Mark Teaching:

Linda teaching:

And class participants working on exercises – including the cognitive interviewing exercise:

I’ll be starting off with Equifactor® equipment troubleshooting tomorrow.

The crossing, which carries a public footpath and bridleway over a two-track railway, is close to housing and an industrial estate. It is also on the route of the Timberland Trail, a multi-user recreational pathway and cycle route.

Kings Mill crossing is equipped with gates which are intended to be self-closing, and telephones (for use by people in charge of animals) which provide communication with the railway control centre at Derby. Instructions relating to the crossing are displayed on signs on both sides of the railway.

The RAIB’s investigation will identify the sequence of events, including the actions of the cyclist, that led to the accident. It will also examine the condition of Kings Mill crossing and its history, design, operation and management.

The RAIB’s investigation is independent of any investigations by the British Transport Police and the safety authority (the Office of Rail Regulation).

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation. This report will be available on the RAIB website. 

Setting the stage

As the manager of occupational safety for Arkema, Inc., a global chemical company, protecting the safety, health and welfare of our employees is paramount to everything I do.  Our Americas-based operations include 34 facilities across the United States, Canada and Mexico with approximately 2,400 employees working in three main business groups: Vinyl Products, Industrial Chemicals and Performance Products. I know that accidents happen, but I always try and learn from them and absolutely aim to create an environment that prevents them from occurring in the first place.  With complex and diverse production and manufacturing facilities as well as thousands of employees, safety awareness and prevention is at the core of our corporate culture.   That’s where TapRooT® fits in.

TapRooT® delivers comprehensive investigative process

I’m a checklist-type of person who likes structure and having a roadmap to assist me in investigations.  Having the right people as part of an analysis is critical, but knowing how to communicate, query and build a solid knowledge base among the right people is even more important to getting to the root cause of any incident.  TapRooT® helps us to arrive at a point to show true, unbiased facts that lead to corrective actions.  By using TapRooT® and implementing advanced company-wide safety programs, we are able to deliver a safer working environment at all of our facilities; I am very proud of that.

Using TapRooT® to find root causes

We started using TapRooT® more than 15 years ago.  We learned early on that it offered good methodology and had a solid structure for our incident investigations that ultimately helped us arrive at the root causes of incidents.  Once we started implementing TapRooT® in our discovery phases, our levels of investigations deepened and we could complete investigations and determine the root causes with reliable corrective actions.  Prior to that, the company didn’t have a standard method of analyzing incidents for root causes, and our corrective actions didn’t consistently address the root causes of the incidents when they were identified.  TapRooT® helped address our needs and enabled us to be more thorough and consistent in our high risk investigations.

TapRooT® in action

To give you an idea how this comes to life for us via TapRooT®, here’s an example: one of our employees was seriously injured at one of our production facilities. Instead of immediately penalizing the employee for not following certain procedures, using TapRooT®, we implemented a very thorough and unbiased investigation to look at the incident with a 360-degree view to see if there were other factors to consider. TapRooT® enabled us to identify equipment difficulties, management system issues, human engineering issues, supervision issues and employee procedural issues, all of which played a part in the incident.  From this information, we were able to establish and implement corrective actions that we use to this day across our company.  TapRooT® led us to more comprehensive investigation results, which ultimately made us better as a company.

What TapRooT® has meant to our business

* Better safety conditions, low OSHA recordable injury rate ratings

* Commitment to our company’s Responsible Care^® program

* Company-wide corporate standards for investigations

* Unbiased, fact-based comprehensive investigations

From the information gleaned from our TapRooT® investigations — preventative measures and corrective actions — our incidents rates has declined dramatically over the years; and we proudly continue to earn top OSHA ratings for workplace safety.  In addition, we are able to more thoroughly uphold management’s and the company’s commitment to the Responsible Care^® initiative.

TapRooT® delivered many different methodologies into one compact, concise problem-solving system that we could eventually implement company-wide in the United States.  The consistency and effectiveness of our investigations improved across all facilities.  Today our U.S. sites have TapRooT®-trained personnel onsite to lead investigations of major incidents and major near misses. That is our corporate standard.

The magazine reports:  “… in this what-have-you-done-for-me-yesterday world, business managers often press their Six Sigma teams for rapid results.  So the book’s chapters reinforce your previous green belt learning to guide you through completing good projects in a 90-day time frame.”

Six Sigma Green Belt, Round 2 is available at ASQ Quality Press.

Previous weeks: 1 2 3 4

Next week, we’ll see Akiva Northern of Global ALL Well with a truly innovative application of the TapRooT® process.

Learning how to perform an Audit... it is not just about compliance!

Covering Step 2 of the 7-Step TapRooT® Process

Often when teaching Onsite TapRooT® Root Cause Analysis Courses, we get to teach two different companies in back to back courses. Doing this actually saves our clients on instructor airplane travel costs. Last week in Trinidad, I had the opportunity to work with IPSL (pictured above) and Tucker Energy (pictured below).

Learning about the SnapCharT®

Working on the Root Cause Analysis

Working on final excercise

Working on Root Cause Analysis

Just some of the Testimonials after the final exercise:

“Very engaging, eye opening! Be neutral!”   (bias kills an investigation every time the students learn)

“Today’s session was detailed and gave a clear idea on how to investigate an incident totally and fair.”

“The course highlighted that we used the wrong approach for incident investigations in the past.”  (They found conflicting evidence that had not been verified yet)

“Very good hands on approach; assistance from the facilitators (instructors) was very helpful throughout the course.”