Root Cause Analysis Blog

 

Learn TapRooT® in Denver

Posted: May 14th, 2018 in Career Development, Courses, Local Attractions, TapRooT

Expand your skills in Denver!

In less than a week, you can learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your expertise and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Westin Denver Downtown on June 11. You may want to make plans to explore your host city while you’re there.

Register here for the course.

Soak up Denver

Denver is packed with must-do thrills: Stand exactly one mile high on the west steps of the state capitol and see 200 mountains from its dome. Set your eyes on the world’s greatest collection of Native American art at an architectural wonder, the Denver Art Museum. Check out Old West history in a trendy downtown at Golden, Colorado’s first capital, where you can sip a beer while kayakers paddle by.

The Mile High City is a paradise for outdoor adventure and pro sports. The choices are wide-ranging: walking trails, urban hikes, parks, sporting events, and more Denver adventures.

Colorado’s landscape is awe-inspiring. Take Garden of the Gods in Colorado Springs, little more than a hour from Denver. You can go front range climbing, take a jeep or segway tour, or tour via bike or electric bike. If you’re a photography buff, this is a natural for you.

Go brewery touring and get a closeup taste of the culture Denver’s famous for.

Denver’s historic district, or Lower Downtown, is called LoDo. Amid 28 square blocks, you can enjoy excellent restaurants, live music, and fun brewpubs. Walk, sightsee, window shop in downtown Larimer Square among a vibrant district of Victorian buildings restored to hip shops and restaurants.

The creative community of Denver shows up in galleries, studios, and cultural attractions across seven art districts.

Visit Red Rock Canyon Park & Amphitheatre for hiking, walking, and biking trails, or dine at Red Rock’s Ship Rock Grille and admire the view.

Check out Union Station, a transportation hub, historic landmark, and cool space for noshing–such as Mercantile Dining & Provision–gathering, and shopping.

At El Taco De Mexico, 714 Santa Fe Dr., it’s all about being the authentic taqueria.

Try breakfast or lunch at Maria Empanada, a great bakery and cafe offering a taste of Argentina.

At the vintage-inspired ice cream shop Little Man, people line up around the block on 16th Street for homemade flavors like peach cobbler, oatmeal cookie, salted Oreo, and creme fraiche.

Discover more to explore from our Denver Pinterest board and begin planning your TapRooT® trip to Colorado today.

We hope to see you at the IHI/NPSF Patient Safety Conference!

Posted: May 14th, 2018 in Career Development, Medical/Healthcare, TapRooT

If you plan to attend the 2018 IHI/NPSF Patient Safety Conference in Boston, MA on May 23 -25, stop by and say “hello.” Per Ohstrom, Anne Roberts, and Barb Carr (pictured left to right) will be at Booth #316 in Exhibit Hall C discussing how TapRooT® can help you and answer any questions you might have.

We will be at Booth #316 during these times:

Wednesday: 3:30pm – 5:30pm

Thursday: 12:00pm – 1:30pm & 4:30pm – 6:30pm

Friday: 7:00am – 8:30am

The first 500 visitors will receive a special prize, so do not miss out on your free gift! Stop by early to increase your chances in receiving a prize.

Hope to see you there!

“It was such a simple mistake!”

Posted: May 14th, 2018 in Investigations, Root Causes, TapRooT

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When you have a major incident (fire, environmental release, etc.), your investigation will most likely identify several causal factors (CF) that, if they had not occurred, we probably would not have had the incident.  They are often relatively straight forward, and TapRooT® does a great job identifying those CFs and subsequent root causes.

Sometimes, the simplest problems can be the most frustrating to analyze and fix.  We think to ourselves, “How could the employee have made such a simple mistake?  He just needs to be more careful!”  Luckily, TapRooT® can help even with these “simple” mistakes.

Let’s look at an example.  Let’s say you are out on a ship at sea.  The vessel takes a bit of a roll, and a door goes shut on one of your employees.  His finger is caught in the door as it shuts, causing an injury.  Simple problem, right?  Maybe the employee should just be more aware of where he is putting his hands!  We will probably need more effective fixes if we really want to prevent this in the future.

