Pre-Summit Courses June 23-24 (Cost: $1,095 without Summit or $1,895 for Course and Summit)
2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
In just two days you will learn the basics of the TapRooT® System for finding the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and other types of problems. Once you find the real root causes using this systematic process, learn to develop effective fixes that will keep problems from happening again. Check your corrective action effectiveness using the SMARTER technique.
Learn to find and fix problems proactively BEFORE an accident or incident occurs and to analyze the Safeguards that keep problems from happening or from getting worse once a single Safeguard fails.
Also, learn what to include in effective presentations to management when presenting the results of a root cause analysis.
Course participants receive the TapRooT® Book, the pocket sized Root Cause Tree® Dictionary, a laminated Root Cause Tree®, and a course workbook. In addition they will get a 45 day free trial of the TapRooT® Software.
Day 1 (8:00 am - 5:00 pm)
Intro & Opening Exercise
TapRooT® Investigation Process
SnapCharT® - "What Happened?"
Exercise: Draw a SnapCharT®
Using the Root Cause Tree®
Tips for Using TapRooT®
Find Root & Generic Causes
Developing Effective Fixes
SMARTER & Corrective Action Helper®
Exercise: Find Root Causes & Develop Corrective Actions
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Day 2 (8:00 am - 4:00 pm)
Using TapRooT® Proactively in Audits
Exercise: Proactive Root Cause Analysis
Analyzing Safeguards
Exercise: Safeguard Analysis
Strategies & Presenting to Management
Investigation Team Exercise
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Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis
Why should you attend a 2-Day Equifactor® Course?
To learn to fix the real root causes of equipment failures!
This is the shortened version of the Equifactor® Course made to fit in the two days before the TapRooT® Summit.
In just two days learn the basics of the TapRooT® System for finding the root causes PLUS the Equifactor® Equipment Troubleshooting Technique for Root Cause Failure Analysis of Equipment Problems. Once you find the real root causes using this systematic process, learn to develop effective fixes that will keep problems from happening again. Check your corrective action effectiveness using the SMARTER technique.
Also, learn to find and fix equipment problems proactively BEFORE an accident or incident occurs and to analyze the Safeguards that keep problems from happening or from getting worse once a single Safeguard fails.
Learn what to include in effective presentations to management when presenting the results of a root cause analysis.
Course participants receive the book, Machinery Failure Analysis and Troubleshooting, the TapRooT® Book, the pocket sized Root Cause Tree® Dictionary, and a laminated Root Cause Tree®. Attendees can purchase an individual user version of the TapRooT® Software which includes a computerized version of Heinz Bloch's Equipment and Component Troubleshooting Tables for just $795. That is a $700 savings off the software list price of $1495.
Day 1 (8:00 am - 5:00 pm)
Intro & Opening
Exercise TapRooT® Investigation Process
SnapCharT® - "What Happened?"
Exercise: Draw a SnapCharT®
Using the Root Cause Tree® to Find Root & Generic Causes
Developing Effective Fixes
SMARTER & Corrective Action Helper®
Exercise: Find Root Causes &
Develop Corrective Actions
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Day 2 (8:00 am - 4:00 pm)
TapRooT® + Equifactor® Process
Drawing SnapCharT®s for Equipment Problems
Equifactor® Troubleshooting Equipment/Components/Electrical
Exercise: Component Checklist
Investigation Team Exercise
Exercise: Equipment Checklist
FRETT
Equifactor® Exercise: FRETT
Failure Agent
Change Analysis & Exercise
Root Cause Analysis Exercise: Equipment Failure
Team Exercise (attendee example)
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Advanced Trending Techniques
Do you really understand trending? Learn why most people misuse trends and special techniques to trend infrequently occurring accidents, incidents, and human errors. Mark Paradies, (President of SI and co-designer of the TapRooT® System) developed this course after seeing so many inappropriate examples of trending used to make major corporate and regulatory decisions. Kevin and Mark will teach you the simple yet powerful techniques to spot real trends and recognize everyday variation. You will also get a complimentary fully working edition of an advanced trending template to use with Microsoft Excel to produce the specialized trending graphs taught in the course.
Day 1
Why trend?
Trending Basics
Pareto Charts for Spotting Areas Begging
for Improvement
Advanced Pareto Charting
Trending Over Time (Basics)
Exercise
Simple Math for Trending Over Time
Exercise
Process Behavior Charts
Exercise
Advanced Process Behavior Charts (infrequent data)
Exercise
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Day 2
Game - Trending Jeopardy
Exercise - Putting Trends to Work to Spot and Solve Problems
Getting Good Data - Including Uses of Lagging & Leading Indicators
Exercise
Using Your Data to Spot Problems and Improve Performance
Exercise
Planning to Improve Your Use of Data to Improve Performance
Exercise
Developing a Management Presentation for Your Return to Work
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Engineering Equipment Reliability Techniques
A common problem in industry is poor data collection with little value gained from plant history. Reliability techniques provide metrics and and in some cases solutions while in most studies we need RCFA to provide the answers to improve performance. In this workshop Dave Thompson, a Reliability and Maintenance Engineer with over 40 years of experience, will show how to collect better data and use systematic techniques to analyze and make informed decisions. The course is focused on practical applications rather than complicated formulas. The first day focuses on how to more effectively analyze CMMS and process data. On day two, attendees will learn how to analyze plant systems and equipment performance using RAM models.
