Root Cause Analysis Blog

 

What does a bad day look like?

Posted: July 30th, 2015 in Pictures

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Want to see more of these? “What Does a Bad Day Look Like” is a column in our weekly eNewsletter (distributed every Tuesday) that often makes our subscribers feel they are having a pretty good day!  If you’d like to subscribe, contact Barb at editor@taproot.com.

TapRooT® Public Courses in Central & South America

Posted: July 30th, 2015 in Courses

Monterrey_skyline

Monterrey, Mexico

Upcoming TapRooT® Public Courses:

Central America: 

Monterrey, Mexico | 5-Day | August 24, 2015 (Language: Spanish)

South America: 

Sao Paulo, Brazil | 5-Day | August 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | August 26, 2015 (Language: Spanish)

Bogota, Colombia | 3-Day | August 26, 2015 (Language: Spanish)

Sao Paulo, Brazil | 2-Day | September 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | September 22, 2015 (Language: Spanish)

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

Public TapRooT® Course in Stavanger, Norway

Posted: July 30th, 2015 in Courses, Local Attractions

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Who is joining us in beautiful Stavanger, Norway for the TapRooT® Public Course coming up September 9, 2015?  Stavanger is known for many things such as one of Europe’s energy capitals, host of the Offshore Northern Seas (ONS) energy conference and a capital of culture. A beneficial learning experience through a 2-Day TapRooT® Incident Investigation Course along with sightseeing and experiencing a new city, what more could you want?

Food:

NoodleNoodle: If you love asian style and flavored noodles, this is your place. The locals love it and the tourists rave about it.

Cardinal: You can’t go to a country in Europe without visiting a local, proper pub, right? Enjoy the best that Norway has to offer at Cardinal.

Dognvill Bar & Burger: Something a little familiar, something a little local. Try the Norwegian spin on the hamburger, you won’t be disappointed.

Attractions:

Flor og Fjaere: Norwegian botanical gardens. You don’t need to be a botanist to appreciate a paradise like this.

Museums: Stavanger has several museums that have been a crowd-favorite among tourists. Try one or all!

-Canning Museum

-Maritime Museum

-Petroleum Museum

Viking Stadium: Catch a game of football (American soccer) to experience the love that Norwegians have for this beloved sport.

 

Ready to Register? Click here.

Interested in other Public Courses we offer? Click here. 

Want to inquire about an Onsite Course? Click here.

When is a safety incident a crime? Would making it a corporate crime improve corporate and management behavior?

Posted: July 29th, 2015 in Accidents, Current Events, Human Performance

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I think we all agree that a fatality is a very unfortunate event. But it may not be a criminal act.

When one asks after an accident if a crime has been committed, the answer depends on the country where the accident occurred. A crime in China may not be a crime in the UK. A crime in the UK may not be a crime in the USA. And a crime in the USA may not be a crime in China.

Even experts may disagree on what constitutes a crime. For example, University of Maryland Law Professor Rena Steinzor wrote an article on her blog titled: “Kill a Worker? You’re Not a Criminal. Steal a Worker’s Pay? You Are One.” that her belief is that Du Pont and Du Pont’s managers should have faced criminal prosecution after an accident at their LaPorte, Texas, facility. She cited behavior by Du Pont’s management as “extraordinarily reckless.”

OSHA Chief David Michaels disagrees with Professor Steinzor. He is quoted in a different article as saying during a press conference that Professor Steinzor’s conclusions and article are, “… simply wrong.”

The debate should raise a significant question: Is making an accident – especially a fatal accident – a corporate crime a good way to change corporate/management behavior and improve worker safety?

Having worked for Du Pont back in the late 1980’s, I know that management was very concerned about safety. They really took safety to heart. I don’t know if that attitude changed as Du Pont transformed itself to increase return on equity … Perhaps they lost their way. But would making poor management decisions a crime make Du Pont a safer place to work?

Making accidents a crime would definitely making performing an accident investigation more difficult. Would employees and managers cooperate with ANY investigation (internal, OSHA, or criminal) IF the outcome could be a jail sentence? I can picture every interviewee consulting with their attorney prior to answering an investigator’s question.

I believe the lack of cooperation would make finding and fixing root causes much more difficult. And finding and fixing the root causes of accidents is extremely important when trying to improve safety. Thus, I believe increased criminalization of accidents would actually work against improving safety.

I believe that Du Pont will take action to turn around safety performance after a series of serious and sometimes fatal accidents. I think they will do this out of concern for their employees. I don’t think the potential for managers going to jail would improve the odds that this improvement will occur.

