To kick off our weekly drawing, I drew not one, but two names in our “Recommend for a Chance to Win” contest today.
Congrats to Cyrus S. and Tony L.!
And if your name wasn’t drawn, you still may win in our future weekly drawings. Thanks for recommending us!
Cyrus, who recommended our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, noticed that TapRooT® works across all industries. That is a comment that we love to hear, and we are looking forward to our next Global TapRooT® Summit April 7 – 11, 2014 where oil refineries, hospitals, aviation, oil E&P, nuclear plants, high tech manufacturing facilities, shipping, pipelines, mining, rail and light rail, chemical plants, and electricity transmission and distribution will all be represented.
Tony mentioned in his recommendation of our 5-Day course that he appreciates we are only a phone call or e-mail away. We strive to make folks who attend our courses and our Summit feel like they are part of the TapRooT® Team — not just an attendee.
Thank you, Tony and Cyrus, for sharing your experience with TapRooT®!
Want to learn more about what others think about TapRooT®? Read the full recommendations by visiting our Services page on LinkedIn:
If you want to learn more about our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, visit:
And there’s still time to sign up for the 2014 Global TapRooT® Summit! Learn more here:
Already been to a TapRooT® Course? You can recommend for a chance to win:
A few photos that TapRooT® Instructor Boris Risnic shared from our recent onsite course in Brazil.
TapRooT® Instructor Harry Thorburn shared these photos from our current 5-Day TapRooT® Root Cause Analysis Team Leader Training in Stavanger, Norway. (March 10-14) If you’re interested in learning more about our root cause analysis courses around the world, click here.
Natural disaster? Mechanical malfunction? Or something more insidious? While we still have few answers to our questions about the loss of Malaysia Airlines flight MH370, the investigation continues. It would be very difficult to make a SnapCharT® of events, because we have very little information regarding the incident. The evidence included a salvaged airplane door, two stolen passports, and an ocean oil slick that would be consistent with the potential location and type of incident.
In the face of this grievous incident, the world wants answers. Read the following articles for more details on the investigation, and let us know: Do you think it’s a good idea to do what the author of The Star article does by making guesses as to the root cause of the incident? At what point does one have enough facts to conduct an adequate investigation? Is “pilot fault” a valid root cause?
The New York Times: Search for Jet Compounds the Mystery
The Star: Missing MH370: 5 theories on what could have happened to MH370
Graphic courtesy of The Star.
Monday Accident & Lessons Learned: UK RAIB reports on fatal accident at Athelney level crossing, near Taunton, Somerset on 21 March 2013Posted: March 10th, 2014 in Accidents, Current Events, Investigations, Pictures
The following this the summary of the accident report from the UK Rail Accident Investigation Brach about a fatal accident at a level crossing in the UK. The full report includes four recommendations to improve level crossing safety. See the full report at: http://www.raib.gov.uk/cms_resources.cfm?file=/140224_R042014_Athelney.pdf
At about 06:23 hrs on Thursday 21 March 2013, a car drove around the barriers of Athelney automatic half barrier crossing, near Taunton in Somerset. This took the car into the path of a train which was approaching the crossing at high speed. The driver of the car was killed in the resulting collision.
The motorist drove around the barriers without waiting for a train to pass and the barriers to re-open. The level crossing was closed to road traffic for longer than normal before the arrival of the train, because of earlier engineering work that had affected the automatic operation of the crossing. The motorist may have believed that the crossing had failed with the barriers in the closed position, or that the approaching train had been delayed.
He did not contact the signaller by telephone before he drove around the barriers.The RAIB has made two recommendations to Network Rail. These relate to reducing the risk resulting from extended operating times of automatic level crossings andto modifying the location of the pedestrian stop lines at Athelney level crossing. A further recommendation is addressed to Network Rail in conjunction with RSSB,to consider means of improving the presentation of telephones at automatic level crossings for non-emergency use. One recommendation is addressed to the Office of Rail Regulation, to incorporate any resulting improvements which are reasonably practicable into the guidance it publishes on level crossings.
Last week we learned how to do a quick self-evaluation of our job performance. How did you do? This week we’ll dig a little deeper and look at it from a different perspective, not what we think about ourselves but what our boss thinks about us.
While unemployed workers seem more optimistic about finding a job in 2014, the pressure to be more innovative, productive and flexible has never been greater. If you are currently employed, you may not be thinking about what this means to you … but you should. Don’t be blindsided by an unexpected layoff.
Here are 6 critical questions to ask yourself to find out if your boss thinks you are irreplaceable.
Question #1: What skills do I possess that meet the current and future demands of my job market?
It is crucial to understand the current wants and needs of the job market even when we are employed. We have no control over this factor but we can work to understand market trends and tweak our skills to align with them. Your boss is thinking about the capabilities of workers in your position, so make sure you are up-to-date.
Question #2: What am I doing to improve my performance for the facility I work for?
Seek to improve your personal skill set on a daily basis. Today’s successful employee is not simply doing what they are paid to do but looking to bring value to what they provide. Get noticed!