This workshop will require the use of a laptop. Please ensure you have MS Excel and the rights to install demo software. PowerPoint slides, handouts, exercises provided.
Day 1
How to make more effectively use of CMMS & Process data.
Different data handling methods and analysis techniques
Introduction to failure patterns including Weibull parameters
Estimating failure rates based on expert judgement
Selecting task frequencies based on risk and costs of maintenance
How to analyse data from CMMS history and to evaluate if PM is effective
How to analyse data from process data - i.e. event data
Analysis of data sets with single and multi failure modes
Analysis of condition (degradation) data
How to conduct Maintainability studies
Case Studies
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Day 2
How to analyse Plant, Systems and Equipment Performance using RAM Modelling Techniques.
Analysis of systems using Reliability Block Diagrams
Analyse complex systems using linked RBDs
Algebraic and simulation techniques explained
Model simple and complex systems including duty and standby systems,
Evaluate different policies, RTF, FTM, OCM
Optimising replacements
Learn how to evaluate different design options, conduct what-ifs
How to obtain life cycle costing data
Various availability calculations
Analyse high value spares policies
Identify critical items in the system
Case studies
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Interviewing and Evidence Collection
When you investigate an incident, you need solid, verified, validated factual information. Without it, finding root causes & developing effective fixes is impossible. Isn't it time you learned how to collect & document evidence in a systematic, objective way? Dana Barclay uses his years of investigation experience to teach how to professionally, yet rapidly, gather and document evidence to solve prob-lems. Attendees get an Evidence Gathering and Documentation Workbook and an Incident Investigation Sequence/Flow book with laminate flow chart and checklist.
Day 1
Intro
The "Four Elements" Basics
What to Look For/Exercise
The "People" Element (Witness Interviews)
The Multi-Step Progression & "How Memory Works"
LUNCH
Interviewing Exercise
Documentation/Records
What to look for & Where to find it
Exercise Incident Update
End of Class Summary
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Day 2
Physical Evidence and its Documentation
Incident Scene/Site Diagrams
Photographic/Video Documentation
Photography Exercise
LUNCH
Incident Scene/Site Hazards
Site Hazards Exercise
Incident Investigation Kit
Course Exercise Completion
Exercise Review Evaluation
End of Course Summary
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Stopping Human Error
Why should you attend this course?
Because human errors are the most likely cause of accidents, incidents, and loss causing events at your facility. You need to stop them!
Learn why people make mistakes and what you can do to stop them. Dr. Joel Haight, TapRooT® Instructor and professor at Penn State, will teach you advanced techniques to analyze and stop human errors.
Even though Dr. Haight is a PhD, this is not an academic style course. Dr. Haight has 19 years of experience in the oil and petrochemical industry including over-seas operations. He brings a wealth of practical, industrial perspective to the latest in human factors research.
Day Outline(s)
