Root Cause Analysis Blog

We celebrated the 20th Bitrthday of TapRooT® at the TapRooT® Summit in Las Vegas. It was a great time. Here’s some pictures that prove it:

First, there was the showgirls. (Who just happened to drop by - everyone wants to know the root cause!)

(with our staff)

(with Mark)

(and with Summit participants)

Next, there was Elvis…

And the 50’s/60’s/70’s Costume Judging…

And the Birthday Cake …

And the prize drawing…

And a good time for all…

Here are the pictures for attendees to download:

Bill Sirois, Senior Vice President and COO of Circadian Technologies, Inc. presented Fatigue Accident Causation Testing System (FACTS) at the 2008 TapRooT® Summit. To dowload a copy of the .pdf, click on the following link:

http://www.taproot.com/download/Circadian_-_Fatigue_Accident_Causation_Testing_System_(FACTS).pdf

Bill Sirois, Senior Vice President and COO of Circadian Technologies, Inc. presented Design Specs of the Human Machine: Minimizing Fatigue Related Human Error in a 24/7 World at the 2008 TapRooT® Summit. To dowload a copy of the .pdf, click on the following link:

http://www.taproot.com/download/Circadian_-_Design_Specs_of_the_Human_Machine.pdf

Bill Sirois, Senior Vice President and COO of Circadian Technologies, Inc. presented Design Specs of the Human Machine: Minimizing Fatigue-Related Human Error in Medical Environments at the 2008 TapRooT® Summit. To dowload a copy of the .pdf, click on the icon below:

Leilani Kicklighter of The Kicklighter Group presented How Improving Patient Safety and Reducing Risk Go Hand in Hand at the 2008 TapRooT® Summit. To download a .pdf copy of the presentation, click on the icon below:

Kay Gallogly, Founder of The 42 Group LLC, and Steve Swarthout, TapRooT® Instructor, presented Using TapRooT® to Evaluate Common Causes, Extent of Condition & Extent of Cause at the 2008 TapRooT® Summit. To download a copy of this presentation, click on the icon below:

Malcolm Gresham, TapRooT® Instructor and principal consultant at Practical Solutions Group in Australia presented Managing Risks Associated with Change at the TapRooT Summit. To download a .pdf of this presentation, click on the icon below:

Darby Allan of Woodland Grange in the UK presented Senior Executives - Gaining Involvement at the 2008 TapRooT® Summit. To download a .pdf of this presentation, click on the icon below:

Dave Thompson of RAMsoft Ltd in the UK presented Tools & Techniques for the Reliability Engineer at the 2008 TapRooT® Summit.  

Click on the icon below to open this presentation:

Brian Locker, TapRooT® Instructor and President of KnoW Problem Inc. presented the Investigation Lessons Learned from the Field at the 2008 TapRooT® Summit.

Click on the icon below to download a .pdf of the presentation:

Kevin McManus, TapRooT® Instructor and principal consultant for Great Systems! in Rainier, Oregon presented Culture Shift Secrets at the 2008 TapRooT® Summit.  Click the icon below to open this presentation:

Tommy Garnett and David Davis, TapRooT® Instructors and principal consultants for Patient Safety Solutions & Consulting Company presented The ABCs of Investigating a Healthcare Sentinel Event at the 2008 TapRooT® Summit. Click on the icon below for a .pdf copy of the presentation:  

Kevin McManus, TapRooT® instructor and principal consultant for Great Systems! in Ranier, Oregan presented Pursuing Process Excellence at the 2008 TapRooT® Summit.

Click the icon below to download a .pdf of this presentation:

Amsterdam police say 15 camels, two zebras and an undetermined number of llamas and potbellied swine briefly escaped from a traveling Dutch circus after a giraffe kicked a hole in their cage… read the rest in “Giraffe helps camels”.

Some people think that identifying “safety culture” is hard. I think it’s easy. Here’s a talk that I just gave about it.

Wow! What a talk.

I just left the talk by Lt Col Ralph Hayles who spoke at the TapRooT® Summit.

I can’t help but get mad when I hear that good people - heros in our military - died needlessly and then other good people get blamed to cover up the failings of the “system.”

The Army circled the wagons and blamed the individual to avoid pointing to generic problems that exist in our weapons systems and command structure.