Question #3: What is the main thing I do during my work day that keeps my boss from replacing me right now?
If you want to measure how easy your boss thinks it is to replace you, you need to consider 1) current competition for your position and 2) how well you understand what your boss wants you to do. Staying competitive and doing what your boss needs done secures your position.
Question #4: Do I engage each day in the most important tasks associated with my position?
Strategic focus is looking at the day ahead, and deciding to spend your time on the most productive activities. Stop chasing rabbit trails. Choose the activities that have the greatest impact on your bottom line.
Question #5: Am I relying too much on digital technology to communicate with my boss?
Email won’t shed much light on your personality and admirable characteristics. It may be tempting to e-mail every communication to your boss, but picking up the phone, or walking into his or her office for a face-to-face will increase your positive interaction and relationship. Do face time. Not Apple FaceTime, but real face time.
Question #6: Do people seek my advice in my area of expertise?
Position yourself so that people you work with seek you out as an authority to make decisions in your area of expertise. When you become an expert inside and outside of your organization, you increase your value.
So, now you have an idea of what your boss is thinks about you. But what if you are the boss? Do your employees trust you to see the hard work they are doing? Next week we will talk about 3 qualities of a trustworthy boss.
Would you like help building your reputation as an irreplaceable employee?
TapRooT® training can help you improve your skill-set. What many people don’t know is that we offer courses beyond our root cause analysis courses. We have 13 2-day exclusive Pre-Summit courses about many career-changing topics scheduled for April 7 – 8 in Horseshoe Bay, Texas. Some of these courses include topics like:
Analyzing & Fixing Safety Culture Issues
Reducing Serious Injuries
Preventing Slips, Trips and Falls
Learn about Pre-Summit Courses, April 7 – 8.
Learn about the 3-Day Summit April 9 – 11.
(And for more info about being irreplaceable at work, read: Invaluable: The Secret to Becoming Irreplaceable, by Dave Crenshaw.)
What do past Summit Attendees have to say about their experience at the Global TapRooT® Summit? Find out in this short video. Some highlights:
“I’ll be bringing a couple of best practices home. [One] of the things I was interested in, specifically, was trending.” -Darryl H.
“There are several very mature organizations that I’ve met over these last 5 days that have very robust programs [to learn from].” – Nancy H.
“I got a chance to meet a lot of good people… it was overall a fabulous time.” – Patricia R.
Watch the video below to learn more of the insights you & your Summit colleagues shared with us over the last few years:
Have you registered for the Summit yet? It’s just a month away, so sign up today. You’ll learn best practices, network with professionals across industries, and enjoy the beautiful Horseshoe Bay Resort near Austin, Texas.
Press Release by the UK Rail Accident Investigation Branch: Passenger dragged a short distance by a train at Holborn stationPosted: March 8th, 2014 in Accidents, Current Events, Investigations, Pictures
Image showing a train in the westbound Piccadilly Line platform at Holborn station
The RAIB is investigating an incident in which a passenger was dragged for a short distance by a train departing from Holborn station on the London Underground system.
The incident occurred on the westbound Piccadilly Line platform at around 19:00 hrs on Monday 3 February 2014. The train had stopped normally in the platform and passengers had alighted and boarded. A member of staff on the platform (station assistant) signalled to the Train Operator to close the doors by raising a baton above his head. The Train Operator observed the raised baton and started to close the train’s doors. At this point a passenger arrived on the platform and moved towards the train, stopping as she realised that the doors were closing. As she stopped, the end of the scarf that she was wearing continued to swing towards the train and became trapped between the closing doors.
The Train Operator was unaware that the scarf was trapped in the door and after confirming that all doors were closed, started to move the train into the tunnel. The passenger was dragged along the platform by her scarf as the train started to move. The station assistant tried to help the passenger by holding on to her and they both fell to the ground. This resulted in the scarf being forcibly removed from the passenger’s neck and carried into the tunnel by the train.
The passenger suffered injuries to her neck and back and was taken to hospital; she is now recovering. The RAIB’s investigation will seek to understand the sequence of events and will examine the arrangements in place for safe despatch of trains from London Underground stations where station assistants are provided on the platform.
The RAIB’s investigation is independent of any investigation by the Office of Rail Regulation. The RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.
The Name Game: Network with Safety, Quality, Health, Environment, and Investigation Professionals at the 2014 Global TapRooT® Summit!Posted: March 7th, 2014 in Pictures, Summit
Do you want to connect with other safety, quality, or investigation professionals in your industry, but find it hard to break the ice? Have you ever attended a conference chock-full of interesting individuals, only to return home with just a couple of business cards? Networking can be difficult and, let’s face it, awkward. At the Global TapRooT® Summit, you won’t have to worry about that. We’ll break the ice for you during the Name Game.
The Name Game takes place during the first general session of the Summit. You’ll meet three hand-picked professionals to connect with. As a participation prize, you’ll receive a free TapRooT® polo shirt.
