Root Cause Analysis Blog

 

Technically Speaking – Helpdesk Humor

Posted: May 21st, 2018 in Software, Technical Support, Technically Speaking

Would you consider this a good Safeguard? Of course not! Thinking of implementing new safeguards at the company you work for? Get some great ideas at one of our upcoming TapRooT® training courses. Take a look at your next course here.

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, it doesn’t mean it has to be complicated!

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

Posted: May 21st, 2018 in Accidents, Great Human Factors, investigation, Investigations

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years. 

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing. 

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB.  The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

  • Captain’s actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Company’s safety management system
  • Inadequate company oversight
  • Need for damage control plan
  • Flooding in cargo holds
  • Loss of propulsion
  • Downflooding through ventilation closures
  • Need for damage control plan
  • Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 21st, 2018 in Career Development, Courses, Job Postings, Training

When you are TapRooT® trained, you can rely on your expertise to convey the level to which you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer. If you have invested yourself in TapRooT® training and skills, explore professional advancement with confidence through one of these global opportunities.

Patient Safety Program Coordinator (PSPC)

Associate – Senior Engineer Nuclear (Electrical)

Safety & Health Specialist

Pipeline Risk/Integrity Engineer

EHS Drilling Specialist

Safety Manager

Safety Professional

Patient Safety Program Coordinator

Patient Safety Analyst

QHSSE Advisor

Safety & Health Specialist

HES Manager

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

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

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Lake Tahoe, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

Manchester, United Kingdom, October 1, 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 or 865.357.0080.

Friday Joke

Posted: May 18th, 2018 in Jokes

2018 Global TapRooT® Summit Best Practices – Implement a Dedicated Investigation Team

Posted: May 17th, 2018 in Best Practice Presentations, investigation, Summit, Video

After you’ve attended a TapRooT® course and learned how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? And what do team members require to optimally focus on the actual investigation process?

At the 2018 Global TapRooT® Summit, attendees listened and learned about implementing best practices for a dedicated investigation team. Shelley Hassen, HSE Assurance & Compliance Manager, Willbros, a leading contractor in specialty energy infrastructure, was an informative part of this discussion, as you will learn from this Vimeo.

 

 

For another look at Shelley’s insights into best practices, see the blog, Success Story Contest: Saving Time, Resources & Effort with Single User Software.

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

Root Cause Tip: Repeat-Back Strengthens Positive Communication

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

Misunderstood verbal communication can lead to a serious incident.

Risk Engineer and HSE expert, Jim Whiting, shared this report with us recently highlighting four incidents where breakdowns in positive communications were factors. In each circumstance, an operator proceeded into shared areas without making positive communication with another operator.

Read: Positive communication failures result in collisions.

Repeat-back (sometimes referred to as 3-way communication) can reinforce positive communication. This technique may be required by policy or procedure and reinforced during training on a task for better compliance.

Repeat-back is used to ensure the information shared during a work process is clear and complete. In the repeat back process, the sender initiates the communication using the receiver’s name, the receiver repeats the information back, and the sender acknowledges the accuracy of the repeat back or repeats the communication if it is not accurate.

There are many reasons why communications are misunderstood. Workers make assumptions about an unclear message based on their experiences or expectations. A sender may choose poor words for communication or deliver messages that are too long to remember. The message may not be delivered by the sender in the receiver’s primary language. A message delivered in the same language but by a worker from a different geographical region may be confusing because the words do not sound the same across regions.

Can you think of other reasons a repeat-back technique can be helpful? Please comment below.

See you today for TapRooT® Facebook Live at noon Eastern

Posted: May 16th, 2018 in Career Development Tips, Presentations, Topic of the Week, Video

Tune into TapRooT®’s Facebook Live today as we talk with TapRooT® Senior Associate Chris Vallee about Quality Problem Solving. 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, May 16

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

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

Avoid Big Problems By Paying Attention to the Small Stuff

Posted: May 16th, 2018 in Accidents, Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that get’s bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

What does a bad day look like?

Posted: May 15th, 2018 in Bad day, Pictures

“Joke’s on you! The neighbors actually have a flying car, and thus no need for a driveway that smoothly goes into the garage. Psssh, tires are sooooo 2015, right?”

