Root Cause Analysis Blog

 

Remembering An Accident: Savar Building Collapse

Posted: April 25th, 2018 in Accidents

On April 24, 2013 in Savar Upazila of Dhaka District, Bangladesh a five story commercial building called the Rana Plaza collapsed and killed 1,134 people. On May 13, 2013 rescue efforts where halted and approximately 2,500 people were rescued, but injured from the collapsed building. This incident is considered the deadliest garment-factory accident in recent history. So why did an accident like this happen in modern day? Keep on reading to find out.

The 400 page report exposed multiple causes in why the building collapsed. One of which, the mayor and owners of the building wrongfully granted construction permits to have additional floors built. To make this situation even worse they used substandard materials, and ignored building code violations while constructing the new floors.

In order for the factory to remain efficient the owners had large generators installed on the upper floors, so the factory could keep producing when blackouts occurred. This added lots of strain and weight to the already poorly built upper levels. The report reflects that every time the generators would turn on it would shake the building.

On April 23, cracks began to form in the foundations and walls. An engineer was called in to examine the building and declared it unsafe, but the owners demanded that their works return despite the unsafe working conditions. Then on April 24, 2013 during the morning rush hour the building collapsed.

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes reactively and significant issues that may lead to major problems proactively.

To learn more about our courses and their locations click on the links below.

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

 

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

Posted: April 25th, 2018 in Accidents, investigation, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipo’s” (high potential incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence events. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

 If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometime it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why its is important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

Lunch & Learn: Meet TapRooT® at noon EST today on Facebook Live!

Posted: April 25th, 2018 in Uncategorized

Tune into TapRooT®’s Facebook Live today. You’ll join TapRooT® professionals as we explore a contemporary, workplace-relevant topic. We look forward to being with you on Wednesdays!

Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, April 25

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Is April just a bad month?

Posted: April 24th, 2018 in Accidents, Courses, Pictures, Summit

I was reading a history of industrial/process safety accidents and noticed that all the following happened in April:

Texas city nitrate explosion

April 16, 1947 – 2,200 tons of ammonium nitrate detonates in Texas City, Teas, destroying multiple facilities and killing 581 people.

Deepwater horizon

April 20, 2010 – A blowout, explosions, and fire destroy the Deepwater Horizon, killing 11. This was the worst oil spill in US history.

West texas

April 17, 2013 – 10 tons of ammonium nitrate detonates in West, Texas, destroying most of the town and killing 15 people.

Maybe this is just my selective vision making a trend out of nothing or maybe Spring is a bad time for process safety? I’m sure it is a coincidence but it sure seems strange.

Do you ever notice “trends” that you make you wonder … “Is this really a trend?”

The best way to know is to apply our advanced trending techniques. Watch for our new book coming out this Summer and then plan to attend the course next March prior to the 2019 Global TapRooT® Summit.

We hope to see you at the ASQ 2018 World Conference

Posted: April 23rd, 2018 in Media Room, Meet Our Staff, TapRooT

If you plan to attend the ASQ 2018 World Conference in Seattle, Washington on April 30 – May 2, stop by and say “hello.” Chris Vallee and Dave Janney (pictured left to right) will be at booth #301 discussing how TapRooT® can help you and answer any questions you might have.

 

The first 500 visitors will receive a special prize, so do not miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Hope to see you there!

Monday Accidents & Lessons Learned: Putting Yourself on the Right Side of Survival

Posted: April 23rd, 2018 in Accidents, Current Events, Human Performance, investigation, TapRooT

While building an embankment to circumvent any material from a water supply, a front end loader operator experienced a close call. On March 13, 2018, the operator backed his front end loader over the top of a roadway berm; the loader and operator slipped down the embankment; and the loader landed turning over onto its roof. Fortunately, the operator was wearing his seat belt. He unfastened the seat belt and escaped the upside-down machine through the broken right-side window of the loader door.

Front end loaders are often involved in accidents due to a shift in the machine’s center of gravity. The U.S. Department of Labor Mine Safety and Health Administration (MSHA) documented this incident and issued the statement and best practices below for operating front end loaders.

