Root Cause Analysis Blog

 

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

Posted: August 15th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, TapRooT, Topic of the Week, Video

Join our Facebook Live session today as TapRooT® professionals Ken Reed and Benna Dortch discuss human factors. As you listen and glean takeaways from this discussion, start making plans to learn even more from the Human Factor Track at the 2019 Global TapRooT® Summit, designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s only part of what you’ll get through attending the Human Factor Track at the 2019 Summit.

Plan ahead to tune in for next week’s Wednesday with FB Live. Put a reminder on your calendar, in your phone, or a post-it on your forehead to tune in for TapRooT®’s FB Live. Dig in with us as we explore a workplace-relevant topic with takeaways. And, as always, feel free to join the discussion via comments on our Facebook page.

Here’s the scoop for tuning in:

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

When? Today, Wednesday, August 15, 2018

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Intelex and TapRooT® Partner to Offer In-Depth Root Cause Analysis

Posted: August 14th, 2018 in Current Events, Media Room, Meet Our Staff, Performance Improvement, Presentations, Quality, TapRooT® Instructor, Topic of the Week, Video

In this video, hear about TapRooT®’s recent partnership with Intelex Technologies, a leading global provider of cloud-based Environmental, Health, Safety and Quality (EHSQ) management software. The integration of Intelex Technologies with TapRooT® allows customers to enter an injury in Intelex, perform a detailed root cause analysis using TapRooT®, and capture the result of the root cause analysis within Intelex. Customers are able to leverage Intelex’s powerful reporting and analytics foresight on injury and root cause data, ultimately producing better decisions and reducing the risk of repeat incidents, injuries and illnesses. The integration will also remove the administrative and record keeping hassle of managing two disparate incident and root cause analysis tools.

About the partnership, TapRooT®’s Vice President and Chief Technology Officer Dan Verlinde said, “We’re excited to establish a partnership with Intelex. TapRooT® and Intelex both create safer work places and help companies achieve operational excellence—that’s why this was an obvious opportunity to collaborate. This partnership will allow our joint customers to realize an integrated Environmental Health and Safety and Root Cause Analysis solution, while reducing duplicate effort.” And, Kristen Duda, Vice President, Strategic Alliances and Partnerships at Intelex, observed of the new integration, “This partnership provides customers with an industry-leading, integrated solution for taking their injury and root cause analysis data to the next level. By leveraging Intelex and TapRooT®, customers can drive impactful proactive safety decisions.”

Connect with us on Wednesdays for TapRooT®’s Facebook Live:

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

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Nashville, TN

Posted: August 17th, 2018 in Courses, Pictures, TapRooT, Training

Thank you Marcus Miller for sending in these fabulous pictures of a recent 2-Day TapRooT® Training course held in Nashville, TN. Looks like everyone is having a great time learning the TapRooT® method!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. To view our upcoming public course click here.

 

 

Friday Joke

Posted: August 17th, 2018 in Jokes

Chris Watts Interview: DeCoding his Nonverbal Behavior

Posted: August 17th, 2018 in Current Events, evidence collection, Investigations

During an investigative interview, an interviewee’s nonverbal behavior will give clues as to whether or not he or she is confident in what he or she is saying. We can’t determine whether someone is lying by his/her body language, but lack of confidence may indicate that the interviewee:

  1. doesn’t remember.
  2. is not sure of what he/she remembers.
  3. is hiding the true story.

These are moments where we, as investigators, want to question and probe further for answers.

The recent news about Shannan Watts and her children is tragic and incomprehensible. After watching the Chris Watts interview (which occurred shortly after his wife and daughters went missing but before their bodies were recovered), I noted these red flags.

