Root Cause Analysis Blog

 

Do You Follow the Instructions? (Miller Auto Darkening Helments)

Posted: December 19th, 2014 in Current Events, Pictures

A TapRooT® User sent us this warning to distribute …

 Miller Auto Darkening Helmets 

The manufacturer’s safety instructions found in the top of the Miller Auto Darkening Helmet states the following:
Do not weld in the overhead position while using this helmet.

This warning was noticed by Vale employees after reading the warning label in the top of the helmet.

Although auto darkening helmets are an often used tool, they must be used as per manufacturer’s directions and design.

Please see the pictures below for further clarification.

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Friday Joke: Make It So!

Posted: December 19th, 2014 in Jokes, Video

PC World Headline: “Human error root cause of November Microsoft Azure outage”

Posted: December 18th, 2014 in Current Events, Root Causes

There they go again. HUMAN ERROR as a root cause.

See the story at: http://www.pcworld.com/article/2860936/human-error-root-cause-of-november-microsoft-azure-outage.html

Haven’t they read my article at:

http://www.taproot.com/archives/44542

Human error is a symptom, not the root cause.

Attend a TapRooT® Course and find out how you can find and fix the real causes of human error.

TapRooT® Around the World: Antwerp, Belgium

Posted: December 18th, 2014 in Courses, Local Attractions

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Join TapRooT® on February 4-5, 2015 in Antwerp, Belgium for a 2-Day Incident Investigation and Root Cause Analysis Course. Antwerp is the second largest city in Belgium that contains one of the biggest ports in the world, Port of Antwerp, making it known as a global city. Along with the educational, beneficial course TapRooT® is offering, Antwerp is a beautiful, historic city that needs exploring. Many of the buildings have been restored for the public to appreciate since a large portion has been destroyed over the many years of battles and wars. Take in all the history and Root Cause Analysis all in one.

 

Food: 

Caffe Mundi: A small coffee shop that specializes in their fresh, gourmet coffee and lunch menu.

Het Gerecht: The name of this French cuisine restaurant is translated as The Court. Come enjoy a fine dining cuisine like you’ve never had before.

Simply Emily: A quaint little cafe serving only the freshest homemade soups and quiches.

Attraction: 

Central Station: One of the beautiful train stations in all of Europe and voted as one of the top choices of touring by travelers.

Museum aan de Stroom: This museum is an attraction worth visiting to take in it’s beautiful architecture and interesting exhibits.

Steen Castle: Visit a real life castle and study the details of the architecture and the history behind it.

 

Interested in registering for this course? Click here

Want to learn more about our International Public and Onsite courses? Click here

Don’t forget to Save the Date for our upcoming annual Global TapRooT® Summit in June 2015 in Las Vegas. Click here for more information.

TapRooT® Around the World: Central and South America

Posted: December 18th, 2014 in Courses, Pictures

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Sao Paulo, Brazil

Upcoming TapRooT® Public Courses:

Sao Paulo, Brazil 2-Day February 26, 2015 

For more information regarding our public courses around the world, click here.

What does a bad day look like?

Posted: December 18th, 2014 in Pictures

Next time it is snowing, and you think you are having a bad day … it could be worse …

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Keeping TapRooT® Investigations Out of Court

Posted: December 18th, 2014 in Accidents, Investigations, Performance Improvement

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We would all agree that performing accident investigations and investigations of quality issues to prevent repeat accidents is a good idea. But some may be reluctant to perform investigations because of the legal liability they think the investigation report may represent.

Of course, they are at least partially right. Frequently, significant accidents result in lawsuits. And if your investigators aren’t careful, they may put poorly chosen words or even un-true statements in their investigation report. Thus, company counsel or outside counsel may prefer that the actual accident investigation reports be excluded from evidence in a court proceeding to reduce the liability that an accident investigation report may represent.

Excluding a report performed after an accident to look for ways to prevent future accidents is a protected activity under federal law. FRE Rule 407. Subsequent Remedial Measures, states:

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

How can you help preserve your right to exclude your report from discovery and use at trial? Outside counsel for one of our clients has suggested that all TapRooT® users add one of the following preambles or appendices to every TapRooT® Investigation. We thought this sounded like a good idea and so we are passing along the following preambles or appendices for you to consider when writing your investigations….

