Root Cause Analysis Blog

 

Forbes Reports: “… Nuclear Navy has the best safety record of any industry.”

Posted: October 30th, 2014 in Current Events, Performance Improvement, Pictures

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Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:

America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.

And no one ever discusses it.

Well, not no one. We’ve been discussing it for years! And the philosophy that keeps the Nuclear Navy safe is outlined in our Fatality Prevention Course and at the TapRooT® Summit.

See the article at:

http://www.forbes.com/sites/jamesconca/2014/10/28/americas-navy-the-unsung-heroes-of-nuclear-energy/

The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos. 

Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?

Stupid indeed.

Did Retiring Warthogs to “Save Money” Lead to The Recent Friendly Fire Accident In Afganistan?

Posted: October 30th, 2014 in Accidents, Current Events, Investigations, Pictures

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And interesting article in the Washing Post suggests that using a B-1B for night time close air support and insufficient training led to the death of 7 Americans and 3 allies in a friendly fire accident.

See the story at THIS LINK and see what you think.

TapRooT® Around the World: Cape Town, South Africa

Posted: October 30th, 2014 in Uncategorized

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Among the many reasons to visit Cape Town, South Africa, a TapRooT® Course is one of the best. Join us on December 4, 2014 for a 2-Day TapRooT® Incident Investigation and Root Cause Analysis Public Course and gain the knowledge and ability to help improve your business. According to the New York Times this past year, Cape Town is the best place in the world to visit. The world famous harbour and natural setting in the Cape floral kingdom bring tourists from all over the world to admire its beauty. You’ll fall in love with this city.

Food: 

The Test Kitchen: Looking for something a little different? The Test Kitchen offers a warm atmosphere with genuine flavours prepared by their world-famous chef.

Miller’s Thumb:  This fun, colorful restaurant is sure to show you a good time and feed you delicious, fresh fish.

Myoga: Relaxation can be a key factor when choosing where to eat dinner. Myoga strives to entertain you with their open kitchen and earthy ambience to bring complete relaxation with your meal.

Attractions:

Table Mountain National Park: Cape Town being on the beautiful harbour, opens up their incredible natural attraction to the public for a fun, unique experience.

The Old Biscuit Mill: Located in the heart of Woodstock, The Old Biscuit Mill brings in local artists to show their passions to the public in an intriguing environment.

Two Oceans Aquarium: Bringing the family with you the Cape Town? Spend the day at Two Oceans Aquarium for an exciting, interactive, educational day.

 

Want to know more about our courses or register for one? Click here.

 

What does a bad day look like?

Posted: October 30th, 2014 in Pictures

When you are having a bad day, sometimes others misfortune can make it seem not so bad by comparison…

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TapRooT® Around the World: Onsite Course in Argentina

Posted: October 28th, 2014 in Courses, Pictures

Thanks to Piedad Colmenares for sending us these great pictures from some recent onsite courses at ENAP and SIPETROL in Argentina.

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Want more information regarding onsite courses or public courses? Click Here.

How Far Away Is Death?

Posted: October 28th, 2014 in How Far Away Is Death?, Pictures

Who would think this was safe?

Who would think this was safe?

8 Reasons to Ask for Help with an Investigation

Posted: October 28th, 2014 in Root Cause Analysis Tips, Root Causes, TapRooT

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People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator.

But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?

Here are eight examples that could help you decide when to ask for help:

1. LEGAL ISSUES

Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.

2. CUSTOMER DISPUTE

It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.

3. UNION ISSUE

Ever had an investigation that gets contentious with a union?

This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.

4. COMPLEX ACCIDENTS

TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.

5. INDEPENDENT INVESTIGATION / NEW SET OF EYES

Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.

6. CONTROVERSIAL INVESTIGATION

I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.

7. COACHING

Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.

8. OVERWHELMED

Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Still not sure? Contact us at: http://www.taproot.com/contact-us for more information.

