Root Cause Analysis Blog

 

Onsite TapRooT® Course in Peru

Posted: April 1st, 2015 in Courses, Pictures

TapRooT® Onsite Course in Peru taught by course instructor Marco Flores.

unnamed

unnamed-2

peru

Does your company need an Onsite TapRooT® course? Click here for more information. 

Want to send your employees to a Public TapRooT® course? Click here for dates and locations.

2015 Global TapRooT® Summit After Hours: The Jersey Boys

Posted: March 31st, 2015 in Local Attractions, Summit

Have you registered for the 2015 Global TapRooT® Summit in Las Vegas, NV (June 1 – 5, 2015)? This column highlights some fun things to do after hours.

jerseyboys

Vegas is known for amazing entertainment, and there are several awesome shows to choose from for a fun evening out during Summit Week.

Jersey Boys, Le Theatre Des Arts at Paris Las Vegas, is a true heart-wrenching off-broadway show that will leave you with tears of joy from such a sweet story. The story line isn’t the only highly reviewed aspect of the show, though,  the music and talented quartet are nothing short of exceptional. There’s a reason The Jersey Boys won a Grammy Award for Best Musical Theater in 2007 and four Tony Awards in the Musical category in 2006. If you’re in the mood to see true musical entertainment in the heart of The Strip, this one will not let you down.

Watch a sneak peek here!

And CLICK HERE to register today for the 2015 Global TapRooT® Summit!

Or CLICK HERE for more info about the Summit!

PS – Want to learn more about shows going on during Summit Week? Check out Zarkana by Cirque Du Soleil and Million Dollar Quartet!

Weekly Wisdom: Learn from your mistakes.

Posted: March 31st, 2015 in Wisdom Quote

mistakes are teachers

 

“Mistakes are the best teachers,” -Unkown

TapRooT® Around the World: Lima

Posted: March 31st, 2015 in Courses, TapRooT

TapRooT® Instructor, Marco Flores, sent in this great class photo from Lima.

Lima

We have some awesome training opportunities coming up, including 15 exclusive 2-day courses on every subject from interviewing to stopping human error.  If you missed the recent post, check them out here:  http://www.taproot.com/archives/49008

Global TapRooT® Summit Trivia … Can You Answer These Questions?

Posted: March 30th, 2015 in Pictures, Summit, TapRooT

 

Screen Shot 2015 03 30 at 4 05 42 PM

1. Where was the first TapRooT® Summit (then called the TapRooT® Conference) held?

a) Knoxville

b) Orlando

c) San Antonio

d) Gatlinburg

Screen Shot 2015 03 30 at 4 06 43 PM

2. How many TapRooT® Summits have been held since the first Summit?

a) 18

b) 15

c) 10

d) 6

DSCN0087

3. In what year was the first TapRooT® Summit Held?

a) 1988

b) 1994

c) 1997

d) 2000

DSCN0839

4. Who was presented with the “Most Beloved Speaker” Award?

a) Ed Skompski

b) Mark Paradies

c) Beverly Chiodo

d) ED Hill

Tina  Ken 2

5. Counting this year, how many times has the Global TapRooT® Summit been held in Las Vegas?

a) 1

b) 3

c) 5

d) 7

DSCN0100

6. Where was the largest (by attendance) Global TapRooT® Summit ever held?

a) Austin

b) London

c) Houston

d) Las Vegas

NewImage

7. How was JR Ewing connected to the Global TapRooT® Summit?

a) He invented it.

b) People from his oil company always attend.

c) He was involved in a TapRooT® investigation.

d) A JR look alike attended the TapRooT® Summit reception in 1988 at the Southfork Ranch.

DSCN0129

8. How many Summit Best Practice Tracks are there at this year’s Global TapRoot® Summit?

a) 4

b) 7

c) 9

d) 11

KenPinkShirt2

9. You can customize your Summit schedule by picking topics from different Best Practice Tracks.

a) True

b) False

P1000128

10. Last years Global TapRooT® Summit was held in?

a) Las Vegas

b) Austin

c) Calgary

d) Orlando

 

Check the comments field below for the answers!

