Today, Instructor Harry Thorburn delivered his final TapRooT® course. Harry has been an instructor with Matrix Risk Control and System Improvements for the past 5 years. We hate to see him go, but we wish him the best of luck and a happy retirement.
Harry with his final TapRooT® students.
Matrix Director, Mhorvan Sherret, giving Harry a token of appreciation.
The last paragraph of the article was:
“Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.“
So here is what the Aiken Standard wrote about the SRNS root cause analysis:
“Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”
What do you think? Did they look into Management System causes?
If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident?
In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures.
I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes.
This is how a culture of expediency exists alongside a culture of blame.
What can you learn from this incident?
One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame.
Here’s scenario #1:
An incident occurs.
The supervisor performs a 5-Whys analysis, or maybe just does a few interviews with a few employees out on the plant floor. The supervisor collects just enough information to fill out the company report, or to satisfy his manager because this is a task done in his spare time. Once someone or something is found to pin the cause on, the supervisor thinks of a solution, (typically an employee gets disciplined or a piece of equipment gets fixed), and the root cause analysis is complete.
The downside to doing root cause analysis in your spare time like this is you’ll probably see repeat incidents. You’ll miss root causes or not get to the root. So, instead of saving time doing the investigation in your spare time, you have created more work. Plus, you are working within your own knowledge. You may be very experienced, but a bias (and we all have them) can cause you to overlook important information. Also, morale will be affected because employees do not want to live under the fear of punishment if they make a mistake. And let’s not forget when near misses and small problems aren’t solved, chances are a major incident is building on the horizon. Don’t let your facility be the next headline!
Here’s scenario #2:
An incident occurs.
The supervisor performs a TapRooT® investigation in his or her spare time. Her company does not have a blame culture– hooray! She only had time to attend one day of a 2-day TapRooT® course, but the former supervisor showed her the basics. The supervisor uses the Root Cause Tree® as a “pick list,” (without using a Root Cause Tree® Dictionary to dig deeper – she is not even aware there is a dictionary), until one root cause and a couple of causal factors are found. Sigh of relief. Corrective actions to the root cause are implemented. Check! This root cause analysis is complete!
The downside to this TapRooT® “spare time” root cause analysis is similar to scenario #1 in that you will probably experience repeat incidents because you’ll miss root causes that won’t be fixed, and there was not sufficient training on the TapRooT® tools. You may progress beyond your own knowledge in identifying root causes using the Root Cause Tree® and that’s a plus, but you may not be casting a wide enough net by using all of the tools in the TapRooT® system. Take shortcuts and don’t use all the tools available to you, and you will lose the power of TapRooT® to effectively guide you in your root cause analysis to find and fix incidents.
Don’t be that supervisor!
To get the full benefit of TapRooT®, join us at a course to receive all of these tools and understand how to use them:
SnapChart® – a visual technique for collecting and organizing information to understand what happened.
Root Cause Tree® – a way to see beyond your current knowledge (with additional help from the Root Cause Tree® Dictionary)
Corrective Action Helper® – a tool to help you think “outside the box” to develop effective corrective actions.
Safeguard Analysis – identify and confirm causal factors
This is how you find all the root causes and fix them once and for all. Smaller problems are also found before they turn into major disasters. It’s a win for everyone!
Are you doing spare time root cause analysis? There is still time to join us for a course in 2015 and make 2016 a different story.
Had an interesting discussion today about cross industry / cross discipline performance improvement benchmarking.
It seems that many people benchmark inside their industry. Oil industry people benchmark with oil industry people. Heathcare with Healthcare. Nuclear with Nuclear. The list goes on and on.
Also, safety people go to safety conferences. Quality people go to quality conferences. Maintenance and reliability people go to maintenance and reliability conference.
So, I had someone ask me where they could do cross industry/cross discipline benchmarking. Nuclear safety people with Pharmaceutical Quality folks. Aviation safety folks with healthcare quality people. Refining process safety folks with Aviation safety people.
The answer? Plan on attending the 2016 Global TapRooT® Summit on August 1-5 in San Antonio.
We don’t have the final schedule out yet but it will be out soon. But I can guarantee that there will be sessions from all sorts of experts and people attending from all sorts of industries and disciplines. That’s what is so special about the TapRooT® Summit. We make a special effort to get people from different industries and different disciplines together to meet, make friends, and benchmark their improvement initiatives.
So start planning to attend.
There will be people there from all over the world.
And consider bringing a team from your company that includes people from safety, process safety, quality, operations, and maintenance. Contact us by clicking HERE for information about group discounts.
Hope to see someone from every TapRooT® User company (and some folks who are only thinking about using TapRooT®) there!
Join TapRooT® in Lake Charles on December 15 for a 2-Day Incident Investigation and Root Cause Analysis Public Course.
Acadania, the official title for the French Louisiana region. This area is a major cultural and educational center in the Southwest United States. Lake Charles is a diverse area containing a major petrochemical refining center, gaming center, home to McNeese State University, and the Festival Capital of Louisiana, with over 75 festivals held annually. Especially in December, Lake Charles is a great vacation spot with its tropical climate and Southern hospitality.
Tony’s Pizza: A popular Lake Charles pizza place with the areas best salads, pastas, pizzas, Po Boys and more.
Pujo Street Café: Classic Louisiana cuisine as well as a wide selection of burgers and sandwiches. The Shrimp Bisque is a crowd favorite and a Pujo Street Café tradition.
Pats of Henderson: Authentic Cajun kitchen serving Lake Charles for more than 50 years. Gumbos, crawfish, frog legs, and alligator, it doesn’t get more Cajun than that.
Creole Nature Trail: One of the first National Scenic Byways and considered one of America’s “Last Great Wildernesses”. Enjoy this more than 180-mile stretch through Louisiana’s Outback.
Graywood Championship Golf Course: . Named one of Golf Digest’s top 100 public courses in the country, and ESPN ranked it as “extraordinary” in its review of the country’s top golf clubs. It’s a must for all players.
The Mardi Gras Museum of Imperial Calcasieu: This museum features the largest collection of Mardi Gras Costumes on the Gulf Coast. Take in the heart behind Louisiana’s culture.
Want to register? Click here.
Inquire about an Onsite Course here.
Upcoming TapRooT® Public Courses:
Want a course in your region? Inquire about an Onsite Course here.
For more information regarding our public courses around the world, click here.
Upcoming TapRooT® Public Courses:
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.
Still deciding? Watch the video below to hear our Equifactor® instructor, Ken Reed, talk about why this course is right for you.
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
Upcoming Equifactor® Public Courses:
New Orleans, LA
Upcoming Courses in USA:
For more courses around the world, click here.