What do you think? Do you agree or disagree. Or better yet, do you have evidence of criminal proceedings improving or hindering safety improvement?

Let me know by leaving a comment below.

 

TapRooT® Public Courses in Europe, Africa & Middle East

Posted: July 29th, 2015 in Courses

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Aberdeen, Scotland

Upcoming TapRooT® Public Courses:

Europe: 

Stavanger, Norway | 2-Day | September 9, 2015

Stavanger, Norway | 3-Day | September 9, 2015

Hamburg, Germany | 2-Day | September 14, 2015

Aberdeen, Scotland | 5-Day | September 21, 2015

Africa: 

Johannesburg, South Africa | 5-Day | August 24, 2015

Middle East: 

There are no upcoming public courses scheduled for August and September in this region. Check back frequently for updates or inquire about an onsite course.

 

Job Openings for People with TapRooT® Root Cause Analysis Training

Posted: July 29th, 2015 in Job Postings

Have you learned to use the TapRooT® System to find and fix the root causes of problems? If so, here are some employers interested in your skills:

NABU Quality Manager – TESCO Corporation – Houston, TX, USA

Reliability EngineerD22 Jurong, Jurong Island, Tuas, Singapore

Safety Specialist – Danos – Louisiana, USA

What’s the most important information in a root cause analysis?

Posted: July 29th, 2015 in Root Cause Analysis Tips

Welcome to this week’s root cause tips column. So what is the most important information or criteria in a good root cause analysis? (By the way, this is a trick question)

I started a list:

• A timeline of what happened
• Complete evidence
• Identification of causal factors
• Safeguards analysis (what failed)
• Safeguards Analysis (what worked)
• Root Causes substantiated by evidence
• Generic (system) Causes identified
• Corrective Actions that eliminate the root causes
• Corrective Actions that are implemented
• Corrective Actions that have been verified effective

So what do you think? Have I missed anything? Please comment below if you have any other ideas.

And which are the most important?

Yes, it is a trick question. They are ALL important.

For example, what if you did a really good job of collecting evidence and got good root causes but wrote weak corrective actions? Have you ever seen training as a corrective action for root causes that had nothing to do with training? Of course you have, that’s my point.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

What if you had great corrective actions but they were never implemented (or checked to see if they were effective)?

The fact of the matter is you have to have all these things for an effective investigation and root cause analysis. It is easy to miss things, we’re all human and we all have different experiences, knowledge, and biases. But the good news is that this is all built into how TapRooT® functions. Just follow the process and you will have a good root cause analysis.

You must know WHAT happened before you can determine why. This is why evidence collection is so important.

You must know WHY before you can write corrective actions. If you do not have good evidence you will miss causal factors and root causes. ALL root causes have to be substantiated with evidence.

You must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

Think of it as a chain link fence. If any part of the chain is broken, the fence is compromised, and in this case, so is your investigation.

If you are interested in learning the TapRooT® Root Cause Analysis, our 2-day course offers all the process essentials needed to conduct an investigation including:

  • SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
  • Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
  • Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.

Check out our schedule for a course near you:  http://www.taproot.com/courses#2-day-incident

I hope I’ve given you some food for thought. Thanks for visiting our blog and happy investigating.

3 Characteristics that Separate Leaders from Managers

Posted: July 29th, 2015 in Career Development, Career Development Tips

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A manager and a leader have two very different yet critical roles for the success of every business. It is extremely rare to find an individual who can serve both roles.

It may seem intuitive to know which role you’re in, but sometimes a manager will find himself miserable in a position because he is a leader, and a leader doing a manager’s job is like trying to fit a round peg into a square hole.

Knowing whether you are a leader or a manager helps you fit into the organizational structure of your company, and benefits both you and the company.

Here are three primary differences between and manager and a leader:

 

Manager: You’ve been told you’re the “brains of the business.”

Leader: You’ve been told you “inspire action” with your ideas.

Manager: You set exciting goals, i.e., how many green widgets will be produced and sold this week.

Leader: You respectfully question exciting goals, i.e., is the sale of green widgets in line with our company’s core values?

Manager: You major in the “how” and “when,” establishing systems, operating procedures and incentive programs.

Leader: You major in the “what” and “why,” establishing the mission statement, long-term vision, and the direction of the company.

People ask the difference between a leader and a boss. The leader leads and the boss drives. ~ Theodore Roosevelt

While it’s true that some managers inspire and some leaders can create great systems, these are not their primary strengths.

