Root Cause Analysis Blog

 

Cancel your lunch plans! Join TapRooT® today at noon EST!

Posted: July 11th, 2018 in Career Development Tips, evidence collection, Investigations, Presentations, RCA Tip Videos, Root Cause Analysis Tips, TapRooT, TapRooT® Instructor, Topic of the Week, Video

Join TapRooT® professionals Benna Dortch and Ken Reed today at noon EST for TapRooT®’s Facebook Live discussion.

We 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? Today, Wednesday, July 11

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

Recently, on TapRooT®’s Facebook Live, we learned that only through effective listening will you learn to pick up on the “right” questions to ask in your investigations. TapRooT® Instructor Barb Carr gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below, featuring TapRooT® professionals Benna Dortch and Barb Carr, to review your skills:


Do your own investigation into our courses and discover what TapRooT® can do for you.

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.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Join TapRooT® for Facebook Live Wednesday at noon EST

Posted: July 10th, 2018 in Career Development Tips, TapRooT, Topic of the Week, Video

Make plans now to join TapRooT® professionals Benna Dortch and Ken Reed tomorrow for our Facebook Live discussion.

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? Wednesday, July 11

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Onsite Course, Ensign Energy, Neuquén, Argentina

Posted: July 10th, 2018 in Career Development, Courses, Meet Our Staff, Pictures, TapRooT® Instructor, Training

TapRooT® Instructor Piedad Colmenares sent us some “course captures” of the recent 2-Day TapRooT® Root Cause Analysis Training class she taught in Neuquén, in chilly Argentine Patagonia, onsite at Ensign Energy.

Piedad says, “Despite the intense cold of winter, it was a very special course. We shared experiences, and it was also very pleasant to experience the excitement of the World Cup. It was very exciting to receive the gift they gave me: a shirt of the Argentine soccer team, autographed by all the students.” Piedad gives a shout-out of thanks to all the participants of the Ensign Energy onsite course.

In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Piedad for sharing these pictures of action and insights into the interactive learning during the course!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are a few of our upcoming courses:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader 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

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

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.

Bias and Blame in Healthcare’s Culture Has To Change

Posted: July 10th, 2018 in Uncategorized

 

Taking the blame out of root cause analysis is critical.  See this article for more information on a physician in the UK who was charged with manslaughter when the system failed her and her patient. Click here.  The physician wasn’t at fault.  She didn’t intentionally make an error.  The system and processes need analyzed and improved so mistakes aren’t made again.  It actually does harm to put a physician in jail because of  process or system errors.  It takes the focus off of the real problems.  It diverts time and resources from where they are truly needed.  It incentives physicians to cover up errors which could be analyzed for lessons learned resulting in better outcomes.  Physician burn out and suicide rates are at an all time high because of the pressure physicians are under. Click here for more info.  They are held accountable and blamed for bad outcomes when something goes wrong.  The responsibility and burden on physicians must be tremendous.  Until Healthcare catches up to other industries that do train their teams on how to conduct unbiased root cause analysis as part of their continuous quality improvement process, the culture will be hard pressed to change.

 

To find more information on TapRooT’s® comprehensive quality improvement process, please contact me at marcus.miller@taproot.com.

What does a bad day look like?

Posted: July 10th, 2018 in Bad day

“Well, look at it this way: At least the driveway will be super fun when it snows! We’ll never get our car in and out without denting the front or back, but our sledding game is going to be the bomb.”

Acquire TapRooT® in Atlanta

Posted: July 9th, 2018 in Career Development, Courses, Local Attractions, Training

TapRooT® Training in Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

 

Exposure to the 2-Day TapRooT® Root Cause Analysis Training course in Atlanta will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Atlanta, you will want to get out and about. Below, to route you on the road to Atlanta, we’ve included highlights of this Southern city. Be sure to discover even more gems to explore on our Atlanta Pinterest board.

Experience Atlanta

Atlanta has grown from a railway town to a Southern icon due to its cultural community, as well as for its position as a financial and commercial center. The bustling city maintains its identity as a crucial hub for transportation. Atlanta—with incredible charm, generally mild-weathered climate, and attractions such as the Georgia Aquarium, the College Football Hall of Fame, and Piedmont Park—has drawn in celebrity chefs, media magnates, and a diverse population.

