Root Cause Analysis Blog

 

Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Houston, TX

Posted: January 23rd, 2015 in Courses, Pictures, TapRooT

Linda Unger, VP at SI, sent these pictures of Ken Turnbull, one of our contract instructors, teaching a bunch of great students.

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Friday Joke: Please Follow the Rules on the Sign

Posted: January 23rd, 2015 in Jokes

Violators will be rewarded! Yes!

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And don’t drink and make signs either.

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I know it will be hard, but just please try.

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Even in Humor, You can learn about Root Cause and People from Dr. Deming

Posted: January 22nd, 2015 in Accidents, Best Practice Presenters, Human Performance, Performance Improvement, Quality, Root Causes, Summit, TapRooT, Video

Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…

… your own actions.

… your understanding of other peoples actions.

… your past corrective or preventative actions.

Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.

To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance  excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.

To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit

If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw

TapRooT® Public Courses In South America

Posted: January 22nd, 2015 in Courses, Pictures

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Bogota, Colombia

Upcoming TapRooT® Public Courses:

Sao Paulo, Brazil 2-Day February 26, 2015 

Bogota, Colombia 2-Day March 11, 2015

Bogota, Colombia 3-Day March 11, 2015

For more information regarding our public courses around the world, click here.

TapRooT® Around the World: Cape Industries

Posted: January 22nd, 2015 in Courses, Pictures

Thank you to Derek Rutherford for sharing these photos with us from a recent Onsite course at Cape Industries.

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Want more information regarding our Onsite and Public courses? Click Here. 

Will Falling Oil Prices Put the Cost Cutting Axe to Safety Improvement?

Posted: January 22nd, 2015 in Current Events, Performance Improvement, Pictures, Summit

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It’s easy for a CEO and management to claim to support safety. But the proof comes when times get tough. 

The price of oil has declined more that 50% in just six months. That has the oil field in crisis mode. Knee jerk budget cuts, travel restrictions, and layoffs have already started. 

What does this mean to safety improvement? Many oil industry safety professionals get ideas about ways to improve by attending the TapRooT® Summit, networking with industry leaders and performance improvement experts, hearing about the latest best practices that will help them solve their toughest problems, and developing plans to take safety to a whole new and better level. But if travel budgets are slashed and conferences are not allowed, these new best practices won’t be learned, safety improvement will stop, and lives that could have been saved will be lost.

Now is the time for management to show their commitment to safety improvement. They can stand up, resist the fear of low oil prices, and demand that safety improvement continues even in times of budget restraint. 

After all, safety is not just a priority that can be discarded when times get tough. Safety is a value that must be supported every day, year in and year out, in good times and bad, or people will start to believe that safety is option and the only real value is profit.

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Don’t let safety improvement become an unsupported slogan. Register for the TapRooT® Summit today!

What does a bad day look like?

Posted: January 22nd, 2015 in Pictures

Just like this if you own a Subway …

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Upcoming TapRooT® Public Course in New Plymouth, New Zealand

Posted: January 22nd, 2015 in Courses, Local Attractions, Pictures, TapRooT

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TapRooT® hosts public courses all over the world, including New Zealand. Come out to New Plymouth, New Zealand on February 16, 2015 for a 5-Day Advanced Root Cause Analysis Team Leader Training to learn how you can be proactive and perform better investigations. New Plymouth is a coastal city on the west coast of New Zealand that has been named a “model community” because of its beautiful infrastructure. The small population walks and cycles along the coastal walkway (pictured above) and enjoys the each other’s company and the view. Talk about a great place to visit and take a TapRooT® course!

Food:

Table Restaurant: Placed within the Nice Hotel, this gourmet, award winning restaurant ensures you will enjoy food, wine and friends.

The Mayfair: Want a burger, fries, salads, pizzas or snacks? The Mayfair has it all and some drinks to go with it.

Cow Ree: This small vintage cottage set right on the beach makes for a fun, enjoyable evening out for a great meal.

Attractions:

Pukekura Park:  You’ve never experienced a local park with such beautiful scenery and events-including a lights show you won’t forget!

Coastal Walkway: Enjoy a nice walk along the coast with a perfect view of the mountains.

Taranaki Aviation Transport and Technology Museum: If you’re interested in all things to do with aviation and technological transportation, then this museum is for you.

 

REGISTER HERE for this Public Course today

SAVE THE DATE for the upcoming Global TapRooT® Summit. For more information and registration click on the links.

Find and Fix the Root Causes of Equipment Related Failures

Posted: January 21st, 2015 in Courses, Equipment/Equifactor®

Don’t end up “fixing” the same equipment problems over and over again. Don’t let equipment issues cause quality, operations, and safety issues. Find the real root causes of your equipment reliability issues and develop effective fixes that will keep them from happening again by using this systematic process.