How can we use TapRooT® to figure this out?  First of all, it is important to fully document the accident using a SnapCharT®.  Don’t skip this just because you think that the problem is simple.  The SnapCharT® forces you to ask good questions and makes sure you aren’t missing anything.  The simple problem may have aspects that you would have missed without fully using this technique.  In this example, maybe you find that this door is different than other doors, which have latches to hold them open, or handles to make it easier to open the door.  Imagine that this door might have been a bathroom stall door.  It would probably be set up differently than doors / hatches in other parts of the ship.

So, what are your Causal Factors?  First, I probably would not consider the sudden movement of the ship as a CF.  Remember, the definition of a CF states that it is a mistake or an error that directly leads to the incident. In this case, I think that it is expected that a ship will pitch or roll while underway; therefore, this would not be a CF. It is just a fact. This would be similar to the case where, in Alaska, someone slipped on a snow-covered sidewalk. I would not list that “it was snowing” as a CF.  This is an expected event in Alaska. It would not be under Natural Disaster / Sabotage, either, since snow is something I should be able to reasonably protect against by design.

In this case, I would consider the pitch / roll of the vessel as a normal occurrence.  There is really nothing wrong with the vessel rolling. The only time this would be a problem is if we made some mistake that caused an excessive roll of the vessel, causing the door to unexpectedly slam shut in spite of our normal precautions. If that were the case, I might consider the rolling of the ship to be a CF.  That isn’t the case in this example.

You would probably want to look at 2 other items that come to mind:

1.  Why did the door go shut, in spite of the vessel operating normally?
If we are on a vessel that is expected to move, our doors should probably not be allowed to swing open and shut on their own. There should be latches / shock absorbers / catches that hold the door in position when not being operated. Also, while the door is actually being operated, there should be a mechanism that does not depend on the operator to hold it steady while using the door. I remember on my Navy vessel all of our large hatches had catches and mechanisms that held the doors in place, EXCEPT FOR ONE HEAVY HATCH. We used to tell everyone to “be careful with that hatch, because it could crush you if we take a roll.” We had several injuries to people going through that hatch in rough seas. Looking back on that, telling people to “be careful” was probably not a very strong safeguard.

Depending on what you find here, the root causes for this could possibly be found under Human Engineering, maybe “arrangement/placement”, “tools/instruments NI”, excessive lifting/force”, “controls NI”, etc.

2. Why did the employee have his hand in a place that could cause the door to catch his hand?
We should also take a look to understand why the employee had his hand on the door frame, allowing the door to catch his finger.  I am not advocating, “Tell the employee to be careful and do not put your hand in possible pinch points.” That will not work too well. However, you should take a look and see if we have sufficient ways of holding the door (does it have a conventional door knob? Is it like a conventional toilet stall, with no handle or method of holding the door, except on the edge?). We might also want to check to see if we had a slippery floor, causing the employee to hold on to the edge of the door / frame for support. Lots of possibilities here.

Another suggestion: Whenever I have what I consider a “simple” mistake that I just can’t seem to understand (“How did the worker just fall down the stairs!?”), I find that performing a Critical Human Action Profile (CHAP) can be helpful.  This tool helps me fully understand EXACTLY what was going on when the employee made a very simple yet significant mistake.

TapRooT® works really well when you are trying to understand “simple” mistakes.  It gets you beyond telling the employee to be more careful next time, and allows you to focus on more human performance-based root causes and corrective actions that are much more likely to prevent problems in the future.

Caption Contest Winner!

Posted: May 14th, 2018 in Uncategorized

The April Caption Contest is over, and the votes have been tallied! But, before I announce the winner, I want to thank everyone for their submissions and participation. The Caption Contest always makes me laugh, and I enjoy reading your comments as they come in.

And, now, without further ado, the winner of the March Caption Contest is….Drrrrrrrrrrrrrrrrrum-roll!

Holly Patey with “Stairway to Heaven.”

 

We also have several honorable mentions.

“Still looking for your cat.” – Tom S.

“Going to hang safety banner.” – Mark Sullivan

“Beam me up Scotty!!!!” – Claude

Again, thank you for playing along. Don’t forget, just because you won a past Caption Contest doesn’t mean you can’t enter to win again. The more captions you come up with, the greater your chances of winning!