Have you ever left a position because you were managing instead of leading, or vice versa?

Do you consider yourself an investigative team leader? We’d love to see you in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training!  Check out our Global Schedule for a course near you!

Simple Corporate Turnaround – Go from a money losing operation to a money making good example.

Posted: July 28th, 2015 in Performance Improvement, Pictures

How do you go from being a money losing operation to a money making good example?

Here’s a quick answer:

1. Send at team to TapRooT® Root Cause Analysis Training.

2. When they get back to work, put them to work solving your most expensive problems.

Don’t think this will work? Then see this success story…

http://www.taproot.com/archives/18976

Want more proof? See the rest of the success stories at:

http://www.taproot.com/archives/category/success-stories

If you need to improve your sites profitability, learn to use TapRooT® Root Cause Analysis to solve operational and maintenance problems. See our public course schedule for courses being held around the world at:

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

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Weekly Wisdom: Stay focused on what’s important

Posted: July 28th, 2015 in Wisdom Quote

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“We become what we think about.” -Earl Nightingale

How far away is death?

Posted: July 28th, 2015 in Video

From last year …

TapRooT® Public Courses in Canada

Posted: July 27th, 2015 in Courses

CalgaryIsland

Calgary, Canada

Upcoming TapRooT® Public Courses:

Calgary | 2-Day | August 18, 2015

St. John’s | 2-Day | August 25, 2015

Edmonton | 2-Day | September 21, 2015

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

Final presentations at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Posted: July 24th, 2015 in Courses, Pictures, TapRooT

Great work by all participants! Here’s one of the presentations and the audience …

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Friday Joke: Enforcement NI

Posted: July 24th, 2015 in Jokes, Video

Need to improve your enforcement? Try Terry Tate!

Public TapRooT® Course in Monterrey, Mexico

Posted: July 23rd, 2015 in Courses, Local Attractions

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Are you planning to join TapRooT® in Monterrey, Mexico for a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training (Spanish) on August 24, 2015?

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.

TapRooT® Public Courses in Central & South America

Posted: July 23rd, 2015 in Courses

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Bogota, Colombia

Upcoming TapRooT® Public Courses:

Central America: 

Monterrey, Mexico | 5-Day | August 24, 2015 (Language: Spanish)

South America: 

Sao Paulo, Brazil | 5-Day | August 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | August 26, 2015 (Language: Spanish)

Bogota, Colombia | 3-Day | August 26, 2015 (Language: Spanish)

Sao Paulo, Brazil | 2-Day | September 17, 2015 (Language: Portuguese)

Bogota, Colombia | 2-Day | September 22, 2015 (Language: Spanish)

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

TapRooT® Public Courses in Europe, Africa & Middle East

Posted: July 22nd, 2015 in Courses

Johannesburg_Sunrise,_City_of_Gold

Johannesburg, South Africa

Upcoming TapRooT® Public Courses:

Europe: 

Stavanger, Norway | 2-Day | September 9, 2015

Stavanger, Norway | 3-Day | September 9, 2015

Hamburg, Germany | 2-Day | September 14, 2015

Aberdeen, Scotland | 5-Day | September 21, 2015

Africa: 

Johannesburg, South Africa | 5-Day | August 24, 2015

Middle East: 

There are no upcoming public courses scheduled for August and September in this region. Check back frequently for updates or inquire about an onsite course.

 

Root Cause Analysis Tip: 6 Reasons to Look for Generic Root Causes

Posted: July 22nd, 2015 in Investigations, Performance Improvement, Root Cause Analysis Tips, Root Causes

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“Allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.”

You have established a good performance improvement program, supported by performing solid incident investigations.  Your teams are finding good root causes, and your corrective action program is tracking through to completion.  But you still seem to be seeing more repeat issues than you expect.  What could be the problem?

We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations.  But many companies are skipping over the Generic Cause Analysis portion of the investigation process.  While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.

6 Reasons to Look for Generic Root Causes

Here are 6 reasons to conduct a generic cause analysis on your investigation results:

1. The same incident occurs again at another facility.

2. Your annual review shows the same root cause from several incident investigations.

3.  Your audits show recurrence of the same behavior issues.

4. You apply the same corrective action over and over.

5. Similar incidents occur in different departments.

6. The same Causal Factor keeps showing up.

These indicators point to the need to look deeper for generic causes.  These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents.  When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present.  Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.

Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis.  There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.

Learn more about finding and fixing root causes in our 2-day or 5-day TapRooT® Root Cause Analysis courses!

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Exelon Nuclear
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