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.
Laptop Information
In order to get the most out of the course and learn the software, bring a laptop and a mouse to practice (required) with the examples given in class.
Click here for more information on this course.
Contenido del curso de TapRooT(R) de 2 días para la Cumbre.
(Spanish) 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course
Este es un curso especial que se enfoca particularmente a la adquisición de evidencia. Es el curso normal de TapRooT®,pero se hace hincapié en cómo recopilar y organizar la evidencia, sin entrar en todos los detalles de los diferentes mecanismos para obtener evidencia.
Día 1:
Primer tema: Preparación (SnapCharT® de Primavera. Qué se requiere tener para prepararse para hacer una investigación de un incidente.)
- Ejercicio de realización de una SnapCharT®, basándose en un incendio de una planta en Latinoamérica. (Qué preguntar y a quién preguntar.)
- Qué es un Factor Causal y cómo definirlo. Cómo se hace en la práctica.
- Manejo del método TapRooT®. (Árbol de Causa Raíz, Diccionario y Apoyo para Acciones Correctivas.)
- Ejercicio de manejo del método (con Software y sin Software), hasta encontrar Causa Raíz.
- Ejercicio de uso del método hasta encontrar causas raíz.
- Causas Genéricas. Cómo encontrarlas y qué hacer con ellas.
- Acciones Correctivas (SMARTER).
- Ejercicio de Acciones Correctivas, para causas específicas y genéricas.
Día 2:
- Examen,incluyendo presentación a la Administración.
- Uso de TapRooT® Proactivo.
- Barreras y Ejercicios.
- Presentando a la Administración. Repaso.
- Uso de TapRooT®. Cómo trabajar en equipo.
- Ejercicio final (análisis de un incidente propio).
- SnapCharT® de trabajo
- Definir Factores Causales
- Definir Causa Raíz - específicas y genéricas
- Desarrollo de acciones correctivas
- Presentación y retroalimentación
Registro
Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course
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 $1100 savings off the software list price of $1895.
Laptop Information
In order to get the most out of the course and learn the software, bring a laptop and a mouse to practice (required) with the examples given in class.
TapRooT® Software
Registration for this course will allow you to access our downloadable TapRooT® Software. This is a time-limited trial version and will expire 45 days after installation.
Minimum Software Requirements: MOUSE REQUIRED
• 500 MHz Pentium processor or better
• Microsoft® Windows® 2000 with 128 MB of RAM
• Microsoft® Windows® XP with Service Pack 1 and 192 MB of RAM
• 350 MB of available hard disk space
• CD-ROM drive is required for software installation
• Monitor with XGA (1024 x 768) resolution or better
Please note that Windows 3.1 and 95 are not compatible. Windows 98, ME, and NT 4 SP 6 are not currently supported.
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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)
Equifactor® Process
• Troubleshooting Tables
• Custom Tables
• Evidence Gathering
• Failure Modes
• Failure Agents
SnapCharT® Class Exercise
Equipment Change Analysis
Problem within a Problem Class Exercise
Final Team Exercise
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Advanced TapRooT® Techniques
Prerequisite: Participants for this course must have previously attended a 2, 3 or 5 day TapRooT® course.
This course is for TapRooT® users who want to learn the most recent advances (2008) in applying TapRooT®.
The course presents the latest information from the new TapRooT® Book (2008), and shares best practices from the seven step process. The course will emphasize the development of causal factors that accurately define the problems that cause incidents. Participants will participate in several case studies with real-world examples of major accidents to practice the techniques they learn.
This course is also a great refresher for those who have learned TapRooT® but don’t get a chance to use it frequently.
Course participants receive the NEW TapRooT® Book (2008), the pocket sized Root Cause Tree® Dictionary (2007), a laminated Root Cause Tree® (2007), NEW Corrective Action Helper® (2008), and a course workbook.
NOTE: Participants should bring one of their completed investigations for an analysis exercise and a laptop with TapRooT® installed. We will make a 45 day trial version available for those attendees who do not have software.
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Day 1 (8:00 am - 5:00 pm)
What’s New in the 2008 Book
SnapCharT® Best Practices
The 4 Step Method for defining Causal Factors
Defining Causal Factors using Safeguards
Safeguards Exercise
Causal Factors – Advanced techniques for defining Causal Factors
Causal Factor Exercise – BP Texas City
Causal Factor Exercise – Chemo Overdose
Causal Factor Exercise – Electrocution
Causal Factor Exercise – Atlanta Bus Accident
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Day 2 (8:00 am - 5:00 pm)
Using the Root Cause Tree® - Best practices
Generic Causes
Corrective Actions - SMARTER & Corrective Action Helper®
Corrective Actions – Implementation, Verification, and Validation
Working with Contractors
Enforcement
Analysis of Causal Factors Exercise (with your incident)
Causal Factor Exercise – Fatal Fall
Causal Factor Exercise – Pipeline explosion
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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 McManus 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.
