Root Cause Analysis Blog

The Food and Drug Administration (FDA) found that a Chinese plant is at the center of a controversy over the safety of Baxter’s blood thinning drug heparin. Changzhou SPL has problems with impurities, the quality and use of its equipment, and overall quality control. These problems were found in a preliminary inspection by the FDA.

You may remember that in a previous blog entry, the FDA had declined to inspect the plant because of a name mix-up in the FDA’s manufacturer database.

For more information, see:

http://www.washingtonpost.com/wp-dyn/content/article/2008/02/28/AR2008022803046.html?hpid=moreheadlines

Conducts root cause analysis on specific project areas. Monitors quality of software products, processes, and standards. Performs in-process and phase end assessments. Establish and the successful execution of Supplier Development Plans.

For complete info, see:

http://www.hotgigs.com/logged_in/search/index.cfm?profileid=Ji5RVipYTlYnCg%3D%3D&userid=JS5BWixYXkQgCg%3D%3D&id=Ji5RVipYTlYnCg%3D%3D&page=viewsearchresults&Mode=G&override=true&jobview=yes

On February 25th, the Federal Deposit Insurance Corporation (FDIC) made public their January Enforcement Actions. Of course my first thoughts were… “where’s my money? is it safe in my bank?” Evidently my bank is doing fine because it did not make the hit list… or is it? So what kind of errors were the financial institutes making?

The core statement in all the findings seemed to be “unsafe or unsound banking practices”. Lower down the chain of complaints were comments such as no independent reviewer, management not certified, no internal audits conducted, and inadequate transactions which did not follow FDIC regulations. For TapRooT® root cause analysis system users, these words sound quite familiar: procedure and policy not used, independent quality control needs improvement, worker selection needs improvement. So the question is what is the tie between FDIC failed audits and an incident investigation…. the answer is none.

The incident or scope of the analysis (investigation) for the FDIC audit could be “Completed Commercial Loan Applications did go through an external review per regulation”. In a safety incident we start with a sequence of events. In the Loan Application we start with the transaction such as customer applies for loan. See below for an example of a SnapCharT® - “What Happened?”, combined with a Six Sigma Tool Called a Swimlane. Had the the financial institutions performed a proactive analysis using this process could they have prevented the audit failure? Keep in mind that once SnapCharT® was developed for this investigation, problems would be grouped, causal factors would be identified, and then effective corrective actions would be developed using TapRooT®’s SMARTER Checklist.

Think about it…. how often in your business are you auditing your business risk processes to identify possible Significant Issues before they happen? Do you have engineering gateways such as IPDS that are failing? In your integrated supply chain what processes are failing? If you fail an audit are your investigating the transaction or process using TapRooT®? If you use Six Sigma for Root Cause Analysis are you using the most effective process accepted by businesses worldwide? If not Call us at System Improvements, Inc. at 865.539.2139. Register for the Summit in Las Vegas in June, where we will be discussing how to improve your Lean Six Sigma Root Cause Analyses.

You need to be a professional stuntman to do this…

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The UK Rail Accident Investigation Branch has released two new accident investigation reports.

The first is about the derailment at Hooley Cutting, near Merstham, Surry. The report includes seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/2008-02-28_R052008_Merstham.pdf

The second report is about a track worker fatality at Ruscombe Junction. It also has seven improvement recommendations. To download the pdf, see:

http://www.raib.gov.uk/cms_resources/080228_R42008_Ruscombe.pdf

“Have you seen our new support section? We are currently working on support articles for the TapRooT® System Software Version 5 and we want to hear from you! Tell us what type of articles you would like to see on the Knowledge Base. Would you rather see dry, picture-less articles with just the text detailing how to do something or do you want to see lots of screenshots for each step? We value our clients’ suggestions and want to provide you with a useful and informative Knowledge Base in case things go wrong or you have a question. You can send your requests to version5@taproot(dot)com”

Watch the videos and hope your flight doesn’t land in these conditions…

IMO’s Maritime Safety Division’s Maritime Safety Committee is considering amending SOLAS (Safety of Life at Sea  Convention) at their May meeting. The amended standard would become effective in 2009.

