Today’s video comes from none other than the TapRooT 2007 Summit. This video highlights a few of the lighter moments in the proceedings, and rest assured we here at System Improvements know how to have fun…
Hello. My name is Raycraft, Steve Raycraft, and I’m the new man behind the wildly successful Tech Support Thursday here at System Improvements. I am a recent addition to the SI family and have been asked to assist in creating the Tech Support blog entries.
As I learn the Taproot software and become more familiar with it, I will continue the tradition of posting insightful articles to help you maximize the potential of the software. Having a interest in IT Security, I may from time to time also post some general IT security practices that if used, will help minimize the amount of viruses or spyware that get on your machine.
Again, my name is Steve and I look forward to this opportunity and believe that you will continue to find the Tech Support Blog very helpful.
TapRooT® Instructors Michele Lindsay and Mark Olson just finished teaching a 2-Day TapRooT® Incident Investigation and Root Cause Analysis course in beautiful Niagra Falls.
Here are some pictures of the group working hard on the final exercise:
Our summer courses are filling up in Calgary, Dallas, Lake Tahoe, Seattle and more. Don’t get stuck on a waitlist . . . check out the course page and register!
The following press release is from the U.S. Chemical Safety Board, Washington DC
CSB Finds Unspent Aircraft Oxygen Generators Contributed to Rapid Spread of Fire at EQ Facility in Apex, N.C. in 2006 Safety Advisory and Urgent Recommendation Issued
Raleigh, N.C., June 27, 2007 - The U.S. Chemical Safety Board (CSB) today announced it is issuing a Safety Advisory concerning the dangers of transporting and handling unspent aircraft chemical oxygen generators. The action follows a CSB investigative finding that the devices most likely contributed to the rapid spread of a fire at the EQ Industrial Services (EQ) hazardous waste facility in Apex, NC on the night of October 5, 2006. The fire resulted in the evacuation of thousands of residents of Apex, located about 16 miles southwest of Raleigh, and destroyed the EQ facility’s hazardous waste building. (more…)
- improving root cause analysis
- reducing human error
- improving safety & risk management
- stopping sentinel events
- improving your corrective action program
- achieving operational excellence
- improving your lean or six sigma program
- improving uptime and increasing equipment reliability
- becoming a better TapRooT® instructor or software administrator
Then you should be interested in the TapRooT® Summit.
The 2007 Summit was held in San Antonio on April 25-28, 2007. The follwing movies (choose either QuickTime - .mov - or Windows - .wmv - formats) let you see and hear what attendees thought about the 2007 Summit.
Click on the world picture above to play the .mov movie.
Once you see what they have to say, you will be ready to attend the 2008 Summit on June 25-27 in Las Vegas.
Click on the Summit button above for more details (the full Summit site should be up and running by the end of August 2007).
A two part series based on
a talk at the 2007 TapRooT® Summit
by Mark Paradies & Kevin McManus
Lean Intro
What is Lean? It starts with the Toyota Production System, a highly efficient, customer focused, streamlined manufacturing process that helped Toyota survive when faced with competition from GM and Ford after WW II. The Toyota Production System started with Sakichi Toyoda at his textile mills and at his son’s (Kiichiro Toyoda) company, Toyota Motor Corp. Much of the credit for developing Lean is given to a Toyota engineer, Taiichi Ohno, and a consultant, Shigeo Shingo.
The main goal of Lean is to drive waste (muda) out of the production system. The seven forms of “deadly waste” are:
These types of waste should be reduced (or eliminated) through the application of systematic tools to improve efficiency and effectiveness. Some of the systematic tools that are commonly part of a Lean implementation are:
• Value Stream Mapping • Poka-Yoke (mistake proofing) • Kanban (pull production) • Kaizen (change for the better) • Just-in-Time (inventory reduction) • Total Productive Maintenance • Quick Changeover • Cellular Manufacturing • 5S (sort, set order, standardize, shine, and sustain)
These systematic manufacturing improvement tools are applied to provide the customer with what they want, when they want it. For details about the Toyota Production System, see Modern Approaches to Manufacturing Improvement: The Shingo System by Shigeo Shingo and Toyota Production System: Beyond Large-scale Production by Taiichi Ohno.
Who is the Customer?
Lean production gives the customer what they want, when they want it. This requires understanding of what adds value from the customer’s perspective. Waste comes from producing things that the customer doesn’t want. So the root cause analyst should ask:
• Who is the customer for my root cause analysis?
• What does the customer really want?
Perhaps you have already determined that your customer is management. And we all know what management wants:
• STOP THE PROBLEM.
• Don’t spend much time.
• Everything should continue as normal without disrupting any work and without causing delays to the tasks that the investigators were assigned prior to the investigation.
• Don’t point blame at management (especially senior management).