TapRooT® Around the World: Bogota, Colombia

Posted: May 15th, 2018 in Courses, Pictures, TapRooT, Training

Many thanks to Diana Munevar for these TapRooT® training photos from a three-day TapRooT® training course led by Hernando Godoy and Piedad Colmenares in Bogota, Colombia! Looks like they are having fun and learning a lot!

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.

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

July 17 – Milwaukee, Wisconsin, 2-Day TapRooT® Root Cause Analysis Training

July 25 – Lake Tahoe, Nevada, 2-Day Root Cause Analysis Training

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

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

August 27 – Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Training

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

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

October 14 – Dubai, UAE, 5-Day Advanced Root Cause Analysis Training

 If you’re interested in pursuing a TapRooT® course that is near you or for a specific date, look further via these two links:

2-Day TapRooT® Root Cause Analysis Training

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

Testimonial Tuesday

Posted: May 15th, 2018 in Courses, Testimonials

TapRooT® is a world-class software system designed to help investigators solve every day hurtles. TapRooT® take the investigator beyond his or her knowledge to choose root causes that are “outside the box” of common root causes such as writing poor procedures or inadequate training. To learn more about our courses and what people have to say about them continue reading.

Here’s what clients had to say about our 2-Day course:

  • “This course met my expectations, will be back for a 5-Day training.” – Charles
  • “The Final Team Exercise was thought provoking and tied concepts learned all together.” – John
  • “RCA will be greatly improved.” – Huckeaberry

Interested in our 5-Day? Here’s what our clients had to say:

  • “I learned new ways to gather information, in line of questions.” – Davis
  • “I like the optimal tools especially CHAP®.” – Gias
  • “This is a powerful process, if it is followed through it will eliminate many preconceived thoughts.” – Kyle
  • “I liked the use of safeguard hierarchy. This can help me make “stronger” corrective actions after the investigation.” – Inger

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

Learn TapRooT® in Denver

Posted: May 14th, 2018 in Career Development, Courses, Local Attractions, TapRooT

Expand your skills in Denver!

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

From beginners to experts, TapRooT® is designed for learners at all levels. 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 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 expertise 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.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Westin Denver Downtown on June 11. You may want to make plans to explore your host city while you’re there.

Register here for the course.

Soak up Denver

Denver is packed with must-do thrills: Stand exactly one mile high on the west steps of the state capitol and see 200 mountains from its dome. Set your eyes on the world’s greatest collection of Native American art at an architectural wonder, the Denver Art Museum. Check out Old West history in a trendy downtown at Golden, Colorado’s first capital, where you can sip a beer while kayakers paddle by.

The Mile High City is a paradise for outdoor adventure and pro sports. The choices are wide-ranging: walking trails, urban hikes, parks, sporting events, and more Denver adventures.

Colorado’s landscape is awe-inspiring. Take Garden of the Gods in Colorado Springs, little more than a hour from Denver. You can go front range climbing, take a jeep or segway tour, or tour via bike or electric bike. If you’re a photography buff, this is a natural for you.

Go brewery touring and get a closeup taste of the culture Denver’s famous for.

Denver’s historic district, or Lower Downtown, is called LoDo. Amid 28 square blocks, you can enjoy excellent restaurants, live music, and fun brewpubs. Walk, sightsee, window shop in downtown Larimer Square among a vibrant district of Victorian buildings restored to hip shops and restaurants.

The creative community of Denver shows up in galleries, studios, and cultural attractions across seven art districts.

Visit Red Rock Canyon Park & Amphitheatre for hiking, walking, and biking trails, or dine at Red Rock’s Ship Rock Grille and admire the view.

Check out Union Station, a transportation hub, historic landmark, and cool space for noshing–such as Mercantile Dining & Provision–gathering, and shopping.

At El Taco De Mexico, 714 Santa Fe Dr., it’s all about being the authentic taqueria.

Try breakfast or lunch at Maria Empanada, a great bakery and cafe offering a taste of Argentina.

At the vintage-inspired ice cream shop Little Man, people line up around the block on 16th Street for homemade flavors like peach cobbler, oatmeal cookie, salted Oreo, and creme fraiche.

Discover more to explore from our Denver Pinterest board and begin planning your TapRooT® trip to Colorado today.

We hope to see you at the IHI/NPSF Patient Safety Conference!