Laptop Information
In order to get the most out of the course and learn the software, bring a laptop and a mouse to practice (required) with the examples given in class.
TapRooT® Software
Registration for this course will allow you to access our downloadable TapRooT® Software. This is a time-limited trial version and will expire 45 days after installation.
Minimum Software Requirements: MOUSE REQUIRED
• 500 MHz Pentium processor or better
• Microsoft® Windows® 2000 with 128 MB of RAM
• Microsoft® Windows® XP with Service Pack 1 and 192 MB of RAM
• 350 MB of available hard disk space
• CD-ROM drive is required for software installation
• Monitor with XGA (1024 x 768) resolution or better
Please note that Windows 3.1 and 95 are not compatible. Windows 98, ME, and NT 4 SP 6 are not currently supported.
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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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Interviewing & 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.
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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
This course has been completely revolutionized for 2009 but the reasons to attend it are still the same…
Human error is the biggest cause of accidents, incidents, hospital sentinel events, equipment failures, operational errors, quality problems, and accidental environmental releases. So, if you are trying to stop these problems, you need to learn the latest best practices to stop human error and turbo-charge performance at your facility.
The main focus of the course is on practical solutions to the most common industrial and service industry causes of human error. We know about these problems because we see them in TapRooT® Classes around the world. Problems we address in this course include:
• Failure to follow procedures
• Miscommunications
• Poor training
• Poor work preparation
• Errors when following a procedure
• Bad displays, controls, and tools
• Employees who won’t follow the rules
But that’s not all. This hands-on course is based on the latest human factors best practices and presents applicable human factors expert theory. Therefore, you get practical application with the theory you need to understand it.
The course also shows you how to combine the sensing-cognitive-response model with the TapRooT® CHAP (Critical Human Action Profile) technique for collecting information to analyze a human error.
Also, the course teaches ways to use the Root Cause Tree® as a checklist to evaluate new processes/facilities proactively to prevent human errors before an accident happens. (Why wait for an accident to start human performance improvement?)
Before this high-powered course is finished, you will develop a custom plan to apply what you have learned to improve human performance (Stop Human Error or reduce risk) at your facility.
In addition, the course includes techniques to measure human performance and human error. With these techniques you can prove the return-on-investment of your efforts and show your management that the human performance improvement program is effective.
Here’s a course outline…
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Stopping Human Error - Day One
1. The Theory of Human Error
- “Swiss Cheese” Model
- Nuclear Industry Model
- THERP (Technique for Human Error Rate Prediction)
- The TapRooT® Model
2. Analyzing Human Performance with Critical Human Action Performance (CHAP) and the sensing-cognitive-response model
- What is CHAP and how can we use a model with CHAP?
- Seeing through the Eyes of the Worker
- Reactive and Proactive CHAP Exercises
3. Using TapRooT® to Analyze Human Error
- Reactive verses Proactive System Analysis
- Proactive Exercise: Using the Root Cause Tree® as an evaluation checklist
4. Human Factors Solutions to STOP Human Error Producing Problems
- Why Won’t People Follow the Rules?
- Why Didn’t People Learn in Our Training?
Stopping Human Error - Day Two
4. Human Factors Solutions to STOP Human Error Producing Problems (continued)
- Why Can’t People Follow Our Procedures?
- Why Didn’t They Hear What Was Said?
- Why Did They Make Simple Errors or Misunderstand Their Displays/Controls?
- Why Do Supervisors Fail To Prevent Problems?
5. Measuring Human Performance Risks and Improvements
- Establishing Your Riskiest Human Performance Areas and Tasks
- Saving Time by Analyzing and Auditing the Right Areas First
- Proving that You Made A Difference
6. When Do You Need a Human Performance Expert?
- When Application of a Stopping Human Error Course is not Enough
- Picking an Expert
7. Develop a Custom Improvement Plan (HELP)
- Share Your Plan with the Class
- Schedule a Free Follow Up with Your Stopping Human Error Instructor
8. Putting it All Together: A Final Human Performance Improvement Exercise
- An Advanced Example to Test Your New Skills
The course includes links to several free on-line human factors references, a course workbook, a free 45 day trial of the TapRooT® Software, and the newest (2008) TapRooT® Book, Corrective Action Helper® Book, Root Cause Tree®, and Root Cause Tree® Dictionary.
Although we assume that most attendees will have already attended a TapRooT® Root Cause Analysis Course, prior TapRooT® Course attendance is not required to take this course.
Please bring a laptop with Microsoft Office installed for use in exercises.
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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 has updated the content of this course for 2009 so it will be consistent with the new international ISO 31000 and IEC 31010 Risk Management Standards. 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.
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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
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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 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® Version 5 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.
Dan Verlinde, Software Project Manager and Ed Skompski, Vice President & Partner at System Improvements, will lead this course and get your Software Administrators ready to get the most out of your software.