  1. Just 34 seconds into the interview his mouth becomes very dry. We know this because he licks his lips. This occurs again at 1:22. There are some things we can control about body language; other things, like things we do when dry mouth occurs when we are extremely nervous, are controlled by the oldest human brain system, the reptilian brain. We can’t cover it up. Investigators, when you notice someone licking his/her lips or swallowing hard during an interview, the question should be, “What could the interviewee be nervous about?” It’s not necessarily an indication of lying (you can’t prove a lie with body language); however, it is a flag that the interviewee is unusually nervous. This is early in the interview – note whether he becomes more uncomfortable or more comfortable. Typically, in an investigative interview, an interviewee will show some cues of discomfort in the beginning, and then show more relaxed, less guarded nonverbal cues as the interview progresses.
  2. At around 1:26 minutes, as he spells the names of his daughter Celeste, he closes his eyes. This is a blocking behavior. It may indicate, “I can’t look at this.” It may be a response that comes from him truly knowing what happened to his daughter and not wanting to “see” it. After spelling her name, he swallows hard. Investigators: when an interviewee closes his/her eyes, note the words he/she is saying. Ask, “What does this person not want to see?” We commonly see this behavior when an employee witnesses a traumatic event, such as a serious injury or death on the job, and is retelling it. Also, note when nonverbal communication signals are thrown off in rapid succession. That is a reliable sign that you need to do follow-up questions on that part of the interview.
  3. After he says “Bella is four, Celeste is three,” we see that he compresses his lips. (He draws them inward and they seem to disappear.) This is sometimes a sign that an interviewee is holding something back. Investigators, when you note this behavior, gently probe for more information. The interviewee may be keeping information he/she is unsure about providing. Assure the interviewee that no detail is too small to report.
  4. At 1:52 minutes he touches the side (the bulb) of his nose. Touching or covering the nose is sometimes a body language sign that the interviewee is not certain of what he is saying and is nervous about how it will be received. There are many nerve endings in the nose, so the nose tingles under stress. We may touch it without thinking about what we are doing or why we are doing it. Investigators – this may occur because the interviewee doesn’t remember, is not sure about what he/she remembers, or he/she does remember and is attempting to cover something up. Always note when an interviewee brings his/her hands to his/her face, listening carefully to the words that are being spoken at that moment. Gently probe for more information.
  5. At around 2:20 minutes, when he is telling the interviewer he hopes his wife is somewhere safe, it is interesting to note his facial expression doesn’t match what he is saying. If your loved one is missing and you are hoping he/she is safe, would you have a pleasant, almost smiling, expression? Investigators – when evaluating an interviewee’s statement, does his/her facial expression match what his/her words are saying? If it doesn’t match, what is the interviewee trying to hide by masking his/her expression? He goes on to talk about how he misses his children, with the same pleasant expression, and when he says, “it was tearing me apart” he closes his eyes again, displaying blocking behavior.
  6. 3:53 Again, licking his lips due to dry mouth at, “I just want everybody to come home” after talking about missing his wife and children.
  7. 3:55 – 4:03 Extended lip compression at “Whereever they are at, come home. That’s what I want.”
  8. The camera pans off of him for a few seconds, and when it returns we see he is crossing his arms. The way he is crossing his arms makes me feel he is not defending himself, but comforting himself. He looks like he is cradling himself. Occasionally he will move his left arm, but immediately returns it to cradling. Investigators – self-comforting is a non-verbal behavior to note. Why does the interviewee need to self-comfort?
  9. 5:00 He states, “I just want them back” and laughs. Again, laughter is not an emotion you would expect from a worried husband and father. Investigators – note when an interviewee’s laughter or facial expression doesn’t match his/her words.
  10. At around six minutes, when the interviewer asks about what the police are saying, he licks his lips again and swallows hard, indicating continued discomfort.
  11. At 6:48 there is extended lip compression, and he licks his lips again as he describes how police looked for surveillance cameras in the neighborhood but find nothing. This may indicate that he is concerned about the police looking for evidence.
  12. At around seven minutes when the interviewer asks him what he would say to his wife if he could, he closes his eyes after he says his wife’s name (blocking behavior). He is also shaking his head “no” even though the words he is saying would align with a “yes” nod. This may indicate that he knows they are not coming back. Investigators – note when an interviewee shakes his/her head “yes” or “no.” Do the words match “yes” or “no”? These clues appear in rapid succession and should be analyzed.

After watching this short interview once, I identified these nonverbal behaviors that made me question the validity of his story.  Never rely solely on the words an interviewee says. Evaluate whether his/her mood matches the words, and carefully note each body language signal that indicates what he/she just stated may need to be probed further.

If you investigate accidents and incidents, and would like to learn more about interviewing techniques to solve problems at your facility, contact us at editor@taproot.com. We offer onsite and public courses.

Strange Aviation Incident

Posted: August 16th, 2018 in Accidents, Current Events, Video

Imagine your corporate safety investigation of this…

Technically Speaking – Help Desk Humor

Posted: August 16th, 2018 in Technical Support, Technically Speaking

When the instructions are just not clear enough and you find your self in a load of laundry.

Click HERE to find a TapRooT® course near you to learn how to identify the Root Cause.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Can Your Management Learn?

Posted: August 15th, 2018 in Human Performance, Performance Improvement, Pictures

Challenger

Long ago, my boss was tasked with reviewing the Challenger space shuttle accident for lessons learned for a major chemical company. I assisted him and his conclusion was that all the same management system causes were present at our company.