• Don’t provide evidence for lawsuits or for fines by government regulators.
• Find a few simple, inexpensive fixes that can be implemented easily.
This is NOT a joke. These are the desires of many managers who ask for a root cause analysis. And who wouldn’t want something like this? The desire is completely unreasonable, but understandable.
Therefore, as the leader of a lean root cause analysis, you must manage your customer’s (management’s) expectations. Make sure that your customer knows what they are buying. Management must have a reasonable expectation as to the cost for a good root cause analysis. And they must understand that root cause analysis IS NOT a magic bullet to solve all problems with no investment. Rather, advanced root cause analysis is a sophisticated performance improvement tool that when applied with diligence and thought, can lead to excellent (but perhaps not perfect) performance.
More Customers
Before you think this is all that you have to do, you may need to think more about who the customer is. First, “management” isn’t a good enough definition. What level of management? What manager (or managers) in particular?
The need to manage expectations and competing priorities from several managers and different levels of management can complicate delivery of a root cause analysis that is “just what the customer ordered.”
This should focus the analyst on their MAIN objective – stopping the problem. If the problem doesn’t stop (if an effective fix isn’t found for a serious safety, environmental, production, maintenance, or quality issue), then no level of management will be happy for long.
Next, you need to think about another set of unintended customers. These unintended customers include:
• The Government Regulator
• Workers
• The General Public
• Critics
• The Press
• The Company’s Shareholders
• Financial Analysts
• The Plaintiff’s Attorney
You may not be able to produce a report that satisfies all of the customers, but you should make rational decisions about the competing priorities.
Working to produce what the customer wants can produce radical changes in your root cause analysis and the reasonable desires of the customer.
Now that the first source of waste has been removed by producing a root cause analysis that is in line with reasonable customer expectations, the analyst can look for other ways to streamline the root cause analysis process to make it even leaner.
The first of those ways may seem very simple:
Only Investigate Incidents Worth Investigating
This sounds easy enough, but many companies have started by investigating only the biggest problems and then gone to the extreme of:
Investigating Everything!
Using root cause analysis to improve performance makes sense. But you have to pick targets with value to realize a return on your investment. You don’t need to investigate every burnt out bulb.
We will complete this discussion of applying Lean principles to root cause analysis in the September Root Cause Network™ Newsletter. If you would like to subscribe, CLICK HERE.
This was taken from the Alameda County District Attorney’s Office publication “The Point of View.” In a murder trial, the defense attorney was cross-examining a pathologist. Here’s what happened:
Attorney: Before you signed the death certificate, had you taken the pulse?
Coroner: No.
Attorney: Did you listen to the heart?
Coroner: No.
Attorney: Did you check for breathing?
Coroner: No.
Attorney: So, when you signed the death certificate you weren’t sure the man was dead, were you?
Coroner: Well, let me put it this way. The man’s brain was sitting in a jar on my desk. But I guess it’s possible he could be out there practicing law somewhere.
A California refinery was sentenced to three years probation and ordered to pay a criminal penalty for violating the Safe Drinking Water Act. The company must apply $500,000 of the $1 million penalty towards the Los Padres National Forest Restoration Project. The company pleaded guilty on April 12 and was sentenced in U.S. District Court, Central District of California on Monday.
Three individual defendants have also pleaded guilty to making false statements to EPA in connection with this case. They each face statutory maximum sentences of five years in federal prison. Sentencing is pending.
The Rail Accident Investigation Branch (RAIB) has released its report into a runaway permanent way trolley incident at Notting Hill Gate on 24 May 2006. The RAIB has made nine recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into a locomotive runaway near East Didsbury on 27 August 2006. The RAIB has made eight recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into a fatal accident involving a train driver at Deal on 29 July 2006. The RAIB has made nine recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into a derailment at Starr Gate on the Blackpool Tramway on 30 May 2006. The RAIB has made two recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into two near misses at Crofton Old Station No. 1 level crossing near Wakefield on the 01 and 18 May 2006. The RAIB has made six recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into a tram collision at Soho Benson Road on Midland Metro on 19 December 2006. The RAIB has made three recommendations. Full report here:
The Rail Accident Investigation Branch (RAIB) has released its report into the collision between a tram and a road vehicle at New Swan Lane level crossing on Midland Metro on 08 June 2006. The RAIB has made two recommendations. Full report here:
The following press release is from the U.S. Chemical Safety Board, Washington DC
CSB Issues Safety Bulletin on Dangers of a Major Chlorine Release During Railcar Unloading; Agency Calls on U.S. Department of Transportation to Expand Regulatory Coverage to Require Emergency Shutdown Systems
Washington, DC, June 14, 2007 - The U.S. Chemical Safety Board (CSB) today released a safety bulletin warning that some chlorine railcar transfer systems lack effective detection and emergency shutdown devices, leaving the public vulnerable to potential large-scale toxic releases.