Posted: May 14th, 2018 in Career Development, Medical/Healthcare, TapRooT

If you plan to attend the 2018 IHI/NPSF Patient Safety Conference in Boston, MA on May 23 -25, stop by and say “hello.” Per Ohstrom, Anne Roberts, and Barb Carr (pictured left to right) will be at Booth #316 in Exhibit Hall C discussing how TapRooT® can help you and answer any questions you might have.

We will be at Booth #316 during these times:

Wednesday: 3:30pm – 5:30pm

Thursday: 12:00pm – 1:30pm & 4:30pm – 6:30pm

Friday: 7:00am – 8:30am

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!

“It was such a simple mistake!”

Posted: May 14th, 2018 in Investigations, Root Causes, TapRooT

mistake

 

 

 

 

 

 

 

 

 

When you have a major incident (fire, environmental release, etc.), your investigation will most likely identify several causal factors (CF) that, if they had not occurred, we probably would not have had the incident.  They are often relatively straight forward, and TapRooT® does a great job identifying those CFs and subsequent root causes.

Sometimes, the simplest problems can be the most frustrating to analyze and fix.  We think to ourselves, “How could the employee have made such a simple mistake?  He just needs to be more careful!”  Luckily, TapRooT® can help even with these “simple” mistakes.

Let’s look at an example.  Let’s say you are out on a ship at sea.  The vessel takes a bit of a roll, and a door goes shut on one of your employees.  His finger is caught in the door as it shuts, causing an injury.  Simple problem, right?  Maybe the employee should just be more aware of where he is putting his hands!  We will probably need more effective fixes if we really want to prevent this in the future.

How can we use TapRooT® to figure this out?  First of all, it is important to fully document the accident using a SnapCharT®.  Don’t skip this just because you think that the problem is simple.  The SnapCharT® forces you to ask good questions and makes sure you aren’t missing anything.  The simple problem may have aspects that you would have missed without fully using this technique.  In this example, maybe you find that this door is different than other doors, which have latches to hold them open, or handles to make it easier to open the door.  Imagine that this door might have been a bathroom stall door.  It would probably be set up differently than doors / hatches in other parts of the ship.

So, what are your Causal Factors?  First, I probably would not consider the sudden movement of the ship as a CF.  Remember, the definition of a CF states that it is a mistake or an error that directly leads to the incident. In this case, I think that it is expected that a ship will pitch or roll while underway; therefore, this would not be a CF. It is just a fact. This would be similar to the case where, in Alaska, someone slipped on a snow-covered sidewalk. I would not list that “it was snowing” as a CF.  This is an expected event in Alaska. It would not be under Natural Disaster / Sabotage, either, since snow is something I should be able to reasonably protect against by design.

In this case, I would consider the pitch / roll of the vessel as a normal occurrence.  There is really nothing wrong with the vessel rolling. The only time this would be a problem is if we made some mistake that caused an excessive roll of the vessel, causing the door to unexpectedly slam shut in spite of our normal precautions. If that were the case, I might consider the rolling of the ship to be a CF.  That isn’t the case in this example.

You would probably want to look at 2 other items that come to mind:

1.  Why did the door go shut, in spite of the vessel operating normally?
If we are on a vessel that is expected to move, our doors should probably not be allowed to swing open and shut on their own. There should be latches / shock absorbers / catches that hold the door in position when not being operated. Also, while the door is actually being operated, there should be a mechanism that does not depend on the operator to hold it steady while using the door. I remember on my Navy vessel all of our large hatches had catches and mechanisms that held the doors in place, EXCEPT FOR ONE HEAVY HATCH. We used to tell everyone to “be careful with that hatch, because it could crush you if we take a roll.” We had several injuries to people going through that hatch in rough seas. Looking back on that, telling people to “be careful” was probably not a very strong safeguard.

Depending on what you find here, the root causes for this could possibly be found under Human Engineering, maybe “arrangement/placement”, “tools/instruments NI”, excessive lifting/force”, “controls NI”, etc.

2. Why did the employee have his hand in a place that could cause the door to catch his hand?
We should also take a look to understand why the employee had his hand on the door frame, allowing the door to catch his finger.  I am not advocating, “Tell the employee to be careful and do not put your hand in possible pinch points.” That will not work too well. However, you should take a look and see if we have sufficient ways of holding the door (does it have a conventional door knob? Is it like a conventional toilet stall, with no handle or method of holding the door, except on the edge?). We might also want to check to see if we had a slippery floor, causing the employee to hold on to the edge of the door / frame for support. Lots of possibilities here.