For safety investigations at a company, the preamble suggested by the attorneys was as follows:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

COMPANY TapRooT® Investigation Preamble

In order improve COMPANY’s overall safety performance and to prevent or significantly reduce the likelihood of the same or a similar work-related incident/injury/illness (“incident”) from reoccurring, COMPANY conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant performance problems and/or equipment failures that may arise from time to time during its operations. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow COMPANY to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within COMPANY’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes COMPANY management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of COMPANY’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures COMPANY may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging COMPANY to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage COMPANY to take, or at least not discourage them from taking steps in furtherance of added safety.

Incidents, injuries and illness may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors and/or vendors. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT® inasmuch as COMPANY management has no control over errors made by these vendors except expected conformance with their duties owed to COMPANY.

Even though COMPANY makes every effort to determine what happened during an incident and to minimize future incidents through the COMPANY investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT® determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside COMPANY retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

For quality investigations subsequent to an issue with a product, the following preamble/appendix is suggested:

– – –

Note:

1. Substitute/insert the correct company name for “COMPANY” throughout, and

2. Add this preamble to every TapRooT® investigative report.

VENDOR TapRooT® Investigation Preamble

In order improve VENDOR’s overall quality performance and to prevent or significantly reduce the likelihood of the same or a similar quality issues from reoccurring which may lead to work-related incident/injury/illness or client related issues (“incident”), VENDOR conducts a TapRooT® systematic investigative approach to incident investigation and analysis to solve significant quality and/or performance problems and/or equipment failures that may arise from time to time during the use or manufacture of its products. TapRooT® is an efficient and effective method that helps to identify best practices and/or missing knowledge related to an incident, which will allow VENDOR to execute/institute lasting fixes faster, thereby increasing reliability thru identification of remedial measures.  TapRooT® reveals root causes, causal factors, events, and/or conditions within VENDOR’s management control so that corrective action can be taken. Said more succinctly, root causes in TapRooT® are causes VENDOR management has control over.  The information generated during a TapRooT® investigation is essential to implementing an effective prevention program under the control of VENDOR’s management by using hindsight analysis of the incident to perform remedial measures.

TapRooT® is a system used to determine subsequent remedial measures VENDOR may take to improve future performance.  This investigation therefore is excluded from evidence under Federal Rule of Evidence 407 based on the policy of encouraging VENDOR to remedy hazardous conditions without fear that their actions will be used as evidence against them, that is, to encourage VENDOR to take, or at least not discourage them from taking steps in furtherance of added safety and quality.

Incidents, injuries, illness, and quality issues may occur as a result of third parties’ conduct.  TapRooT® may not focus on the acts and/or omissions of third parties, contractors, subcontractors, vendors, and/or clients. Errors made by third-parties in design, repair, assembly, installation, construction, etc. are not the focus of TapRooT inasmuch as VENDOR management has no control over errors made by these third parties except expected conformance with their duties owed to VENDOR.

Even though VENDOR makes every effort to determine what happened during an incident and to minimize future incidents through the VENDOR investigative team, TapRooT® is generated in hindsight and does not determine legal cause(s), “but for” causation, or proximate cause(s) of an incident. To infer this from a TapRooT® investigation would be a misuse of the TapRooT® analysis. Instead, TapRooT determines events, conditions and causal factors in the root cause analysis. Each causal factor may have one or more root causes.  Any causal factors and/or recommendations which may be generated in a TapRooT® investigation are based on the investigator/ investigation team’s own views, observation, educated opinions, experience, and qualifications. TapRooT® identifies remedial measures to reduce the probability of events such as the one being investigated from happening in the future.  This information is not intended to replace the advice or opinion of outside VENDOR retained experts who may have more specialized knowledge in an area made the basis of this investigation. Equally important, while information gathered during a TapRooT® investigation is obtained from sources deemed reliable, the accuracy, completeness, reliability, or timeliness of the information is preliminary in nature until the final report is issued. Thus, the findings and/or conclusions of a TapRooT® investigation are subject to change based on information and data gathered during subsequent investigations by experts who may be more focused on legal causation, which is outside the scope of TapRooT®.

(1) FRE Rule 407. Subsequent Remedial Measures

When measures are taken that would have made an earlier injury or harm less likely to occur, evidence of the subsequent measures is not admissible to prove:

  • negligence;
  • culpable conduct;
  • a defect in a product or its design; or
  • a need for a warning or instruction.

But the court may admit this evidence for another purpose, such as impeachment or — if disputed — proving ownership, control, or the feasibility of precautionary measures.

– – –

Of course, before adopting any advice to reduce potential liabilities in future courtroom actions, you should consult your own in-house or outside counsel. They may modify the forms provided above or have other wording that they prefer.