The size and weight of front end loaders, combined with the limited visibility from the cab, makes the job of backing a front end loader potentially hazardous. To prevent a mishap when operating a front end loader:
• Load the bucket evenly and avoid overloading (refer to the load limits in the operating manual). Keep the bucket low when operating on hills.
• Construct berms or other restraints of adequate height and strength to prevent overtravel and warn operators of hazardous areas.
• Ensure that objects inside of the cab are secured so they don’t become airborne during an accident.
• ALWAYS wear your seatbelt.
• Maintain control of mobile equipment by traveling safe speeds and not
overloading equipment.

We would add the following best practices for loaders:
• Check the manufacturer’s recommendations and supplement appropriate wheel ballast or counterweight.
• Employ maximum stabilizing factors, such as moving the wheels to the widest setting.
• Ensure everyone within range of the loader location is a safe distance away.
• Operate the loader with its load as close to the ground as possible. Should the rear of the tractor tip, its bucket will hit the ground before the tractor tips.

Use the TapRooT® System to put safety first and to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: April 23rd, 2018 in Career Development, Courses, Job Postings, Training

If you are TapRooT® trained, you can count on your education, experience, and expertise to speak volumes about your preparation for successful career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis will communicate confidence and competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step into a brand-new position through one of these global opportunities.

Associate-Senior Engineer Nuclear (Electrical)

Environmental Safety & Health Manager

Integrity Risk Engineer

Manager – EHS/Quality

Patient Safety Analyst Nurse

Pipeline Risk/Integrity Engineer

Regional EHS Director

Regional EHS Director

Reliability Engineer

Senior Process Engineer

Senior Process Engineer (Multiple Unit Technologies)

Specialist – Customer Quality

 

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is clearly the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Pensacola, Florida, April 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Toronto, Canada, May 7, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, May 28, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Perth, Australia, May 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Friday joke

Posted: April 20th, 2018 in Jokes

How far away is death?

Posted: April 19th, 2018 in Accidents, Human Performance

Lockout-tagout fail: Notepaper sign – “Don’t start”

Lunch & Learn: Meet TapRooT® at noon EST on Facebook Live!

Posted: April 18th, 2018 in Career Development, Presentations, TapRooT, Topic of the Week, Video

Tune into TapRooT®’s Facebook Live today. You’ll join TapRooT® professionals as we explore a contemporary, workplace-relevant topic. We look forward to being with you on Wednesdays!

Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, April 18

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Gear up with TapRooT® in Gatlinburg

Posted: April 18th, 2018 in Career Development, Courses, investigation, Local Attractions, TapRooT, Training

In less than a week, learn everything you need to know to conduct an investigation and develop effective Corrective Actions. A TapRooT® course can be a career booster or a professional game changer.

From beginners to experts, TapRooT® Techniques are designed for everyone. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques learned include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

For the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, we’ll gather at Hilton Garden Inn Gatlinburg on June 4. The inn offers out-the-door convenience to local highlights or for a stroll through downtown Gatlinburg.

Experience Gatlinburg
Wrapped by the hazy blue Smoky Mountains, Gatlinburg is beautiful by day and by night. Take a break from your coursework and soak up live music (and maybe some moonshine!) at one of these venues: Smoky Mountain Brewery, Crystelle Creek Restaurant and Grill, Ole Smoky Moonshine Distillery, Sugarlands Distilling Company. If you want to go farther afield, Townsend, Pigeon Forge, and Sevierville have much to offer.

Catch a show at the Space Needle or Sweet Fanny Adams Theatre. Soar up Crockett Mountain on the Gatlinburg Sky Lift by night for one of the best panoramic overlooks of the mountain town. Ascend to Ober Gatlinburg for indoor ice skating, a wildlife encounter, the alpine slide, and a scenic chairlift.

Hiking and biking are great ways to get next to nature in the Smokies. The sky’s the limit here: Cades Cove, Greenbriar, Mount LeConte, Ramsey Cascades, Laurel Falls, and so many more. Drive through Roaring Fork Motor Trail for a true taste of the grandeur of these ancient mountains. Insider’s tip: Roll your car windows down on this motor trail and listen to the force of the water.

Discover gems to explore on our Gatlinburg Pinterest page and plan your TapRooT® trip to Gatlinburg today.

Register here to advance your professional development in beautiful Gatlinburg, Tennessee.

