Away Is Death?, Video

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Special thanks to TapRooT® instructor, Jim Whiting, for sending in the video.

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