Keep an eye out for a new Caption Contest coming next week.

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 14th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you become TapRooT® trained, you can rely on your expertise to communicate how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer across the desk from you. If you have invested yourself in TapRooT® training and skills, explore professional advancement through one of these global opportunities.

Patient Safety Analyst Nurse

Field Service Manager – Wireline & Perforating

HSEQ Manager

Chemical Manufacturing

Environment, Quality and Safety Coordinator –  Collections Division

HES Operations Specialist

Maintenance Manager

Reliability Engineer I

Manager – EHS/Quality

Associate-Senior Engineer Nuclear (Electrical) 

Safety & Health Specialist (Remote)

Patient Safety Program Coordinator

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, May 28, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Perth, Australia, May 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139 or 865.357.0080.

Monday Accidents & Lessons Learned: Airplane Mode

Posted: May 14th, 2018 in Accidents, Human Performance, TapRooT

When you hear the words “mode” and “aviation,” many of us who are frequent flyers may quickly intuit the discussion is heading toward the digital disconnection of our cellular voice and data connection in a device, or airplane mode. Webster defines “mode” as “a particular functioning arrangement or condition,” and an aircraft’s system’s operating mode is characterized by a particular list of active functions for a named condition, or “mode.” Multiple modes of operation are employed by most aircraft systems—each with distinct functions—to accommodate the broad range of needs that exist in the current operating environment.

With ever-increasing aviation mode complexities, pilots must be thoroughly familiar with scores of operating modes and functions. No matter which aircraft system is being operated, when a pilot is operating automation that controls an aircraft, the mode awareness, mode selection, and mode expectation are all capable of presenting hazards that require know-how and management. Sure, these hazards may be obvious, but they are also often complex and difficult to grasp.

NASA’s Aviation Safety Reporting System (ASRS) receives reports that suggest pilots are uninformed or unaware of a current operating mode, or what functions are available in a specific mode. At this juncture, the pilots experience the “What is it doing now?” syndrome. Often, the aircraft is transitioning to, or in, a mode the pilot didn’t select. Further, the pilot may not recognize that a transition has occurred. The aircraft then does something autonomously and unanticipated by the pilot, typically causing confusion and increasing the potential for hazard.

The following report gives us insight into the problems involving aircraft automation that pilots experience with mode awareness, mode selection, and mode expectation.

“On departure, an Air Carrier Captain selected the required navigation mode, but it did not engage. He immediately attempted to correct the condition and subsequently experienced how fast a situation can deteriorate when navigating in the wrong mode.

“I was the Captain of the flight from Ronald Reagan Washington National Airport (DCA). During our departure briefing at the gate, we specifically noted that the winds were 170 at 6, and traffic was departing Runway 1. Although the winds favored Runway 19, we acknowledged that they were within our limits for a tailwind takeoff on Runway 1. We also noted that windshear advisories were in effect, and we followed required procedure using a no–flex, maximum thrust takeoff. We also briefed the special single engine procedure and the location of [prohibited airspace] P-56. Given the visual [meteorological] conditions of 10 miles visibility, few clouds at 2,000 feet, and scattered clouds at 16,000 feet, our method of compliance was visual reference, and we briefed, “to stay over the river, and at no time cross east of the river.

“Taxi out was normal, and we were issued a takeoff clearance [that included the JDUBB One Departure] from Runway 1. At 400 feet AGL, the FO was the Pilot Flying and incorrectly called for HEADING MODE. I was the Pilot Monitoring and responded correctly with “NAV MODE” and selected NAV MODE on the Flight Control Panel. The two lights adjacent to the NAV MODE button illuminated. I referenced my PFD and noticed that the airplane was still in HEADING MODE and that NAV MODE was not armed. Our ground speed was higher than normal due to the tailwind, and we were rapidly approaching the departure course. Again, I reached up and selected NAV MODE, with the same result. I referenced our location on the Multi-Function Display (MFD), and we were exactly over the intended departure course; however, we were still following the flight director incorrectly on runway heading. I said, “Turn left,” and shouted, “IMMEDIATELY!” The FO banked into a left turn. I observed the river from the Captain’s side window, and we were directly over the river and clear of P-56. I spun the heading bug directly to the first fix, ADAXE, and we proceeded toward ADAXE.