He had a dilemma. How should he present this to senior management? He would be presenting to the company President and all the Senior Vice Presidents. He knew they were NOT expecting to here that they had problems. This might severely hurt his career.

He decided to just present the “facts” and that they would reach the same conclusions that he did.

He made the presentation. I was there. At the end, the President of the company thanked him for his hard work and said to everyone else that it was good that there was no similarities between NASA’s management and our company’s management. In other words, no lessons for us.

So much for just presenting the facts.

Why didn’t senior management reach the same conclusions that my boss did when presented with the same facts? The problem was that our management couldn’t critically review their own management systems. They thought that they were doing great and any other feedback was outside their paradigm. They were not being self-critical. They could not face the facts. And no one else was willing to tell them that they needed to improve (lot’s of “yes men” around them).

Of course, NASA’s management didn’t learn their lesson. They went on to have the Colombia shuttle accident because they didn’t learn from their experience and could not face the facts.

Another example of management not being able to learn was the BP’s management after the BP Texas City Refinery explosion.

First, they had a hard time getting past blaming the operators and supervisors (five were fired). There was an internal BP group (the Bonse report – see Bonse Main Report.pdf) that recommended management discipline (blaming the lower levels of senior management). However, no immediate disciplinary action was taken. Within two years, all the senior line management from the Refinery General Manager to the CEO were gone (none were fired immediately as part of the incident response). So the ability of that management to learn didn’t make any difference – they were gone!

However, managers on the upstream (exploration and production) side of the organization, didn’t seem to learn from the the accident on the downstream side of the organization. The result? The BP Deepwater Horizon accident happened because of failure to apply process safety lessons learned to the management of exploration operations.

These examples of failures to learn are the reasons why I ask the question in the title of this article:

Can your management learn?

That brings up the question:

What should managers do to learn?

Here are some ideas…

First, management has to be self-critical. Instead of blaming people at the pointy end of the stick (operators, maintenance people, and supervisors), they should say…

What did we do to cause this incident?
What should we do differently to prevent future incidents?

Being self-critical also means understanding Rickover’s “Facing the Facts” concept. See more about that concept at:

http://www.taproot.com/archives/53656

Second, senior management needs to understand root cause analysis. This may be more common today than it was thirty plus years ago because more senior managers have had some experience with advanced root cause systems (TapRooT®). They need to understand their (management’s) impact on management systems and their impact on investigations and implementation of corrective actions.

Management may also need to understand advanced trending concepts (we are publishing a book later this year about this) to be able to learn from their company’s statistics (or at least be critical of presentations about statistics).

What ideas do you have? Leave them as comments to share with others.

Monday Accidents & Lessons Learned: An Assumption Can Lead You to Being All Wet

Posted: August 13th, 2018 in Accidents, Great Human Factors, Human Performance

IOGP Well Control Incident Lesson Sharing

The International Association of Oil & Gas Producers (IOGP) is the voice of the global upstream oil and gas industry. The industry of oil and gas provides a significant proportion of the world’s energy to meet growing demands for heat, light, and transport. IOGP members produce 40 percent of the world’s oil and gas, operating in the Americas, Africa, Europe, the Middle East, the Caspian, Asia, and Australia.

IOGP shares a Well Control Incident Lesson Sharing report recounting a breakdown in communication, preparation and monitoring, and process control. Importantly, through the findings, we identify that the overarching project plan was erroneously based on the expectation, albeit assumption, that the reservoir was depleted. Let’s track this incident:

What happened?
In a field subjected to water flooding, when drilling through shales and expecting to enter a depleted reservoir, gas readings suddenly increased. Subsequently, the mud weight was increased, the well was shut-in, and the drill string became stuck when the hole collapsed during kill operations. Water-flood break-through risks were not communicated to the drill crew, and the drill crew failed to adequately monitor the well during connections. The loss of well control, hole, and drill string was due to poor communication and well-monitoring.

  • Drilling 8″1/2 x 9″1/2 hole with 1.30SG mud weight (MW) at 2248m – this mud density is used to drill the top section shales for borehole stability purpose
  • Crossed an identified sands layer which was expected to be sub-hydrostatic (0.5SG)
  • Observed a connection gas reading up to 60% + pack off tendency.
  • Increased mud weight by step to 1.35SG but gas readings were still high
  • Decided to shut the well in and observed pressure in the well SIDP 400 psi – SICP 510 psi
  • A Gain of +/- 10m3 was estimated later (by postmortem analysis of the previous pipe connection and pump-off logs)
  • Performed Driller’s Method and killed the well by displacing 1.51 SG kill mud
  • Open hole collapsed during circulation with the consequence of string getting stuck and kick zone isolated

What went wrong? 
The reservoir was expected to be depleted. This part of the field was artificially over-pressurized by a water injector well. This was not identified during the well preparation phase. and the risk was not transmitted to the drilling teams. Lack of crew vigilance. Poor well monitoring during DP connections. The high connection gas observed at surface were the result of a crude contamination in the mud system. Significant gain volumes were taken during the previous pipe connections without being detected.