And don’t miss the 2015 Global TapRoot® Summit. For more information see:

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

Career Development: Ace the Interview!

Posted: March 30th, 2015 in Career Development, Career Development Tips

So you got an invitation to interview for a job — what now? Time to collect your thoughts to ensure you ace the interview. The first thing you should do is take a few moments to research and take notes on the company. Then take some time to become very familiar with the job description, and make notes on how your skills match it. Also, make a list of questions that you can ask the employer about the position.

Last but not least, get ready for the questions the employer will ask you. The Center for Career Development at Biola University has a list of the top 50 Interview Questions and tips on how to handle them. Learn more here:

https://career.biola.edu/interviewing-2/top-50-interview-questions/

And don’t forget, additional training will open up more career opportunities for you. Check out our upcoming training schedule here:

http://www.taproot.com/courses

UK Rail Accident Investigation Board Investigating a Signal Passed at Danger

Posted: March 27th, 2015 in Accidents, Current Events, Investigations, Pictures

A press release from the UK RAIB:

RAIB is investigating an incident that occurred at 17:25 hrs on Saturday 7 March 2015, in which train reporting number 1Z67, the 16:35 hrs service from Bristol Temple Meads to Southend, passed a signal at danger on the approach to Wootton Bassett junction, Wiltshire. The train subsequently came to a stand across the junction. The signal was being maintained at danger in order to protect the movement of a previous train. However, at the time that the SPAD occurred, this previous train had already passed through the junction and was continuing on its journey. No injuries, damage or derailment occurred as a result of the SPAD.

Wootton Bassett junction is situated between Chippenham and Swindon stations on the Great Western main line and is the point at which the line from Bristol, via Bath, converges with the line from South Wales. It is a double track high speed junction which also features low speed crossovers between the up and down main lines (see figure below for detail).

NewImageWootton Bassett junction in 2012 – the lines shown from left to right are the Up Goods,
Up Badminton, Down Badminton, Up Main and Down Main (image courtesy of Network Rail)

The junction is protected from trains approaching on the up main from Chippenham by signal number SN45, which is equipped with both the Automatic Warning System (AWS) and the Train Protection and Warning System (TPWS). This signal is preceded on the up main by signal SN43, which is also equipped with AWS and TPWS. The maximum permitted line speed for trains approaching the junction from this direction is normally 125 mph. However, on 7 March, a temporary speed restriction (TSR) of 85 mph was in place on the approach to signal SN45. A temporary AWS magnet had been placed on the approach to signal SN43 to warn drivers of this TSR.

Screen Shot 2015 03 27 at 12 28 07 PMA diagram of the layout of Wootton Bassett junction – note that some features have been omitted for clarity (not to scale)

The train which passed signal SN45 at danger consisted of steam locomotive number 34067 ‘Tangmere’, and its tender, coupled to 13 coaches. The locomotive is equipped with AWS and TPWS equipment.
The RAIB’s preliminary examination has shown that, at around 17:24 hrs, train 1Z67 was approaching signal SN43 at 59 mph, when it passed over the temporary AWS magnet associated with the TSR. This created both an audible and visual warning in the locomotive’s cab. However, as the driver did not acknowledge this warning within 2.7 seconds, the AWS system on the locomotive automatically applied the train’s brakes. This brake application should have resulted in the train being brought to a stand. In these circumstances, the railway rule book requires that the driver immediately contact the signaller.

The RAIB has found evidence that the driver of 1Z67 did not bring the train to a stand and contact the signaller after experiencing this brake application. Evidence shows that the driver and fireman instead took an action which cancelled the effect of the AWS braking demand after a short period and a reduction in train speed of only around 8 mph. The action taken also had the effect of making subsequent AWS or TPWS brake demands ineffective.
Shortly after passing the AWS magnet for the TSR, the train passed signal SN43, which was at caution. Although the AWS warning associated with this signal was acknowledged by the driver, the speed of the train was not then reduced appropriately on the approach to the next signal, SN45, which was at danger. Because of the earlier actions of the driver and fireman, the TPWS equipment associated with signal SN45 was unable to control the speed of the train on approach to this signal.

