Root Cause Analysis Blog

 

Technically Speaking – Help Desk Humor

Posted: April 27th, 2017 in TapRooT, Technical Support, Technically Speaking, Training

New to the TapRooT® VI software? Don’t fear, Webinar Wednesdays are here! Yes, it’s Thursday BUT it’s always a good practice to plan ahead!

Webinar Wednesday occurs the fourth Wednesday of every month!  If you have been trained in TapRooT®, and want to optimize your investigations, join us. Every month we will be offering a software-specific webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software.

Get the most out of your investment.
 What you need to know: 
  • When: Webinar Wednesdays occur the fourth Wednesday of every month
  • Time: 2:00-3:30pm Eastern Time
  • Length: 90 minutes
  • Price: $195 per seat
  • Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.

Interested? REGISTER HERE FOR WEBINAR WEDNESDAY MAY 24th, 2017.

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!

What does a bad day look like?

Posted: April 25th, 2017 in Accidents

Well, it could start like this…

TapRooT® Around the World: Kyrgyzstan Course

Posted: April 25th, 2017 in Courses, Pictures

Great group from Kumtor Gold Mine in Kyrgyzstan last week!

Interested in bringing TapRooT® to your company for training? Inquire here.

Interested in sending your team to a TapRooT® course? Check our course schedule here.

TapRooT® Course in Monterrey, Mexico!

Posted: April 24th, 2017 in Courses, Local Attractions

Are you planning to join TapRooT® in Monterrey, Mexico for a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (Spanish) on August 21, 2017?

Monterrey is one of the largest cities in Mexico, and is home to many important industries and businesses such as CEMEX and Mercedez-Benz Mexico. Not only is it an industrial hub, it’s filled with culture and beauty, as well. This city is surrounded by the Sierra Madre Oriental mountains which have public trails and canyons for anyone to admire the natural beauty that Monterrey has to offer. We still have a few spots left, you won’t want to miss this opportunity to travel and gain knowledge to benefit your company.

Food:

El Gaucho: This warm, friendly restaurant offers classic Mexican cuisine that can cater to all pallets.

Sante Fe: In the mood for a little fine dining? Sante Fe offers all the best gourmet dishes, wines and desserts.

Bread Panaderos: Everyone loves a fresh bread bakery that also serves freshly ground coffee. Order a snack or a whole loaf to take home with you.

Attractions:

Horno 3: A museum of technological history, innovations and interactive exhibits must be interesting. Check out this museo del acero to find out for yourself.

Parque Fundidora: This large municipal park is always hosting activities for all ages and is a great place for site seeing the beautiful city.

Planetario Alfa: Museums and an IMAX Theater all in one. Take a tour through Mexican history or watch the latest educational movie in the state of the art IMAX Theater.

REGISTRATION, click here.

For more information regarding our other Public Courses, click here.

Remembering an Accident: Oppau Explosion in Germany

Posted: April 21st, 2017 in Accidents

The explosion occurred September 21, 1921, when a silo that was storing 4,500 tonnes of an ammonium sulfate and ammonium nitrate fertilizer mixture exploded at the Oppau plant in Germany. It killed between 500 – 600 people and there were about 2,000+ people who were injured. The blast was felt for miles, damaging the factory and the surrounding community.

What Happened? 

In 1911 the plant was producing ammonium sulfate when Germany was unable to obtain the necessary sulfur during WWI. It was also producing ammonium nitrate during the same time period. The combination of the two plus the pressure of its own weight, turned the mixture into a plaster-like substance.

The workers had to take pickaxes to remove the plaster-like substance from inside the silos. To make their work easier the workers took small charges of dynamite to loosen the mixture. Before the explosion happened it was estimated that there where as many as 20,000 firings before that fatal day. It is now a well known fact that ammonium nitrate is highly explosive even when mixed, due to this tragic incident.

To read more about this tragic accident please click on the link below.

http://en.wikipedia.org/wiki/Oppau_explosion

To find out how to find and fix root causes at your facility to avoid disasters large and small, visit:

http://www.taproot.com/products-services/about-taproot

Trapped in the Blame Vision

Posted: April 20th, 2017 in Jokes, Performance Improvement, Root Cause Analysis Tips, TapRooT

From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.

The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.

NewImage

They were trapped in the Blame Vision.

The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.

The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:

I didn’t do it! 
Nobody saw me do it! 
You can’t prove I did it!

