Root Cause Analysis Blog

 

Friday Joke: Need a Repeat Back?

Posted: September 19th, 2014 in Jokes, Video

Best of The Root Cause Network™ Newsletter – Beat ‘Em or Lead ‘Em … A Tale of Two Plants

Posted: September 18th, 2014 in Accidents, Investigations, Performance Improvement, Pictures

Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.

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BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS
 

You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.

The turbine trips. 

The plant trips.

If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) good-bye.

To make matter worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator – the NRC) is sending a special inspection team to look at the plant’s culture. That could mean days, weeks or even months of down time due to regulatory startup delays. 

What do you do???

PLANT 1 – RAPID ACTION

He who hesitates is lost!

Corporate expects heads to roll!

You don’t want to be the first, so you:

  1. Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
  2. Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
  3. Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale. 
  4. Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us any more.
  5. Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs and a quick start-up will keep the PUC happy.

PLANT 2 – ALTERNATIVE ACTION

No one likes these types of situations, but you are prepared, so you:

  1. Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify. 
  2. Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts sharing your root cause analyses means that they have confidence that you will do a thorough investigation. 
  3. “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault finding, and results in future lies and cover-ups.
  4. Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems  to avoid the big ones.
  5. Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
  6. Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to show off your team’s capabilities while in the heat of battle. Reward them while the sweat is still on their brow.
  7. Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.

DIFFERENCES

Which culture is more common in your industry? 

Which plant would you rather manage?

Where would you rather work?

What makes Plant 1 and Plant 2 so different? It is really quite simple…

  • Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose that to help then succeed by giving them the tools they need to get the job done right.
  • Trust: Everyone trusts everyone on this team. This starts with good face to face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
  • Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.

Which plant exhibited these characteristics?

HOW TO CHANGE

Can you change from Plant 1 to Plant 2? YES! But how???

The first step has to be made by senior managers. The right attitude must be adopted before trust can be developed and a systematic approach can succeed.

Part of exhibiting the belief in your people is making sure that they have the tools they need. This includes:

  • Choosing an advanced, systematic root cause analysis tool (TapRooT®).
  • Adopting a written accident/incident investigation policy that shows managements commitment to thorough investigations and detailed root cause analysis.
  • Creating a database to trend incident causes and track corrective actions to completion.
  • Training people to use the root cause analysis tool and the databases that go with them.
  • Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
  • Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.

Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implement and experienced by folks in the field, trust in management will become a forgone conclusion. 

YOU CAN CHANGE

Have faith that your plant can change. If you are senior management, take the first step: Trust your people. 

Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world class.

_ _ _ 

Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting.

What does a bad day look like?

Posted: September 18th, 2014 in Pictures

Having a bad day? look at these pictures and your day might not seem so bad…

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TapRooT® Around the World: Bogota Course Photos

Posted: September 18th, 2014 in Courses, Pictures, TapRooT

Thanks to Diana Munevar for these great photos of our August 27-29, 2014 course in Bogota, Colombia.

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Click here to learn more or register for our South America TapRooT(R) Courses.

Final Exercise at the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, Ohio

Posted: September 16th, 2014 in Courses, Pictures, TapRooT

Final presentations by the teams after performing a root cause analysis on their incident that they brought to the course…

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How Far Away is Death?

Posted: September 16th, 2014 in How Far Away Is Death?, Pictures

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He didn’t die … but his boss was fined £5,000 by the HSE.

Career Development: How to Handle an Unsupportive Boss

Posted: September 16th, 2014 in Career Development, Career Development Tips

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In this column, we share a lot of ideas and tips for building and moving forward in your career. But sometimes management can present obstacles to your success, whether it’s a personality difference, micromanagement, stifling a promotion, or undermining your hard work. Don’t simply live with the negative situation, or quit only to find another imperfect job in the future. Try the following tips to improve your relationship with your boss and empower your career.