TapRooT® Around the World: Colombia

Posted: April 17th, 2018 in Career Development, Courses, Performance Improvement, Training

Many thanks to Diana Munevar for this TapRooT® training photo from a refresher course at Occidental de Colombia, LLC in Colombia!

Put yourself in this picture. Advance your career and your development through TapRooT® training!

We are global to meet your needs. Register today for a TapRooT® Training course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.

May 2, 2018: Oklahoma City, Oklahoma, 2-Day TapRooT® Root Cause Analysis Training

May 7, 2018: Toronto, Canada, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

May 14, 2018: Cape Town, South Africa, 5-Day Advanced Root Cause Analysis Team Leader Training

May 24, 2018: Pittsburgh, Pennsylvania, 2-Day TapRooT® Root Cause Analysis Training

June 04, 2018: Gatlinburg, Tennessee, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

June 06, 2018: Aberdeen, Scotland, 2-Day TapRooT® Root Cause Analysis Training

June 11, 2018: Denver, Colorado, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

July 16, 2018: Auckland, New Zealand, 2-Day TapRooT® Root Cause Analysis Training

August 08, 2018: Sao Paulo, Brazil, 2-Day TapRooT® Root Cause Analysis Training

August 27, 2018: Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

September 26, 2018: Amsterdam, Netherlands, 2-Day TapRooT® Root Cause Analysis Training

October 14, 2018: Dubai, UAE, 5-Day Advanced Root Cause Analysis Team Leader Training

Are you ready for quality root cause analysis of a precursor incident?

Posted: April 17th, 2018 in Accidents, investigation, Pictures, Root Cause Analysis Tips, TapRooT

Many companies use TapRooT® to investigate major accidents. But investigating a major accident is like closing the barn door after the horse has bolted.

What should you be doing? Quality investigations of incidents that could have been major accidents. We call these precursor incidents. They could have been major accidents if something else had gone wrong, another safeguard had failed, or you were “unlucky” that day.

How do you do a quality investigation of a precursor incident? TapRooT® of course! See the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book.

NewImage

Or attend one of our TapRooT® Root Cause Analysis Courses.

Press Release: TapRooT®’s New Software Update Enhances Tools for Root Cause Analysis Used by Incident Investigators

Posted: April 17th, 2018 in Media Room, Press Releases, Software Updates

 

Incident investigators around the world use TapRooT® software as a central repository for their root cause analysis investigations.

View Press Release.

Evidence Collection: Two things every investigator should know about scene management

Posted: April 17th, 2018 in Accidents, investigation, Investigations, Root Cause Analysis Tips

You may not be part of scene management when an incident occurs at your facility but there are two things every investigator should know:

  1. Hazards that are present in the work area and how to handle them. It’s impossible to anticipate every accident that could happen but we can evaluate hazards that are present at our facilities that could affect employees and the community at large to structure a scene management plan.
  2. Priorities for evidence collection. The opportunity to collect evidence decreases over time. Here are a few things to keep in mind during, and immediately following, scene management.
    • Fragile evidence goes away.
    • Witnesses forget what they saw.
    • Environmental conditions change making it hard to understand why an incident occurred.
    • Clean-up and restart begins; thus, changing the scene from its original state.

Learn more by holding our 1-Day Effective Interviewing & Evidence Collection Training at your facility. It is a standalone course but also fits well with our 2-Day TapRooT® Root Cause Analysis Training. Contact me for details: carr@taproot.com.

 

Testimonial Tuesday

Posted: April 17th, 2018 in Uncategorized

Are you interested in attending one of our TapRooT® courses? Here are some recent comments we received from our clients that have attended a 5-Day or 2-Day TapRooT® Training course.

5-Day TapRooT® Advance Team Leader Training Comments:

  • “It was very useful for me. It was the #1 course among the classes that I have attended, EVER.” – Chang
  • “Excellent course. Highly recommend for any HSE & QA personnel who are involved in Investigations & Audits.” – Sheeth
  • “This is the BEST investigation tool I have come across in my 9 yr. career.” – Usman

2-Day TapRooT® Root Cause Analysis Training Comments:

  • “Excellent for integrating and reinforcing concepts with real events of their own.” – Irma
  • “Became more effective in defining corrective and preventing actions.” – Veronica
  • “Will be a big help in reducing reoccurring incidents by finding the root cause on any incident.” – Todd

 

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location by clicking on the links below.