The amended code would make it mandatory for flag states to carry out investigations and will make a distinction between establishing what happened and apportioning liability.

To meet the new requirements flag states will have to establish investigation bodies, such as the UK’s Marine Accident Investigation Branch, or use third party investigators.

For more info, see:

http://www.gadball.com/jobs/details.aspx?query=13049456/manager-electrical-reliability.aspx&AspxAutoDetectCookieSupport=1

The following is news release by Oregon’s Occupational Safety and Health Division:

The Oregon Department of Consumer and Business Services, Occupational Safety and Health Division (Oregon OSHA) has fined Siemens Power Generation Inc. a total of $10,500 for safety violations related to an Aug. 25, 2007 wind turbine tower collapse that killed one worker and injured another.

“The investigation found no structural problems with the tower,” said Michael Wood, Oregon OSHA  administrator. “This tragedy was the result of a system that allowed the operator to restart the turbine after  service while the blades were locked in a hazardous position. Siemens has made changes to the tower’s engineering controls to ensure it does not happen again.”

The event took place at the Klondike III Wind Farm near Wasco, where three wind technicians were performing  maintenance on a wind turbine tower. After applying a service brake to stop the blades from moving, one of the  workers entered the hub of the turbine. He then positioned all three blades to the maximum wind resistance  position and closed all three energy isolation devices on the blades. The devices are designed to control the  mechanism that directs the blade pitch so that workers don’t get injured while they are working in the hub.

Before leaving the confined space, the worker did not return the energy isolation devices to the operational  position. As a result, when he released the service brake, wind energy on the out-of-position blades caused an  “overspeed” condition, causing one of the blades to strike the tower and the tower to collapse, the Oregon  OSHA investigation found.

Chadd Mitchell, who was working at the top of the tower, died in the collapse. William Trossen, who was on  his way down a ladder in the tower when it collapsed, was injured. The third worker was outside the tower and  unharmed.

During the investigation, Oregon OSHA found several violations of safety rules:

• Workers were not properly instructed and supervised in the safe operation of machinery, tools,  equipment, process, or practice they were authorized to use or apply. The technicians working on the  turbine each had less than two months’ experience, and there was no supervisor on site. The workers  were unaware of the potential for catastrophic failure of the turbine that could occur as a result of not  restoring energy isolation devices to the operational position.

• The company’s procedures for controlling potentially hazardous energy during service or maintenance  activities did not fully comply with Oregon OSHA regulations. Oregon OSHA requirements include developing, documenting, and using detailed procedures and applying lockout or tagout devices to secure hazardous energy in a “safe” or “off” position during service or maintenance. Several energy  isolation devices in the towers, such as valves and lock pins, were not designed to hold a lockout device, and energy control procedures in place at the time of the accident did not include the application and removal of tagout devices.

• Employees who were required to enter the hub (a permit-required confined space) or act as attendants to employees entering the hub had not been trained in emergency rescue procedures from the hub.

Siemens Power Generation has 30 days to appeal the citation.

Here are some links for more information:

http://www.reuters.com/article/domesticNews/idUSN2664121920080227

http://ap.google.com/article/ALeqM5hHI4Ql8XfZuPMktRM7fQxHjXbz1QD8V2O01O0

http://www.miamiherald.com/news/breaking_news/story/434132.html

http://www.ktvu.com/news/15424754/detail.html

http://www.cnn.com/2008/US/02/26/florida.power/index.html

I see snowflakes in Tennessee! Let’s run and get some bread and find a ditch to slide into!

Here’s a dramatic example of the problems people (and pedestrians) have when driving in the snow…

(Click the Read More link to see it!)

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If you are interested in Operational Excellence, Lean, Six Sigma, or proactive improvement, you should attend the TapRooT® Summit. The Summit has a Best Practices Track focused on these topics. What’s in the track? Here are the speakers and topics:

Pursuing Process Excellence - What It Takes to be One of the Best - Kevin McManus, President, Great Systems!