As train 1Z67 approached signal SN45, the driver saw that it was at danger and fully applied the train’s brakes. However, by this point there was insufficient distance remaining to bring the train to a stand before it reached the junction beyond SN45. The train subsequently stopped, standing on both the crossovers and the up and down Badminton lines, at around 17:26 hrs. The signalling system had already set the points at the junction in anticipation of the later movement of 1Z67 across it; this meant that no damage was sustained to either the train or the infrastructure as a result of the SPAD.
The RAIB has found no evidence of any malfunction of the signalling, AWS or TPWS equipment involved in the incident.
The RAIB’s investigation will consider the factors that contributed to signal SN45 being passed at danger, including the position of the temporary AWS magnet associated with the TSR. The investigation will also examine the factors that influenced the actions of the train crew, the adequacy of the safety systems installed on the locomotive and the safety management arrangements. 

RAIB’s investigation is independent of any investigation by the Office of Rail Regulation.

We will publish our findings, including any recommendations to improve safety, at the conclusion of our investigation.

These findings will be available on the our website.

Do Accidents Target a Particular Race?

Posted: March 27th, 2015 in Accidents, Performance Improvement

The Houston Chronicle published an article by Rafael Moure-Eraso of the Chemical Safety Board that was titled: “Hazardous work takes toll on Latinos”.

In the article, Rafael Moure-Eraso claims that Latinos’ “… fatality and injury rates are disproportionately high.” He provides statistics on Latino fatalities and injuries in various industries. He references a report that states the obvious (as many Latinos are recent immigrants, they tend to get lower paying and more dangerous jobs). He also states that latinos are more likely to be at risk as residents near chemical plants (once again, obviously rich people usually don’t site their mansions next to chemical plants and the poor are more likely to buy cheap housing in a less desirable locations – like next door to an industrial site).

The article seems to be a mix of environmental justice political speech and a call for new federal regulations to improve chemical plant safety.

He ends the article with:

You can’t put a price on someone’s life. Latinos help drive the country’s economy working hard for companies big and small, often in dangerous occupations. They have a right to safer workplaces and communities.

That made me think …

  • Are new rights (the right to safety … whatever that is) and new federal programs really the way to improve safety in the workplace? 
  • Do accidents really target specific races? 
  • Would a federally run workplace be safer than those run by commercial companies? 
  • Would safety improve faster with more federal direction?
  • Does the government know better than those in commercial industry how to improve safety?
  • What does management at major companies need to do if they want to avoid a whole new level of “one size fits all” government regulation of process safety and industrial safety?

These are all very interesting questions that take considerable thought. I’d be interested in your opinions. Leave a comment here.

What Pre-Summit Course Should You Attend?

Posted: March 26th, 2015 in Courses, Pictures, Summit, TapRooT

There are 15 potential Pre-Summit Courses to choose from in June and five of the courses are new. That’s probably why so many people are asking which course would be best for them. Therefore, I thought I’d share my thoughts to help people make the best choice.

First, the 15 Courses are:

Next, let me say that I like all these courses. I’ve hand-picked them to be included before the Summit because I think they will help you solve some of your biggest problems. But I understand that you can only attend one of these courses and that you want to pick the best one, so I’ll offer some advice.

DSC00091

If you haven’t attended a TapRooT® Root Cause Analysis Course before, then you should consider attending the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course. This is the basic/starter TapRooT® Course that all investigators/root cause analysts should take. It will make the Summit much more valuable if you understand how the TapRooT® Root Cause Analysis System works. And it will help you perform much better investigations of safety, quality, and production issues. This course (like all Pre-Summit Courses) is completely guaranteed. We know that you and your management will agree that you will find root causes that you previously would have missed and develop much more effective corrective actions.