“Upon reaching ADAXE, we incorrectly overflew it, and I insisted the FO turn right to rejoin the departure. He turned right, and I said, “You have to follow the white needle,” specifically referencing our FMS/GPS navigation. He responded, “I don’t have a white needle.” He then reached down and turned the Navigation Selector Knob to FMS 2, which gave him proper FMS/GPS navigation. We were able to engage the autopilot at this point and complete the remainder of the JDUBB One Departure. I missed the hand–off to Departure Control, and Tower asked me again to call them, which I did. Before the hand–off to Center, the Departure Controller gave me a phone number to call because of a possible entry into P-56.”

We thank ASRS for this report, and for helping to underscore TapRooT®’s raison d’être.

We encourage you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Remembering An Accident: Enschede Fireworks Disaster

Posted: May 13th, 2018 in Accidents, TapRooT

On May 13, 2000 in the eastern Dutch city of Enschede a fireworks warehouse caught fire and lead to an enormous explosion. The explosion caused 22 deaths, with 4 fire-fighters among the causalities, another 974 individual were injured, and 500 homes and businesses were severely damaged and/or destroyed during the blast. After the dust had settled a 13 meter diameter, 1.3 meter deep crater could be observed where concrete round cells C9 and C11 – C 15 once stood. To create a crater that size it would take a TNT equivalent between 4 and 5 tonnes. The largest blast was felt up to 30 kilometers away (19 miles).

  

What makes this incident so interesting is the fact that whatever started the fire was never really discovered. Two possibilities seem to be the likely cause. One possibility discussed was arson. The Dutch police made several arrest, but none of whom had been arrested were convicted of arson for the Enschede Fireworks Disaster. The other theory comes from the fire department stating that accidental ignition via an electrical short circuit could have also been the cause of the fire.

Because of the incident and investigation results the fireworks disaster lead to stronger safety regulations in the Netherlands concerning the sales, storage, and distribution of fireworks. Since the catastrophe three illegal firework warehouses were closed down and the Roombeek area that was destroyed by the explosion has been rebuilt.

  

To read the full detailed report click here.

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

 

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training

Posted: May 11th, 2018 in Career Development, Presentations, TapRooT, Topic of the Week, Video, Website Info and Updates

Last week on TapRooT® TV, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® and the positive impact it can have on your professional career. We pack a lot into our blog!

Among our blog features are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

We always look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Every Wednesday

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Catch up on the conversation with Michelle and Benna  via Vimeo:

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

If you want to chime in the conversation, or have a question or comment, feel free to shout out here and we’ll get right back to you. Thank you for watching TapRoot® TV!

Friday Joke

Posted: May 11th, 2018 in Jokes

Acquire TapRooT® Training in Aberdeen

Posted: May 11th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

Meet us in Scotland for TapRooT® training!

Two days. That’s the amount of time it will take for you to learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® Techniques are designed for everyone. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques learned include: SnapCharT®, Root Cause Tree®, & Corrective Action Helper®. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

We’ll meet and begin the 2-Day TapRooT® Root Cause Analysis Training at the Holiday Inn Aberdeen, West, on June 6. Register here for the course and count on seeing a bit of your host city while you’re there.

Experience Aberdeen, the Granite City
Aberdeen’s rich history began as two separate towns on the North Sea. Along the Don River were Old Aberdeen and the cathedral and university; New Aberdeen, on the Dee River, was the hub for trading and the fishing village. Today, Aberdeen is Britain’s largest granite-exporting industry and the chief seaport of northern Scotland. Stop in at Aberdeen Maritime Museum on Shiprow, overlooking the busy harbor. Learn about the city’s legendary relationship with the sea through collections spanning shipbuilding, fast sailing ships, fishing, and port history. The museum is the UK’s sole location with displays on the North Sea’s gas and oil industry. Catch more seafaring history at Fooddee (pronounced “FIT-ee” locally), an old fishing village straight from a postcard. You may see dolphins leaping up at the harbor mouth!

