Root Cause Analysis Blog

 

TapRooT® Around the World: Athens, Greece Onsite Course

Posted: October 20th, 2014 in Uncategorized

Thank you to Harry Thorburn for sending us these great pictures from the most recent Onsite Course in Athens, Greece.

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Visit our website for more information on our Onsite and Public Courses.

SAVE THE DATE for the 2015 Global TapRooT® Summit

Posted: October 20th, 2014 in Summit

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Be proactive in gaining valuable new skills to improve safety, equipment reliability, operations, and quality. Mark your calendar for June 1 – 5, 2015, and get your budget approved for the 2015 Global TapRooT® Summit.

Where will the Summit be held? The Summit will be held at The Flamingo Las Vegas Hotel. Learn more about the location and determine your budget for travel.

What are the costs for registration? Budget $995 for the Summit, $1295 for a pre-Summit course or budget $2,090 for the Summit and a pre-Summit Course (a $200 savings!).

Summit attendees share experience, learn to apply the latest research, and meet in small groups (best practice sessions) with leading industry experts to share information and ideas across industry and organizational boundaries. The best practice sessions are organized under Best Practice Tracks to make it easier for attendees to create their Summit schedules. The 9 Best Practice Tracks planned for 2015 are:

1. Equipment Reliability Improvement & Troubleshooting

2. Human Error Reduction & Behavior Change

3. Improving Healthcare Quality & Patient Safety

4. Incident Investigation and Root Cause Analysis

5. Process Quality and Corrective Action Programs

6. Safety Improvement

7. TapRooT® Software

8. Certified TapRooT® Instructor

9. Special Topics

But the Best Practice Tracks are not set in stone. Each person that registers has the opportunity to create a custom track.

So, SAVE THE DATE, start thinking about which sessions you’d like to attend, get your registration fees and travel plans in the budget.

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We are pleased to announce that Richard Phillips, Real Life Inspiration for the Movie Captain Phillips, Starring Tom Hanks; Author, A Captain’s Duty: Somali Pirates, Navy SEALs, and Dangerous Days at Sea has confirmed to be our Keynote Speaker on Friday, June 5, 2015!

 

Watch for more info in upcoming newsletters and in the future Root Cause Analysis Blog posts.

Visit the Summit website for more info.

Monday Motivation: Keep Calm

Posted: October 20th, 2014 in Pictures

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Root Cause Analysis Tips: 2014 Global TapRooT® Summit Attendees Share Favorite Aspects from the Summit

Posted: October 17th, 2014 in Courses, Summit, Testimonials, Video

Rich Horan from PPL Electric Utilities shared some of his favorite aspects of the 2014 Global TapRooT® Summit in Horseshoe Bay, TX. Listen to what content he enjoyed most and what he will be taking back to his workplace to implement some of the Best Practices shared at the Summit.

Don’t have time for the whole video? Read below some questions we asked him and what he had to say.

How did you like the Summit? 

“I loved it! Very well organized. It was my first Summit and from the beginning right up to the end today it was very enjoyable and very nice to meet a lot of the people looking for the same experience and networking.”

What was your favorite session? 

“I would have to say the Best Practices and Learning. It was very interactive but there was a lot we walked away with, that I walked away with that get to take back to my work place and apply some of those lessons learned. So, I would have to say that was the better session of all of them.”

Can you think of any of those Best Practices that you’d like to share with us?

“The corrective actions and the effectiveness reviews. So the quality of the investigation is important but most important is the corrective actions and the effectiveness review as far as a follow up to see if there is some quality in those investigations.”

Did you attend the reception? How did you enjoy that? 

“Well, it was absolutely wonderful. It was a good way to break away and meet some people. There was beautiful weather, good music, and probably one of the better receptions I’ve been to in some of the conferences over the years, so, well done!”

How was the networking and the people that you met here? 

“I think that networking is very important and from that, learning what others are doing and sharing what I have done in the past two years as a TapRooT® instructor. So, very valuable to meet other people and continue that networking after the conference.”

For more information regarding the upcoming 2015 Global TapRooT® Summit in June, click here.

Friday Joke: Programmer Joke

Posted: October 17th, 2014 in Jokes

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The programmer’s wife tells him: “Run to the store and pick up a loaf of bread. If they have eggs, get a dozen.”

The programmer comes home with 12 loaves of bread.

What does a bad day look like?

Posted: October 16th, 2014 in Pictures

Your day isn’t so bad after all…

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Root Cause Analysis Video Tips: How TapRooT® Can Help with The Joint Commission Requirements

Posted: October 15th, 2014 in Medical/Healthcare, Root Cause Analysis Tips, Video

This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.

Click here for more information regarding our TapRooT® courses around the world.

And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.

