Root Cause Analysis Blog

 

TapRooT® at Torex Gold, Minera Media Luna Project

Posted: September 11th, 2017 in Courses

TapRooT® instructor, Jesus Alonso sent in these great photos from a recent onsite course. Get in the picture! Contact us to schedule an onsite course at your facility!


Monday Motivation: Build your personal advisory board!

Posted: September 11th, 2017 in Career Development, Career Development Tips

“Pulling a good network together takes effort, sincerity and time.”
Alan Collins, author of “Unwritten HR Rules”

Part of valuing your time is investing in the right relationships. Spend your time on relationships that matter the most.  For career development, those relationships include people who are willing to help guide your career goals. It takes thought, time and effort to find them. However, the more you procrastinate building your own personal advisory board, the more disconnected you will be from opportunities that could advance your career.

Join us for a fun, exciting and rewarding opportunity to network and build relationships at the 2018 Global TapRooT Summit in Knoxville, Tennessee, February 26 – March 2.  Learn more here.

Remembering an Accident: Ryanggang Explosion in North Korea

Posted: September 9th, 2017 in Accidents

On this day in history, September 9, 2004, a mysterious explosion occurred in North Korea suspiciously close to the border of China. Deep in the mountains in the Ryanggang Province where a secret underground military base was located, a large mushroom cloud arose causing concern and confusion. The seismic activity reported after the accident helped them determine that the large cloud indicated a nuclear explosion, but there wasn’t enough evidence to determine if it was actually an accident. Needless to say, this explosion did not only cause concern for the local citizens, but also other countries. Fortunately, there weren’t any casualties. But the question on everyone’s mind was, “Why would there be a mysterious yet seemingly planned nuclear explosion?”.

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https://www.theguardian.com/world/2004/sep/13/northkorea

https://en.wikipedia.org/wiki/Ryanggang_explosion

Although this explosion was more than likely not an accident, the TapRooT® Advanced Root Cause Analysis and Team Leader Training public courses teach our dynamic techniques that are the best for investigating incidents like this. TapRooT® techniques are also frequently used so prevent incidents from ever occurring.

Find out more about TapRooT® Advanced Root Cause Analysis Training.

Friday Joke: Today’s Special

Posted: September 8th, 2017 in Jokes

And if you can’t, well good luck to you!

Technically Speaking – August Customer Satisfaction Survey Prize Winner

Posted: September 7th, 2017 in Software, Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner.

This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.
Everyone, congratulate Jeff Salter as the winner for the month of August!

New Caption Contest!

Posted: September 7th, 2017 in Contest

This is an unconventional way to get the job done. How would you caption this video? Put on your creative hat and enter your caption in the comments below.

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by October 31.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Have fun!

Caption Contest Winner!

Posted: September 7th, 2017 in Contest

Thanks for playing along with us during our recent contest.

Judging was fierce and so close! But our winner is:

Toney Mitchell with “He lost the ‘boxing’ match.”

Congratulations Toney!

 

The world’s most modern Navy struggles with outdated culture

Posted: September 6th, 2017 in Accidents, Current Events, Root Cause Analysis Tips

To students of safety and accident prevention, the recent collisions involving the guided missile destroyers USS Fitzgerald (DDG 62) and USS John S. McCain (DDG 56) seem strange. How can this happen with top shelf modern warships, equipped with state-of-the-art electronics, radar and GPS? Hint: look for human performance issues, and a culture of blame and punishment.

These are tragic accidents, with unnecessary loss of lives. The Navy’s immediate response was a 24-hour “safety stand down,” and a 60-day review of surface fleet operations, training, and certification. Perhaps more significantly, the Seventh Fleet commander Vice Admiral Aucoin was fired, due to a “loss of confidence in his ability to command.”

And this is where the problems start. To an outside observer, the Navy culture of “firing those responsible” seems very old fashioned. Not only do we waste money on repairing ship damage that should never have happened, we also voluntarily get rid of a large investment in recruiting and training with each officer let go.