Aberdeen and Aberdeenshire make up part of Scotland’s castle country, as in more than 300 castles. Listen to the sound of the traditional Scots language, a local Doric, while you’re drinking up the atmosphere here. Play a round of golf at Royal Aberdeen Golf Club, founded in 1780, while you take in North Sea coastal views. Enjoy the rugged cliffs and sandy bays at St. Cyrus National Nature Reserve, or explore mountains, lochs, wildlife, and distilleries at Cairngorms National Park.

History and architecture
Get to know a bit of Aberdeen history beginning with St. Machar’s Cathedral, (1424) and Provost Skene’s House (c. 1545). Visit the Union Street parish church of St. Nicholas, divided into two parts: the West Church (built in 1755) is separate from the East Church (built in 1838), divided by the original 13th-century transept and 19th-century steeple. Compare two medieval bridges, the Brig o’ Balgownie (1320), which spans the Don, and the Old Bridge of Dee (1527). You’ll notice a mix of styles, from the Neoclassical-style Music Hall (1822) to Broad Street’s Marischal College (1844), the latter said to be the largest granite building in the world. Founded in 1845, King’s College, now the University of Aberdeen and home of five Nobel Laureates, is known for its famous crown spire and Renaissance style.

Fun fact: Yes, the jaw-dropping architecture is gray granite and there’s a lot of it. Look closely and you’ll see the buildings take on a silver sparkle in sunlight due to their high mica content.

Eateries and entertainment
Books & Beans, 22 Belmont St: Coffee + WiFi

Foodstory, 13-15 Thistle St: Soups, salads, scones, lasagna, great coffee, and fun folks

The Lemon Tree, 5 West North St: Cool beverages and music

The Sanddollar Cafe & Bistro, 2 Beach Esplanade: Delicious dinners, ample wine list, and jazz nights

Ross Bakery, 44 Chapel St: Pies, breads and scones, burgers and sandwiches, cakes

Moonfish, 9 Correction Wynd: Modern British cuisine, generous gin list, set amid medieval streets of Aberdeen’s merchant quarter with views of the 12th-century St. Nicholas church

Maggie’s Grill, 242 Holburn Street:  Angus steaks; locally sourced hickory-smoked pulled pork; pastrami; locally sourced cheeses, vegetables, breads, beer, and coffee; all served with the motto,“Field to fork and made with soul!”

The Silver Darling, North Pier, Pocra Quay: Dine with panoramic views of the water.  Here’s a sample of the scrumptious fare: brown crab, prawns and pan-fried sea trout with carrot & cardamom purée

Almondine, 39 – 43 Thistle Street: Macarons of every description, afternoon tea, and a French bakery

Discover more of Scotland to explore from our Aberdeen Pinterest page and begin planning your TapRooT® trip to Aberdeen today.

High road or low road, we hope to see you in Scotland!

TapRooT® Around the World: Houston

Posted: May 11th, 2018 in Courses, Pictures

Last day of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Houston, Texas. Heidi Reed and I are looking forward to seeing our course attendees’ final presentations. It’s been an awesome week! Click here and get in the picture.

 

Auditing: A better way to approach investigations on problems and losses

Posted: May 10th, 2018 in Career Development, Presentations, TapRooT, Topic of the Week, Video

This Wednesday, for our Facebook Live discussion, TapRooT® professionals Benna Dortch and Dave Janney tackled why companies are not proactive in addressing and solving recurring problems and the key differences between incident investigation root cause analysis and the root cause analysis of audit findings. Within this conversation, we touched on inadequate or ineffective audits and why it is those fall short of yielding improvements.

Dave’s book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement, is part of the TapRooT® for Audits set that fleshes out the topic of audits into seven steps. Feel free to order the set and call on us for further discussion or a training course.

Watch the discussion via Vimeo

Why are Auditing and Proactive Improvement so important? from TapRooT® Root Cause Analysis on Vimeo.

Tune in for our Wednesday Facebook Live next week. We look forward to being with you on Wednesdays! Here’s how to connect with us for next week’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When?  Wednesday, May 16

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

 

TapRooT® Around the World: Recent TapRooT® Course Photos

Posted: May 9th, 2018 in Pictures, Training

Many thanks to Diana Munevar for the TapRooT® training photos from a recent course held in Bogota, Colombia. Looks like everyone there had a blast and learned a lot!