Another suggestion: Whenever I have what I consider a “simple” mistake that I just can’t seem to understand (“How did the worker just fall down the stairs!?”), I find that performing a Critical Human Action Profile (CHAP) can be helpful.  This tool helps me fully understand EXACTLY what was going on when the employee made a very simple yet significant mistake.

TapRooT® works really well when you are trying to understand “simple” mistakes.  It gets you beyond telling the employee to be more careful next time, and allows you to focus on more human performance-based root causes and corrective actions that are much more likely to prevent problems in the future.

Caption Contest Winner!

Posted: May 14th, 2018 in Uncategorized

The April Caption Contest is over, and the votes have been tallied! But, before I announce the winner, I want to thank everyone for their submissions and participation. The Caption Contest always makes me laugh, and I enjoy reading your comments as they come in.

And, now, without further ado, the winner of the March Caption Contest is….Drrrrrrrrrrrrrrrrrum-roll!

Holly Patey with “Stairway to Heaven.”

 

We also have several honorable mentions.

“Still looking for your cat.” – Tom S.

“Going to hang safety banner.” – Mark Sullivan

“Beam me up Scotty!!!!” – Claude

Again, thank you for playing along. Don’t forget, just because you won a past Caption Contest doesn’t mean you can’t enter to win again. The more captions you come up with, the greater your chances of winning!

Keep an eye out for a new Caption Contest coming next week.

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 14th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you become TapRooT® trained, you can rely on your expertise to communicate how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer across the desk from you. If you have invested yourself in TapRooT® training and skills, explore professional advancement through one of these global opportunities.

Patient Safety Analyst Nurse

Field Service Manager – Wireline & Perforating

HSEQ Manager

Chemical Manufacturing

Environment, Quality and Safety Coordinator –  Collections Division

HES Operations Specialist

Maintenance Manager

Reliability Engineer I

Manager – EHS/Quality

Associate-Senior Engineer Nuclear (Electrical) 

Safety & Health Specialist (Remote)

Patient Safety Program Coordinator

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

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

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis 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

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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

Manchester, United Kingdom, October 1, 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 or 865.357.0080.

Monday Accidents & Lessons Learned: Airplane Mode

Posted: May 14th, 2018 in Accidents, Human Performance, TapRooT

When you hear the words “mode” and “aviation,” many of us who are frequent flyers may quickly intuit the discussion is heading toward the digital disconnection of our cellular voice and data connection in a device, or airplane mode. Webster defines “mode” as “a particular functioning arrangement or condition,” and an aircraft’s system’s operating mode is characterized by a particular list of active functions for a named condition, or “mode.” Multiple modes of operation are employed by most aircraft systems—each with distinct functions—to accommodate the broad range of needs that exist in the current operating environment.

With ever-increasing aviation mode complexities, pilots must be thoroughly familiar with scores of operating modes and functions. No matter which aircraft system is being operated, when a pilot is operating automation that controls an aircraft, the mode awareness, mode selection, and mode expectation are all capable of presenting hazards that require know-how and management. Sure, these hazards may be obvious, but they are also often complex and difficult to grasp.

NASA’s Aviation Safety Reporting System (ASRS) receives reports that suggest pilots are uninformed or unaware of a current operating mode, or what functions are available in a specific mode. At this juncture, the pilots experience the “What is it doing now?” syndrome. Often, the aircraft is transitioning to, or in, a mode the pilot didn’t select. Further, the pilot may not recognize that a transition has occurred. The aircraft then does something autonomously and unanticipated by the pilot, typically causing confusion and increasing the potential for hazard.

The following report gives us insight into the problems involving aircraft automation that pilots experience with mode awareness, mode selection, and mode expectation.

“On departure, an Air Carrier Captain selected the required navigation mode, but it did not engage. He immediately attempted to correct the condition and subsequently experienced how fast a situation can deteriorate when navigating in the wrong mode.