DSC00076

Need to improve equipment reliability and apply advanced equipment troubleshooting techniques? Then the Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course is for you. You will learn to apply Heinz Bloch’s advanced troubleshooting techniques to understand how equipment failures occurred. You will then learn to take that information, organize it in a SnapCharT®, identify the Causal Factors, and find each Causal Factors root causes using the TapRooT® Root Cause Tree®. Even equipment troubleshooting experts that have attended this course have commented on the helpfulness of the Heinz Bloch troubleshooting tables and the TapRooT® Root Cause Analysis System.

DSC00096

Want to improve your TapRoot® Skills, especially your ability to identify Causal Factors? Then the Advanced Causal Factor Development Course is for you. Ken Turnbull teaches this course using recent examples of accidents, incidents, and near-misses – some straight from the press. You will get lot’s of hands-on exercise practice and instructor feedback.

P1020817

Do you need to learn to trend your safety and performance data? Especially data from infrequently occurring accident statistics? Would you like to prove that you have improved performance? Or do you need to mathematically demonstrate that a “trend” really isn’t a trend, but rather, is just normal process variation? That’s what the Advanced Trending Techniques Course is all about. I developed after I saw a client’s advanced trending best practices that blew me away. This was trending that really worked and showed when a trend was real and when it was just normal process variation. It was based on advanced lean/six sigma techniques that were specially modified for low frequency accident data. But the same techniques can be applied to all your data. It truly is a one size fits all trending program that will help your management focus their improvement initiative. In the course you will learn how to draw advanced graphs and practice your skills so that you can apply the techniques to your data back home. The course is taught by Kevin McManus, a quality/safety guru, and I know that you will find it enlightening and very useful.

IMG 2678

The topic of Safety Culture is a hot button in the nuclear, oil, and aviation industry. If you would like to analyze and improve your safety culture, then the TapRooT® Analyzing and Fixing Safety Culture Issues Course is for you. Brian Tink and Brian Tink (Jr & Sr) will show you how to use TapRooT® Tools along with culture analysis tools to analyze and fix safety culture issues. Part of this course is a practice safety culture analysis for your company. If safety culture is a hot button topic at your company, don’t miss this course.

IMG 2661

Interested in risk assessment and management? Want to learn about the latest international standards and how they can help keep your management out of trouble? Then you need to listen to risk management guru Jim Whiting in his course: Risk Assessment and Management Best Practices. Jim shares all the latest risk management techniques and tons of documentation that you will use when you return to work

P1020822

Interested in applying advanced root cause analysis techniques in a Lean, Six Sigma, or Quality program? Then attend the TapRooT® Quality/Six Sigma/Lean Advanced Root Cause Analysis Training taught by Chris Vallee. Chris is a Six Sigma Black Belt. He will show you how to use TapRooT® Techniques to analyze and fix quality problems, lean waste issues, and problems discovered using Six Sigma techniques.

IMG 2671

Do you provide technical support for the TapRooT® Software? Are you a TapRooT® Software “Power Users” who wants to learn the latest tricks and see the latest software updates? Are you interested in the changes coming in Version 6 of the TapRooT® Software. Are you responsible for setting up the TapRoot® Software and preparing the trending fields and linking the software to other databases? Then you want to attend the Getting the Most from Your TapRooT® Software Course taught by Dan VerLinde, VP for Software Development at SI. You will be amazed how much you learn and how much better your software usage will be.

IMG 2679

What is a hazard? Do you see them before they can cause an accident? If you are interested in Hazard recognition and elimination, then the Hazard Recognition Course is for you. Peter Berkholtz, a TapRoot® Instructor from Australia with 25 years of mining and industrial experience, will teach this practical course. Don’t let hazards sneak up on you. Recognize and eliminate them!

P1020874

Did you know you could use the TapRooT® System to solve problems before they cause a crisis? If you want to stop problems BEFORE they happen, then the Proactive Use of TapRooT® Course is for you! Dave Janney developed this course after realizing that people would rather stop fatalities before they happen rather than investigate fatalities after they happen. He explains how TapRooT® can be applied to improve auditing, observations and BBS, and pre-job hazard assessments. Learn new ways to apply the TapRoot® System to proactively improve performance at your facility.

