IT DIDN’T HAVE TO HAPPEN
An anesthesia machine cuts off oxygen to a patient causing extensive brian damage. The investigation team finds a mechanical defect that was undetectable without complex testing. They also find that the sentinel event almost happened before.
The baggage door on a 747 opens after takeoff, tearing off part of the plane. Four people are swept out the hole to their death. The investigation uncovers poor, less catastrophic accidents of a similar nature and a history of problems with the door on this particular aircraft.
A plant upset occurs due to corrective maintenance. A relief lifts but fails to shut when pressure decreases. Operators, initially preoccupied with other alarms, misdiagnose the problem and shut off critical safety equipment. The “impossible” accident – a core meltdown – happens at Three Mile Island. The investigation uncovers similar, precursor incidents and a history of relief valve failure at TMI.
These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?
- Suffering for survivors and surviving loved ones.
- Millions – no billions – of Dollars (Yen, Euros, and Pounds).
We could prevent ALL of them. Why don’t we? Don’t we know that:
An ounce of prevention is worth a pound of cure?
Maybe it is:
- Intellectual laziness?
- Just plain bad management?
- A bad system to identify problems?
- Bad investigation techniques?
- Something else?
What would it take to start learning?
STEP 1: MANAGEMENT UNDERSTANDING
Your management – from the CEO down – must understand the problem … People and machines are variable (you might call them unreliable) BY NATURE.
Our job is to reduce the variability and make systems reliable and safe.
In the long run a safe, reliable system will always out perform an unreliable, unsafe systems.
Therefore, improving reliability and safety provides your company with a competitive advantage.
The competitive advantage IS NOT FREE. It requires up front effort and investment in root cause analysis and improvements. It requires persistent attention to detail.
Thus, attaining reliability and safety is the challenge.
STEP 2: GET A PERFORMANCE IMPROVEMENT & ROOT CAUSE ANALYSIS SYSTEM THAT WORKS
Although Ben Franklin’s advice seems simple, consistently identifying the right “ounce of prevention” can be complex.
How dangerous is it to reason from insufficient data.
Improving safety and reliability requires a systematic approach and the use of sophisticated performance improvement techniques. You need a good performance monitoring system.
A good performance monitoring system includes:
- self-reporting of near misses
- reporting and instigation of accidents and incidents
- audits, observations, and self-assessments
- advanced root cause analysis (TapRooT®)
- advanced statistical analysis of trends
- understanding of how to fix human performance problems
- training for those who make the system work
Is putting together this kind of a system a tall order? You bet. Bit it is worth it.
If you need help putting this type of system together, we have the experience to help you and we can provide the training that people need. Call us at 865-539-2139 or drop us a note.
STEP 3: USE THE SYSTEM & FIX PROBLEMS
Get your facts first.
Then you can distort them as much as you please.
Preventing accidents is NOT a quick fix. Something you can do once and forget. Management needs to stay involved. You must be consistently persistent.
Find and fix the root causes of accidents, incidents, near-misses, and audit findings.
The first measure of the effective of the system IS NOT a reduced accident rate (although this will come along quickly enough). The first measure of success is an increased rate of finding and implementing effective corrective actions.
Management needs to demand that people properly using the system to investigate problems, find their root causes, identify effective fixes, and get them implements. If management doesn’t demand this, it won’t happen.
STEP 4: NEVER STOP IMPROVING
If you aren’t better today than you were yesterday, you are falling behind. As my boss once said:
If you’re not peddling, you are going downhill.
Captain William J. Rodriguez, United Staes Navy
Never stop looking for areas that need improvement. This should include improving your improvement system!
We can help. How? Several ways…
- Call us at 865-539-2139 and we can discuss your plans to improve. The call is FREE and we may be able to suggest ways to make your plan even better.
- We can conduct an independent review of your root cause analysis implementation, trending, and performance improvement systems. Although this isn’t free, we guarantee it will be worth the time and money. Just drop us a note to get things started.
- Attend the TapRooT® Summit. Each year we design the Summit to help people learn to solve the toughest problems facing industry. You will network with some of the world’s most knowledgeable performance improvement experts and peers who have faced the same types of problems that you face and found best practices to solve their problems.
Don’t wait for the next “missed opportunity”. Do something to make improvement happen before a major accident takes place.
Save lives – save money – save jobs – improve quality and reliability – that’s what TapRooT® is all about.
(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)
Kevin McManus and I are teaching the 5 day course in Portland this week. Here are some pictures from day one:
Why not join us for a future course? You can view the schedule and register HERE
Thank you to Harry Thorburn for sending us these great pictures from the most recent Onsite Course in Athens, Greece.
Visit our website for more information on our Onsite and Public Courses.