 

Are you interested in attending a TapRooT® Training Course? Click on the links below to view our upcoming courses to a city near you.

2-Day TapRooT® Root Cause Analysis Training
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)

Posted: May 9th, 2018 in Pictures, Root Cause Analysis Tips, TapRooT

Find the Root Cause

I hear people say that 5-Whys is a good root cause analysis system for “simple” incidents. So, I thought I would show a simple incident that was provided as an example by a very experienced 5-Why user and compare it to the analysis that would be performed using TapRooT®.

Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, is the source of the example – a robot failure. He used the example to teach employees the 5-Why technique while he was at Toyota. Here is the example as he described it…

1.    Why did the robot stop?

–    The circuit has overloaded, causing a blown fuse.

2.    Why did the circuit overload?

–    There was insufficient lubrication on the bearings, so they locked up.

3.    Why was there insufficient lubrication on the bearings?

–    The oil pump on the robot is not circulating sufficient oil.

4.    Why is the pump not circulating sufficient oil?

–    The pump intake is clogged with metal shavings.

5.    Why is the intake clogged with metal shavings?

–    Because there is no filter on the pump.

For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.

Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.

TapRooT® Root Cause Analysis

TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with either the TapRooT® 5-Step Process for low-to-medium risk incidents or the the TapRooT® 7-Step Process for major investigations. The 5-Step Process is shown below…

To start investigating the problem, one gathers evidence and draws a SnapCharT® (shown below being drawn by a team in a TapRooT® 2-Day Root Cause Analysis Course).

Notice that the 5-Whys that Mr. Ohno asked in the example above turned out to be mainly the sequence of events leading up to the failure in the  SnapCharT® (shown below).

The SnapCharT® makes the example event easier to understand than the 5-Why example above. Plus, the SnapCharT® goes beyond the 5-Whys by indicating that there was no low oil pressure alarm.

In TapRooT®, if the investigator decides that there is more to learn, the investigator continues to collect evidence (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.

First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?

Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?

The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.

Notice that in TapRooT®, we complete the collection of evidence about what caused the metal filings and what caused the filter to be missing. These were significant issues that were left out of the 5-Why analysis. This type of omission is common in 5-Why analyses – even when experts apply 5-Whys. Thus the problem isn’t with the investigator or their training – it is embedded in the 5-Why system.

Causal Factors

Once one understands what happened, the third step is to identify the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. A simple technique called Safeguard Analysis is used to do this. The four Causal Factors for the Robot Stops incident were identified as:

  1. Mechanic A uses cloth to cover openings in system.
  2. Mechanic A does not report metal shaving contamination.
  3. Mechanic B does not install oil filter.
  4. Operator does not know oil pressure is low.

Where Mr. Ohno only had one root cause, TapRooT® has already identified four Causal Factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys: that it usually focuses on a single cause and misses additional causes (and the needed corrective actions for those root causes that aren’t identified).

TapRooT® Root Causes

In fourth step of the TapRooT® 5-Step Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).

For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend  attending a 2-Day or 5-Day TapRooT® Course.

However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”

This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.

Copyright © 2015 by System Improvements, Inc.
Used by permission. Duplication prohibited.

In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).

Thus, it was determined that if the operator needed an oil pressure display/alarm (displays NI root cause) to make the detection of a problem possible (errors not detectable root cause). If the display/alarm had been present, then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.

The corrective action for these two root causes would be to install a bearing lube oil pressure indicator and a low bearing lube oil pressure alarm to notify the operator of impending equipment problems before the bearing would lock up.

After analyzing just one Causal Factor using the TapRooT® Root Cause Tree® we have found that even an expert like Taiichi Ohno could miss important root causes when using 5-Whys. But there is more. There are still three more Causal Factors to analyze (and then Generic Causes – an optional technique in the 5-Step Process).

Why would you use a root cause tool with known, proven weaknesses? Why would you risk lives, your corporate reputation, and large sums of money on an inferior approach to problem solving? If something is worth fixing, it is worth fixing it right! Learn and apply TapRooT® Advanced Root Cause Analysis to find the real root causes of problems and effectively fix them. Attend an upcoming course to learn more.

