Taproot

TapRooT® Instructor Harry Thorburn sent us these photos from our recent TapRooT® course in Aberdeen. Enjoy!

Interested in boosting your company’s root cause analysis & incident investigation? Attend a TapRooT® Course. Learn more at http://www.taproot.com/courses

In 2012, a little over 12,000 people were trained to use TapRooT® to find and fix root causes.

That’s a record.

If the first quarter of 2013, course registrations are up. We think 2013 will see even more people in TapRooT® Courses.

That good news for the people who will have their lives saved, see product quality improved, see hospital patient safety improved, and get better equipment reliability at their facility … when TapRooT® is applied as part of a performance improvement program (see success stories by clicking here).

What’s the bad news? The popularity of TapRooT® Training means that sometimes our public courses are filling up early. Sometimes even two months before the course takes place.

Also, our training schedule for on-site courses is filling up.

What does that mean to you? If you are planning to attend a specific public TapRooT® Course – SIGN UP EARLY.

If you want to have a course at your site, get it scheduled NOW! (Contact us by CLICKING HERE.)

The new Scanadu Scout is being promoted as a device that can help anyone conduct their own physical exams from the comfort of their own homes. The device reportedly tracks your vital sign, temperature, ECG, heart rate, even stress.  According to the company’s website, you can use the device to scan your body and “learn ways that different people, locations, activities, foods, beverages, and medicines affect your body.”

Mashable reports that “On a basic level, you can see that your temperature or heart rate is elevated from the norm at any given time. On a larger level, you can also see potential problems headed your way by noticing abnormalities before they become physical issues.”

What do you think? Will this help people get to the root cause of medical issues or simply identify symptoms? Will users understand how to interpret the results? Will people come to rely on it too much as a proactive healthcare tool and feel annual exams are not necessary?

Part 2: Holding the drill…

17 have been confirmed dead with the death toll expected to rise to 28. See:

http://online.wsj.com/article/SB10001424127887323463704578494841690795414.html

There are no secrets to success. It is the result of preparation, hard work, and learning from failure.
- Colin Powell

At the 2013 Global TapRooT® Summit, Mark Paradies gave a General Session talk about Process Safety. We’ll have it here for you on the blog for the next few weeks.

Watch the first installment here:

Learn more about our 2014 Global TapRooT® Summit at http://www.taproot.com/summit.

The next time someone says they used 5-Whys to investigate an accident, just thing …

5-Whys = Root Cause Analysis Malpractice

Because 5-Whys is almost always root cause analysis malpractice. If you don’t believe it, assign someone who is good at 5-Whys to analyze a problem and someone who is good at using TapRooT® to analyze the same problem. Look at the results and you will see what I’m talking about.

That’s the lesson learned for today.

From despair.com …

See:

http://news.yahoo.com/probe-begins-conn-commuter-trains-crash-070249473.html

HES Advisor – Occidental Petroleum – Hobbs, NM

It takes more than being qualified for a position to win an interview in a competitive market. Here are some common things interviewees say that seem innocent enough, but can be a big turn-off to potential employers. Have you ever said any of these things?

I can do anything …

I can try …

I remember we used to …

Why do you …

I didn’t get an opportunity to grow …

Why are these so wrong? Head over to DailyWorth and read:

5 Things Not to Say in a Job Interview

and some of the answers may surprise you!

(Photo courtesy of Dreamstime.)

TapRooT® Instructor Sanjay Gandhi sent over these photos of our recent 5-Day course in Cape Town, South Africa.

Interested in a TapRooT® Root Cause Analysis Course in your area? Check out our courses page at http://www.taproot.com/courses

1,127 workers were killed in what is reportedly the worst disaster in the history of the global apparel industry.

One survivor said she heard from colleagues that cracks had appeared in the building and was reluctant to enter but was told by management that there was no problem. The building owner had been accused of using shoddy building materials and building extra floors, and then filling them with heavy equipment:

Read more in the Los Angeles Times:

http://www.latimes.com/news/world/worldnow/la-fg-wn-bangladesh-building-collapse-search-for-bodies-20130513,0,3014839.story

What is wrong with this picture?

West, Texas, May 16, 2013 – As other agencies wrapped up their on-site investigations into the ammonium nitrate explosion at West Fertilizer in West, Texas, the U.S. Chemical Safety Board (CSB) announced its work to examine all aspects of the tragedy will continue in the town of West, at the Western Regional Office in Denver, and at the agency’s headquarters in Washington, DC.