Using TapRooT® to Improve Lean/Six Sigma - Chris Vallee, Six Sigma Black Belt, System Improvements

Culture Shift Secrets - Changing Systems to Shift Cultures Towards High Performance - Kevin McManus, President, Great Systems!

Measuring Performance - The Latest Research on Performance Measures - Dr. Joel Haight, Penn State University

Dealing with Obstacles that Make Change Difficult - Hal Curry, Consultant, Hal Curry & Associates

Managing the Risks Associated with Change - Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia, & Jim Whiting, Managing Director, Risk @ Workplaces Pty. Ltd. Australia

Applying Performance Measures in Industry & Healthcare - Dr. Joel Haight, Penn State University

TapRooT® User Best Practices - Linda Unger, VP, System Improvements, & Michele Lindsay, Principal Consultant, P2, Canada

Character Driven Success - Dr. Beverly Chiodo, Texas State University

Changing Behavior by Praising the 49 Character Traits - Dr. Beverly Chiodo, Texas State University

Planning Your Improvements

In addition to these Best Practice Sessions, there are great Keynote Speakers. For the complete list see:

http://www.taproot.com/keynote_speakers.html

The Summit will be June 25-27 in Las Vegas.

To register for the Summit, or for more information, see:

http://www.taproot.com/summit.php

Watch the video below and see how NOT to make a quick turn at sea…

Software written internally by HSBC caused an intermittent failure (don’t you hate those) of Mastercard’s Maestro system last weekend. This caused thousands of HSBC’s customers to be unable to make purchases or withdraw cash.

The bank is now conducting a “major incident review” that should be completed by Friday. The review will look at the problems with the software and why recovery took so long (four hours after the offending software was removed).

How is a root cause analysis of a software failure different than the root cause analysis of a equipment failure or a human error that causes an explosion or plant shutdown? Really, there isn’t a difference in the tools to use. The only difference is the technology involved.

I found this out back in the 90’s when working with Gerald Starling at BellSouth. He used TapRooT® to investigate telecommunications incidents (network reliability, 911 outages, etc.). These were often software issues. And using TapRooT®, he found fixable root causes that improved performance.

The technology (network reliability) was very different than the types of investigations I had perviously performed. Even though I am an electrical engineer, the terminology of network reliability was completely foreign to me. Yet the reasons for human errors and system failures were in the Root Cause Tree® (part of the TapRooT® System).

The reason for this is that the causes of unreliable human performance (mistakes - human errors) are the same no matter what type of technology the human is involved with. Therefore, the ways to achieve reliable human performance are a basic part of the analysis that TapRooT® helps an investigator perform.

Nothing to do with root cause analysis, but sometimes people send me photos that I just have to publish. These came from Idaho and were taken earlier this month. Robert Peterson sent them to me (the photographers are labeled on each photo). They reminded me of living in Idaho back in 1979. Living in Tennessee, I forget the real challenges of winter.

So what can you do with these photos? Use them the next time you get too worked up about global warming. Just look at them and chill out!

(Actually, that the Salmon River)

A man was struck and killed by the red line Luas Tram last weekend. The tram operator, Veolia Transport, is conducting an investigation in coordination with the Irish Railway Safety Agency. This is the first fatal accident since the tram was inaugurated in 2004. There were 17 “contact” incidents between people and the tram in 2007. A December 2007 incident caused serious head injuries to another man.

For a video report see:
http://www.rte.ie/news/2008/0225/luas_av.html

If your improvement program needs best practices to measure performance and better manage your facilities, you should be planning to attend the TapRooT® Summit in Las Vegas on June 25-27. Read the session titles below if you are interested in setting or changing your company culture or setting up a reliable performance measurement system. 