Where will the Summit be held? The Summit will be held at The Flamingo Las Vegas Hotel. Learn more about the location and determine your budget for travel.
What are the costs for registration? Budget $995 for the Summit, $1295 for a pre-Summit course or budget $2,090 for the Summit and a pre-Summit Course (a $200 savings!).
Summit attendees share experience, learn to apply the latest research, and meet in small groups (best practice sessions) with leading industry experts to share information and ideas across industry and organizational boundaries. The best practice sessions are organized under Best Practice Tracks to make it easier for attendees to create their Summit schedules. The 9 Best Practice Tracks planned for 2015 are:
1. Equipment Reliability Improvement & Troubleshooting
2. Human Error Reduction & Behavior Change
3. Improving Healthcare Quality & Patient Safety
4. Incident Investigation and Root Cause Analysis
5. Process Quality and Corrective Action Programs
6. Safety Improvement
7. TapRooT® Software
8. Certified TapRooT® Instructor
9. Special Topics
But the Best Practice Tracks are not set in stone. Each person that registers has the opportunity to create a custom track.
So, SAVE THE DATE, start thinking about which sessions you’d like to attend, get your registration fees and travel plans in the budget.
We are pleased to announce that Richard Phillips, real life inspiration for the Movie Captain Phillips, starring Tom Hanks; and author of A Captain’s Duty: Somali Pirates, Navy SEALs, and Dangerous Days at Sea has confirmed to be our Keynote Speaker on Friday, June 5, 2015!
Watch for more info in upcoming newsletters and in the future Root Cause Analysis Blog posts.
Visit the Summit website for more info.
Rich Horan from PPL Electric Utilities shared some of his favorite aspects of the 2014 Global TapRooT® Summit in Horseshoe Bay, TX. Listen to what content he enjoyed most and what he will be taking back to his workplace to implement some of the Best Practices shared at the Summit.
Don’t have time for the whole video? Read below some questions we asked him and what he had to say.
How did you like the Summit?
“I loved it! Very well organized. It was my first Summit and from the beginning right up to the end today it was very enjoyable and very nice to meet a lot of the people looking for the same experience and networking.”
What was your favorite session?
“I would have to say the Best Practices and Learning. It was very interactive but there was a lot we walked away with, that I walked away with that get to take back to my work place and apply some of those lessons learned. So, I would have to say that was the better session of all of them.”
Can you think of any of those Best Practices that you’d like to share with us?
“The corrective actions and the effectiveness reviews. So the quality of the investigation is important but most important is the corrective actions and the effectiveness review as far as a follow up to see if there is some quality in those investigations.”
Did you attend the reception? How did you enjoy that?
“Well, it was absolutely wonderful. It was a good way to break away and meet some people. There was beautiful weather, good music, and probably one of the better receptions I’ve been to in some of the conferences over the years, so, well done!”
How was the networking and the people that you met here?
“I think that networking is very important and from that, learning what others are doing and sharing what I have done in the past two years as a TapRooT® instructor. So, very valuable to meet other people and continue that networking after the conference.”
For more information regarding the upcoming 2015 Global TapRooT® Summit in June, click here.
This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.
Click here for more information regarding our TapRooT® courses around the world.
And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.
Do you wish you could use your LinkedIn profile to find a new job or network to get more business for your current job? Here are 3 tips that will optimize your personal profile and make these wishes more likely to come true.
1. Add a profile picture (it will make your profile 7 times more likely to get noticed). Don’t just upload any profile picture, choose a clear photo of your face that is appropriate for business networking.
2. Get recommendations. LinkedIn offers tools that make it so easy to request recommendations. Go to your profile and click the dropdown menu next to “Complete your profile.” Choose “Ask to be recommended,” and you will be guided through a series of prompts to complete your first recommendation request. Painless!
3. Customize your profile URL. Customize your URL with your name to help search engines identify you. (Learn how).
Why not take ten minutes to invest in your career development? A few tweaks to your LinkedIn profile will help you become more visible and lend greater credibility to your professional image.
What do you have planned to keep walkways clear this winter?
Juan Silva attended the 2014 Global TapRooT® Summit this past April in Horseshoe Bay, Texas and shared with us his favorite aspects, best practices and sessions in Spanish.
For training at your site, you need to call us (865-539-2139) or CLICK HERE to drop us a note. We still have a few dates open in November and December but you need to get your training scheduled soon or all the 2014 training dates will be full.
For our public TapRooT® Courses, you can see the entire worldwide list of courses remaining for 2014 and the first half of 2015 at:
Or you can click on a particular continent to see the courses being held there. Or just click on the continent below that you are interested in:
Don’t wait to register. TapRooT® Courses fill up fast and there may be a waiting list.
Hope to see you at one of the upcoming courses!