The Board formally recommended that the U.S. Department of Transportation (DOT) expand its regulatory coverage to require facilities that unload chlorine railcars to install remotely operated emergency isolation devices to quickly shut down the flow of chlorine in the event of a hose rupture or other failure in the unloading equipment. The safety bulletin cites two previous incidents of accidental chlorine releases that occurred as a result of ruptured transfer hoses.
Chlorine railcars are equipped with an internal excess flow valve (EFV) that is designed to stop the flow of chlorine if an external valve breaks off while the railcar is in transit. However, these EFVs are not designed to stop leaks during railcar unloading, and the failure of a transfer hose may not activate the EFV and the toxic chlorine will continue to escape. Companies should install emergency shutdown systems that can quickly stop the flow of chlorine if a hose ruptures during the unloading operation, the bulletin said.
In August 2002 a hose ruptured at a DPC Enterprises plant near Festus, Missouri. The emergency shutdown valves did not close as designed due to poor maintenance, and the EFV did not close. The only way to stop the release of chlorine from the railcar was to send emergency responders through a four-foot deep yellowish-green fog of chlorine vapor to manually close shutdown valves located on top of the railcar. Incidents such as the one at DPC demonstrate why EFVs should not be relied upon to stop hazardous material releases during unloading operations.
However, in a survey of drinking water and wastewater treatment facilities conducted by the CSB, investigators found that approximately 30 percent of the bulk chlorine users contacted continue to rely solely on the EFV to stop chlorine flow in the event of a transfer hose rupture. (more…)
Hello everybody and welcome to another edition of Tech Support Thursday. It’s been awhile since we last spoke, but I assure it is not because I’ve had nothing to do. On the contrary, we’re plenty busy over here at TapRooT HQ.
Today we’re going to be talking about rescuing SnapCharTs that have crashed. If the chart your working on has crashed, DON’T DO ANYTHING until you read these directions!
Regional Reporting, Inc. is looking for candidates with five years of industry experience in safety and health to work in insurance loss control nationwide (full-time, part-time and independent contractors). For more information, visit their website:
Best Practices from the Malcolm Baldrige National Quality Award
How to Develop a High Performance Work Culture
And in his spare time at the Summit, he also worked in these breakout sessions:
Incident Investigations - Best Practices
as well as the Improving Quality and Processes, Panel Discussion: Comparison of Root Cause Techniques and Lean Root Cause Analysis breakouts.
He also co-taught a pre-Summit course, Advanced Trending Techniques. Best of all, he has agreed to come back and share his experience and wisdom with our 2008 Summit attendees (but we have promised not to work him so hard!).
Kevin is the President of Great Systems! and provides performance improvement coaching from his office in Seattle, Washington. He has served as an industrial engineer, Training Manager, Production Manager, Plant Manager, and Director of Quality during his 23 year business career. He served as a Examiner and Senior Examiner for the Malcolm Baldrige National Quality Award for six years. Kevin also writes the monthly Performance Improvement column for Industrial Engineer magazine and is a regular speaker at a variety of regional and national events. No wonder he has so much to share!
Thank you, Kevin, for your hard work and dedication to changing the way the world solves problems!
Men unhook harnesses at mall construction site to repair pin holding a bolt in place on scaffolding. “In the process there was too much weight placed on that end and the cable holding that scaffolding, suspended broke,” explained Sgt. Matt Mount, from the Indianapolis Metropolitan Police Department.
The following is a press release from the U.S. Chemical Safety Board, Washington DC …
Test of Key Valve in Ghent, West Virginia, Fatal Convenience Store Explosion Points to Likely Source of Propane Release
Washington, DC, June 7, 2007 - The U.S. Chemical Safety Board today announced that initial testing of the propane tank recovered after a West Virginia convenience store explosion reveals that the liquid withdrawal valve on the tank malfunctions and leaks and was the likely source of the large propane release that exploded, killing four people and injuring five others.
The accident occurred on January 30, 2007, at The Little General Store in Ghent. On the day of the accident, investigators believe personnel involved in the installation of a new propane tank at the store removed a metal screw cap on the liquid withdrawal valve, in preparation for removing propane from the old tank. When operating normally, a spring-loaded actuator prevents the valve from leaking when the screw cap is removed.
Testing also demonstrated that the fill valve, relief valve, and the tank itself do not leak. Experts and representatives of other interest parties observed the testing, which was conducted yesterday at a West Virginia contract laboratory. The nondestructive testing was conducted by filling the tank with gas and observing the rate of leakage at a range of pressures.
Following the testing yesterday, the CSB removed the liquid withdrawal valve from the tank. The CSB will be developing additional testing protocols to determine the cause of the valve malfunction. Further testing of the valve will occur in the next few months after the protocols are developed.