But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:

Why be fair when you can be arbitrary?

A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up. 

One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself. 

The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement. 

Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him. 

If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.

Technically Speaking – TapRooT® VI User Settings Menu

Posted: April 20th, 2017 in Software, Technical Support, Technically Speaking, Video, Video Depot

Here is a quick video highlighting the new User Settings menu in TapRooT® VI.

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!

TapRooT® in Krakow

Posted: April 19th, 2017 in Courses, Pictures

Here are some recent photos from our class in Krakow, Poland.

What Would You Do If You Saw a Bad 5-Why Example?

Posted: April 19th, 2017 in Performance Improvement, Root Cause Analysis Tips, Root Causes

It seems that I’m continually confronted by folks that think 5-Whys is an acceptable root cause analysis tool. 

The reason they bring up the subject to me is that I have frequently published articles pointing out the drawbacks of 5-Whys. Here are some examples…

Article in Quality Progress: Under Scrutiny (page 32)

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

That got me thinking … Have I EVER seen a good example of a 5-Why root cause analysis that I thought was a good example of a root cause analysis? And the answer was “NO.”

So here is my question … 

What do you do when you see someone presenting a bad root cause analysis where they are missing the point?

Leave a comment below and let me know the tack that you take … What do you think?

Keep Up Your TapRooT® Software Skills with Our Software Webinars

Posted: April 19th, 2017 in Software, Technical Support, Training

mark your calendars

Join us for Webinar Wednesdays!

If you have been trained in TapRooT®, and want to enhance your software skills, join us for our webinar. Every month we will be offering a software webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software. We’ll even go over the newest features!
Get the most out of your investment. Register today.

What you need to know: 

  • When: Webinar Wednesdays occur the fourth Wednesday of every month
  • Time: 2:00-3:30pm Eastern Time
  • Length: 90 minutes
  • Price: $195 per seat
  • Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.

HERE IS A COMPLETE LIST OF UPCOMING WEBINARS

THE NEXT ONE IS APRIL 26, 2017

Are you attending the ASQ World Conference on Quality in Charlotte?

Posted: April 19th, 2017 in Courses, Pictures, Quality, Root Causes, Software, TapRooT, TapRooT® Instructor

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

TapRooT® Around the World: Silao, Mexico

Posted: April 18th, 2017 in Courses, Pictures, Training

Another great TapRooT® root cause analysis course in Mexico. Looks like a great class!

Interested in bringing TapRooT® to your company for training? Inquire here. 

Interested in sending your team to a TapRooT® course? Check our course schedule here.

Caption Contest Winner!

Posted: April 18th, 2017 in Contest

Thanks to everyone who participated in this month’s caption contest. You gave everyone here at the TapRooT® office a good laugh! We did have to pick one winner for the best caption, though. And that person is….

The Grand Prize Winner is Adover with the caption “I could’ve had a V8”.

Congratulations, Adover!

Here is the short video to go with the winning caption.

via GIPHY

As always, thanks for participating. Keep on the lookout for more contests coming up!

Should We Continue to Fund the CSB?

Posted: April 17th, 2017 in Current Events, Performance Improvement

The Trump Administration has cut funding for several independent agencies in their 2017 budget request. One is the US Chemical Safety Board.

The CSB has produced this video and a report to justify their continued funding.

REPORT LINK

The question taxpayers need to ask and answer is, what are the returns on the investment in the CSB?

The CSB produces investigation reports, videos, and a wish list of improvements.  In 2016 the agency published seven reports and two videos  (it has six investigations that are currently open). That makes it a cost of $1.2 million per report/video produced when you divide their $11 million 2016 budget by their key products.

The 2017 budget request from the CSB was $12,436,000 (a 13% increase from their 2016 budget).

Should the government spend about $12 million per year on this independent agency? Or are these types of improvements better developed by industry, other regulatory agencies (EPA and OSHA), and not-for-profit organizations (like the Center for Chemical Process Safety)?

Leave your comments here (click on the comments link below) to share your ideas. I’d be interested in what you think. Or write your representatives to provide your thoughts.

Are You Writing the Same Corrective Actions?

Posted: April 17th, 2017 in Human Performance, Investigations, Media Room, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, Video, Video Depot

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

Friday Jokes: Easy open

Posted: April 14th, 2017 in Jokes

easy open

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