 

Career Development: LinkedIn – 3 Tips to Optimize Your Personal Profile

Posted: October 15th, 2014 in Career Development, Career Development Tips

Do you wish you could use your LinkedIn profile to find a new job or network to get more business for your current job? Here are 3 tips that will optimize your personal profile and make these wishes more likely to come true.

1. Add a profile picture (it will make your profile 7 times more likely to get noticed). Don’t just upload any profile picture, choose a clear photo of your face that is appropriate for business networking.

2. Get recommendations. LinkedIn offers tools that make it so easy to request recommendations. Go to your profile and click the dropdown menu next to “Complete your profile.” Choose “Ask to be recommended,” and you will be guided through a series of prompts to complete your first recommendation request. Painless!

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3. Customize your profile URL.  Customize your URL with your name to help search engines identify you. (Learn how).

Why not take ten minutes to invest in your career development? A few tweaks to your LinkedIn profile will help you become more visible and lend greater credibility to your professional image.

Monday Accident & Lessons Learned: Remove the Hazard – Snow & Ice Removal

Posted: October 13th, 2014 in Accidents, Current Events, Performance Improvement, Pictures

What do you have planned to keep walkways clear this winter?

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Monday Motivation: Make Things Happen!

Posted: October 13th, 2014 in Pictures

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See Andrew G. Rosen’s  “7 Ways to Get Motivated” at:

http://www.drewrosen.com/7-ways-i-get-motivated/

Weekly Wisdom for Root Cause Failure Analysis

Posted: October 13th, 2014 in Wisdom Quote

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“Look beyond the failure of others.” – Jeremy Gutsche, Exploiting Chaos

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Attendees Share Favorite Aspects of the Summit

Posted: October 10th, 2014 in Courses, Summit, Testimonials, Video

Juan Silva attended the 2014 Global TapRooT® Summit this past April in Horseshoe Bay, Texas and shared with us his favorite aspects, best practices and sessions in Spanish.

Click here to learn more about the upcoming Global TapRooT® Summit in Las Vegas June 1-5.

Can You Still Get TapRooT® Training in 2014?

Posted: October 10th, 2014 in Courses, TapRooT

YES!

There is still time to get TapRooT® Training scheduled either at your site or for you to attend a public TapRooT® Root Cause Analysis Course

For training at your site, you need to call us (865-539-2139) or CLICK HERE to drop us a note. We still have a few dates open in November and December but you need to get your training scheduled soon or all the 2014 training dates will be full.

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For our public TapRooT® Courses, you can see the entire worldwide list of courses remaining for 2014 and the first half of 2015 at:

http://www.taproot.com/store/Courses/

 Or you can click on a particular continent to see the courses being held there. Or just click on the continent below that you are interested in:

USA / Canada / Mexico

Central / South America

Europe

Middle East

Africa

Asia

Australia / New Zealand

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Don’t wait to register. TapRooT® Courses fill up fast and there may be a waiting list.

Hope to see you at one of the upcoming courses!

Friday Joke: Don’t We All Need One of These?

Posted: October 10th, 2014 in Jokes, Pictures

This came to my e-mail account from an on-line retailer …

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Maybe it could include an optional Darth Vader voice changer?

Root Cause Tip: Making Team Investigations Work (A Best of Article from the Root Cause Network™ Newsletter)

Posted: October 9th, 2014 in Investigations, Performance Improvement, Pictures

Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.

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MAKING TEAM INVESTIGATIONS WORK

WHY USE A TEAM?

First, team investigations are now required for process safety related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?

Quite simply because two heads are better than one! Why? Several reasons:

  • A team’s resources can more quickly investigate an incident before the trail goes cold.
  • For complex systems, more than one person is usually needed to understand the problem. 
  • Several organizations that were involved in the incident need to participate in the investigation.
  • A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrom.)

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MAKING THE TEAM WORK

Investigating an incident using a team is different than performing an individual investigation. To make the team work, you need to consider several factors:

  • Who to include on the team.
  • The training required for team members.
  • Division of work between team members and coordinating the team’s activities.
  • Record keeping of the team’s meetings.
  • Software to facilitate the team’s work.
  • Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.

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WHO’S ON THE TEAM?

The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:

  • Engineering/technical assistance for hardware expertise.
  • Human engineering/ergonomics experts for human performance analysis.
  • Operations/maintenance personnel who understand the work practices.
  • An investigation coach/facilitator who is experienced in performing investigation.
  • A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
  • A union rep.
  • A safety professional.

TRAINING THE TEAM

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A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgement to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. Hopever, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.

What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…

  • Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
  • Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
  • People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness. 

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 KEEPING ON TRACK

 One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice. 

MORE TO LEARN

This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE. Or contact us to schedule a course at your site.

What does a bad day look like?

Posted: October 9th, 2014 in Pictures

You think you are having a bad day? Have a look at these pictures of a bad day in the military and you might feel better by comparison…

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