So consider the advice provided above and get your own protective wording added to all your standard reports. We are looking at ways to add this to the TapRooT® Software and we’ll let you know when we’ve figured out a way to do it. Until then, we suggest manually adding the wording to your official final reports.

LAST CHANCE to Lock In Course Rates Before January Price Increase!

Posted: December 17th, 2014 in Courses

Are you planning to take TapRooT® training in 2015? We wanted to let you know course rates will increase January 1, but you can still reserve your seat in a 2015 public course at 2014 rates if you register before midnight, December 31, 2014.

This recent public course in Calgary, Canada is looking good!

This recent public course in Calgary, Canada is looking good!

TapRooT® is not only valued by accident investigators, but is also a valued skill for those who:

  • need to solve quality-related issues
  • have equipment downtime problems
  • experience failure to achieve optimal operational success

Take a look at the course list, and save up to $300 per course by locking in on 2014 rates. Register now:

http://www.taproot.com/courses

Find and Fix the Root Causes of Equipment Related Failures

Posted: December 17th, 2014 in Courses, Equipment/Equifactor®

Don’t end up “fixing” the same equipment problems over and over again. Don’t let equipment issues cause quality, operations, and safety issues. Find the real root causes of your equipment reliability issues and develop effective fixes that will keep them from happening again by using this systematic process.

Did you know that we have 3-day and 1-day courses? What’s the difference? 3-Day Courses include the 1-Day Equifactor® Course along with the 2-Day Incident Investigation and Root Cause Analysis Course so you have it all in one. The 1-Day courses are just the separate Equifactor® course that requires a previously taken 2-Day course along with it, not necessarily all in one trip.

Why take an Equifactor® course? You will not only receive invaluable knowledge for your business, but also a Free single-user copy of TapRooT® Software. (A $2890 Value!) You can’t get a better deal than that.

 

Watch this video for more information regarding Equifactor® course.

 

Steps to register for the course and Free Software.

1) CLICK HERE

2) Select a 1-Day Equifactor® Course of your choice (Having already taken a 2-Day course or accompanying it with a 2-Day course)

3) Register for the course and add it to your cart

4) Done!

 

Upcoming Equifactor® Public Courses:

Las Vegas, Nevada | December 10. 2014

Calgary, Alberta | January 16, 2015

Houston, Texas | March 16, 2015

How Far Away is Death?

Posted: December 16th, 2014 in Pictures

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Can TapRooT® Help You Stop Quality Issues?

Posted: December 16th, 2014 in Performance Improvement, Quality, Root Cause Analysis Tips

Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:

“Can TapRooT® be used to solve quality issues?”

I was surprised by the question. Of course, the answer is YES!

We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.

Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?

The only answer was … We had not told him!

Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors. 

Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.

For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.

That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.

So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!

Attend one of our public 2-Day, 3-Day, or 5-Day TapRooT® Courses and find out how well TapRooT® can help you solve your toughest issues.

Weekly Wisdom for Maintaining An Organization

Posted: December 16th, 2014 in Pictures, Wisdom Quote

live and work quote

“An organization, no matter how well designed, is only as good as the people who live and work in it.” -Dee Hock

Career Development: Why Do You Do What You Do?

Posted: December 16th, 2014 in Career Development, Career Development Tips

Is not your resources that matter, it’s your resourcefulness. The decisions we make today about using (or not using) the skill of resourcefulness are shaping our destinies.

It’s Back! Early-bird Registration Drawing for the 2015 Global TapRooT® Summit!

Posted: December 15th, 2014 in Summit

early birdYou can win a great prize by REGISTERING EARLY for the 2015 Global TapRooT® Summit.

We are giving away an iPad Mini to the 2015 Global TapRooT® Summit early bird prize drawing winner.  An iPad Mini has all the great features of an iPad offering millions of ways to learn, work and play.

To enter the drawing, simply submit your paid Summit registration to our office before the end of February, 2015.

Here’s how you can get the most tickets to win – register for the Summit:

by December 31 and you’ll get 3 tickets plus two BONUS TICKETS for a total of 5 tickets in the drawing.

by January 31 and you’ll get 2 tickets in the drawing.

by February 28 and you’ll get 1 ticket in the drawing.

The early registration drawing will be held at the Kickoff Session, Wednesday, June 3, 2015 at 8:00 a.m. at The Flamingo Las Vegas Hotel (You must be present to win!). This drawing is in addition to the other prize giveaways we have planned for the 2015 Summit.

If you are planning to register for the Summit, don’t delay!  Increase your odds of winning an iPad Mini.

LEARN MORE about the Summit.