Acknowledge Your Role

Rather than blame your boss for the obstacle you’re facing, put aside any emotional bias you may have (SHRM). Don’t gossip about your boss, and try to understand the situation more clearly (Tech Republic). Honestly evaluate your own role in the situation. Do you have unrealistic expectations of your boss? Do your professional skills measure up to the requirements of that promotion? Have you failed to earn the trust of your micromanaging boss? Have you really achieved all the goals of your current role? Do your work achievements reflect well on your boss and team? Think of this as your “HR root cause analysis.” Truly evaluate all the facts about your performance and relationships at work, then devise practical methods for improving these.

Communicate with Your Boss

In our “HR root cause analysis,” one of the corrective actions will almost always include talking with your boss. Difficult though it may be, coming to your boss in a professional manner is the right thing to do and will likely make a positive impression on him or her. When you do, come with a positive outlook with ideas for improvement. Don’t simply come with complaints and no attempts at a solution, which may only make your situation worse.

The best approach is to arrange a performance review meeting with your boss. Make it clear during this meeting that you want to grow professionally, and you’d like to find out what it will take to do so. Ask him or her how you’re meeting and not meeting the goals of your position, and brainstorm action steps to reach those goals. As you receive the criticism, take it with grace and not defensiveness.

If there’s something you need from your boss that you’re not receiving, simply ask for it in a logical manner (Chron) (SHRM). Make it an easy request to grant. For example, instead of simply complaining “You micromanage me too much,” ask if it would help your boss if you provided regular status updates to ease his or her mind.

Make it clear at this meeting that you are committed to your boss’ success as well (Chron).

Develop Your Professional Skills

After you’ve met with your boss, take this feedback to heart. If you’ve received concrete ways in which you can improve, make these your goals and stick to them. Exceed your boss’ expectations and you’ll likely gain his or her trust (Chron).

If your conversation does not go well, there are still options. Take your problem to HR, even if all you need is a second opinion on some aspects of the problem. It always helps to bring in a third party ro evaluate the situation.

If you need additional support, start by building your professional network by pursuing a mentoring and/or networking opportunity (Tech Republic). A mentor can provide a second opinion and unbiased advice on your career. This relationship just may provide the support you need to move forward in your career. Continue to build your network through events, LinkedIn, and pursuing one-on-one meetings with colleagues (Diversity MBA).

Prepare for a future job change and safeguard your interests by building a file that includes your updated resume, certifications, accomplishments, successful projects, and any awards you’ve earned (Diversity MBA). As you move forward within the  company, or if you decide to seek advancement elsewhere, you’ll be ready to put your best foot forward.

Linda Unger Teaching the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, Ohio

Posted: September 15th, 2014 in Courses, Pictures, TapRooT

 

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Need root cause analysis training at your site? Contact us to set up a TapRooT® Course by CLICKING HERE.

Teams Working on Their SnapCharT®s at the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Dayton, Ohio

Posted: September 15th, 2014 in Courses, Pictures, TapRooT

You have to understand what happened before you can understand why it happened. The SnapChart helps you do just that. These folks at the 2-Day class in Dayton are practicing their newly learned skills…

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For the next public TapRooT® Course near you, click on your continent at:

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

Monday Accident & Lesson Learned: Wheelchair / Baby Stroller Rolls onto the Tracks

Posted: September 15th, 2014 in Accidents, Current Events, Investigations, Pictures

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The UK Rail Accident Investigation Branch has published a report about two accidents where things (a wheelchair and a baby stroller) rolled onto the tracks.

To see the report and the one lesson learned, CLICK HERE.

Monday Motivation: Vince Lombardi

Posted: September 15th, 2014 in Pictures

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A man can be as great as he wants to be.
If you believe in yourself and have the courage,
the determination, the dedication, the competitive drive and
if you are willing to sacrifice the little things in life and
pay the price for the things that are worthwhile,
it can be done. ~ Vince Lombardi

Mark Paradies Teaching a Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Dayton, Ohio

Posted: September 15th, 2014 in Courses, Pictures, TapRooT

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Want to find out more about TapRooT® Root Cause Analysis Training? Then visit our web site:

http://www.taproot.com/courses

TapRooT® Root Cause Analysis Training in South America – Bogota Course Photos

Posted: September 15th, 2014 in Courses, Pictures

On August 21-22, we held a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Bogota, Colombia. Course Planner Diana Munevar shared these photos of the Marble Game, SnapCharT® creating, and interviewing during the course. Enjoy!