I think everyone left this session with a better understanding of how useless blame is in achieving performance improvements and how blame can actually stop progress and kill good investigations.

I wish every senior executive could hear Lt Col Ralph Hayles story. The lessons learned go far beyond the military.

Mark, Ken, and Alex actually drove to the Summit in Vegas from Tennessee. Here they are at a stop in Arizona at the meteor crater …

Here are the revised teams…

(1) Brian Locker (leader of the 2007 winning team)
Clarence Natomagan
Brian Tink
Keith Recsky

(2) Richard Mesker
Patrick James
Robert Lamarche
Paul Dewar

(3) Dan Verlinde
Shane Deichman
Suzie Farley
Richard Little

(4) Ken Reed
Ronald Joseph
Steve Franker
Renee Jourdin

(5) Kevin McManus
Mikkel Broas
Johnny Collazo
Gerald Perrier

(6) Sanjay Gandhi
Tracy Moy
Brian Dolin
Phil Dortch

(7) Mark Olson
Dennis Bagnoche
Tony Orr
Ken Scott

(8) Edward Skompski
Steve Dobbs
Peter Berkholz
Darren Marvin

(9) Chris Vallee
Ronald Pryor
Richard Despres
Paul White

(10) Mark Paradies
Mike Rodriguez
Amber Butterfield
Mark Cade

(11) Linda Unger
John Buehrig
Ron Babineau
Anthony Daley

(12) Malcolm Gresham
Tom Brower
Larry McGuffee

From an audit done by a TapRooT® User…

The breaker box.

The labels…

Here we are in Vegas!

Michele’s Innovation and Creative Solutions Course:

Our two 2-Day Incident Investigation and Root Cause Analysis Courses:

Advanced Trending Techniques:

Special 2-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course:

FMEA & TapRooT® for Healthcare Root Cause Analysis:

Getting the Most from Your TapRooT® Software:

Risk Management Best Practices

Interviewing & Gathering Evidence:

Stopping Human Error:

Over 180 people are attending the pre-Summit Courses being held in Las Vegas today. They are learning advanced topics about root cause analysis, trending, hazard recognition, innovation, advanced root cause analysis software, investigation data collection, plus more.

I’ll try to post some picture of class attendees later.

Please note: Regular posts will resume after the 4th of July.

For those of you packing for the 2008 Summit in Las Vegas next week — here are a couple of hot tips:

A blackjack dealer and a player with a thirteen count in his hand were arguing about whether or not it was appropriate to tip the dealer.

The player said, “When I get bad cards, it’s not the dealers fault. Accordingly, when I get good cards, the dealer obviously had nothing to do with it so why should I tip him?”

The dealer said, “When you eat out do you tip the waiter?”

“Yes.”

“Well then, he serves you food, I’m serving you cards so you should tip me.”

“OK, but, the waiter gives me what I ask for…I’ll take an eight.”

* * * * *

Two friends, Smith and Jones, went together to play the slot machines at the casino. Each agreed that when his allotted money was gone, he would go to the front of the casino and sit on the bench to wait for his friend.

Jones quickly lost all of his money and went to sit on the bench. He waited and waited and waited and waited.

After what seemed an eternity, he saw Smith coming toward him carrying a huge sack of coins.

“Hey, Jones,” said Smith, “how’d you do?”

“Well, Smith”, said Jones, “you see me here on this bench- what do you think? It looks like you hit it big, though.”

“Oh yeah,” said Smith, “did I find a good machine! It’s way in the back. I’ll show it to you-you can’t lose! Every time you put a dollar in, four quarters come out!”

* * * *

See you in Vegas!

Sometimes you read articles about errors, root causes, and performance improvement and you are enlightened. Other times you wonder …

Why did they bother writing this?

Read the article at this link:

http://www.redorbit.com/news/health/1432251/errors_in_medicine_administration_how_can_they_be_minimised/

Then tell me what you think. Is this a step into new territory or the same old thinking that got us to where we are today?

Lots of people ask me about the “dress code” at the Summit.

Here is my advice.

1. Speakers generally wear a coat and tie (or the equivalent for women).

2. Attendees generally wear “smart casual” or “work casual” if your company has a casual dress policy.

3. Friday is generally “golf casual” (because of the tournament).

Remember, even though Vegas is HOT, conference rooms can be COLD.