1. Class Introduction - And - what was your biggest blunder?
2. Opening Exercise
2.1. Random vs. Systematic Error Exercise
2.2. Speed-Accuracy Trade Off Exercise
2.3. The "F" Sentence and Tongue Twisters
2.4. Peter Piper
2.5. Discussion of errors in our daily life
3. What is Human Error?
4. What Does Human Error Do?
4.1. Why do humans err?
4.2. Consequences?
4.3. What does 99.9% success mean?
5. Causes of Human Error
5.1. Influences
5.2. Human-Error Causation Model
5.3. Performance Shaping Factors
5.4. System Caused Errors
5.4.1. Management Causes
5.4.2. Culture Causes - Culture Exercise
5.4.3. Design Causes
5.4.4. Automation System Causes?
5.4.5. Reducing System Causes
5.5. Overload
5.5.1. Causes and Outcomes of Overload
5.5.2. Capacity
5.5.3. Load
5.5.4. State - Stress/Overload Exercise
5.5.5. Aging
5.5.6. Reducing Overload-Caused Errors
5.6. Decision to Err
5.6.1. Logical Decision to Err
5.6.2. Proneness
5.6.3. Perception of Risk
5.6.4. Reducing Decisions to Err
6. Concepts of Uncertainty
6.1. Poisson Distributions
6.2. Binomial Distributions
7. Prediction of Human Error - Quantify its Potential
7.1. Error Likely Situations
7.2. Human Reliability Analysis
7.2.1. THERP (Technique for Human Error Rate Prediction - Exercise )
7.2.2. MAPPS (Maintenance Personnel Performance Simulation - Furnace Tube Replacement Exercise)
7.2.3. OAT (Operator-Action Tree Method)
7.2.4. Fault Tree Analysis (Human Error Application Exercise)
8. Stopping Human Error
8.1. Human Error Reduction Concepts
8.2. Work Situation Approach
8.3. Human Factors Engineering
8.4. "Change the Worker"
8.5. "Change the System"
8.6. Reduce System Impact
9. Class Exercise - Real Life Case Study - THERP or Fault Tree Analysis |
Innovation and Creative Solutions
This interactive and practical workshop will provide participants with a process and tools to uncover innovative and creative solutions and discover opportunities that will lead to breakthrough thinking. Follow this process for increasing creativity in process improvement, strategic thinking, or product design. Included in this workshop is Dr. Edward de Bono's Six Thinking Hats™.
Day 1 and 2 Course Outlines
•Identify and remove roadblocks to Creativity & Innovation
•We are not all born creative - understanding how to get there
•Describe and practice the Innovation process, which includes:
•Focus - Define the problem or opportunity and bring it into focus
•Uncover Alternatives - New ways to solve old problems, open the creativity tool box to help build
solutions and NEW ideas.
•Narrow your choices - Effectively and efficiently make decisions in teams that break down walls
and create team collaboration including the using the globally renowned Six Thinking Hats™
method.
•Create alignment in decision making
•Apply the process and tools to a current business problem or opportunity
•Lay the groundwork for successful implementation
•Build a climate of innovation |
Risk Management Best Practices
Australian risk management expert and TapRooT® Instructor Jim Whiting (leader of the committee that wrote AS / NZS 4360:1999, the de facto international risk management standard) will teach attendees how to combine risk management best practices with root cause analysis to provide a single streamlined root cause / risk management process. Jim brings his risk management and root cause analysis experience and best practices from around the world (Australia/New Zealand, North America, Asia, Africa, and Europe) to this course. If you are interested in improving the efficiency of your improvement efforts by getting the most out of your use of risk management and root cause analysis techniques, then attend this course. This will be the only time this year that this course will be offered in the US.
Day 1
- Introduction
- Overview of Risk Management
- Purposes, Approaches and Methods
- Strengths and Limitations
- Positivity of RM compared to Loss Control
- RM a new safety culture
- US and International Standards incl. AS/NZS 4360 Risk Management
- Risk Communication
- Risk Identification incl. construction and use of Risk Maps ( compared to SnapCharts®)
- Exercise in Risk Mapping
LUNCH
- Risk Analysis - 3 levels of Risk Analysis
- Qualitative
- Semi-Quantitative
- Full Quantitative Risk Analysis (QRA)
- Quantitative Logic Trees
- Calculating Risk Semi-Quantitatively with R3 -- the Risk Rating and Ranking Tool
- Exercises in Risk Analysis
- Summary of Class Topics
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Day 2
- Revision of Previous Topics
- Risk Evaluation - risk tolerability criteria and frameworks at all levels
- personal
- social
- corporate / industry
- national / international
- Demonstrating ALARP - As Low As Reasonably Practicable
- Risk Treatment - contrast to Corrective Actions and Risk Controls
- Hierarchy of Risk Controls - principles and applications
- Risk Tolerability Treatment Options RTTO - principles and methods of choice
- Exercises in Risk Evaluation and Treatment
LUNCH
- Exercises with Attendees' own examples
- Successes and Traps in Setting up RM systems and processes
- Summary of the Whole Course |
Hazard Recognition Best Practices
This course focuses on the tried and true methods of hazard recognition including at risk or safe behavior, legislation implications, and hazard identification and rectification. The instructor, Peter Burkholz, is a TapRooT® Instructor with over 25 years of mining and industrial experience. The course includes a site visit to an industrial site for practical application of the theories learned.
Getting the Most From Your TapRooT® Software
To get the most from your TapRooT® Workgroup or Enterprise Software you need an administrator who understands all the built in features. They need to know how to:
• Install the software for best performance.
• Set-up custom fields and lists.
• Backup data and recover "lost" data.
• Link the software to other databases.
• Answer users' common questions.
• Explain the basics of using the software.
• Develop custom reports.
Ed Skompski, TapRooT® Instructor, Partner at System Improvements, and Software Development Project Manager, will lead this course and get your Software Administrators ready to get the most out of your software.
TapRooT® and FEMA for Your Healthcare Root Cause Analysis
TapRooT® instructors Tommy Garnett and David Davis have extensive careers in the healthcare industry. TapRooT® Users will learn to use tools to perform JCAHO required healthcare FMEA as part of proactive risk reduction/performance improvement program. Learn team-based,systematic, proactive approaches to identify how a process or design can fail, why it fails, and how to make it safer. These techniques can be applied to find and fix the root causes of issues to improve patient safety & stop healthcare sentinel events before they happen.