Admiral Rickover’s 7 Rules

Posted: May 9th, 2018 in Performance Improvement, TapRooT

Hyman Rickover 1955

Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

Are you using advanced root cause analysis to learn from past mistakes? Learn more about advanced root cause analysis by CLICKING HERE.

See you today on Facebook Live!

Posted: May 9th, 2018 in Career Development, Career Development Tips, Topic of the Week, Video

Ben Franklin said it best, “An ounce of prevention is worth a pound of cure.” How can being proactive turn your organization around? A root cause audit can address many problems and losses that persistently plague companies. Join today’s Facebook Live discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, May 9

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Newest Aircraft Carrier Breaks Down During Sea Trials

Posted: May 8th, 2018 in Current Events, Equipment/Equifactor®, Video

USS Ford underway for sea trials …

An article in Popular Mechanics said the the USS Ford had to return early from sea trials because of an overheating thrust bearing on one of the four main engines. Bloomberg reported that:

“inspection of the parts involved in the January 2018 incident revealed improperly machined gears at GE’s facility in Lynn, Massachusetts as the ‘root cause.'”

Is “improperly machined gears” a root cause? That would be a Causal Factor and the start of a root cause analysis in the TapRooT® System. And why wasn’t the “improper” machining detected prior to installation and sea trials?

Here is some footage of sea trials (including a brief glimpse of one main shaft turning).

Join TapRooT®’s Facebook Live tomorrow

Posted: May 8th, 2018 in Career Development, Career Development Tips, Topic of the Week, Video

We cannot overstate Ben Franklin’s sage advice in his safety axiom, “An ounce of prevention is worth a pound of cure.” Many problems and losses that persistently plague companies can be best addressed by proactively performing a root cause audit. Join the discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, May 9

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Last week, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® blog and the significantly positive impact it can have on your professional career. Connect to this important discussion via our Vimeo.

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

Come learn with us in Cape Town!

Posted: May 7th, 2018 in Career Development, Courses, Local Attractions, Training

Broaden your horizons and enhance your career in Cape Town!

Mark your calendar and pack your bag to join us in Cape Town for a TapRooT® training course sure to change the way you think about solving problems. In just 5 days, you’ll learn TapRooT® to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events and other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper® plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement.

Whether you’re a TapRooT® expert or a beginner, there is always something new and exciting to learn at our 5-Day course. Once you’ve completed the course, you will receive a training certificate and a 90-day subscription to TapRooT® VI. Be sure to bring a safety incident or quality issue when you attend the course. The reports may be a written report, or you have extensive knowledge of an incident without a written report. We will divide into teams of 2-4 people, with each team analyzing a different problem.

Experience Cape Town
Start your exploration with a early morning trek up Table Mountain and take in panoramic views of the city. Ascend the mountain by hiking or via cable car. You’ll be atop one of the New Seven Wonders of the World!

Cape Town is brimming with adventure, culture, and culinary arts. The original city of South Africa, Cape Town was established in 1652 as a refueling station for ships sailing the Spice Route. As it gave birth to civilization, the city is called “the Mother City” by locals and travelers.

If peacefulness, beauty, recreation, nature, and bird-watching are high on your list, jog, hike, or picnic at Kirstenbosch National Botanical Garden or Green Point Park. Cycle, fish, swim or get into water sports at a beach or nature reserve such as West Coast National Park. Find more gardens and parks here.

From aboard a Ceres Rail Company steam train, glimpse the picturesque Ceres Valley landscape.

Visit St. George’s Cathedral, referred to as the “People’s Cathedral” for its role in the resistance against apartheid. The cathedral was designed by Sir Herbert Baker and is the oldest cathedral in Southern Africa and mother church of the Anglican Diocese of Cape Town.

Take a 30-minute walk through Silvermine Nature Reserve and take in the hidden waterfall in the reserve’s southeastern area. Or immerse yourself in a 90-minute city walk through some of Cape Town’s most noted historic culture: Two free walking tours,  the Historic City Tour and the Vibrant Bo-Kaap Tour, start at the City Sightseeing ticket office at 81 Long Street (stop 5, look for the bright red umbrellas).