Corrective actions and recommendations 
-The incident was shared with drilling personnel and used for training purposes.

-Shared the experience and emphasized to reinforce the well preparation process with a rigorous risk identification: the hazard related to a continuous injection in a mature field to be emphasized.

-Reinforce well monitoring. Specifically, during pipe connections.

-Review mapping of injection on the field.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and 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.

Weekly Wisdom

Posted: August 13th, 2018 in Career Development, Wisdom Quote

 

Career Opportunities for Candidates with TapRooT® Skills

Posted: August 13th, 2018 in Career Development, Courses, Job Postings, Performance Improvement, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Specialist HES Operations

Senior Process Engineer

HSE Technical & Administrative Assistant 

Patient Safety Analyst

HES Drilling Specialist

Safety Specialist/Safety Officer 

Service Specialist

HSE Associate Coordinator

Service Operator 

Associate- Senior Engineer Nuclear

Site Safety Coordinator

Safety Coordinator

Nurse

Senior Safety Advisor

Specialist HSE

SHE Coordinator

Project Operations Manager 

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

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, August 31, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Atlanta, Georgia: September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Friday joke

Posted: August 10th, 2018 in Jokes

No matter how it’s spelled, you heard him.

Technically Speaking – TapRooT® VI Attachments & Reports

Posted: August 9th, 2018 in Software, Software, Technical Support, Technically Speaking, Video

We’ve had a couple questions lately about adding attachments to a report so I thought a video detailing the process wpuld be beneficial to our users.

What’s Wrong with Pharmaceutical Root Cause Analysis?

Posted: August 8th, 2018 in Current Events, Investigations, Root Cause Analysis Tips, Root Causes

Pharma

I was forwarded a copy of an interesting letter about American and Canadian Standards Boards with certifying bodies rejecting pharmaceutical quality incident reports because of poor root cause analysis. It stated that 90% of the rejections of reports were due to three types of root causes that were unacceptable (and I quote):

  1. Employee Error / Human Error / Operator Error OR anyone else who made an error is not an acceptable root cause – Was the training ineffective?  Was the procedure too vague?
  2. Misunderstood the requirement / Did not know it was a requirement / Our consultant told us this was ok OR any other misunderstandings is not an acceptable root cause.  Was the training effective?
  3. We had a layoff / Mona was on maternity leave / we moved locations / we scaled back production / we are still closing out Wayne’s 40 deviations from the last audit OR most other employee or business conditions are not acceptable root causes  They are DIRECT CAUSES.

The letter proposed four rules to follow with all future submissions:

  1. RULE #1:  The root cause can not be a re-statement of the deviation.  Example:  Deviation – Company XYZ did not document Preventive Actions as required by procedure.  Root Cause – We did not document Preventive Actions as required by the procedure.
  2. RULE #2:  There can not be an obvious “Why” that can be easily answered to the provided root cause – in this case they have not gone deep enough.  Example: Root Cause – The purchasing coordinator made a mistake and did not check to see if the supplier was approved.  Obvious “WHY” Was the training effective?  Did the procedure provide enough detail in this area?
  3. RULE #3:  The root cause can not be a direct cause.  Example:  Deviation – There were a number of internal audits scheduled for 2008 that were not completed.  Root Cause – We had a layoff and we did not have enough Internal Auditors to conduct the audits.
  4. RULE #4:  The root cause is a brief description of the cause of the problem.  We do not want any long stories regarding direct causes or what they are doing well even though this happened or who said what.  This is un-necessary detail and only adds confusion.

Wow! I would have thought this guidance would not be necessary. Are responses to quality incidents really this poor? Or is this letter a fake?

No wonder TapRooT® Users have no problem getting approvals for their root cause analysis. None of these problems would happen with any investigation using TapRooT®.

Why would TapRooT® Users never stop at the three causes listed above? Because they would understand that some are Causal Factors (the start of the root cause analysis) and they would have guidance provided by the Root Cause Tree® Diagram to help them find the real, fixable root causes of human performance and equipment failure related problems. This includes analyzing things like “internal audits not completed”; “human error”; and “misunderstood requirements.”

In addition, the TapRooT® Software helps investigators develop concise custom reports that only includes the details needed to understand what happened, how it happened, the root causes, and the effective corrective actions needed to prevent recurrence.

