Root Cause Analysis Blog

 

Monday Accident & Lessons Learned: How to Stop a Pellet Plant Explosion

Posted: October 16th, 2017 in Accidents

“One single ounce of oxygen. That’s all it would have taken for an explosion to have occurred… ”

While the potential for explosion is common for this industry, new learnings and experiences are being shared so that the industry is safer.

Read How to Stop a Pellet Plant Explosion on Canadian Biomass Magazine

TapRooT® Around the World: Lake Charles

Posted: October 13th, 2017 in Pictures, Training

We were busy in Lake Charles this week!  Thanks, Angie Comer, for this great class photo!

Friday Joke

Posted: October 13th, 2017 in Jokes

TapRooT® Around the World: Intralox

Posted: October 12th, 2017 in Courses, Pictures

TapRooT® Instructor, Steve Swarthout sent us this course photo from this onsite course this week. Thanks, Steve!

If you have ten or more people to train and are interested in finding out more information about scheduling an onsite course, contact us.

Technically Speaking – September Customer Satisfaction Survey Prize Winner

Posted: October 12th, 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 Scott Bittner, Dover HSES Manager from Edgewell Personal Care as the winner for the month of September!

Why do people jump to conclusions?

Posted: October 10th, 2017 in Human Performance, Performance Improvement, Pictures, Root Cause Analysis Tips

I see examples of people jumping to conclusions all the time. Instead of taking the time to analyze a problem, they suggest their favorite corrective action.

Why do they do this? I think it is because thinking is so hard. As Henry Ford said:

“Thinking is the hardest work there is, which is probably the reason why so few engage in it.”

Did you know that when you think hard, your brain burns more calories? After a day of hard thinking you may feel physically exhausted.

Neuroscientific research at Cal Tech has shown that the more uncertainty there is in a problem (a cause and effect relationship), the more likely a person is to use “one-shot” learning (jumping to conclusions). This simplification saves us lots of work.

What’s the problem with jumping to conclusions?

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And even more important than saving effort in the analysis is that if you jump to a conclusion, you get to recommend the corrective action that you wanted to implement all along. Skip all that hard work of proving what the cause was and the details of developing effective fixes. Just do what you wanted to do before the problem ever happened!

The next time you are tempted to jump to a conclusion … THINK!

Yes, real root cause analysis and developing effective fixes is harder than just implementing the fix that you have been wanting to try even before the accident, but getting to the root (or roots) of the problem and really improving performance is worth the hard work of thinking.

Monday Accident & Lessons Learned: Mid-flight engine explosion forces landing

Posted: October 9th, 2017 in Accidents

“We looked out the window and saw half of the engine was missing.”

A rare emergency in which machinery and other parts broke away from a plane at high velocity occurred on an Airbus A380 with 500 passengers bound for Los Angeles.

The U.S. manufacturer of the engine, Connecticut-based Engine Alliance, said it was investigating the failure.

Read the article on NBC News.

TapRooT® Around the World: Arab Potash

Posted: October 9th, 2017 in Courses, Pictures, TapRooT

TapRooT® instructor, Heidi Reed sent these class photos from 1300 feet below sea level! Looks like a great class!

 

TapRooT® Around the World: Tennessee

Posted: October 6th, 2017 in Courses

It’s a wrap! Dave Janney & I had a great week with this group at our Knoxville 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. It’s not too late to get in the picture.  Here are some upcoming 5-day courses:

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

December 4: Edmonton, AB

December 11: Houston Texas

Friday Joke: No need to take the blame…

Posted: October 6th, 2017 in Jokes

when you can share it!

Technically Speaking – Predictive Location and Currency

Posted: October 5th, 2017 in Software, Technical Support, Technically Speaking

With the latest release of TapRooT® VI comes new features. Two of those features are Predictive Location and Currency, both of which are custom field features.

 

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, doesn’t mean it has to be complicated!

Using TapRooT® Proactively – Mapping Out the Process

Posted: October 5th, 2017 in Summit, Summit Videos, Video, Video Depot

Watch Dave Janney discuss how TapRooT® can be used to map out the process.

Interviewing & Evidence Collection Tip: Get More Out of Interviews

Posted: October 5th, 2017 in Investigations, Root Cause Analysis Tips

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

How Far Away is Death?

Posted: October 5th, 2017 in How Far Away Is Death?

Man’s tumor turns out to be a toy he swallowed as a child. (Read article.)

Root Cause Tip: Courage

Posted: October 4th, 2017 in Root Cause Analysis Tips

Courage is not limited to the battlefield or the Indianapolis 500 or bravely catching a thief in your house.  The real tests of courage are much quieter.  They are inner tests, like remaining faithful when nobody’s looking, like enduring pain when the room is empty, like standing alone when you’re misunderstood. ~ Charles Swindoll

Investigating accidents, incidents, sentinel events, equipment failures, and quality issues requires courage.  Courage to challenge the way work is performed.  Courage to ask questions that people hope won’t be asked.  Courage to point out ways that management can improve the way the facility is managed.

Remember, when you think you face the challenge of confronting people and influencing them to change … courageously look for a different path.

Instead of forcing your views, find a way to make yourself an ally of those you think must change.  Your objective is to create an environment where you have an opportunity to share your vision and create enthusiasm for it.  As an ally, you learn how they view the problem in greater detail.  You may even discover some of your assumptions were wrong.  As an ally, they are more open to receive your ideas.  When you are work as a team – rather than adversaries – the chances of success are much higher.

Why is Root Cause Analysis Applied Reactively More Than Proactively?

Posted: October 3rd, 2017 in Accidents, Human Performance, Performance Improvement, Pictures, TapRooT, Training

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

Mark Paradies’ Interview Scheduled to Air on Fox Business Network and Bloomberg International

Posted: October 2nd, 2017 in Media Room

We’re pleased to announce that Mark Paradies’  interview on Worldwide Business with kathy ireland® is scheduled to air on Fox Business Network as sponsored programming and Bloomberg International.

Please reference the broadcast information below. You may also reference the channel finder below for market by market air times.

Air Date
October 8, 2017
Network and Time
Fox Business Network – 5:30pm EST
Channel Finder
http://www.foxbusiness.com/channel-finder.html

Air Date
October 22, 2017
Network and Time
Bloomberg EMEA – 7:00am GMT
Bloomberg Latin America – 10:00am D.F.
Channel Finder
https://www.bloomberg.com/live/schedule-shows

Monday Accidents & Lessons Learned: Fatal Collision between Tram and Pedestrian

Posted: October 2nd, 2017 in Accidents

 

A tram driver did not see a pedestrian approach a crossing. There were many contributing factors. Read the RAIB report and the lessons learned here.

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