TapRooT® Around the World: Canada

Posted: December 15th, 2014 in Courses, Pictures

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St. John’s, Newfoundland, Canada

Upcoming TapRooT® Public Courses:

Calgary 2-Day January 14, 2015

Calgary 3-Day January 14, 2015

St. John’s 2-Day January 19, 2015

Edmonton 5-Day January 19, 2015

Edmonton 2-Day February 12, 2015

Calgary 5-Day February 23, 2015

For more information regarding our public courses around the world, click here.

TapRooT® Around the World: Onsite Course in France

Posted: December 15th, 2014 in Courses, Pictures

Thanks to Harry Thorburn for these photos from a recent Onsite Course in Champagne, France.

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Want more information regarding our Onsite and Public courses around the world? Click Here. 

Monday Accident & Lessons Learned: OPG Safety Alert 262 – Shallow Gas Leads to Well Control Incident

Posted: December 15th, 2014 in Accidents, Current Events, Investigations

SHALLOW GAS LEADS TO WELL CONTROL INCIDENT

  • The well is located in a well-known, shallow gas prone area.
  • Deep gas wells with high pressurized layers.
  • Crowded platforms with wells anti-collision complex management.
  • SIMOPS including construction and well intervention
  • After each incident, procedures for shallow section drilling were enhanced.

The sequence of events were:

  • 0:00 – Skid rig on well. Batch drilled 12 ¼’’ hole section + 9 5/8’’ intermediate casing
  • 08:30 – Cleaned out CP 24’’ with 17 ½’’ BHA to 131m
  • 16:30 – Drilled 12 ¼’’ hole to 286m with 1.15+ SG mud. Heavy losses (67 m3/h)
  • 20:20 – Homogenize mud to 1.12 SG
  • 20:33 – Resume drilling to 296m. Heavy losses (70 m3/h)21:10 – Spot 10m3 LCM pill. POOH wet.
  • 22:20 – Well swabbing and started to flow. Closed diverter. Started pumping 1.12 SG mud at high flow rate.
  • 23:04 – Pumped kill mud 1.50 SG, followed by sea water at high rate.
  • 00:30 – Flow outside CP. Well out of control. Full rig evacuation.

What Went Wrong?

The cause of the incident could be listed as follows:

1. Supervision on rig

  • POOH wet (no pump out)
  • Continue with pulling operations, despite swabbing, until well kicked in. Shallow gas procedure not followed

2. Mud weight

  • Inconsistency in MW control and reporting
  • Pack off at 291m interpreted as a (new) loss zone

3. Documentation

  • No comprehensive instructions concerning total loss situation

Corrective Actions and Recommendations

  • Maintain a continuous awareness on shallow gas hazard, even when the shallow gas section has already been penetrated in other wells. This aims at avoiding routine approach hence complacency.
  • The standard drilling Instructions should be enriched and reinforced with lessons learnt e.g. Management of Change, the required concentration of KCl for the top hole section, the threshold of heavy losses, hole cleaning procedure for the top hole, responsibility assignment for key personnel, ‘Ready to drill’ checklist.

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Safety Alert Number: 262
OGP Safety Alerts http://info.ogp.org.uk/safety/

Friday Joke: Safety Santa

Posted: December 12th, 2014 in Jokes, Pictures

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TapRooT® Around the World: Aberdeen, Scotland

Posted: December 11th, 2014 in Uncategorized

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Have you ever visited Aberdeen, Scotland? Join TapRooT® for a 5-Day Advanced Root Cause Analysis and Team Leader Training Course on January 26-30, 2015. Aberdeen is known for many things in the northeast such as their busy heliports, oil industry, education and seaport. It was also recognized to be a leading business hub and a “super-city” by the HSBC. Along with their outstanding economy, Aberdeen has beautiful Victorian Era architecture. You won’t regret visiting this wonderful city!

Food: 

Mamma Mia: This quaint Italian restaurant serves a little bit of everything with delicious coffee and desserts.

Bite Me: Freshly made, gourmet dishes in a small cafe in Scotland. Give it a try!

Sand Dollar Cafe: A seaside bistro that serves some of the best seafood around.

Attractions:

The Gordon Highlanders Museum: This highly reviews history museum is a tourist and local hit. Learn some interesting Scottish and World history.

Aberdeen Maritime Museum: Interested in boats and sailing the seas? Enjoy a visit to this historical and informational museum.

Craigievar Castle: Take a step back in time and visit a real life castle.

REGISTER HERE for this Aberdeen course.

Click here for more information on other international TapRooT® courses.

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