And now for the new courses …

IMG 2733

Interviewing and Investigation Basics: We’ve taught this course before but after we had so many positive comments about Barbara Phillips talk on Body language and interviewing at last year’s TapRooT® Summit, we decided to completely revise the course adding new material on interviewing, I think you will find this course to be engaging, useful, practical, and a good use of your time if you are interested in effective cognitive interview and non-verbal techniques and the tools and practices needed to collect information for an effective root cause analysis.

P1020852

Combating Fatigue: fatigue in the workplace (and while driving) is one of the most frequent, and least investigated, causes of accidents. Studies of actual auto accidents that were video tapped inside the car for later analysis showed that actual fatigue and sleeping was often NEVER reported but was the cause of the accident. What can you do to fight fatigue at your company? Get great ideas from fatigue expert Bill Sirois. Learn to understand the risks of fatigue. Learn the five levels of defense against fatigue. Learn to build and improve a Fatigue Risk Management System (required in several industries). Understand specific methods to handle fatigue in high hazard industries. This course has been completely updated since it was last given before the 2012 Summit and we see it as completely new.

P1030850 JoelTeaching

Understanding and Stopping Human Error: Mark Paradies, President of System Improvements and Joel Haight, Professor of Industrial Engineering at the University of Pittsburg, will bring their considerable knowledge of the practical application of human factors engineering to this newly developed course. The course will cover the human abilities and limitations that lead to human error, how to understand error likely situations and error causing designs, and how to apply error reducing techniques that work and to understand why some error reducing techniques that are frequently suggested are of little practical value. If you are interested in human performance and stopping human error (or at least reducing it as far as practical), then don’t miss this course.

DSC 0229

Root Cause Analysis for Sentinel Events & Healthcare Quality Improvement: Ed Skompski, Vice President at System Improvements, has created a 2-Day TapRooT® Course especially for the healthcare community that focuses on the analysis of the root causes of sentinell events and healthcare quality issues. The course is built around real clinical events and uses the TapRooT® System, a recognized good practice in the healthcare industry and that the terminology is recognized by The Joint Commission.

100 3138

Creative Corrective Actions: You may remember this course from the past. Michele Lindsay was a TapRooT® Instructor for over a decade. But she now is a performance improvement coach at a healthcare facility. But this year she will be coming back to the TapRooT® Summit and is presenting a new course on creative corrective actions using Dr. Edward de Bono’s Six Thinking Hats™ techniques.

That’s a lot of training to choose from! But don’t wait too long to register. Seats are limited in these courses and we want you to get your first choice!

Additionally, you get a $200 discount on the training when you also attend the 2015 Global TapRooT® Summit. For more Summit info, see:

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

And if you have any questions about the Pre-Summit Courses or the Summit, please call us at 865-539-2139. Or CLICK HERE to drop us a note with your question.

TapRooT® Public Courses in Central and South America

Posted: March 26th, 2015 in Courses

1024px-Centro-Internacional-Bogotá

Bogota, Colombia

Upcoming TapRooT® Public Courses:

Sao Paulo, Brazil 5-Day April 13, 2015 (Language: Portuguese)

Bogota, Colombia 2-Day April 27, 2015 (Language: Spanish)

Bogota, Colombia 3-Day April 27, 2015 (Language: Spanish)

Sao Paulo, Brazil 2-Day May 14, 2015 (Language: Portuguese)

Barrancarbermeja, Colombia 2-Day May 21, 2015 (Language: Spanish)

 

For more information and registration, click here.

 

What does a bad day look like?

Posted: March 26th, 2015 in Accidents, Video

Like this if you are a fire fighter…

UK RAIB Investigates Two Separate Rail Incidents

Posted: March 26th, 2015 in Accidents, Current Events, Investigations, Pictures

The UK Rail Accident Investigation Branch announced the start of two rail incident investigations.