“I was the Captain of the flight from Ronald Reagan Washington National Airport (DCA). During our departure briefing at the gate, we specifically noted that the winds were 170 at 6, and traffic was departing Runway 1. Although the winds favored Runway 19, we acknowledged that they were within our limits for a tailwind takeoff on Runway 1. We also noted that windshear advisories were in effect, and we followed required procedure using a no–flex, maximum thrust takeoff. We also briefed the special single engine procedure and the location of [prohibited airspace] P-56. Given the visual [meteorological] conditions of 10 miles visibility, few clouds at 2,000 feet, and scattered clouds at 16,000 feet, our method of compliance was visual reference, and we briefed, “to stay over the river, and at no time cross east of the river.

“Taxi out was normal, and we were issued a takeoff clearance [that included the JDUBB One Departure] from Runway 1. At 400 feet AGL, the FO was the Pilot Flying and incorrectly called for HEADING MODE. I was the Pilot Monitoring and responded correctly with “NAV MODE” and selected NAV MODE on the Flight Control Panel. The two lights adjacent to the NAV MODE button illuminated. I referenced my PFD and noticed that the airplane was still in HEADING MODE and that NAV MODE was not armed. Our ground speed was higher than normal due to the tailwind, and we were rapidly approaching the departure course. Again, I reached up and selected NAV MODE, with the same result. I referenced our location on the Multi-Function Display (MFD), and we were exactly over the intended departure course; however, we were still following the flight director incorrectly on runway heading. I said, “Turn left,” and shouted, “IMMEDIATELY!” The FO banked into a left turn. I observed the river from the Captain’s side window, and we were directly over the river and clear of P-56. I spun the heading bug directly to the first fix, ADAXE, and we proceeded toward ADAXE.

“Upon reaching ADAXE, we incorrectly overflew it, and I insisted the FO turn right to rejoin the departure. He turned right, and I said, “You have to follow the white needle,” specifically referencing our FMS/GPS navigation. He responded, “I don’t have a white needle.” He then reached down and turned the Navigation Selector Knob to FMS 2, which gave him proper FMS/GPS navigation. We were able to engage the autopilot at this point and complete the remainder of the JDUBB One Departure. I missed the hand–off to Departure Control, and Tower asked me again to call them, which I did. Before the hand–off to Center, the Departure Controller gave me a phone number to call because of a possible entry into P-56.”

We thank ASRS for this report, and for helping to underscore TapRooT®’s raison d’être.

We encourage 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.

Remembering An Accident: Enschede Fireworks Disaster

Posted: May 13th, 2018 in Accidents, TapRooT

On May 13, 2000 in the eastern Dutch city of Enschede a fireworks warehouse caught fire and lead to an enormous explosion. The explosion caused 22 deaths, with 4 fire-fighters among the causalities, another 974 individual were injured, and 500 homes and businesses were severely damaged and/or destroyed during the blast. After the dust had settled a 13 meter diameter, 1.3 meter deep crater could be observed where concrete round cells C9 and C11 – C 15 once stood. To create a crater that size it would take a TNT equivalent between 4 and 5 tonnes. The largest blast was felt up to 30 kilometers away (19 miles).

  

What makes this incident so interesting is the fact that whatever started the fire was never really discovered. Two possibilities seem to be the likely cause. One possibility discussed was arson. The Dutch police made several arrest, but none of whom had been arrested were convicted of arson for the Enschede Fireworks Disaster. The other theory comes from the fire department stating that accidental ignition via an electrical short circuit could have also been the cause of the fire.

Because of the incident and investigation results the fireworks disaster lead to stronger safety regulations in the Netherlands concerning the sales, storage, and distribution of fireworks. Since the catastrophe three illegal firework warehouses were closed down and the Roombeek area that was destroyed by the explosion has been rebuilt.

  

To read the full detailed report click here.

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 re-actively and help identify precursors that could lead to major problems.

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

 

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training

Posted: May 11th, 2018 in Career Development, Presentations, TapRooT, Topic of the Week, Video, Website Info and Updates

Last week on TapRooT® TV, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® and the positive impact it can have on your professional career. We pack a lot into our blog!

Among our blog features are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

We always 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? Every Wednesday

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

Catch up on the conversation with Michelle and Benna  via Vimeo:

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

If you want to chime in the conversation, or have a question or comment, feel free to shout out here and we’ll get right back to you. Thank you for watching TapRoot® TV!