Weekly Wisdom for Process Improvement and Root Cause Analysis

Posted: October 28th, 2014 in Wisdom Quote

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“Your most unhappy customers are your greatest source of learning.” -Bill Gates

Career Development: Five Quick Ways to Become a Better Speaker

Posted: October 28th, 2014 in Career Development, Career Development Tips

Surveys about fear have revealed that we fear public speaking more than death. That’s why there is a joke that goes something like, “If you are at a funeral, it’s better to be in the coffin than the one delivering the eulogy.”

However, there are many things we can learn about public speaking from the masters. Even better, there are many very simple techniques that will captivate the audience every single time.

Take, for example, the pause:

Pause for two or three seconds and the audience assumes you lost your place. Pause for five seconds and the audience begins to think the pause is intentional… and starts wondering why.

Pause for ten seconds and even the people who were busy tweeting can’t resist glancing up.

These days, if you can get someone to look up from his or her phone during your presentation, you’ve pretty much won at public speaking.

Learn four more ways to be a better speaker from Jeff Haden:

5 Ways to Become a Better Speaker Overnight

How Do We Stop the Ebola Blame Game?

Posted: October 27th, 2014 in Accidents, Medical/Healthcare

The media debate about Ebola is subtly shifting from how to stop the spread of this horrific disease to finger pointing. How do we stop the blame game?

A recent analysis & opinion column (Reuters.com), “Why Finger Pointing about Ebola Makes Americans Less Safe,” suggests:

With Ebola, root cause analysis is going to be key to avoid mistakes in the future, but this will require a culture where it is safe to admit to errors.

Read the opinion here:

http://blogs.reuters.com/great-debate/2014/10/27/why-finger-pointing-about-ebola-makes-americans-less-safe/

And let us know what you think by commenting below. How can the healthcare community create a culture where workers are not afraid to self-report mistakes? Do you think root cause analysis is key to stopping Ebola?

Monday Accident & Lessons Learned: UK RAIB Accident Report on a Passenger Becoming Trapped in a Train Door and Dragged a Short Distance at Newcastle Central Station

Posted: October 27th, 2014 in Accidents, Current Events, Investigations, Pictures

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Here is a summary of the report:

At 17:02 hrs on Wednesday 5 June 2013, a passenger was dragged by a train departing from platform 10 at Newcastle Central station. Her wrist was trapped by an external door of the train and she was forced to move beside it to avoid being pulled off her feet. The train reached a maximum speed of around 5 mph (8 km/h) and travelled around 20 metres before coming to a stop. The train’s brakes were applied either by automatic application following a passenger operating the emergency door release handle, or by the driver responding to an emergency signal from the conductor. The conductor, who was in the rear cab, reported that he responded to someone on the platform shouting at him to stop the train. The passenger suffered severe bruising to her wrist.

This accident occurred because the conductor did not carry out a safety check before signalling to the driver that the train could depart. Platform 10 at Newcastle Central is a curved platform and safe dispatch is particularly reliant upon following the correct dispatch procedure including undertaking the pre-dispatch safety checks.

The investigation found that although the doors complied with the applicable train door standard, they were, in certain circumstances, able to trap a wrist and lock without the door obstruction sensing system detecting it. Once the doors were detected as locked, the train was able to move.

In 2004, although the parties involved in the train’s design and its approval for service were aware of this hazard, the risk associated with it was not formally documented or assessed. The train operator undertook a risk assessment in 2010 following reports of passengers becoming trapped. Although they rated the risk as tolerable, the hazard was not recorded in such a way that it could be monitored and reassessed, either on their own fleet or by operators of similar trains.

As a consequence of this incident, RAIB has made six recommendations. One of these is for operators of trains with this door design to assess the risk of injuries and fatalities due to trapping and dragging incidents and take the appropriate action to mitigate the risk.

Two recommendations have been made to the train’s manufacturer. One of these is to reduce the risk of trapping on future door designs, and the other to review its design processes with respect to hazard identification and recording.
One recommendation has been made to the operator of the train involved in this particular accident. This is related to the management of hazards associated with the design of its trains and assessment of the risks of its train dispatch operations.