The CSB deployed a team of approximately 18 investigators and other technical experts within 24 hours of the incident on April 17, and has maintained an almost continuous presence in West since then.  The sudden blast led to at least 14 fatalities, approximately 200 injuries, and widespread damage and destruction in the small town of West, Texas, located between Dallas and Waco. 

CSB Chairperson Rafael Moure-Eraso said, “On behalf of our investigation team and the board, I would like to thank the mayor, fire and police officials, community members and West Fertilizer employees for their outstanding cooperation with the CSB during an extraordinarily difficult period.  Our hearts go out to the residents, employees, and emergency responders and we want everyone to know we are fully committed to providing a thorough public account of all the factors that led to this catastrophe. After a disaster of this scale, it is essential to pursue improved safety as we look toward the future.”

CSB Western Regional Office Director Don Holmstrom said, “The CSB will be examining many issues surrounding the explosion such as the safe storage and handling of ammonium nitrate, the siting of vulnerable public facilities and residential units near the facility, and emergency responder safety. In addition, the investigation will examine the adequacy of national standards, industry practices, and regulations for the safe storage and handling of ammonium nitrate.”

CSB investigation areas of inquiry will include ammonium nitrate safe handling and storage standards here and in other countries such as the UK and Australia; land use planning and zoning practices for high-hazard facilities in relation to schools, public facilities, and residential areas; ammonium nitrate detonation mechanisms; the effectiveness of regulatory coverage including OSHA, EPA, and the State of Texas; whether there are inherently safer products or safer ways to store and mitigatethe damage should a fire or explosion occur. The investigation will examine the emergency response during the fire at West, and practices, including preparedness, fire codes, and guidelines for good practices found in other jurisdictions.

Dr. Moure-Eraso stressed the CSB does not issue fines or penalties of any kind, or seek civil or criminal sanctions. “We do not look for individual fault or blame with regard to actions taken before an accident or in response to them.  Rather, we produce what are called root cause investigations.”

The CSB is in the process of conducting witness interviews and gathering documents and other evidence. It has documented blast damage and patterns in the community, and will engage in testing chemical samples and conducting a thorough analysis of the nature and magnitude of the blast, and its actual and potential consequences.

Chairperson Moure-Eraso said, “This accident produced far more offsite community damage and destruction than any we have investigated since the agency opened its doors in 1998.  We will release information and findings when possible as we continue our work, and in the end will issue a comprehensive root cause report with recommendations.  We also encourage members of the public and stakeholders to share information directly with the CSB as the investigation progresses.”

The CSB established a Facebook page, www.facebook.com/WestExplosion, to exchange information with the public concerning the investigation.

For more information, contact Communications Manager Hillary Cohen, cell 202-446-8094 or Sandy Gilmour, Public Affairs, cell 202-251-5496.

Everyone is interested in research statistics but the following infographic asserts that some scientists may make up the data, distort the data … even cook the data!

What would you guess is the root cause of bad science? The infographic suggests that one may be that the scientist changes results due to pressure from a funding source.

And what do you think about the ways to make research more honest at the end of the infographic? Would they work?

TapRooT® Instructor Alan Smith sent over these photos from our most recent Bahrain 5-Day course. Looks like a fantastic class.

Interested in a TapRooT® Course?
Check out our courses page: http://www.taproot.com/courses

Harry Thorburn sent over these photos from our recent 3-Day TapRooT® Course in Rotterdam, Holland. Enjoy!

Looking for a job where you can use your TapRooT® skills?

If you are not using the skills you learned in training, you are missing key opportunities for professional development. The proactive and reactive tools your training provided will not only enhance your career but will also contribute to the greater good of saving lives and preventing injuries.

If you have been using your root cause analysis skills for awhile and are interested in a career change, one thing that will stand out on your resume is a record of your demonstrated TapRooT® successes. When you share multiple examples of problems solved or leading teams to success, you will have a significant advantage in the job market.

Remember, TapRooT® is not only a valued skill for employers looking for accident investigators, but is also a valued skill for companies that:

• need to solve quality related issues
• have equipment downtime problems
• experience failure to achieve optimal operational success

Keep up with the leading companies looking to hire people with TapRooT® root cause analysis skills by looking at this link:

http://www.taproot.com/archives/category/career-development/job-postings

Need a refresher? We have several 2-day courses coming up in June:

http://www.taproot.com/store/2-Day-Courses/?coursefilter=Incident+Investigation

And finally, if you have been thinking about getting training to become a TapRooT® Team Leader, get more info about our advanced 5-Day Team Leader Course:

http://www.taproot.com/courses/#5-day-root

If you have a success story to share about how TapRooT® has helped your career development, please share it by commenting below.