Did you know that we have 3-day and 1-day courses? What’s the difference? 3-Day Courses include the 1-Day Equifactor® Course along with the 2-Day Incident Investigation and Root Cause Analysis Course so you have it all in one. The 1-Day courses are just the separate Equifactor® course that requires a previously taken 2-Day course along with it, not necessarily all in one trip.

Why take an Equifactor® course? You will not only receive invaluable knowledge for your business, but also a Free single-user copy of TapRooT® Software. (A $2890 Value!) You can’t get a better deal than that.

Still deciding? Watch the video below to hear our Equifactor® instructor, Ken Reed, talk about why this course is right for you.

 

Steps to register for the course and Free Software.

1) CLICK HERE

2) Select a 1-Day Equifactor® Course of your choice (Having already taken a 2-Day course or accompanying it with a 2-Day course)

3) Register for the course and add it to your cart

4) Done!

 

Upcoming Equifactor® Public Courses:

Calgary, Alberta | January 16, 2015

Houston, Texas | March 18, 2015

Brisbane, Australia | March 18, 2015

Onsite TapRooT® courses

Posted: January 20th, 2015 in Courses

Thanks to TapRooT® instructor Ralph Blessing for sending this picture of an onsite course being held today for one of my clients in Illinois. In the picture, instructor Ralph Brickey is teaching the students how to find Causal Factors.

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By the way, not all of our instructors are named Ralph, but they are all excellent instructors! We can teach any of our courses at your site (10 or more people), and we have instructors throughout the world. If you are interested in holding a course at your site, just e-mail us at info@taproot.com

How Far Away is Death?

Posted: January 20th, 2015 in Pictures

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Weekly Wisdom for Not Holding Back

Posted: January 20th, 2015 in Wisdom Quote

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“Limitations live only in our minds. But if we use our imaginations, our possibilities become limitless.” -Jamie Paolinetti

Career Development: How to Be a Great Leader

Posted: January 20th, 2015 in Career Development

Who is the happiest man every measured by science? And what was he thinking when he was being measured? And what does any of this have to do with business leadership? View this video and find out!

TapRooT® Public Courses In Canada

Posted: January 19th, 2015 in Courses, Pictures

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Calgary, Alberta, Canada

Upcoming TapRooT® Public Courses:

Calgary 5-Day February 23, 2015

Calgary 2-Day March 16, 2015

Edmonton 2-Day March 19, 2015

For more information regarding our public courses around the world, click here.

Monday Accident & Lessons Learned: UK RAIB Report – Near-miss involving construction workers at Heathrow Tunnel Junction, west London, 28 December 2014

Posted: January 19th, 2015 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

UK Rail Accident Investigation Branch Press Release…

The UK RAIB is investigating an incident in which a train almost struck two construction workers, and collided with a small trolley, on the Up Airport line between Heathrow Airport Tunnel and the Stockley Flyover.

NewImageYellow engineering trolley underneath the train after the collision (image courtesy of Carillion)

The incident occurred at about 10:05 hrs on Sunday 28 December 2014 and involved train 1Y40, the 09:48 hrs service from London Heathrow Terminal 5 to London Paddington. The track workers jumped clear just before the approaching train struck a small engineering trolley that they had been placing on the line. The train, formed by a Class 332 electric multiple unit, was travelling at approximately 36 mph (58 km/h) when it struck the trolley. 

The two track workers were among a large number of people carrying out construction work on the approach to a new bridge that had been recently constructed adjacent to the existing Stockley Flyover. This new structure, which carries a new railway track over the mainline from London Paddington to Reading, was built as part of the Crossrail surface works being undertaken by Network Rail.

To enable this work to take place, parts of the operational railway in and around the construction site had been closed for varying periods during the few days before the incident. The two construction workers were unaware that the Up Airport line had returned to operational use a few hours before they started to place the trolley onto this line. They formed part of an eight person workgroup which included a Controller of Site Safety (COSS). The COSS and other group members were not with the two track workers at the time of the incident. The presence of temporary fencing, intended to provide a barrier between construction activities and the operational railway, did not prevent the two track workers accessing the open line.

Network Rail owned the infrastructure at the site of the accident and had employed Carillion Construction as the Principal Contractor for the construction works. The two track workers and the COSS were all employed by sub-contractors.

RAIB’s investigation will establish the sequence of events, examine how the work was planned, how the staff involved were being managed and the way in which railway safety rules are applied on large construction sites adjacent to the operational railway. It will also seek to understand the actions of the people involved, and factors that may have influenced their behaviour.

RAIB will also consider whether there is any overlap between this incident and the factors which resulted in an irregular dangerous occurrence at the same construction site on the previous day. This occurrence involved a gang of railway workers who walked along a line that was open to traffic, and without any form of protection, until other construction workers warned them that the line was open to traffic.