If you are in the pharmaceutical industry and you want to stop having problems with root cause analysis and want to start having effective investigations, root cause analysis, and fixes for problems, attend our TapRooT® Training and learn how simple advanced root cause analysis is.

Tune in Today: TapRooT® Has News You Can Use, Noon EST

Posted: August 8th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, Topic of the Week, Video

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

We ‘re excited to be with you on Wednesdays! Feel free to add comments on TapRoot®’s Facebook page during the discussion. Here’s how to connect with us for today’s Facebook Live:

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

When? Wednesday, August 8

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Onsite, Topaz Marine, Baku, Azerbaijan

Posted: August 7th, 2018 in Career Development, Courses, Human Performance, Investigations, Meet Our Staff, Performance Improvement, Pictures, TapRooT® Instructor, Training

Enjoy a glimpse into a recent 2-Day TapRooT® Root Cause Analysis Training, held onsite at Topaz Marine, in Baku, Azerbaijan, taught by TapRooT® instructor Per Ohstrom. We appreciate Per passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Adealaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Tune in Tomorrow for TapRooT®’s Facebook Live, Noon EST

Posted: August 7th, 2018 in Career Development Tips, Human Performance, Meet Our Staff, Performance Improvement, Topic of the Week, Video

It’s TapRooT® time! Join us tomorrow at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

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

When? Wednesday, August 8

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Monday Accidents & Lessons Learned: Dumping the Electronic Flight Bag En Route

Posted: August 6th, 2018 in Accidents, Career Development Tips, Great Human Factors, Human Performance, Performance Improvement

The electronic flight bag (EFB) has demonstrated improved capability to display aviation information such as airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance. This portable electronic hardware has proven facilitative for flight crews in efficiently performing management tasks. While the EFB provides many advantages and extensive improvements for the aviation community in general and for pilots specifically, some unexpected operational threats have surfaced.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. Today’s particular instance relates to EFB operation in a particular phase of flight:

An ERJ175 pilot attempted to expand the EFB display during light turbulence. Difficulties stemming from the turbulence and marginal EFB location rendered the EFB unusable, so the pilot chose to disregard the EFB entirely.

“We were on short final, perhaps 2,000 feet above field elevation. [It had been a] short and busy flight. I attempted to zoom in to the Jepp Chart, currently displayed on my EFB, to reference some information. The EFB would not respond to my zooming gestures. After multiple attempts, the device swapped pages to a different chart. I was able to get back to the approach page but could not read it without zooming. I attempted to zoom again but, with the light turbulence, I could not hold my arm steady enough to zoom. [There is] no place to rest your arm to steady your hand because of the poor mounting location on the ERJ175.

“After several seconds of getting distracted by…this EFB device, I realized that I was … heads-down for way too long and not paying enough attention to the more important things (e.g., acting as PM). I did not have the information I needed from the EFB. I had inadvertently gotten the EFB onto a company information page, which is bright white rather than the dark nighttime pages, so I turned off my EFB and continued the landing in VMC without the use of my EFB. I asked the PF to go extra slowly clearing the runway to allow me some time to get the taxi chart up after landing.

“… I understand that the EFB is new and there are bugs. This goes way beyond the growing pains. The basic usability is unreliable and distracting. In the cockpit, the device is nearly three feet away from the pilot’s face, mounted almost vertically, at a height level with your knees. All [EFB] gestures in the airplane must be made from the shoulder, not the wrist. Add some turbulence to that, and you have a significant heads-down distraction in the cockpit.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes of some common problems that pilots have experienced. In this issue, we learned about precursor events that have occurred during the EFB’s adolescence.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend situations and find and fix problems. Attend one of our courses. Among our offerings are 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: August 6th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Associate- Senior Engineer Nuclear

Site Safety Coordinator

Safety Coordinator

Senior Safety Advisor

Specialist HSE

SHE Coordinator

Project Operations Manager 

Patient Safety Analyst

Quality Inspector

Field Operations Excellence Leader 

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

Nashville, Tennessee, August 13, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

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

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Sao Paulo, Brazil

Posted: August 3rd, 2018 in Career Development, Courses, Human Performance, Meet Our Staff, Pictures

Here’s a peek into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil, taught by TapRooT® instructors Boris Risnic and Marcelo Marquez. Many thanks to Marcelo for passing along these insightful images!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Adealaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around The World: Bogota, Colombia

Posted: August 3rd, 2018 in Career Development, Courses, Pictures

Many thanks to, Diana Munevar, for sending in these great course photos from last weeks TapRooT® Training class in Bogota, Colombia.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Click here to view some of our upcoming courses.

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