Root Cause Analysis Blog

 

Friday Joke: Oh Nooo….

Posted: October 31st, 2014 in Jokes, Pictures

Here I thought coffee was supposed to help with the Mondays.

Oh, dear...

TapRooT® Around the World: Course Photos from onsite course in Macae, Brazil

Posted: October 31st, 2014 in Courses, Pictures

 

 

 

Thank you to Boris Risnic for the wonderful pictures of two of our onsite TapRooT® course held in Macae, Brazil.

2014-10-23 10.44.56

2014-10-27 08.53.08

2014-10-24 15.03.47

2014-10-24 14.39.41

2014-10-28 09.58.02

2014-10-28 15.11.14

2014-10-23 10.45.02

2014-10-24 15.24.59

2014-10-23 10.45.10

For more information on our onsite courses and how to register for them, click here.

Forbes Reports: “… Nuclear Navy has the best safety record of any industry.”

Posted: October 30th, 2014 in Current Events, Performance Improvement, Pictures

NewImage

Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:

America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.

And no one ever discusses it.

Well, not no one. We’ve been discussing it for years! And the philosophy that keeps the Nuclear Navy safe is outlined in our Fatality Prevention Course and at the TapRooT® Summit.

See the article at:

http://www.forbes.com/sites/jamesconca/2014/10/28/americas-navy-the-unsung-heroes-of-nuclear-energy/

The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos. 

Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?

Stupid indeed.

Did Retiring Warthogs to “Save Money” Lead to The Recent Friendly Fire Accident In Afganistan?

Posted: October 30th, 2014 in Accidents, Current Events, Investigations, Pictures

NewImage

And interesting article in the Washing Post suggests that using a B-1B for night time close air support and insufficient training led to the death of 7 Americans and 3 allies in a friendly fire accident.

See the story at THIS LINK and see what you think.

TapRooT® Around the World: Cape Town, South Africa

Posted: October 30th, 2014 in Uncategorized

CapeTPano123

 

Among the many reasons to visit Cape Town, South Africa, a TapRooT® Course is one of the best. Join us on December 4, 2014 for a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Public Course and gain the knowledge and ability to help improve your business. According to the New York Times this past year, Cape Town is the best place in the world to visit. The world famous harbour and natural setting in the Cape floral kingdom bring tourists from all over the world to admire its beauty. You’ll fall in love with this city.

Food: 

The Test Kitchen: Looking for something a little different? The Test Kitchen offers a warm atmosphere with genuine flavours prepared by their world-famous chef.

Miller’s Thumb:  This fun, colorful restaurant is sure to show you a good time and feed you delicious, fresh fish.

Myoga: Relaxation can be a key factor when choosing where to eat dinner. Myoga strives to entertain you with their open kitchen and earthy ambience to bring complete relaxation with your meal.

Attractions:

Table Mountain National Park: Cape Town being on the beautiful harbour, opens up their incredible natural attraction to the public for a fun, unique experience.

The Old Biscuit Mill: Located in the heart of Woodstock, The Old Biscuit Mill brings in local artists to show their passions to the public in an intriguing environment.

Two Oceans Aquarium: Bringing the family with you the Cape Town? Spend the day at Two Oceans Aquarium for an exciting, interactive, educational day.

 

Want to know more about our courses or register for one? Click here.

 

What does a bad day look like?

Posted: October 30th, 2014 in Pictures

When you are having a bad day, sometimes others misfortune can make it seem not so bad by comparison…

NewImage

TapRooT® Around the World: Onsite Course in Argentina

Posted: October 28th, 2014 in Courses, Pictures

Thanks to Piedad Colmenares for sending us these great pictures from some recent onsite courses at ENAP and SIPETROL in Argentina.

Foto ENAP - Sipetrol Argentina Comodoro Rivadavia - 1 Foto ENAP - Sipetrol Argentina Rio Gallegos - 3 unnamed Foto ENAP - Sipetrol  Argentina Comodoro Rivadavia -2 Foto ENAP - Sipetrol Argentina Rio Gallegos - 2

Want more information regarding onsite courses or public courses? Click Here.

How Far Away Is Death?

Posted: October 28th, 2014 in How Far Away Is Death?, Pictures

Who would think this was safe?

Who would think this was safe?

8 Reasons to Ask for Help with an Investigation

Posted: October 28th, 2014 in Root Cause Analysis Tips, Root Causes, TapRooT

ReportBinder
People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator.

But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?

Here are eight examples that could help you decide when to ask for help:

1. LEGAL ISSUES

Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.

2. CUSTOMER DISPUTE

It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.

3. UNION ISSUE

Ever had an investigation that gets contentious with a union?

This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.

4. COMPLEX ACCIDENTS

TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.

5. INDEPENDENT INVESTIGATION / NEW SET OF EYES

Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.

6. CONTROVERSIAL INVESTIGATION

I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.

7. COACHING

Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.

8. OVERWHELMED

Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Still not sure? Contact us at: http://www.taproot.com/contact-us for more information.

Weekly Wisdom for Process Improvement and Root Cause Analysis

Posted: October 28th, 2014 in Wisdom Quote

Gates

 

“Your most unhappy customers are your greatest source of learning.” -Bill Gates

Career Development: Five Quick Ways to Become a Better Speaker

Posted: October 28th, 2014 in Career Development, Career Development Tips

Surveys about fear have revealed that we fear public speaking more than death. That’s why there is a joke that goes something like, “If you are at a funeral, it’s better to be in the coffin than the one delivering the eulogy.”