2-Day Essentials TapRooT® Training
5-Day Advanced Root Cause Analysis TapRooT® Training

Mark Paradies Speaks about Root Cause Analysis at the Gas Processor’s Association

Posted: April 16th, 2018 in Current Events

Screen Shot 2018 04 16 at 11 29 20 AM

Attending the GPA Conference in Austin?

Then attend the Safety Committee Meeting on Tuesday (1:30 – 5:30) and hear Mark Paradies talk about common root cause analysis problems and how you can solve them.

Caption Contest!

Posted: April 16th, 2018 in Uncategorized

Come one, come all!! The new Caption Contest is up and ready. To enter to win all you have to do is follow the instructions below. Contest ends on May 7th and the winner will be announced May 14th. Good luck!!

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest Instructions:
1. Create your caption to the photo above in five words or lessAll captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by May 7, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Have fun!

You’re invited to Facebook Live for Wednesday lunch

Posted: April 16th, 2018 in Career Development, Investigations, Presentations, Root Cause Analysis Tips, Topic of the Week, Video

We invite you to tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a contemporary, workplace-relevant topic. Put a reminder on your calendar, in your phone, or stick a post-it on your forehead to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s how to connect with us for Wednesday’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, April 18, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Be sure to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Monday Accidents & Lessons Learned: We’re not off the runway yet

Posted: April 16th, 2018 in Accidents, Great Human Factors, investigation, Root Causes

NASA’s Aviation Safety Reporting System (ASRS) from time to time shares contemporary experiences to add value to the growth of aviation wisdom, lessons learned, and to spur a freer flow of reported incidents. ASRS receives, processes, and analyzes these voluntarily submitted reports from pilots, air traffic controllers, flight attendants, maintenance personnel, dispatchers, ground personnel, and others regarding actual or potential hazards to safe aviation operations.

We acknowledge that the element of surprise, or the unexpected, can upend even the best flight plan. But, sometimes, what is perceived as an anomaly pales in comparison to a subsequent occurrence. This was the case when an Air Taxi Captain went the second mile to clear his wingtips while taxiing for takeoff. Just as he thought any threat was mitigated, boom! Let’s listen in to his account:

“Taxiing out for the first flight out of ZZZ, weed whacking was taking place on the south side of the taxiway. Watching to make sure my wing cleared two men mowing [around] a taxi light, I looked forward to continue the taxi. An instant later I heard a ‘thump.’ I then pulled off the taxiway onto the inner ramp area and shut down, assuming I’d hit one of the dogs that run around the airport grounds on a regular basis. I was shocked to find a man, face down, on the side of the taxiway. His coworkers surrounded him and helped him to his feet. He was standing erect and steady. He knew his name and the date. Apparently [he was] not injured badly. I attended to my two revenue passengers and returned the aircraft to the main ramp. I secured the aircraft and called [the Operations Center]. An ambulance was summoned for the injured worker. Our ramp agent was a non-revenue passenger on the flight and took pictures of the scene. He stated that none of the workers was wearing a high visibility vest, which I also observed. They seldom have in the past.

“This has been a recurring problem at ZZZ since I first came here. The operation is never [published in the] NOTAMs [for] an uncontrolled airfield. The pilots just have to see and avoid people and animals at all times. I don’t think the person that collided with my wingtip was one of the men I was watching. I think he must have been stooped down in the grass. The only option to [improve the] safety of the situation would be to stop completely until, hopefully, the workers moved well clear of the taxiway. This is one of…many operational deficiencies that we, the pilots, have to deal with at ZZZ on a daily basis.”

We invite you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

How many investigations are enough?

Posted: April 16th, 2018 in Investigations, Root Causes, TapRooT

 

I’d like you to think about this scenario at work.  You’ve just sent your team to Defensive Driving School, and made sure they were trained and practiced on good driving skills.  They were trained on how to respond when the vehicle is sliding, safe following distances, how to respond to inclement weather conditions, etc.