So if you often feel a chill indoors in AC, bring a light coat or sweater. We won’t think that you are nuts (unless you wear it outside in the 100º heat).

And leave room in your suitcase to bring home some new cloths.

Vegas has great shopping (start at the Fashion Show Mall or the Forum Shops at Caesar’s Palace - both within walking distance of our hotel).

Want even more ideas about what people wear? Have a look at the pictures below … People at the Summit.

And don’t forget your 50’s/60’s attire for the Reception/Birthday Party on Wednesday night (with Elvis).

See you at the Summit!
Mark

See:

http://maintenancetalk.com/blog.php/viblog/reliability_engineer_maintenance_salt_lake_city_utah/

The TapRooT® Super-Computer has just spit out the preliminary pairings for the exciting, upcoming TapRooT® Summit Golf Tournament at the Concord Course of the Revere Golf Club in Las Vegas. The Preliminary Pairings (subject to change with additional registrations) are:

(1) Brian Locker (leader of last year’s winning team)
Clarence Natomagan
Brian Tink
Keith Recsky

(2) Ken Turnbull (leader of the previous year’s winning team)
Patrick James
Robert Lamarche
Paul Dewar

(3) Dan Verlinde
Shane Deichman
Suzie Farley
Richard Little

(4) Ken Reed
Ronald Joseph
Steve Franker
Renee Jourdin

(5) Kevin McManus
Mikkel Broas
Richard Mesker
Johnny Collazo

(6) Sanjay Gandhi
Tracy Moy
Brian Dolin
Phil Dortch

(7) Mark Olson
Dennis Bagnoche
Tony Orr
(need one more here)

(8) Edward Skompski
Steve Dobbs
Peter Berkholz
Darren Marvin

(9) Chris Vallee
Ronald Pryor
Richard Despres
Paul White

(10) Mark Paradies
Nancy Hitchins (just riding - broken foot! - scorekeeper)
Mike Rodriguez
Amber Butterfield
Mark Cade

(11) Linda Unger
Ron Babineau
John Buehrig
Anthony Daley

This is a charity golf tournament. Here are the charity rules:

Each team member can buy 4 charity items for their own use in the tournament. Items costs $10 each. The items are:

Mulligan: Re-do on any tee-off (except the longest drive and closest-to-the-hole competitions).

Bronze Tee-off: Instead of using the regular tee (black for men and silver for women), golfers can use the bronze tee for one hole (not to be used for closest to the hole or longest drive competitions).

Toss: You can advance your ball from where it stops by tossing it as far as you can to “continue” the shot (not to be used for closest to the hole or longest drive competitions).

Save-a-stroke: You can take one stroke off your team’s score.

All of these items can only be used by the individual player that purchased them and can’t be traded or given to other team members.

Money raised will be donated to Oasis of Love Women’s Shelter in Clinton, TN. This not-for-profit, 501-c qualified shelter has been run by Linda Unger’s mother, Janice Wilson, for the past decade. It houses about a dozen women and their children who are seeking a safe transition from an abusive situation to build a new life.

(Picture of Janice Wilson receiving a car for the shelter - donated by System Improvements)

Donations can be made in cash or check (made out to Oasis of Love). Donations will be collected at the clubhouse by Benna (who is coordinating the tournament). Donations in addition to the four items above are welcome. All donations by golfers will be matched by System Improvements. We’ll post the final donation total on the TapRooT® Blog with the results of the tournament.

Here are some additional important notes that all players should read:

1. Bus transportation to and from the course is provided by System Improvements. We will meet in the hotel lobby at 12:15 and depart at 12:30.

2. Lunch, greens fees, a bucket of balls for the driving range, a hat, and a sleeve of balls are included in your tournament fee.

3. Club dress code requires a shirt with a collar. Shorts are permitted.

4. Rental clubs are available by reservation. You can still rent clubs by e-mailing Benna. Rental fees ($65) are payable when you pick up your clubs. Rentals requested for:

Dennis Bagnoche

Peter Berkholz

Mikkel Broas

Anthony Daley

Shane Deichman

Paul Dewar

Sanjay Gandhi

Renee Jourdin

Robert Lamarche

Kevin McManus

Richard Mesker

Tony Orr

Ronald Pryor

Brian Tink

Paul White

RENTERS — I NEED TO KNOW IF YOU NEED LEFT HANDED CLUBS. Otherwise, right handed clubs will be ordered. Let Benna know at: contact us.