MANAGEMENT & MEASURING PERFORMANCE BEST PRACTICES TRACK
Track Leader: Joel Haight (Penn State)

Culture Shift Secrets - Changing Systems to Shift Cultures Towards High Performance - Kevin McManus, President, Great Systems!
Evaluating the Effectiveness of Corrective Actions - Brian Hennesey, First Energy, & Michele Lindsay, Principal Consultant, P2, Canada

Performance Measures
1) The Latest Research on Performance Measures - Dr. Joel Haight, Penn State University
2) Applying Performance Measures in Industry & Healthcare - Dr. Joel Haight, Penn State University

TapRooT® User Best Practices - Linda Unger, VP, System Improvements, & Michele Lindsay, Principal Consultant, P2, Canada

Management & Performance Improvement
1) What Do Managers Need to Know About Performance Improvement & Root Cause Analysis - Mark Paradies, President, System Improvements
2) How to Identify Culture Issues When Performing a Root Cause Analysis - Mark Paradies, President, System Improvements

How to Get & Keep Management Support - Miles Kajioka, Production Manager, ConocoPhillips Bayway Refinery, & Michele Lindsay, Principal Consultant, P2, Canada

Character Driven Success - Dr. Beverly Chiodo, Texas State University
Senior Executive Involvement in Safety
1) Bringing Safety to the Corporate Board - Dave Prewitt, VP FedEx
2) What the Corporate Board Needs to Know About Safety - Bob King & Darby Alan - Woodland Grange, UK

Planning Your Improvements (Facilitated session by TapRooT® Instructors)
These sessions are in addition to the inspiring Keynote Speakers:

Lt. Col. Ralph Hayles (retired), Gulf War Veteran, Lessons Learned from Friendly Fire.

Nikki Stone, Olympic Aerial Skiing Gold Medal Winner, Overcoming Setbacks to Achieve Olympic Success

Carolyn Griffiths, UK Rail Accident Investigation Branch Chief Inspector, Lessons from Setting Up an Independent Accident Investigation Organization

Ed Frederick, Exelon Nuclear (Board Operator at TMI during the accident), The Accident at Three Mile Island - An Insider’s Perspective

Marcia Wieder, Doctor of Dreams, You Can Make Improvement Happen
And to make the week in Las Vegas even more knowledge packed, attend a Monday/Tuesday pre-Summit Course. Two that go amazingly well with the Management and Measuring Performance theme are:

Advanced Trending Techniques

or

Risk Management Best Practices

Don’t wait! The Summit is rapidly approaching and you need to get the time scheduled to prevent conflicts from arising. Also, the course size is limited and these courses will fill up fast. So register for the Summit and a pre-Summit course at:

http://taproot.com/summit-single.php

For complete details, see:

http://my.jobstreet.com/jobs/2008/2/default/10/576976.htm?fr=R

The Air Force has declared a “temporary pause” to review safety procedures for flying the B-2 after a crash at a Guam air base.

This is the first time a B-2 had crashed. However, even a single crash is significant because each B-2 is worth more than $1 billion. Perhaps that is why all B-2’s will be grounded (oops - I mean temporarily paused) while safety reviews are conducted.

Air Force officials were careful to explain that this action was not a “stand-down” or “grounding” and that the planes could return to service at any time they were needed. A stand-down or grounding occurs only if senior Air Force commander order it. Officials said that has not happened.

What happens when you lie to the Coast Guard during an investigation of a maritime accident? You end up facing federal charges! See this story from the San Francisco Chronicle:

http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2008/02/23/BAVTV7DN8.DTL

How far will some people go to break a rule?

A 39 year old man in New Zealand was ticketed 32 times in 5 years for not wearing a seatbelt. His answer? He created a fake seatbelt.

He died in a low speed crash on 2/24/08. He was wearing his fake seatbelt. If he had been wearing a real seatbelt, he probably would have survived.

Here’s a short story about the accident:

http://www.shortnews.com/start.cfm?id=68733

The following accident took place in Denmark during a storm on 2/22/08.

Here’s the first view:

Here’s the second:

Yes - that is a truck at the base of the windmill when it self-destructs. I’m not sure if I can see people near the truck in the video or not.

The “cause” of the accident was the failure of the brake that limits the speed of the windmill during a storm. The speed of the blades were approaching the speed of sound when they failed.

Root cause analysis can help you improve performance. Sometimes at little or no cost. But the article linked below takes a different view. They think that increased reliability isn’t worth the cost.