Now that they’re back at work, how many managers would tell their recently-trained employees, “I’m glad we’ve provided you with additional skills to keep yourself safe on those dangerous roads.  Now, I only want you to apply that training when you’re in bad weather conditions.  On sunny days, please don’t worry about it.”  Would you expect them to ONLY use those skills when the roads are snow-covered?  Or ONLY at rush hour?  I think we would all agree that this would be a pretty odd thing to tell your team!

Yet, that’s what I often hear!

I teach TapRooT® courses all over the world. We normally start off the class by asking the students why they’re at the course and what they are expecting to get from the class. I often hear something that goes like this:

“I’m here to get a more structured and accurate root cause analysis process that is easy for my staff to use and gets repeatable results.  I don’t expect to use TapRooT® very often because we don’t have that many incidents,  but when we do, we want to be using a great process.”

Now, don’t get me wrong, I appreciate the sentiment (we don’t expect to have many serious incidents at our company), and we can definitely meet all of the other criteria.  However, it does get a little frustrating to hear that some companies are going to reserve using this fantastic product to only a few incidents each year.  Doesn’t that seem to be a waste of terrific training?  Why would we only want our employees to use their training on the big stuff, but not worry about using that same great training on the smaller stuff?

There are a couple of reasons that I can think of that we have this misconception on when to use TapRooT®:

  • Some managers honestly believe that they don’t have many incidents.  Trust me, they are not looking very hard! Our people (including ourselves) are making mistakes every day.  Wouldn’t it be nice if we went out there, found those small mistakes, and applied TapRooT® to find solid root causes and corrective actions to fix those small issues before they became large incidents?
  • Some people think that it takes too long to do a good RCA.  Instead, they spend time using an inferior investigation technique on smaller problems that doesn’t fix anything anyway.  If you’re going to take time to perform some type of RCA, why waste any time at all on a system that gives you poor results?
  • Some people don’t realize that all training is perishable.  Remember those defensive driving skills?  If you never practice them, do you ever get good at them?

I recognize that you can’t do an RCA on every paper cut that occurs at your facility.  Nobody has the resources for that.  So there must be some level of “incident” at which makes sense to perform a good analysis.  So, how do we figure out this trip point?

Here are some guidelines and tips you can follow to help you figure out what level of problem should be investigated using TapRooT®:

  • First of all, we highly recommend that your investigators perform one TapRooT® investigation at least every month.  Any longer than that, and your investigation skills start becoming dull.  Think about any skill you’ve learned.  “Use it, or lose it.”
    • Keep in mind that this guideline is for each investigator.  If you have 10 investigators, each one should be involved in using TapRooT® at least monthly.  This doesn’t have to be a full investigation, but they should use some of the tools or be involved in an investigation at least every month.
  • Once you figure out how many investigations you should perform each year to keep your team proficient, you can then figure out what level of problem requires a TapRooT® investigation.  Here is an example.
    • Let’s say you have 3 investigators at your company.  You would want them to perform at least one investigation each month.  That would be about 36 investigations each year.  If you have about 20 first aid cases each year, that sounds like a good level to initiate a TapRooT® investigation.  You would update your company policy to say that any first aid case (or more serious) would require a TapRooT® investigation.
    • You should
      also do the same with other issues at the company.  You might find that your trigger points would be:

      • Any first aid report or above
      • Any reportable environmental release
      • Any equipment damage worth more than $100,000
    • When you add them all up, they might be about 36 investigations each year.  You would adjust these levels to match your minimum number to maintain proficiency.
  • At the end of each year, you should do an evaluation of your investigations.  Did we meet our goals?  Did each investigator only do 4 investigations this year?  Then we wasted some opportunities.  Maybe we need to lower our trip points a bit.  Or maybe we need to do more audits and observations, with a quick root cause analysis of those audit results.  Remember, your goal is to have each investigator use TapRooT® in some capacity at least once each month.
  • Note that all of this should be specified in your company’s investigation policy.  Write it down so that it doesn’t get lost.

Performing TapRooT® investigations only on large problems will give you great results.  However, you are missing the opportunity to fix smaller problems early, before they become major issues.

TapRooT®: It’s not just for major issues anymore!

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Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Reporting of ergonomic illnesses increased by up to 40% in…

Ciba Vision, a Novartis Company

Alaska Airlines adopted System Safety and incorporated TapRooT® into the process to find the root causes…

Alaska Airlines
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