5. The shotgun start is at 2:00. Your Team Number is your starting tee selection (subject to change). Final team notifications will be made at the Summit and final starting tee selections will be announced at lunch at the golf club.

TEAM SCRAMBLE RULES:

This will be a scramble format.

In a scramble all participants tee off and then the team selects the best ball. All participants then hit from that point. This continues until someone sinks a putt. The score is the number of best ball strokes. For example if you all teed off, then everyone chipped (and someone hit the green), and then someone sunk their first putt, the score would be a 3 for that hole.

The Team Captain (in bold above) will be responsible for keeping the score and for selecting the best ball if a team can’t agree on whose ball is best.

There will also be awards for:

1) a closest to the hole and

2) the longest drive.

Men will use the tournament Men’s tees (Black) and Women will use the Silver tees.

I would suggest that teams plot their strategy at the Summit reception on Wednesday night.

ONE MORE WEATHER NOTE:

Some have complained that Vegas is too hot for golf in June. Not to worry. I have already made a request for unusually cool weather on Friday of the tournament. That is why there is unusually hot weather this week - to get it over with! So I expect it to be hot (80s-90s) but less that the 105º they are expecting today. And remember - Vegas is dry heat (imagine your oven). I would recommend sun screen even if we have overcast skies (think of it as basting).

Looking forward to seeing you at the Summit!

From an OPG Safety Alert …

SAFETY ALERT NO. 192: FEW SECOND LAPSE WHILE DRIVING CAN KILL!
Type of Activity: Transport - Land
Type of Injury: Crash injuries

A 3rd party light vehicle interposed between a convoy of four company vehicles travelling towards the oilfields. Subsequently one of the company vehicles swerved onto the oncoming lane into the path of a 3rd party heavy vehicle. This resulted in a head-on collision. The company driver was thrown from the car onto the hardshoulder. He was taken to the nearby hospital, where he died shortly after arrival. The company driver had been on duty for approx. 12 hours at the time of the accident. The investigation team concluded that driver fatigue is one of the main causes of the accident.

What Went Wrong?:

We sometimes seem to think that driving a car is a simple thing to do. Yet, worldwide every year some 1,200,000 people die in road safety accidents. It is estimated that approximately 15 - 20% of road transport accidents are fatigue-related. Why is it that we get such a “simple” thing so seriously wrong so many times? Maybe driving is not such a “simple” thing after all. This accident shows that a few seconds’ lapse in attention while you are driving can kill you. Safe driving is hard work and requires a well-rested driver.

Corrective actions and Recommendations:

Drivers:

1.Refuse to drive when you feel not fully rested;
2.Advise management of any disability or condition that could prevent you from driving safely;
3.Pull over at a safe location when you feel sleepy - a 15 minute nap often helps;
4.Ask your supervisor to check that your driving and duty time are within the company requirements if you can not meet any of the following:

Do not drive more than 10 hours per day;

Do not drive for more 7 days in a row;

Take a 15 minute rest break every 2 hours.

Supervisors:

1. Always check whether the driver is fit to drive;
2. Inform drivers they have the right to refuse to drive when they feel not fully rested or alert;
3. Encourage drivers to pull over at a safe location for a 15 minute nap when they feel sleepy;
4. Ensure you know and apply the driving and duty time requirements in the mandatory company EP standard.

Journey Manager:

1. Assure the journey is within required time limits;
2. Have available a back-up plan in case of delays.

They all had attendees in our recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course taught in Aberdeen. Look up our updated course schedule to see the next course in Aberdeen or an area close to you. Here are just a few photos of the 17 attendees in session.

Sanjay Gandhi (our instructor from Kenya) sent this picture of another class ready to find and fix the root causes of problems.

the guy in the pink thinks the other guys are dressed too fussy.

See:

http://www.chron.com/disp/story.mpl/front/5830870.html

See:

http://www.thinkenergygroup.com/think.nsf/J/67739?OpenDocument&frm=G01