The first is an investigation of the injury of a passenger that fell between a London Underground train while being dragged by the train. See the preliminary information at:

http://www.raib.gov.uk/publications/current_investigations_register/150312_Clapham_South.cfm

 This is an accident that was prevented from being worse by the alert actions of the train’s operator.

NewImage

The second incident was container blown off a freight train. The preliminary information can be found here:

http://www.raib.gov.uk/publications/current_investigations_register/150307_Scout_Green.cfm

How to Navigate our Online Schedule for the 2015 Global TapRooT® Summit

Posted: March 25th, 2015 in Summit, Video

The hardest thing about registering for the 2015 Global TapRooT® Summit (June 1-5, 2015, Las Vegas) is deciding which best practices sessions to sign up for among all the great options. This video will help you navigate our online schedule so that you can begin thinking about it before you go through the actual registration process. The video also gives a couple of tips about how to modify your schedule during the registration process.  If you need assistance, please contact us at info@taproot.com.

Here is the link to the schedule page: http://www.taproot.com/taproot-summit/summit-schedule

TapRooT® Public Courses in Europe, Africa and the Middle East

Posted: March 25th, 2015 in Courses

863px-Amsterdam_Cityscape

Amsterdam, Netherlands

Upcoming TapRooT® Public Courses:

Europe: 

Amsterdam, Netherlands 5-Day April 20, 2015

Paris, France 2-Day April 22, 2015 (Language: French)

London, England 2-Day May 27, 2015

Africa: 

Nairobi, Kenya 5-Day May 4, 2015

Cape Town, South Africa 5-Day May 18,2015

Middle East: 

No Middle East Courses planned for the months of April or May. Stay tuned for new dates soon!

 

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

Monday Accident & Lessons Learned: Texas City Refinery Explosion 10 Year Anniversary

Posted: March 24th, 2015 in Accidents, Performance Improvement, Video

Here’s a CSB video …

What do you think? Has PSM improved in the past ten years? What can we learn?

Is “inherently safer designs” the answer?

Are PSM regulations going to stop accidents?

Are government approaches to PSM inadequate?

Are the suggestions of the CSB inadequate?

Leave your comments here.

Southlake Hospital Staff Live Their Values

Posted: March 24th, 2015 in Best Practice Presentations, Best Practice Presenters, Medical/Healthcare, Summit

Michele Lindsay, President of Performance Potential Inc. and member of the Quality and Risk Department at Southlake Hospital recently shared this awesome video with us. Join Michele at the Global TapRooT® Summit June 1 and 2 for her exclusive 2-Day Creative Corrective Actions Course and sign up for the Improving Healthcare and Patient Quality track June 3 – 5 to attend her best practice session, RCA of Multiple Events, which is a case study of performing root cause analysis on several incidents that appear to be related. Take the opportunity to learn from many incidents that may not trigger a root cause analysis on their own, but collectively provide significant insights into process and system weaknesses so effective corrective actions can be put in place.

Hope you enjoy the video! Learn more about the 2015 Global TapRooT® Summit at:

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

Weekly Wisdom: Never stop learning.

Posted: March 24th, 2015 in Wisdom Quote

know it alls

 

“The dumbest people I know are those who know it all.” -Malcolm Forbes

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips

Editorial Director

Chris ValleeChris Vallee

Six Sigma

Dan VerlindeDan Verlinde

Software Development

Dave JanneyDave Janney

Safety & Quality

Ed SkompskiEd Skompski

Medical

Gabby MillerGabby Miller

Communications Specialist

Ken ReedKen Reed

Equifactor®

Linda UngerLinda Unger

Vice President

Mark ParadiesMark Paradies

Creator of TapRooT®

Steve RaycraftSteve Raycraft

Technical Support

Success Stories

TapRooT® is a key part of our safety improvement program that has helped us stop injuries and save lives.

Canyon Fuel Company

At our phosphate mining and chemical plants located in White…

PCS Phosphate, White Springs, Florida
Contact Us