Take a walk along the BeltLine, a 22-mile loop connecting parks and trails and encircling major areas of the city. See how many pieces of public art you can spot as you walk.

With 75 acres of fresh outdoor nature experiences and the world of adventure inside, Fernbank Museum of Natural History opens your eyes to a hands-on, wild side, sensory discovery.

Go for a mini-hike up Stone Mountain.

Stroll through Ponce City Market, set in a historic Sears, Roebuck & Co. building, and discover Skyline Park on the rooftop, dine and drink at City Winery, get an epic coffee at Spiller Park.

At the High Museum, explore contemporary and historical art, exhibitions, and architecture.

In downtown Atlanta, Centennial Olympic Park is where you’ll find the Georgia Aquarium.

Martin Luther King Jr. National Historic Park: Visit the park, including the home of Martin Luther King Jr. Be moved by his story in this park dedicated to the African-American leader’s life and heritage.

Atlanta Botanical Garden offers an urban oasis of more than 30 acres, adjacent to Piedmont Park in Midtown.

Taste Atlanta

 

Fork first, into a scrumptious Southern fare at Atlanta Breakfast Club. Among the temptations are fried chicken with waffles, pancakes, omelets, French toast, and, of course, grits.

Make plans to stop at Ponce City Market and get your culinary senses sharpened in Central Food Hall.

Duck into Ria’s Bluebird for a delicious weekend brunch in the downtown heart of Atlanta. The buttermilk pancakes are ranked the world’s best by the New York Times.

Cool off with a crazy-good, flavor-filled treat from the closest King of Pops.

Bite into a Sublime Doughnut to see what all the hubbub is about.

With up to 15 trucks at a time, your options are wide open at Atlanta Food Truck Park.

If you happen to be in East Atlanta or on the West side, savor a slider at Delia’s Chicken Sausage Stand.

Go to Hankook Taqueria near the Georgia Tech campus and settle into some tong dak tacos and sesame fries.

Tuck into some Belgian Fries at Belgian Beer Bar, located in Little 5 Points.

The overstuffed burrito, rice and beans, quesadillas, and more from El Myr are something to look forward to.

Atlanta is all about the food halls. In the middle of Inman Park, you’ll find Watchman’s Seafood & Spirits featuring fresh Gulf of Mexico fare in Krog Street Market.

Register here for our Atlanta 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

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

Winners and Losers in Healthcare’s Shift to Value-Based Payments

Posted: July 9th, 2018 in Investigations, Medical/Healthcare, Performance Improvement, Quality, Root Causes, TapRooT, Uncategorized

 

Image result for scale budget

The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Career Opportunities for Candidates with TapRooT® Skills

Posted: July 9th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

HSE Manager

Chemical Manufacturing

Field Operations Excellence Leader 

Patient Safety Analyst 

Senior Process Engineer

Associate- Senior Engineer Nuclear

Patient Safety Assistant Coordinator

Patient Safety Analyst

Patient Safety Assistant Coordinator

Lead Engineer

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

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dallas, Texas, August 6, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 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.

Monday Accident & Lessons Learned: Fatal Accident While Unloading a Truck

Posted: July 9th, 2018 in Accidents, Current Events, Pictures, Video

WKBW TV reported that two employees were killed when a stack of Corian counter tops that weighed 800 pounds per slab (11 slabs total) fell on them. The accident occurred at 1:30 a.m. and the employees were pronounced dead at the scene.

The company issued a statement that said:

“We’re saddened to report that a tragic accident occurred this morning at our facility in Lockport, NY that resulted in the death of two of our colleagues. We’re working with our safety team and local law enforcement to understand the circumstances under which this tragedy occurred. Our deepest sympathies are with their families and our Lockport team members.”

OSHA will be conducting an investigation of the deaths. OSHA has investigated two other serious injuries at XPO facilities elsewhere in New York state.

What was the Hazard in this accident?

The heavy, high-piled load.

Who were the targets?

The two employees.

What were the Safeguards?

From the newspaper articles, we don’t know.

We also don’t know any of the reasons for the Safeguard’s failure.

The root cause analysis will have to determine the Safeguards, why they failed, and if they were sufficient. (Do we need additional Safeguards?)

In the TapRooT® System, a SnapCharT® would be used to collect and organize the information about what happened.

Then the failed Safeguards would be identified.

Next, the failed Safeguards (Causal Factors) would be analyzed to find their root causes using the Root Cause Tree® Diagram.

Once the root causes for all the Safeguards were found, the team would start developing corrective actions.

The Safeguards would be reviewed to see if after they were strengthened, if they would be adequate. If they would not be adequate, either additional Safeguards would be developed or the process could be modified to reduce or remove the hazard. For example, stack the counter tops no more that 16 inches high.

To improve the Safeguards that failed, you would address each of the root causes by developing SMARTER corrective actions using the Corrective Action Helper® Module of TapRooT® Software.

What is a SMARTER corrective action?

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

To learn more about the TapRooT® System, SnapCharT®, Safeguard Analysis, Causal Factors, the Root Cause Tree® Diagram, the Corrective Action Helper® Module, the TapRooT® Software, and SMARTER, attend one of our 2-Day or 5-Day TapRooT® Courses. Here is a list of the dates and locations of the courses being held around the world:

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

Friday Joke

Posted: July 6th, 2018 in Jokes

“Okay—who put my lunch through the mass spectrometer…?”

Ever have trouble with root cause analysis during batch production with impurities?

Posted: July 6th, 2018 in Equipment/Equifactor®, Investigations, Medical/Healthcare, Performance Improvement, Quality, Root Cause Analysis Tips, TapRooT

We received the question below in our TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn, please join the discussion with your experiences and best practices.

How would one do a SnapCharT® for intermittent product quality issues that span weeks/months?

The only way to detect the product impurity is to use the product. Even so, the impurity seems random in the same batch or lot, at different weeks or months, with different upstream raw material suppliers, with different personnel. Past root cause analysis was not systematic enough to find the rc. Fixes did not solve.

TapRooT® Training in Bogota

Posted: July 6th, 2018 in Career Development Tips, Courses, Local Attractions, TapRooT, Training

To advance your professional development through TapRooT® Training in Colombia, register for our upcoming courses in Bogota.

Bogota, Colombia: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course:

Bogota, Colombia: 2-Day TapRooT® Root Cause Analysis Training:

Bogota, Colombia: Special 2-Day Equifactor® Equipment Troubleshooting & Root Cause Analysis Course: 

Bogota: 3-Day TapRooT® /Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course:

Bogota: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course:

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

Expand your professional knowledge and advance your career in Bogota, Colombia, with TapRooT®. Within a TapRooT® course, you’ll gain experience and perspective for myriad workplace situations. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

Bogota, Colombia—flanked to the east and west by mountain ranges, it’s often called “the city of art, adventure, and architecture.” While in Bogota, you will want to get out and about, to admire the architecture of its many churches, taste its diverse fruits and culinary delights, and experience its history and heritage. Below, to route you on the road to Bogota, we’ve included highlights of this vibrant city. Be sure to discover even more gems to explore on our Bogota Pinterest board.

Experience Bogota

Visit Bogota and discover an attractive, vibrant city abuzz with great coffee shops, culinary hotspots, a wealth of heritage and cultural high points, and colorful neighborhoods. Colombia has the world’s largest number of orchids, its national flower. In Bogota’s mountains, you will find a diversity of these orchids, as well as a wealth of species of flowers, birds, and butterflies. Below are some suggestions and highlights of Bogota for you to explore:

El Carmen Church (Iglesia Nuestra Señora del Carmen): You’ll easily spot the iconic 187-foot, red-and-white brick steeple in the Candelaria district. Decorated with Arabic and Byzantine art, this Gothic-style church was built between 1926 and 1938 with architecture that reflects the Spanish colonial tradition. See other churches in Candelaria here.

Plaza de Bolivar: A visit to Bogota often begins here, in the heart of the original town. In this square is the city’s first public monument, the 1846 bronze statue of Simon Bolivar, known as El Libertador.

La Catedral PrimidaGothic-style with a French influence, the Holy Cathedral Church has five naves, 88 columns, and 72 vaults. 

The Gold Museum (Museo del Oro), in the cobblestoned La Candelaria, houses the largest collection of pre-Colombian gold work in the world. Among the 55,000 pieces of ancient works by indigenous cultures of Colombia, you’ll see gold, pottery, rock, precious stones, and textiles, lending scientists and archaeologists insight into the cultures of South America civilizations prior to the arrival of Europeans.

Visit La Candelaria in daylight hours. You’ll find this the place to experience Bogota’s colorful, cultural heritage, as the neighborhood is full of art deco, Spanish colonial, and Baroque architecture. La Carrera Septima is a good beginning for wandering your way to La Candelaria.

Take in panoramic views of the city and faraway hills atop Monserrate Mountain, a 10,341-foot mountain with a 17th-century church, gardens, and a Colombian spiritual shrine. Ascend to the mountain by cable car, railway, or on foot. The cable car views are preferred by most visitors. On the mountain, you will also find a couple of restaurants and a market.

Taste Bogota

How many of these Colombian fruits have you tried?

  • Badea
  • Borojo
  • Carambolo
  • Feijoa
  • Chontaduro
  • Passion fruit
  • Soursop
  • Naranjilla
  • Spanish lime
  • Cherimoya
  • Granadilla
  • Guanabana
  • Brazilian guava
  • Lulo fruit
  • Mamoncillo
  • Maracuya
  • Pitahaya
  • Tomate de arbol (tamarillo)
  • Peruvian groundcherry
  • Curuba
  • Higo

Paloquemao Market is one of the most traditional Bogota markets, where you will discover a wide range of fresh Colombian fruits, vegetables, and flowers.

On your way back from the Salt Cathedral, enjoy dinner and then the nightlife in Chia at Andres Carne de ResTry the coconut milk lemonade.

For modern Colombian, go to Mini Mal; for street food Peruvian-style, try El Carrito Sanguchero; and to savor Lebanese-style deliciousness, head to Zatar.

Enjoy the baked goods! Pandebonos (a cheese bread), pan de yuca, and almojabanas are usually offered in any bakery. Some good locations are La Puerta Falsa and La Rioja in Chapinero.

La Puerta Falsa: Order the ajiaco, a delicious soup with chicken, potatoes, corn, and guascas, a local herb. Other ingredients are added according to personal taste: rice, avocado, capers, cream. Other great locations for this time-honored dish: La Pola in Las Aguas or at Las Cazuelas de la Abuela in Chapinero.

Know before you go: Bring a jacket. At 8,612 feet, Bogota has mild temperature year-round, but gets chilly in the evening. 

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

Happy 4th of July

Posted: July 4th, 2018 in Current Events, Pictures

4th

In the US we celebrate declaring our independence from The British crown on the 4th of July. It was a great risk for a minor colony to stand up to the world’s mightiest power. Perhaps were were foolish or you might say reckless … but the outcome was a system without a king and with a constitution that affirmed and guaranteed our God given rights.

So today when you are celebrating somewhere in the US, remember those who risked all for the freedoms we enjoy today and those who stand ready to do that today.

Happy Independence Day!

Technically Speaking – Happy Independence Day!

Posted: July 3rd, 2018 in Technical Support, Technically Speaking

We are going to be closed July 4th and 5th to celebrate Independence Day. We will be back in the office on Friday, July 6th at 8:00 am Eastern Time. Thank you for your support of TapRooT® and we look forward to talking with you again on Friday!

One Safeguard Eliminated = Death

Posted: July 3rd, 2018 in Accidents, Current Events, How Far Away Is Death?, Video

Watch the video and see what could have been done to avoid a fatality…

I think there was an obvious Safeguard missing. What was it?

Testimonial Tuesday

Posted: July 3rd, 2018 in Courses, Pictures, Testimonials, Training

Are you interested in learning TapRooT®, but you’re not sure where to start? Below I’ve provided some 2-Day and 5-Day TapRooT® Training Testimonials to help you decide which course is right for you.

TapRooT® is a world-class software system designed to help investigators solve every day hurdles. TapRooT® take the investigator beyond his or her knowledge to choose root causes that are “outside the box” of common root causes such as writing poor procedures or inadequate training.

2-Day Client Testimonials:

  • “Great interactive exercises to better understand the basics of SnapCharT®.” – Aspinall
  • “Very informative section on how to correctly identify causal factors.” – Neil
  • “Excellent software that quickened the process.” – Tony
  • “Great group exercises working in small teams using the Root Cause Tree®.” – Fox

5-Day Client Testimonials:

  • “I enjoyed the “Putting It All Togehter” unit, because it helped me remember all the things we have learned and how to implement these strategies.” – Einini
  • “Great approach to actually solving issues and behaviors.” – Anonymous
  • “Enjoyed working through a real incident. Very beneficial.” – Evan
  • “It wasn’t all lecture, the practical hands-on training was great.” – Robby

 

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location and reserve your seat today by clicking on the links below.

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

Caption Contest!

Posted: July 2nd, 2018 in Contest, Pictures

A new month means a new caption contest! This month’s caption contest photo comes from my husband, Jared.

So, here is your chance to win some free TapRooT® swag! All you have to do is follow the easy instructions below.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest instructions:
1. Create your caption to the photo above in six words or lessAll captions with more than six words will be disqualified.
2. Type your caption in the comments section of this post by July 23, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Good luck and, most importantly, have fun!

Monday Accidents & Lessons Learned: Where Did We Put the Departure Course?

Posted: July 2nd, 2018 in Accidents, Current Events, Great Human Factors, Human Performance

Have you ever encountered a new methodology or product that you deemed the best thing ever, only to discover in a too-close-for-comfort circumstance that what seemed a game changer had a real downside?

In aviation, the Electronic Flight Bag (EFB) is the electronic equivalent to the pilot’s traditional flight bag. It contains electronic data and hosts EFB applications, and it is generally replacing the pilots’ conventional papers in the cockpit. The EFB has demonstrated improved capability to display aviation information such as airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance.

The EFB platform, frequently a tablet device, introduces a relatively new human-machine interface into the cockpit. While the EFB provides many advantages and extensive improvements for the aviation community in general and for pilots specifically, some unexpected operational threats have surfaced during its early years.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One typical problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, thereby unknowingly “slides” important information off the screen, making it no longer visible.

An Airbus A320 crew was given a vector to intercept course and resume the departure procedure, but the advantage that the EFB provided in one area generated a threat in another.

From the Captain’s Report:

“Air Traffic Control (ATC) cleared us to fly a 030 heading to join the GABRE1 [Departure]. I had never flown this Standard Instrument Departure (SID). I had my [tablet] zoomed in on the Runway 6L/R departure side so I wouldn’t miss the charted headings. This put Seal Beach [VOR] out of view on the [tablet]. I mistakenly asked the First Officer to sequence the Flight Management Guidance Computer (FMGC) between GABRE and FOGEX.”

From the First Officer’s Report:

“During our departure off Runway 6R at LAX [while flying the] GABRE1 Departure, ATC issued, ‘Turn left 030 and join the GABRE1 Departure.’ This was the first time for both pilots performing this SID and the first time departing this runway for the FO. Once instructed to join the departure on the 030 heading, I extended the inbound radial to FOGEX and inserted it into the FMGC. With concurrence from the Captain, I executed it. ATC queried our course and advised us that we were supposed to intercept the Seal Beach VOR 346 radial northbound. Upon review, both pilots had the departure zoomed in on [our tablets] and did not have the Seal Beach [VOR] displayed.”

CALLBACK is the award-winning publication and monthly safety newsletter from NASA’s Aviation Safety Reporting System (ASRS). CALLBACK shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and 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.

Career Opportunities for Candidates with TapRooT® Skills

Posted: July 2nd, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Lead Engineer

Associate- Senior Engineer Nuclear

Patient Safety Assistant Coordinator

Service Delivery Manager

Field Engineer I

Patient Safety Analyst

Patient Safety Program Coordinator

Process Hazard Analysis (PHA) Specialist 

Field Engineer II

Patient Safety Assistant Coordinator

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

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Dallas, Texas, August 6, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 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.

Friday Joke

Posted: June 29th, 2018 in Jokes

Investigative Interviewing Series, (Part 3 of 3): Extension Techniques

Posted: June 28th, 2018 in Investigations, Root Cause Analysis Tips

Ever wondered how to get more than one word or one sentence answers from the witnesses you interview? Here’s your answer!

What are extension techniques and why are they so important from TapRooT® Root Cause Analysis on Vimeo.

TapRooT® & You in Sao Paulo

Posted: June 27th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

Skyscrapers-blue-sky-sao-paulo-things-to-do-Brazil

Upcoming training dates: August 8 | October 17 | December 12

Take a couple of days to expand your professional knowledge and advance your career in fascinating Sao Paulo, Brazil, with TapRooT®! Within these two days, you’ll gain experience and perspective in myriad workplace situations. A TapRooT® course is a career booster and can be a professional game changer for you. 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 categories of problems. Among the unique TapRooT® techniques, you’ll work with SnapCharT®, Root Cause Tree® & Corrective Action Helper®.

At course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Importantly, you will have the advantage of professional training in your expertise and on your resume!

In the 2-Day TapRooT® course, we’ll participate in an exercise, using safety incidents or quality issues from your work environment. Be sure to bring one for us to dive into. This may be a written report, or you may share knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a unique problem. You’ll be amazed at how much you learn in two days that you can immediately apply!

We will gather on August 8 for the 2-Day TapRooT® course. While in Sao Paulo, you will likely want to get out and about. Be sure to discover more gems to explore on our Sao Paulo Pinterest board. Below, to route you on the road to Sao Paulo, we’ve included highlights of this vibrant city.

Experience Sao Paulo

South America’s largest city, Sao Paulo, is surrounded by rivers, and punctuated with rich architecture, from neo-Gothic to modernist. The city is so big that it’s a good idea to have a game plan of what you’d like to include in your adventure.

Go for a refreshing walk among 500 different plant species in Ibirapuera Park. Inside the park, you will find sport courts and a jogging track, bike racks, restaurants, as well as the Contemporary Art Museum, the Modern Art Museum, the Afro Brazilian Museum, the Ibirapuera Auditorium, the Japanese Pavillion, the Oca, and many other structures.

Culture note: A person born in Sao Paulo state is called a paulista; someone born in the city is a paulistano.

Just north of Sao Paulo’s city center is one of the world’s largest urban forests. Walk or hike in the Parque Estadual da Cantareira (Cantareira State Park) to see monkeys and birds as well as native flora. Climb the Serra da Cantareira high enough and you will take in a panoramic view of the city.

The Soccer Museum: The museum is located in the Pacaembu Stadium, and provides an amazing audiovisual experience.

In downtown Sao Paulo, go to the Liberdade district to visit Japanese Town, home to the largest Japanese community in the world outside Japan. Here, you’ll spot iconic red torii Shinto shrine gates lining the streets along with markets and restaurants.

Did you know? Among their influences in Brazil, Japanese immigrants introduced organized farming to the Amazon and initiated the commercial cultivation of pepper, putting Brazil on its way to being the world’s fourth largest producer of this spice.

Sao Paulo culinary experiences

Try what the locals love: Bacalhau is a Brazilian-adopted Portuguese dish containing onions, olives, tomatoes, potatoes, and herbs. Fried fish cakes (bolinho de bacalhau) are consumed with gusto (and often with beer). Tiny tasty rolls (pão de queijo) eaten typically for breakfast—you would call them “cheese bread”—with a cup of coffee with milk (pingado), found in Brazilian bakeries.

Experience the falafels, crispy on the outside and filled with goodness, at Tent of the Nile (Tenda do Nilo).

Taste an African-influenced fritter (acarajé) at Star City

Indulge your sweet tooth at Casa Mathilde.

Have an afternoon or evening drink at Frank Bar.

Dive into a coxinha at Bar do Luiz Fernandes.

Savor feijoada, Brazil’s beans-and-pork stew.

Swing into Caso do Sabor for a tropical chocolate experience, from those who best know cocoa beans and cacao.

To advance your professional development through TapRooT® training, register here for Sao Paulo.

Upcoming training dates: August 8 | October 17 | December 12

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

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

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