Two recommendations have been made to RSSB. One is to add guidance to the standard on passenger train doors to raise awareness that it may be possible to overcome door obstruction detection even though doors satisfy the tests specified within the standard. The other recommendation is the consideration of additional data which should be recorded within its national safety management information system to provide more complete data relating to the risk of trapping and dragging incidents.

See the complete report here:

http://www.raib.gov.uk/cms_resources.cfm?file=/140918_R192014_Newcastle.pdf

6,600,000 Preventable Deaths

Posted: October 24th, 2014 in Current Events, Video

What is the key intervention for preventing 6,600,000 death? You may be surprised by this solution, which is also the key intervention for reducing Ebola outbreak. It is the simple act of handwashing with soap. Invest 12 minutes of your time viewing this video and learn about the power of handwashing.

Did you know that TapRooT® is recognized worldwide as a premier “knowledge broker”? Stay in the know with relevant root cause analysis tips by joining our weekly email list:

http://www.taproot.com/contact-us

Some recent tips include:

Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry: (View video.)

Missed Opportunities: (Read post.)

What Makes a World Class Root Cause Analysis System? (View video.)

What does a bad day look like?

Posted: October 23rd, 2014 in Pictures

See, your day seems better already …

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Root Cause Analysis Training in Johannesburg, South Africa

Posted: October 23rd, 2014 in Courses, Local Attractions, Pictures, Training

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On November 17, 2014, TapRooT® will be hosting a 5-Day Advanced Root Cause Analysis Team Leader Training Public Course in Johannesburg, South Africa. Will you be joining us? Johannesburg, or JoBurg as locals call it, has quite interesting and intriguing facts, history and landmarks that pull people in. It is said to be the world’s largest city not located directly on a water source, however, it is located on mineral rich land where the city’s source of gold and diamonds come from. It is known as Africa’s economic powerhouse due to it being the largest economy of any metropolitan area in Sub-Saharan Africa. There is so much offered in this massive city that you’re sure enjoy inside and outside of our course.

Food:

Mugg & Bean Cafe: This delicious little cafe offers a little of everything from barbeque and quesadillas to cupcakes and soups.

The GrillHouse Rosebank: Enjoy a fabulous steak dinner in a warm atmosphere with live music here at The GrillHouse.

SalvationCafe: If you love gourmet flavors and branching out from the everyday menu, check out this quaint cafe.

Attractions:

Gold Reef City: Fun on every corner! Theme parks, dining, theaters, etc await you as you stroll through and take it all in.

Apartheid Museum: History museums are always an educational, impacting experience for anyone!

Peacemakers Museum: What an inspirational and interesting exhibit full of the history of all Nobel Peace Laureates. You’re sure to learn something new and leave encouraged by all the incredible men and women all across the globe.

 

 

Missed Opportunities (A Best Of Article from the Root Cause Network™ Newsletter)

Posted: October 22nd, 2014 in Performance Improvement, Pictures

 

MISSED OPPORTUNITIES

IT DIDN’T HAVE TO HAPPEN

An anesthesia machine cuts off oxygen to a patient causing extensive brain 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.

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These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?

  • Lives.
  • 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?
Benjamin Franklin

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Maybe it is:

  • Intellectual laziness?
  • Shortsightedness?
  • 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.
Sherlock Holmes

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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.
Mark Twain

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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

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Never stop looking for areas that need improvement. This should include improving your improvement system!

We can help. How? Several ways…

  1. 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.
  2. 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.
  3. 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.

TapRooTWorld

(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)

TapRooT® Around the World: Onsite Course in Makae, Brazil

Posted: October 21st, 2014 in Courses, Pictures

Thank you to Marco Flores-Verdugo from one of our recent onsite courses in Makae, Brazil for these great pictures.

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Join us for a Public Course near your or inquire about our Onsite Courses.

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