Welcome to our weekly series of Root Cause Analysis Tips from our 2013 Global TapRooT® Summit. This week and the next few weeks following, we’ll be talking about Serious Injuries & Fatalities. At the Summit this year, Mark Paradies gave a great talk about Serious Injuries & Fatalities and how you can prevent them.

This is the first part of the Q & A portion at the end of the session, in which participants discuss SIF situations in their workplace with Mark.

Watch it here:

Interested in attending our 2014 Global TapRooT® Summit?

Visit our Summit page here: http://taproot.com/summit

Watch Part 1 here: http://www.taproot.com/archives/37877
Part 2: http://www.taproot.com/archives/37972
Part 3: http://www.taproot.com/archives/38015

Why NOT Ask Why?

Some people teach the “5-Why” technique for root cause analysis as their preferred method to solve problems. If you have read this blog for very long, you’ve probably been convinced that 5-Whys is at best a rudimentary technique with many inherent flaws. But you may not know that asking “Why” during an investigation interview is also a mistake.

In the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, we spend a majority of the second day teaching fact finding and interviewing. This section of the course highlights an advanced interviewing technique called “Cognitive Interviewing”.

Cognitive Interviewing helps the interviewee recall information that they might have otherwise forgotten or thought too unimportant to share. The Cognitive Interviewing training in our course emphasizes that the interviewer should not ask the interviewee “Why?” during the interview.

Why not ask Why? Because the question elicits justifications from the interviewee rather than getting them to share additional information from their long term memory. The “Why?” question is seen by the interviewee as accusatory (Why did you do that?) rather than a request for more information.

What should the interviewer do? Cognitive Interviewing teaches a systematic process to get the interviewee to tell their story, recalling as much as they can from their long term memory. It also teaches the interviewer to ask “What” and “How” questions to get additional information (instead of “Why?”).

Find out more about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course by CLICKING HERE.

Ken Scott and I teaching the two day course this week, here are some pictures of the students working on their first exercise:

Sorry if you missed us on this one, the course filled up several weeks out. We have been experiencing high demand for our training, so if you want to attend, you should enroll as soon as possible. To view the schedule and register, click HERE

There are too many major accidents due to failures in process safety. These accidents go beyond the regulations written by OSHA and EPA (and the regulators in other countries). They go beyond the chemical industry and include the nuclear industry, oil exploration and production, fertilizer storage and distribution, grain elevators (and other dust explosion examples), aviation, shipping, utilities, and even hospitals.

How can these accidents be prevented? First one has to understand process safety and fatality prevention. Unfortunately, many senior managers don’t understand it. And that’s why Mark Paradies started giving talks about this topic at the TapRooT® Summit. Unfortunately, even though the Summits are well attended, thousands need to hear what Mark has to say, but don’t get the chance. That’s why we decided to post links to some of Mark’s Summit talks here.

Of course, attending the sessions at the TapRooT® Summit is much better than looking at slides and watching videos. But the information in these talks needs greater dissemination to help prevent major accidents around the world. Therefore, we’ve selected video clips, slides from mark’s talks, and Admiral Rickover’s testimony before Congress after TMI (written remarks) to provide an overview of some of the concepts that senior managers need to consider to prevent major process safety accidents.

Here are the links:

Mark’s General Session Talk About Fatality Prevention from the 2013 Summit

Marks Talk About SIF Prevention from the 2013 Summit (Part 1)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 2)

Mark’s Talk About SIF Prevention from the 2013 Summit (Part 3)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 1)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 2)

Mark’s Talk About Process Safety & Rickover from the 2012 Summit (Part 3)

Mark’s Slides About Rickover & Process Safety from the 2010 Summit

Rickover’s Testimony to Congress About Reactor Safety (Process Safety)

I know this is a lot of information and the videos are long, but the lives lost each year are a preventable tragedy. Please pass this information on to those that you think many need it.

For those who would like to get Mark to talk to your senior management about management’s role in process safety and how the lessons from Admiral Rickover apply to your facilities, call us at 865-539-2139 or e-mail us by CLICKING HERE.