Shop, dine at, and stroll the V&A (Victoria & Albert) Waterfront; check out the iconic Old Clock Tower while you’re there.

 

Cape Town Eateries

Venture to Long Street’s Royal Eatery for a burger you likely will not soon forget. Select among 50 gourmet burgers, or go for  pizza or vegetarian  in this casual, colorful restaurant.

Relax in the laid-back vibe of Black Sheep Restaurant and feast on honest, uncomplicated, good food made with the best local ingredients.

Relish lunchtime in a Cape Dutch National Monument situated on a lagoon in West Coast National Park. Indulge in local flavors—a blend of Portuguese, Dutch, Norwegian, Italian, and Malay influences—translated through savory, traditional dishes at Geelbek Restaurant.

While you’re at the V&A Waterfront, Balducci’s great vibe and generous wine list accent its great offerings—from steak to pizza and sushi to pasta.

Check out more deliciousness in Cape Town here.

Plot your sightseeing with help from our Cape Town Pinterest board.

Register for the 5-day course in Cape Town here.

Hazards and Targets

Posted: May 7th, 2018 in Accidents, Current Events, Human Performance, Performance Improvement, Pictures, Root Causes, TapRooT

Most of us probably would not think of this as a on the job Hazard … a giraffe.

Screen Shot 2018 05 07 at 9 40 49 AM

But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

Screen Shot 2018 05 07 at 9 42 38 AM

 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 7th, 2018 in Career Development, Courses, Job Postings, Training

If you’re TapRooT® trained, rely on your expertise to speak volumes about how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis will communicate competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step into a new career through one of these global opportunities.

Senior Process Engineer

Reliability Engineer

Patient Safety Program Coordinator

Environmental Safety & Health Manager

HES Operations Specialist 

Patient Safety Assistant Coordinator (PSAC)

PipelineRisk/Integrity Engineer

Senior Process Engineer

Safety Manager

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Cape Town, South Africa, May 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, May 28, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Perth, Australia, May 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Monday Accidents & Lessons Learned: Failing the Mind-Check of Reality

Posted: May 7th, 2018 in Accidents, Human Performance

 

When an RV-7 pilot studied the weather prior to departure, he considered not only the weather but also distractions and personal stress. His situational awareness and decision-making were influenced by these considerations, as you can see in his experience:

“I was cleared to depart on Runway 27L from [midfield at] intersection C. However, I lined up and departed from Runway 9R. No traffic control conflict occurred. I turned on course and coordinated with ATC immediately while airborne.

“I had delayed my departure due to weather [that was] 5 miles east…and just north of the airport on my route. Information Juliet was: “340/04 10SM 9,500 OVC 23/22 29.99, Departing Runway 27L, Runways 9L/27R closed, Runways 5/23 closed.” My mind clued in on [Runway] 09 for departure. In fact, I even set my heading bug to 090. Somehow while worried mostly about the weather, I mentally pictured departing Runway 9R at [taxiway] C. I am not sure how I made that mistake, as the only 9 listed was the closed runway. My focus was not on the runway as it should have been, but mostly on the weather.

“Contributing factors were:

1. Weather

2. No other airport traffic before my departure. (I was looking as I arrived at the airport and completed my preflight and final weather checks)

3. Airport construction. For a Runway 27 departure, typical taxi routing would alleviate any confusion

4. ATIS listing the closed runway with 9 listed first

5. Quicker than expected takeoff clearance

“I do fly for a living. I will be incorporating the runway verification procedure we use on the jet aircraft at my company into my GA flying from now on. Sadly, I didn’t make that procedural change in my GA flying.”

Thanks to NASA’s Aviation Safety Reporting System (ASRS) for contemporarily sharing experiences that offer valuable insight, contributing to the growth of aviation wisdom, lessons learned, and an uninhibited accounting of reported incidents. ASRS receives, processes, and analyzes these voluntarily submitted reports from pilots, air traffic controllers, flight attendants, maintenance personnel, dispatchers, ground personnel, and others entailing actual or potential hazards.

We encourage you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

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