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Are you interested in learning to find and fix the real root causes of problems in your workplace? Click here to learn more about our South America TapRooT® Courses.

Weekly Wisdom for Root Cause Analysis & Equipment Troubleshooting

Posted: September 15th, 2014 in Wisdom Quote

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“Failures are great learning tools… but they must be kept to a minimum.” – Jeffrey Immelt

Root Cause Analysis Training in South America – Brazil Course Photos

Posted: September 11th, 2014 in Courses, Pictures

Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil held August 4-8, 2014 went fantastically! Thanks to TapRooT® Instructor Boris Risnic for these photos and a great course.

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Click here to learn more about our 5-Day TapRooT® Course.

More Pictures of a Bad Day…

Posted: September 11th, 2014 in Pictures

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Tribe of TapRooT® Users Meeting in Las Vegas Next June

Posted: September 11th, 2014 in Pictures, Summit

I heard an interesting speaker last week talk about technology adoption. He spoke about how valued brands developed a “tribe” of users who often networked and shared best practices. This often made the technology (the brand) better and more valuable.

That’s when I realized that TapRooT® Users were a tribe that constantly made TapRooT® a more valuable technology/brand.

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And once a year, the tribe gets together at The Global TapRooT® Summit.

Think of this like the tribal meetings of old. Or mountain men getting together at the rendezvous. Or, if you are from a Norse heritage, a þing (things). 

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If you’ve never been to the Summit, now is the time to start planning to attend. Mark out the dates (June 1-5, 2015) on your calendar. Get any budget requests to travel authorizations started (or at least planned for). See if you can get a team of your best performance improvement experts to register as a group. 

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You’ll return to work from the Summit energized to make improvement happen with great ideas and best practices from around the world. General Summit information is available HERE. The Summit schedule of events will be posted shortly.

Looking forward to seeing you and the rest of the tribe next June.

Mark Paradies
President, System Improvements 
The TapRooT® Folks 

Root Cause Analysis Training in Pittsburgh: Local Attractions

Posted: September 11th, 2014 in Courses, Local Attractions

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Pittsburgh, Pennsylvania is full of wonderful attractions including the 2-day TapRooT® Incident Investigation and Root Cause Analysis Course on October 15th. As you enjoy your time after the course, explore the rich history that Pittsburgh holds on every corner. Between museums, Civil War monuments, the United States Steel Corp. and much more, the overwhelming amount of knowledge and history is there for your enjoyment.

Food:

The Capital Grille of Pittsburgh: The Capital Grille is nestled in the luxurious downtown area surrounded by some of the best attractions Pittsburgh has to offer. Enjoy a little of everything, seafood, steak, hors d’oeuvres, wine, etc, with the whole family.

Lidia’s: When’s the last time you really enjoyed authentic Italian food? Lidia’s is ready to serve you some of the best Italian food around.

The Original Fish Market: The name says it all, The Original Fish Market. If you love fresh, tasty seafood then this is the place for you.

 

Attractions:

The Rivers of Steel National Heritage Area: Tours, driving guides and attractions are only a few of the fun things that this historic area has to offer.

Andy Warhol Museum: This visual arts museum is a must see. One of America’s most talented artists comes to life through his paintings, videos, interactive sections, and prints.

Soldiers and Sailors Memorial Hall & Museum: Have an interest in American history? The Soldiers and Sailors Memorial Hall & Museum is an elegant honorary hall dedicated to all past and present, men and women fighting for our country.

 

Have you registered for the course yet? Click here for more info or to register for our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course in Pittsburgh, PA held October 15-16, 2014.

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