The RAIB investigation is independent of any investigations by the safety authority or the police. RAIB will publish its findings at the conclusion of the investigation. This report will be available on the RAIB website.

- – – – – 

What can we learn BEFORE the investigation is complete?

First, this “near-miss” was actually a hit.

In this case it was called a near-miss because no one was injured. However, the train and trolley were damaged and work was delayed. For operations, maintenance, and construction, this was an incident. In other words, it was a safety near-miss but it was an operation, maintenance, and construction hit.

Many incidents that don’t have immediate safety consequences do have immediate cost, productivity, and reliability consequences that are worthy of an investigation. And in this case, the operations incident also had potential to become a fatality. This even more reason to perform a thorough root cause analysis.

Richard Phillips, Real Life Inspiration for the Movie Captain Phillips, to Speak at 2015 Summit

Posted: January 19th, 2015 in Best Practice Presentations, Best Practice Presenters, Summit

Learn important lessons on leadership at the 2015 Global TapRooT® Summit from Richard Phillips, real life inspiration for the movie, Captain Phillips, who will be the closing keynote speaker on Day 3. The Summit begins on Wednesday, June 3, 2015 right after our 2-day Pre-Summit courses (June 1 and 2, 2015).

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Richard Phillips

For five days in April 2009, the world was glued to their TV screens as Captain Richard Phillips became the center of an extraordinary international drama when he was captured by Somali pirates who hijacked his ship, the first hijacking of a US ship in more than 200 years.

Though Captain Phillips describes himself as a “regular guy,” the world knows that his actions were anything but ordinary after the pirate attack. His harrowing and heroic efforts to survive an ordeal that riveted the world were only matched in valor by his decisive actions to save his crew and the ship they sailed. President Obama said, “I share the country’s admiration for the bravery of Captain Phillips and his selfless concern for his crew. His courage is a model for all Americans.”

REGISTER for the 2015 Global TapRooT® Summit, June 1-5, 2015, Las Vegas.

 

 

 

Do You Need a Job?

Posted: January 16th, 2015 in Courses, Job Postings, TapRooT

Today, Schlumberger announced it was planning on laying off 9,000 employees worldwide. The rapid drop in oil prices is having a negative employment impact.

If any TapRooT® Users find themselves unemployed, I’d like to remind them to watch for job opportunities here:

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

We post new job openings every week for people that have TapRooT® Root Cause Analysis Skills.

What? You haven’t attended a TapRooT® Root Cause Analysis Course? 

NOW is the time BEFORE you need a new job that requires TapRooT® Root Cause Analysis Training.

See our course schedule around the world and click on your continent to see local courses at:

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

Friday Joke: Donkey in the Well

Posted: January 16th, 2015 in Jokes

Donkey In The Well Story…

One day a farmer’s donkey fell down into a well. The animal cried piteously for hours as the farmer tried to figure out what to do.

Finally, he decided the animal was old, and the well needed to be covered up anyway; it just wasn’t worth it to retrieve the donkey.He invited all his neighbors to come over and help him. They all grabbed a shovel and began to shovel dirt into the well.

At first, the donkey realized what was happening and cried horribly. Then, to everyone’s amazement he quieted down.

A few shovel loads later, the farmer finally looked down the well. He was astonished at what he saw. With each shovel of dirt that hit his back, the donkey was doing something amazing. He would shake it off and take a step up. 

As the farmer’s neighbors continued to shovel dirt on top of the animal, he would shake it off and take a step up. Pretty soon, everyone was amazed as the donkey stepped up over the edge of the well and happily trotted off! 

Life is going to shovel dirt on you, all kinds of dirt. The trick to getting out of the well is to shake it off and take a step up. Each of our troubles is a steppingstone. We can get out of the deepest wells just by not stopping, never giving up! Shake it off and take a step up.NOW ——– 

Enough of this BS . . . 

The donkey later came back and bit the the farmer who had tried to bury him.

The gash from the bite got infected, and the farmer eventually died in agony from septic shock.

MORAL FROM TODAY’S LESSON: When you do something wrong and try to cover your ass, it always comes back to bite you. 

Why not try advanced root cause analysis instead!

The Only No-Lose Game in Las Vegas

Posted: January 15th, 2015 in Summit, TapRooT, Training

I was in Las Vegas teaching a TapRooT® Course when I realized … We are the only no-lose game in town!

What do I mean? TapRooT® Training is GUARANTEED.

Here’s the guarantee:

Attend this course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

It’s that simple.

But there’s more.

On June 1-5, System Improvements is holding the only GUARANTEED conference that I know about. The 2015 Global TapRooT® Summit. If you need to learn best practices from around the world that will help you improve performance, you need to be in attendance!

Here’s the Summit guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

Another great guarantee because we know you will love the Summit.

Don’t wait. You can’t afford not to attend TapRooT® Root Cause Analysis Training and the TapRooT® Summit. Get registered today!

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