A better answer is to analyze what happened in each case, find the root causes and put in place corrective actions to prevent the same accidents from happening again. The Navy investigation results are classified, but let me offer up two possible causes:

1. Guided missile destroyers are smaller, leaner and meaner than the conventional destroyers they replaced. They sail with a smaller crew and fewer officers. However, there is still the same amount of horizon to scan, so to say, so officers will have larger spans of responsibility and fewer opportunities to rest. Fatigue is a powerful influence on human performance.

2. The world is a dangerous place, and getting worse. A shrinking Navy is deployed on the same number of missions around the world, not allowing enough time in between for maintenance of ships and systems. Training and development of crews also suffers.

Our long experience in root cause analysis tells us that no matter how sophisticated systems or equipment are, they need maintenance to work properly. There is also always human factors involved. Human performance is fickle, and influenced by many factors such as fatigue, alertness, training, or layout of control panels. It is better to do a thorough RCA to identify causal factors and fix them, than to fire people up and down the chain of command and still have the same issues again later.

#TapRooT_RCA

Are you attending the NSC conference?

Posted: September 6th, 2017 in Current Events

If you are attending the conference, please come by the TapRooT® Booth (3536) and say hello. Barb and I will be there, so we hope to see you!

Corrective Action Advice

Posted: September 6th, 2017 in Pictures, Root Cause Analysis Tips

If you use TapRooT® to find the root causes of incidents, quality issues, hospital sentinel events, equipment failures, production issues, and cost overruns, you are way ahead of your competition that is just asking “Why” five times. But what should you do to stop repeat incidents when you fix the causes of your problems?

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1. Remove the Hazard and/or the Target.

If you have been to TapRooT® Training you know what a Hazard and a Target are. Did you realize that the most effective fix is to get rid of them (if you can).

If you can get rid of them, you still may want to fix the causes of the root causes you identify. However, is there is no Hazard, you can be pretty sure you won’t have that accident happen again.

2. Install a more reliable Safeguard.

Once again, if you have been to TapRooT® Training, you know what a Safeguard is.

To have your previous incident, all the Safeguards for that incident had to fail. These failed Safeguards were your Causal Factors.

Strengthening your failed Safeguards is what root cause analysis is all about. But how much stronger can you make a weak Safeguard?

Perhaps a better idea is to implement a strong Safeguard?

An example would be to replace several weak Human Action Safeguards with a strong Engineered Safeguard.

CAHelperGuide

3. Fix the root causes of the failed Safeguards.

Use your Corrective Action Helper® Guide/Software Module to develop effective fixes for the root causes of the failed Safeguards that you identified. The Corrective Action Helper® Guide is a great way to get new ideas to fix problems that you previously just couldn’t seem to fix.

4. Get your fixes implemented.

It is no use to develop fixes and put them in a database (the backlog) and never get them implemented. make sure that corrective actions get done!

Job Postings for People with TapRooT® Root Cause Analysis Training

Posted: September 5th, 2017 in Career Development, Job Postings

 

TapRooT® root cause training can take your career to the next level.  Here are some openings for people with TapRooT® skills:

HSE Manager, Arkema, Geneseo, New York “Investigator for TapRooT® investigations; provide incident investigation training to site.”

Health & Safety Manager, Bristol, Pennsylvania “Investigator for TapRooT® investigations”

FieldCore (Multiple locations) (“Lead investigator – TapRooT®”)

What are you waiting for? Expand your career options. Sign up for training today!

August 10 Caption Contest

Posted: September 5th, 2017 in Contest

Thanks to those who entered our August 10 caption contest. Our staff is voting for a winner and we’ll announce who it is Thursday, September 7.  Stay tuned!

TapRooT® featured on Worldwide Business with kathy ireland®

Posted: September 5th, 2017 in Human Performance, Media Room, Pictures, Root Cause Analysis Tips, TapRooT, Video

Mark & Kathy discussing root cause analysis and human performance.

Watch the recorded television broadcast below.

What does a bad day look like?

Posted: September 5th, 2017 in Accidents

Monday Accident and Lesson Learned: Have we learned anything from famous downtime fiascos?

Posted: September 4th, 2017 in Accidents

 

Finding root causes is important not only to keep our workplaces safer but also to avoid costly incidents. IT systems downtime can cost companies millions of dollars in lost production.

This article examines the massive power outage in Silicon Valley last April as well as the August outage at Delta Airlines and asks the important question: What have we learned.