Join your new contacts at the Wednesday night reception for more fun & networking, or plan dinner together Thursday night to share best practices and get to know each other.
Your new colleagues can’t wait to meet you at the Name Game at the 2014 Global TapRooT® Summit. Don’t miss it!
On July 17, 1981, a 32-ton, 12-foot long fourth floor walkway that spanned over and across the Hyatt Regency Kansas City lobby collapsed and crashed into the second floor walkway of equal size and weight. Both walkways landed in the lobby /atrium area where a dance competition (with approximately 1,600 people in attendance) was being held. The rescue operation lasted 14 hours, 114 people were killed and another 216 were injured.
Investigators found that changes to the design of the walkway’s steel tie rods were the cause of its failure.
$140 million was awarded to victims and their families, and the tragedy remains a classic model for the study of engineering ethics and errors. After the collapse, the lobby was reconstructed with only one crossing on the second floor, supported by several columns underneath it rather than being suspended from the ceiling.
Download and read report at National Institute of Standards and Technology:
A big thank you to TapRooT® Instructor Sanjay Gandhi for a great onsite course in South Africa, and for these photos of it.
Interested in our Africa root cause analysis training?
TapRooT® Instructor Reb Brickey sent over these photos from our onsite course in Halifax, Nova Scotia, Canada. Click here to contact us and ask about onsite courses.
TapRooT® Instructor Dave Janney shared these course photos from our February 9-13 5-Day TapRooT® Root Cause Analysis Team Leader Training in Doha, Qatar.
My Mom suffered a sentinel event at a hospital in Illinois. Many of the readers here may have had loved ones who died or were significantly injured by mistakes at a hospital. But what can we do to improve patient safety and healthcare quality? Attend the Improving Healthcare Quality & Patient Safety Best Practice Track at the 2014 Global TapRooT® Summit.
When your mom is injured in a hospital sentinel event, you take performance improvement even more seriously. But I started the Improving Healthcare Quality & Patient Safety Best Practice Track back in 1995 – long before sentinel events and patient safety became front page news (and before my mom was injured). But why am I explaining my personal link to this track at the Summit? Because I want you to know how important this session is and how hard we work to bring valuable information to healthcare professional who attend the Summit.
What will you learn as a healthcare professional at the 2014 Global TapRooT® Summit? First, you will take back valuable best practices from these best practice sessions:
- Error Proof Healthcare – How to Accelerate Your Improvement Efforts
- The Emily Jerry Story: From Tragedy to Triumph
- High Reliability Industry Lessons for healthcare
- Slips, Trips, and Falls: The Science Behind Walking
- Fatigue & Human Performance: The Tell-Tale Signs of Fatigue Related Mistakes
- System Root Cause Analysis of Intergenerational Issues
- Advanced Causal Factor Development
- Expert Facilitation of Investigations Using TapRooT® Software
But that’s not all. You will also be motivated by our keynote speakers:
- Christine Cashen – Why Briansorm When You Can Brain El Niño?
- Carl Dixon – A Strange Way to Live
- Mark Paradies – World Class Performance Improvement
- Edward Foulke – Sweeping Workplace Safety Changes
- Rocky Bleier – Be the Best You Can Be
But there’s more … Networking and FUN! From the opening “Name Game” to the closing charity golf tournament, we’ve designed the TapRooT® Summit to make it easy to meet and get to know new people that can help you learn important lessons that will help you improve performance at your facility.
Don’t miss out on this valuable opportunity to save patient’s lives and improve quality at your hospital. Register today at:
If you are a healthcare professional involved in patient safety and quality improvement, you really need to be there.
A 45-year-old food company worker lost part of two fingers that were caught in a rotating drum. The HSE inspector stated that if the machine was properly guarded, the accident wouldn’t have happened. In addition to fines, the company was also banned from using the machine until it was sufficiently guarded. (Read full story on Brent & Kilburn Times.)
Underestimating the power of projectiles, relying on your friends to lift you up, (or catch you when you fall), taking a shortcut – these are all subtitles to funny videos recently posted by Mashable that underscore decisions people make that they immediately regret.
Here is a link to the videos: http://mashable.com/2014/03/03/i-regret-everything/
On a more serious note, it reminds me of the weekly eNewsletter we put together – we include regular columns like “How Far Away is Death” and “Monday Accidents and Lessons Learned” and yes, we always include a joke for our readers too, but sometimes it takes looking at destructive consequences of actions that people take and later regret before we are inspired to make a change and keep our workplaces safer.
If you’re not a subscriber, won’t you join our community of experts around the world as we work together to change the way the world solves problems? Here is our recent weekly edition:
Mark Paradies, President of System Improvements, Inc./TapRooT®, presents a view of lessons *not* learned according previous reports related to Deepwater Horizon & Texas City. In this 2013 Global TapRooT® Summit presentation he critiques the failure to learn and prevent accident recurrence, and offers suggestions to improve investigations.
View four-part video of this presentation: