Root Cause Analysis Blog

 

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

Posted: August 29th, 2017 in Media Room, TapRooT


Tune in Sunday, September 3, 2017 to see Mark Paradies, President of System Improvements, the developer of the TapRooT® System, appear on Worldwide Business with kathy ireland® on Fox Business as sponsored programming and Bloomberg International.

Business with kathy ireland® is a weekly business television program featuring real-world insights from corporate executives from all over the globe which can be viewed on Fox Business Network as part of their sponsored programming lineup, as well as internationally to over 50 countries on Bloomberg International.

Air Date
September 3, 2017
Network and Time
Fox Business Network – 5:30pm EST
Channel Finder

 

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

Root Cause Tip: Equipment difficulty… did the equipment break or wear out?

Posted: August 28th, 2017 in Equipment/Equifactor®, Root Cause Analysis Tips

Teaching TapRooT® Root Cause Analysis and Equifactor® for the last 10 years, I often get this question…

“The tool/component broke while we were using it. Why can’t we just select Equipment Difficulty on the TapRooT® Root Cause Tree®?”

Simple, you have to pass the test below first

NOTE: If the failure was caused by:

  – improper operation;

  – improper maintenance;

  – installation errors;

  – failure to perform scheduled preventive maintenance;

  – programming errors;

  – use for a purpose far beyond the intention of the design; or

  – a design that causes a human performance difficulty

then the failure is NOT an Equipment Difficulty, but rather the failure is a Human Performance Difficulty

Trust me! If a tool, piece of equipment or product breaks, you know the manufacturer, vendor and supplier are going to push back to see if it was used properly and meets the warranty. Shouldn’t you ask first? We say yes!

During my 18 years in aviation in fuel systems troubleshooting and executive jet assembly, we used to have a phrase…

“Our mechanics or assemblers that grew up on the farm are our best and worst mechanics. They can get anything mechanical to work.”

Now there are signs that tools might not be the right ones for the job or that the job was not designed with good Human Engineering in mind. First test… look into the toolboxes in the field.

✔Are the tools modified
✔Are the tools old and worn
✔Are there tools from home

Okay, so tools are easier to see being misused, like a screw driver being used as a scraper or a pry bar, but what about equipment/components being used like a…

✔ Compressor
✔ Switch
✔ Valve
✔ Bottle

Now we must dig a little deeper in our TapRooT® Root Cause and Equifactor® Analysis. We start by mapping out our SnapCharT® (Sequence of Events with supporting Conditions) using system schematics to ensure we know what occurred with the equipment, people and system being operated. A knowledgeable system operator can elaborate on events and conditions such as:

✔ Energized open, mechanically closed
✔ Dynamic or static energy
✔ System work arounds and deficiencies

Why you may ask is this knowledge vital? If an operator knows how the light turns on when you flip a light switch on, then when system does fail, it is easier to start and understand the SnapCharT®.

To pass the first two tests while facilitating TapRooT® Root Cause Analysis, whether for a low to moderate level issue or a major incident, bring along that knowledgeable operator or engineer that can answer the following…

improper operation;
improper maintenance;
installation errors;
failure to perform scheduled preventive maintenance;
programming errors;
use for a purpose far beyond the intention of the design; or
a design that causes a human performance difficulty

Good luck and be safe! Please get rid of those unsafe tools and processes.

LEARN MORE in our 2-day TapRooT® Root Cause Analysis Training.

Monday Accident and Lesson Learned: Arcing and Fire at Windsor & Eton Riverside

Posted: August 28th, 2017 in Accidents

A train barely made it 400 meters from the Windsor & Eton Riverside station before the sixth carriage caught fire, which caused severe electrical arcing. For the full story and what happened next, click here.

(Resource: https://www.gov.uk/raib-reports/arcing-and-fire-at-windsor-eaton-riverside)

Monday Motivation: Invest in your Strengths

Posted: August 28th, 2017 in Career Development, Career Development Tips

“Accept yourself, your strengths, your weaknesses, your truths, and know what tools you have to fulfill your purpose.”
― Steve Maraboli

Commit to your natural strengths that allow your skill sets and capabilities to thrive, and then invest in them.  For example, if you are a good speaker, never assume that your technique doesn’t require improvement.   Take a  class, enhance your abilities and then put them to work more frequently.

Keep in mind that just because you’re good at something, that doesn’t make it a strength. How do you know what your natural strengths are?

Ask yourself these questions:

When do I feel the most engaged at work?

What activities make you feel strong?

What do you do differently than everyone else?

You can’t build your career around your best attributes until you know your strengths!

 

Remembering and Accident: Sayano–Shushenskaya Power Station Accident

Posted: August 25th, 2017 in Accidents

In August 2009, the Sayano-Shushenskaya hydroelectric power station had a turbine completely fall apart causing a significant flood with major collateral damage. Not only were 9-10 turbines broken, the building destroyed and a widespread power outage, but there were 75 fatalities.

So, what happened? Long story short, when the turbines were in installed in 1979, multiple problems with the seals appeared and were fixed. Similar problems occurred again in 2000 and were again worked on and reconditioned. In March 2009, the plant performed scheduled maintenance, repair and modernization on the turbine, but did not properly rebalance the runner causing increased vibrations, which causes damage to turbine seals over time. The night of the accident, the vibrations were out of control, and despite multiple attempts to stop the turbine, it still erupted violently.

For more details of the accident, click here.

Friday Joke

Posted: August 25th, 2017 in Jokes

Interesting Story – Was Quarry Employee Responsible for His Own Death?

Posted: August 24th, 2017 in Accidents, Investigations, Pictures, Root Causes

Jim Whiting, one of our TapRooT® Instructors in Australia, set me this article:

MCG Quarries blames Sean Scovell, 21, for his own death in 2012

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Read the article. What do you think? Where does self responsibility end and management responsibility start? What would your root cause analysis say?

How to Be a Great Root Cause Facilitator (Part 3)

Posted: August 24th, 2017 in Video, Video Depot

In the third and final part of this series, Benna Dortch, Ken Reed and Mark Paradies, Creator of TapRooT®, discuss the last few important and valuable traits of a great root cause facilitator. If you want some best practice tips to help you improve your investigations and just be better at your job, watch this series.

 

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

Technically Speaking – Adding Analysis Comments to Reports

Posted: August 24th, 2017 in Software, Technical Support, Technically Speaking

This week in Technically Speaking we want to introduce an update to the TapRooT® VI software. Users can now add Analysis Comments to their custom report builder! View the PDF below to get the full scoop!

If you are unable to view the copy of this information to store locally on your computer, click on the link below the document to download the white paper to your machine.

 

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!

Second Navy Ship Collides – What is going on?

Posted: August 23rd, 2017 in Accidents, Investigations, Pictures, TapRooT, Video

First, god bless the missing and dead sailors and their families and shipmates who experienced this, the second crash in the past two months.

I’ve waited a couple of days to comment on this second Navy collision with fatalities because I was hoping more information would be released about what happened to cause this collision at sea. Unfortunately, it seems the Navy has clamped down on the flow of information and, therefore, no intelligent comments can be made to compare the collision of the USS John S. McCain with the earlier collision of the USS Fitzgerald.

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What do we know?

  • They are both similar Navy DDG’s with the same staffing levels (only 23 officers).
  • They were both in a shipping channel.
  • They both hit (or were hit by) a merchant ship.
  • The crew was trained to the same Navy standards.

That’s about it.

Of course, we know what they did to those involved in the previous accident (see my previous article HERE).

Was the timing of this second collision just bad luck?

We could use the Navy’s collision statistics to answer that question. Of course, you would have to agree about what is a collision. Would a grounding count? Would there have to be injuries or a fatality?

We would then use the advanced trending techniques that we teach in our pre-Summit trending course to see if the second collision was so close in time to the first that it indicated a significant increase in the collision frequency. To learn about these techniques, see:

http://www.taproot.com/taproot-summit/pre-summit-courses#AdvancedTrendingTrending

Since we don’t have facts (and will probably never get them), what is my guess? The things I would consider for this accident are the same as for the last. Look into what happened including:

  1. Fatigue
  2. Where was the CO?
  3. What did the CIC watch team do?
  4. Experience/training of the bridge and CIC team.

What should the Navy do? A complete, detailed TapRooT® Investigation.

Admiral Richardson (formerly the head of the Navsea 07 – the Nuclear Navy) has the right words about the analysis the Navy is performing. What is missing? A systematic guide for the investigators and prevent them from jumping to conclusions.

In a TapRooT® Investigation, we would start collecting facts and developing a SnapCharT® to truly understand what happened. Next we would identify all the causal Factors before we started analyzing their root causes using the Root Cause Tree® Diagram. Next, we would consider the generic causes and then develop effective (SMARTER) corrective actions. Unfortunately, this will be hard to do because of the Navy’s tradition of blame.

Some of my friends have been asking if I thought that some type of sabotage was involved. Some sort of hacking of the combat systems. In my experience, unless it was extremely foggy, you should be able to use your eyes and the simple bridge radar to navigate. You don’t need fancy technology to keep you from colliding. Simple “constant bearing decreasing range” tells you a collision is coming. To prevent it you turn or slow down (or perhaps speed up) to get a bearing rate of change to bring the other ship down whichever side is appropriate (use the rules of the road).

The trick comes when there are multiple contacts and restricted channels. That’s when it is nice to have someone senior (the Commanding Officer) on hand to second check your judgment and give you some coaching if needed.

Most of the time you spend of the bridge is boring. But when you are steaming in formation or in a shipping channel with lots of traffic, it quickly goes from boring to nerve-racking. And if you are fatigued when it happens … watch out! Add to that an inexperience navigation team (even the Commanding Officer may be inexperienced) and you have an accident waiting to happen.

Is that what happened to the USS John S. McCain? We don’t know.

What we do know is that the Navy’s typical blame and shame response with a safety stand down thrown in won’t address the root causes – whatever they may be – of these accidents.

The Navy seldom releases the results of their investigations without heavily redacting them. What we do know is that previous  investigations of previous collisions were heavy on blame and included little in the way of changes to prevent fatigue or or inexperienced watch standers. The fact is that the corrective actions from previous collisions didn’t prevent this string of collisions.

What can you do? Advise anyone you know in a position of responsibility in the Navy that they need advanced root cause analysis to improve performance. The young men and women that we send to sea deserve nothing less. Navy brass needs to end the blame game and coverup and implement truly effective corrective actions.

TapRooT® Around the World: Bogota, Colombia

Posted: August 23rd, 2017 in Courses, Pictures

Another great course in Bogota, Colombia this August!

Interested in bringing TapRooT® to your company for training? Inquire here.

Interested in sending your team to a TapRooT® course? Check our course schedule here.

Why is getting the best root cause analysis training possible a great investment?

Posted: August 23rd, 2017 in Courses, Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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Why do you train employees to investigate accidents, incidents, quality problems, equipment failures, and process upsets? Because those events:

  • Cost Lives
  • Cause Injuries
  • Ruin the Reputation of Your Product and Company
  • Cause Regulatory Issues (and Big Fines)
  • Cause Expensive Downtime
  • Cause Missed Schedules and Delayed Shipments

You want to learn from past problems to prevent future issues. Its even better if you can learn from small problems to prevent big accidents.

Therefore, you invest in your employees education because you expect a return on your investment. That return is:

  • No Fatalities
  • Reduced Injuries (Better LTI Stats)
  • A Reputation for Excellent Product Quality
  • Good Relations with Your Regulators and Community
  • Excellent Equipment Reliability and Reduced Corrective Maintenance Costs
  • Work Completed on Schedule
  • Shipments Go Out On Time and On Budget

When you think about your investment in root cause analysis training, think about the results you want. Review the diagram below (you’ve probably seen something like it before). Many managers want something for nothing. They want fast, free, and great root cause analysis training. But what does the diagram say? Forget about it! You can’t even have fast-great-cheap (impossible utopia). They usually end up with something dipped in ugly sauce and created with haste and carelessness! (Does 5-Why training ring a bell?)

NewImage(from Len Wilson’s blog)

What should you choose? TapRooT® Training. What does it do for you? Gives you guaranteed return on your investment.

What? A guarantee? That’s right. Here is our TRAINING GUARANTEE:

Attend a course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.

How can we make such an iron-clad guarantee? Because we have spent almost 30 years developing the world’s best root cause analysis system that has been tested and reviewed by experts and used by industry leaders. Over 10,000 people each year are trained to use TapRooT® to find and fix the root causes of accidents, quality problems, and other issues. Because of this extensive worldwide user base, we know that TapRooT® will help you achieve operational excellence. Thus, we know your investment will be worthwhile.

Plus, we think you will be happy with the investment you need to make when you see the results that you will get. What kind of results? That depends on the risk you have to mitigate and the way you apply what you learn, but CLICK HERE to see success stories submitted by TapRooT® Users.

Don’t think that the return on investment has to be a long term waiting game (although long term investments are sometimes worthwhile). Read this story of a FAST ROI example:

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s about a 40000% instant ROI.

How much value can you achieve from your investment in great root cause analysis? Consider these issues:

  • How much is human error costing your company?
  • If the EPA fines you $100,000 per day for an environmental permit violation, how much could it cost?
  • What is your reputation for product quality worth?
  • How much is just one day of downtime worth to your factory?
  • How much would a major accident cost?

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I’m not asking you to take my word for how much great root cause analysis training (TapRooT® Training) will help your company. I’m just asking you to give it a try to see how much it can help your company.

Just send one person to one of our 2-Day or 5-Day TapRooT® Courses. Then see how they can help solve problems using the TapRooT® Techniques. I know that you will be pleased and I’ll feel good about the lives you will save, the improvements in quality that you will make, and the improved bottom line that your company will achieve when you get more people trained.

See the list of upcoming public TapRooT® Training being held around the world:

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

 Or contact us for a quote for a course at your site:

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

Monday Accident and Lesson Learned: Aviation Safety Callback

Posted: August 21st, 2017 in Accidents

As a Tower Controller, your role is vital to ensure the pilots have the information and guidance they need when descending and landing their aircrafts. One Tower Controller was working alone on midday shift when an aircraft was coming in for landing while experiencing minor turbulence. The Tower Controller cleared him for landing and gave instruction, but also had to leave his station to record a PIREP for moderate turbulence on the AISR website. When he returned, the pilot had descended past the assigned altitude, which could have been avoided if the Tower Controller could do two things at once, submit the PIREP to the AISR website and the FSS at the same time.

The suggested corrective action is to allow the Tower Controllers to enter the PIREP to just the FSS allowing them to focus on the current operation.

What do you think?

(Resource: ASRS Callbacks)

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

Posted: August 18th, 2017 in Accidents, Current Events, Investigations, Performance Improvement, Pictures

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

Friday Joke

Posted: August 18th, 2017 in Jokes

Technically Speaking – Help Desk Humor

Posted: August 17th, 2017 in Software, Technical Support, Technically Speaking

Are you stuck trying to find the right questions to ask to determine the Root Cause or what lead up the incident? Let the TapRooT® method and software help you with these questions by using optional techniques. To learn about these optional techniques and the TapRooT® method check into attending a course near you by clicking HERE.

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!

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