Read:

Have We Learned Anything from Famous Downtime Fiascos?

on Inc.

Monday Motivation: Never Stop Learning

Posted: September 4th, 2017 in Career Development, Career Development Tips

Anyone who stops learning is old, whether at twenty or eighty. Anyone who keeps learning stays young. The greatest thing in life is to keep your mind young.
~ Henry Ford

Invest time in obtaining the know-how to accelerate your career advancement. Don’t set back and wait for things to fall into place, shake things up by working on being smarter, wiser and more strategic about how to better manage your career. Know the goals the industry you are serving desires to achieve and how you can contribute and build relationships with key thought leaders.

Begin with a 2-Day TapRooT® Root Cause Analysis Training or 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. For just a small investment of time you can improve the skills that contribute to your success in these types of careers!

SNEAK PEEK: Tune in Sunday for exclusive interview with Mark Paradies, developer of TapRooT® Root Cause Analysis System

Posted: September 1st, 2017 in Media Room

Mark Paradies talks about human factors and how he developed a root cause system that helps investigators ask better questions.

 
View the entire television segment:

Air Date
September 3, 2017
Network and Time
Fox Business Network – 5:30pm EST
Channel Finder
http://www.foxbusiness.com/channel-finder.html

Air Date
September 3, 2017
Network and Time
Bloomberg EMEA – 7:30am GMT
Bloomberg Latin America – 10:30am D.F.
Bloomberg Asia Pacific – 3:00pm HKT
Channel Finder
https://www.bloomberg.com/live/schedule-shows

Friday Joke

Posted: September 1st, 2017 in Jokes

Don’t be this guy!

Technically Speaking – Revisiting the New Attachments Tab

Posted: August 31st, 2017 in Software Updates, Technical Support, Technically Speaking, Video, Video Depot

In an effort to make our new TapRooT® users aware of the great features introduced in TapRooT® VI, we want to highlight some of our previous posts about TapRooT® VI features. Here is a quick video highlighting the Attachments Tab and how to upload files in TapRooT® VI.

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, it doesn’t mean it has to be complicated!

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

Posted: August 30th, 2017 in Accidents, Current Events, Human Performance, Investigations, Pictures, Root Causes

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Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis:

As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

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Should you use TapRooT® to find the root causes of “simple” problems?

Posted: August 30th, 2017 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT, Training

Everybody knows that TapRooT® Root Cause Analysis is a great tool for a team to use when investigating a major accident. But can you (and should you) use the same techniques for a seemingly simple incident?

Lots of people have asked us this question. Instead of just saying “Yes!” (as we did for many years), we have gone a step further. We have created guidance for someone using TapRooT® when investigating low-to-moderate risk incidents.

Can you get this guidance? YES! Where? In our new book:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

TapRooT Essentials Book

For “simple” incidents, we just apply the essential TapRooT® Techniques. This makes the investigation as easy as possible while still getting great results. Also, because you perform a good investigation, you can add your results to a database to find trends and then address the Generic Causes as you collect sufficient data.

Also, this “simple” process is what we teach in the 2-Day TapRooT® Training. See our upcoming public 2-Day TapRooT® Courses here:

http://www.taproot.com/store/2-Day-Courses/

Now … WHY should you use TapRooT® to analyze “simple” problems rather than something “simple” like 5-Whys?

Because:

  1. Even though the incident may seem simple, you want to find and fix the real root causes and not just focus on a single causal factor and end up with “human error” as a root cause (as happens many times when using 5-Whys).
  2. When you use TapRooT® for simple incidents, you get more practice using TapRooT® and your investigators will be ready for a bigger incident (if you have one).
  3. You want to solve small problems to avoid big problems. TapRooT® helps you find and fix the real root causes and will help you get the great results you need.
  4. The root causes you find can be trended and this allows analysis of performance to spot Generic Causes.
  5. Your management and investigators only learn one system, cutting training requirements.
  6. You save effort and avoid needless recommendations by applying the evaluation tool step built into the simple TapRooT® Process. This stops the investigation of problems that aren’t worth investigating.

That’s six good reasons to start using TapRooT® for your “simple” investigation. Get the book or attend the course and get started today!

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