However, there are many things we can learn about public speaking from the masters. Even better, there are many very simple techniques that will captivate the audience every single time.

Take, for example, the pause:

Pause for two or three seconds and the audience assumes you lost your place. Pause for five seconds and the audience begins to think the pause is intentional… and starts wondering why.

Pause for ten seconds and even the people who were busy tweeting can’t resist glancing up.

These days, if you can get someone to look up from his or her phone during your presentation, you’ve pretty much won at public speaking.

Learn four more ways to be a better speaker from Jeff Haden:

5 Ways to Become a Better Speaker Overnight

How Do We Stop the Ebola Blame Game?

Posted: October 27th, 2014 in Accidents, Medical/Healthcare

The media debate about Ebola is subtly shifting from how to stop the spread of this horrific disease to finger pointing. How do we stop the blame game?

A recent analysis & opinion column (Reuters.com), “Why Finger Pointing about Ebola Makes Americans Less Safe,” suggests:

With Ebola, root cause analysis is going to be key to avoid mistakes in the future, but this will require a culture where it is safe to admit to errors.

Read the opinion here:

http://blogs.reuters.com/great-debate/2014/10/27/why-finger-pointing-about-ebola-makes-americans-less-safe/

And let us know what you think by commenting below. How can the healthcare community create a culture where workers are not afraid to self-report mistakes? Do you think root cause analysis is key to stopping Ebola?

Monday Accident & Lessons Learned: UK RAIB Accident Report on a Passenger Becoming Trapped in a Train Door and Dragged a Short Distance at Newcastle Central Station

Posted: October 27th, 2014 in Accidents, Current Events, Investigations, Pictures

Screen Shot 2014 09 18 at 11 33 45 AM

Here is a summary of the report:

At 17:02 hrs on Wednesday 5 June 2013, a passenger was dragged by a train departing from platform 10 at Newcastle Central station. Her wrist was trapped by an external door of the train and she was forced to move beside it to avoid being pulled off her feet. The train reached a maximum speed of around 5 mph (8 km/h) and travelled around 20 metres before coming to a stop. The train’s brakes were applied either by automatic application following a passenger operating the emergency door release handle, or by the driver responding to an emergency signal from the conductor. The conductor, who was in the rear cab, reported that he responded to someone on the platform shouting at him to stop the train. The passenger suffered severe bruising to her wrist.

This accident occurred because the conductor did not carry out a safety check before signalling to the driver that the train could depart. Platform 10 at Newcastle Central is a curved platform and safe dispatch is particularly reliant upon following the correct dispatch procedure including undertaking the pre-dispatch safety checks.

The investigation found that although the doors complied with the applicable train door standard, they were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it. Once the doors were detected as locked, the train was able to move.

In 2004, although the parties involved in the train’s design and its approval for service were aware of this hazard, the risk associated with it was not formally documented or assessed. The train operator undertook a risk assessment in 2010 following reports of passengers becoming trapped. Although they rated the risk as tolerable, the hazard was not recorded in such a way that it could be monitored and reassessed, either on their own fleet or by operators of similar trains.

As a consequence of this incident, RAIB has made six recommendations. One of these is for operators of trains with this door design to assess the risk of injuries and fatalities due to trapping and dragging incidents and take the appropriate action to mitigate the risk.

Two recommendations have been made to the train’s manufacturer. One of these is to reduce the risk of trapping on future door designs, and the other to review its design processes with respect to hazard identification and recording.
One recommendation has been made to the operator of the train involved in this particular accident. This is related to the management of hazards associated with the design of its trains and assessment of the risks of its train dispatch operations.

Two recommendations have been made to RSSB. One is to add guidance to the standard on passenger train doors to raise awareness that it may be possible to overcome door obstruction detection even though doors satisfy the tests specified within the standard. The other recommendation is the consideration of additional data which should be recorded within its national safety management information system to provide more complete data relating to the risk of trapping and dragging incidents.

See the complete report here:

http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf

6,600,000 Preventable Deaths

Posted: October 24th, 2014 in Current Events, Video

What is the key intervention for preventing 6,600,000 death? You may be surprised by this solution, which is also the key intervention for reducing Ebola outbreak. It is the simple act of handwashing with soap. Invest 12 minutes of your time viewing this video and learn about the power of handwashing.

Did you know that TapRooT® is recognized worldwide as a premier “knowledge broker”? Stay in the know with relevant root cause analysis tips by joining our weekly email list:

http://www.taproot.com/contact-us

Some recent tips include:

Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry: (View video.)

Missed Opportunities: (Read post.)

What Makes a World Class Root Cause Analysis System? (View video.)

What does a bad day look like?

Posted: October 23rd, 2014 in Pictures

See, your day seems better already …

Screen Shot 2014 09 04 at 12 14 23 PM

Connect with Us

Filter News

Search News

Authors

Barb PhillipsBarb Phillips
Editorial Director
Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
Information Technology
Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
Equifactor®
Linda UngerLinda Unger
Vice President
Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
Media Specialist
Steve RaycraftSteve Raycraft
Technical Support

Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

We initially started using TapRooT® in 2002 in order to improve the quality…

OCEANEERING
Contact Us