Friday Joke

Posted: May 11th, 2018 in Jokes

Acquire TapRooT® Training in Aberdeen

Posted: May 11th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

Meet us in Scotland for TapRooT® training!

Two days. That’s the amount of time it will take for you to learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

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®. 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.

We’ll meet and begin the 2-Day TapRooT® Root Cause Analysis Training at the Holiday Inn Aberdeen, West, on June 6. Register here for the course and count on seeing a bit of your host city while you’re there.

Experience Aberdeen, the Granite City
Aberdeen’s rich history began as two separate towns on the North Sea. Along the Don River were Old Aberdeen and the cathedral and university; New Aberdeen, on the Dee River, was the hub for trading and the fishing village. Today, Aberdeen is Britain’s largest granite-exporting industry and the chief seaport of northern Scotland. Stop in at Aberdeen Maritime Museum on Shiprow, overlooking the busy harbor. Learn about the city’s legendary relationship with the sea through collections spanning shipbuilding, fast sailing ships, fishing, and port history. The museum is the UK’s sole location with displays on the North Sea’s gas and oil industry. Catch more seafaring history at Fooddee (pronounced “FIT-ee” locally), an old fishing village straight from a postcard. You may see dolphins leaping up at the harbor mouth!

Aberdeen and Aberdeenshire make up part of Scotland’s castle country, as in more than 300 castles. Listen to the sound of the traditional Scots language, a local Doric, while you’re drinking up the atmosphere here. Play a round of golf at Royal Aberdeen Golf Club, founded in 1780, while you take in North Sea coastal views. Enjoy the rugged cliffs and sandy bays at St. Cyrus National Nature Reserve, or explore mountains, lochs, wildlife, and distilleries at Cairngorms National Park.

History and architecture
Get to know a bit of Aberdeen history beginning with St. Machar’s Cathedral, (1424) and Provost Skene’s House (c. 1545). Visit the Union Street parish church of St. Nicholas, divided into two parts: the West Church (built in 1755) is separate from the East Church (built in 1838), divided by the original 13th-century transept and 19th-century steeple. Compare two medieval bridges, the Brig o’ Balgownie (1320), which spans the Don, and the Old Bridge of Dee (1527). You’ll notice a mix of styles, from the Neoclassical-style Music Hall (1822) to Broad Street’s Marischal College (1844), the latter said to be the largest granite building in the world. Founded in 1845, King’s College, now the University of Aberdeen and home of five Nobel Laureates, is known for its famous crown spire and Renaissance style.

Fun fact: Yes, the jaw-dropping architecture is gray granite and there’s a lot of it. Look closely and you’ll see the buildings take on a silver sparkle in sunlight due to their high mica content.

Eateries and entertainment
Books & Beans, 22 Belmont St: Coffee + WiFi

Foodstory, 13-15 Thistle St: Soups, salads, scones, lasagna, great coffee, and fun folks

The Lemon Tree, 5 West North St: Cool beverages and music

The Sanddollar Cafe & Bistro, 2 Beach Esplanade: Delicious dinners, ample wine list, and jazz nights

Ross Bakery, 44 Chapel St: Pies, breads and scones, burgers and sandwiches, cakes

Moonfish, 9 Correction Wynd: Modern British cuisine, generous gin list, set amid medieval streets of Aberdeen’s merchant quarter with views of the 12th-century St. Nicholas church

Maggie’s Grill, 242 Holburn Street:  Angus steaks; locally sourced hickory-smoked pulled pork; pastrami; locally sourced cheeses, vegetables, breads, beer, and coffee; all served with the motto,“Field to fork and made with soul!”

The Silver Darling, North Pier, Pocra Quay: Dine with panoramic views of the water.  Here’s a sample of the scrumptious fare: brown crab, prawns and pan-fried sea trout with carrot & cardamom purée

Almondine, 39 – 43 Thistle Street: Macarons of every description, afternoon tea, and a French bakery

Discover more of Scotland to explore from our Aberdeen Pinterest page and begin planning your TapRooT® trip to Aberdeen today.

High road or low road, we hope to see you in Scotland!

TapRooT® Around the World: Houston

Posted: May 11th, 2018 in Courses, Pictures

Last day of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Houston, Texas. Heidi Reed and I are looking forward to seeing our course attendees’ final presentations. It’s been an awesome week! Click here and get in the picture.

 

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