For more information, contact Director of Public Affairs Dr. Daniel Horowitz, 202-261-7613, cell 202-441-6074.
We have a refining client in the LA area that is looking for an employee or a local consultant that is TapRooT® Trained and can perform RAM Studies. If you have already attended TapRooT® Training and you are interested in this position, drop me a note at info@taproot.com.
Last year in Ontario, 10 people between the ages of 15 and 24 lost their lives because of workplace accidents. In response, a website has been launched by the Workplace Safety and Insurance Board of Ontario, Canada to drive home the importance of workplace safety to young workers. Animated and outrageous enough to catch the interests of a young crowd, the main attraction is the chance to win prizes like cell phones, MP3 players, Xbox 360 consoles and scholarships just for spending a few minutes completing a simple workplace safety quiz. The WSIB plans to run some of the animated ads in movie theaters, on public transit and online.
June is National Safety Month — what better time to assess safety at your workplace?
You can’t afford not to provide the best safety environment. Workplace injuries cost employers medical expenses, attorney’s fees and workers’ comp payments . . . and many employers fail to project that workplace injuries also cost: operations downtime, equipment repair bills, costs and time associated with hiring and training replacements for valuable workers who are injured, decrease in quality and production, and drop in employee morale.
So in honor of National Safety Month, download free safety brochures (which include tips about ergonomics, personal protective equipment, lifting safety, and falls in the workplace) provided by The National Safety Council here:
Yesterday I posted pictures from our public 5-Day Course in Charleston, South Carolina.
Last week, Marco taught a 5-Day on-site course in Rio de Janeiro, Brazil, for MI Swaco. He sent me pictures of class learning and having fun… Marco teaching (picture from another course).
Famous Rio landmark.
Class in discussion.
Team working on exercise.
Marco answers a team’s question (Marco on left).
Class picture.
Socializing after class.
If you are interested in having a TapRooT® Course at your site, contact us by clicking here.
Prior to joining SI’s teaching staff, Ken Turnbull worked for Texaco for 32 years and lead many accident and incident investigations as Texaco’s Corporate Safety manager. He used and taught the TapRooT® method for over eight years at Texaco and was instrumental in convincing executive management of Texaco the importance of reporting and determining the root causes of all incidents, including near misses. Ken is a CSP, a former member of the NFPA 30 Committee, a former member of the Technical Steering Committee of the Center for Chemical Process Safety and a former Chairman of the API Safety and Fire Protection Sub-Committee. Ken specializes in developing proactive measurements for safety programs, coaching executives in demonstrating management commitment to safety and doing root cause investigations. Ken has taught courses in the USA, Canada, Scotland, and Africa.
Ken is also known for his wry sense of humor, commitment to TapRooT® excellence, and, of course, the pretty pink golf shirt we presented to him at the 2007 TapRooT® Summit.
Thanks, Ken, for your hard work and dedication to changing the way the world solves problems!
Just wanted to let you know there are still a few seats open in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Gatlinburg, Tennessee (June 18 to June 22).
This is a beautiful time of year to visit the heart of the Great Smoky Mountains! I think the Great Smoky Mountain National Park is a hiker’s paradise. But even if you don’t like to hike, you’ll enjoy an auto tour, fishing or picnicking. I don’t think it’s possible to leave the mountains without spotting elk or a white-tailed deer. And when you see a cluster of people gathered and pointing into the woods, it’s a sure sign a black bear has been spotted.
Measuring progress is a way to determine if an organization is meeting its goals, but it’s a tricky measurement, because most workers measure tasks completed, not progress.
It’s important to decide whether or not a worker is task oriented or progress oriented to determine the best route to lean efficiency for any organization. Tasks are certainly measurable but is progress measurable? And, if progress is measurable, what are the standards of measurement for progress?
I really like this opinion piece written by Scott Berkun because it challenges current theories on management goal setting:
Giving people the tools to recognize when they’re wasting their time is one of the biggest obligations leaders have. A leader has to define a collective sense of progress that incorporates everyone’s contributions into a meaningful whole and strike a balance between something tangible enough for individual contributors to relate to, but broad enough to define a strategy for the team, organization or company.
Families of injured patients who are concerned and impatient with proactive improvement and medical error prevention are creating online communities to share safety strategies. Read more at The Wall Street Journal:
These grassroot efforts for improved patient safety are a reminder that even though the culture of healthcare is shifting from blame and punishment to root cause analysis, it’s not changing fast enough. If you are interested in changing the culture at your facility and finding ways to help prevent errors and increase patient safety, visit our webpage for information about our 2-Day TapRooT® Incident Investigation and Root Cause Analysis. Learn how to identify errors and anticipate what might cause these failures so they can be eliminated!
Positive change takes time, but together we can accelerate the forward motion toward best healthcare practices!