Of course, Research in Motion has assigned engineers to investigate the problem to make sure it doesn’t happen again (this was the second outage in 10 months). An opportunity for better root cause analysis or a waste of time?

What do you think?

Article Link:

http://www.computerworld.com/action/article.do?command=viewArticleBasic&taxonomyName=mobile_and_wireless&articleId=312950&taxonomyId=15&intsrc=kc_feat

For details, see:

http://www.theengineer.co.uk/Jobs/101454/Quality+Engineer+-+DFMEA.htm

International Cooling Tower pleaded guilty to a violation of the Occupational Health and Safety Act after a July 2005 accident. An apprentice carpenter fell through an uncovered opening in platform and suffering serious spinal injuries that left him paralyzed.

A Labour Ministry investigation found the worker was wearing a full-body harness with a single lanyard that wasn’t attached to a fixed support or lifeline. The ministry’s also found the worker was unaware of the opening because lighting was inadequate and that the worker was inadequately trained in safety procedures.

The Labour Ministry has finally fined the company $150,000.

The 10th person died from burns received from the blast at Imperial Sugar’s plant in Georgia. Thirteen are still in critical condition. For more details see:

http://www.chron.com/disp/story.mpl/business/5563790.html

For details, see:

http://www.chron.com/disp/story.mpl/business/5563715.html

Click on the video below and watch the short takeoff and landing demo.

Yes - people can produce amazing human performance!

For more info, see:

http://www.mechanicalengineer.com/jobseeker/sSetup.asp?runsearch=1&spJobAdId=132635

Another data point on the cost of an accident.

We noted the accident at the Trump Hotel in SoHo on a blog entry on January 14.

Today I saw an article that said the construction contractor at the Trump Hotel SoHo was just allowed to resume work on the first 23 stories of the building, but is NOT being allowed to use cranes, resume pouring concrete, or work above the 23 floor.

Imagine the costs of this construction delay.

Yes, this was a fatality. The first concern should be for the lives (health and safety) of employees. But one of the overlooked costs of an accident is the regulatory consequences (in this case a stop work order by the New York Department of Buildings).

Construction accident prevention, proactive risk reduction, and good root cause analysis of problems can help companies avoid the unexpected and costly constructions delays that a major accident can cause.

But if you’re not, this Croc is waiting patiently to enforce the message!

I wrote about this amazingly stupid government decision to stop research into imporving patient care by using a checklist, but I came across this link to the New Yorker magazine article, so I thought I should include it here:

http://www.newyorker.com/reporting/2007/12/10/071210fa_fact_gawande

If you agree that this is outrageous, write the White House, your Congressman, and your Senator.

Use these links:

Contact the President and Vice-President about this at:

http://www.whitehouse.gov/contact/

Write your Congressman about this by using the following link:

https://forms.house.gov/wyr/welcome.shtml

Write your Senator at this link:

http://www.senate.gov/general/contact_information/senators_cfm.cfm

The healthcare industry is searching for ways to improve healthcare quality, drive down healthcare costs, and stop sentinel events. After a decade of searching for answers, some healthcare professionals are frustrated. Progress just doesn’t seem to come fast enough.

What can healthcare professionals (safety, quality, & risk management professionals, doctors, nurses, and administrators) do to learn proven, effective ways to improve performance and stop sentinel events while reducing healthcare costs? Attend the TapRooT® Summit and learn from other healthcare professionals and from experts in other high reliability industries.

First, the Summit has a track designed just for those looking to improve performance in the healthcare industry. The Medical Error Reduction Track includes the following sessions and speakers:

Morbidity & Mortality Reviews (Hot Case Rounds) - DR. Johnny Griggs, MD, plus David Davis, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc. & Tommy Garnett, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc.

Measuring Performance
1) The Latest Research on Performance Measures - Dr. Joel Haight, Penn State University
2) Applying Performance Measures in Industry & Healthcare - Dr. Joel Haight, Penn State University

The Human Design Spec - Working in a 24/7 Medical Environment - Bill Sirois, VP, Circadian Technologies

Improving Patent Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, Patient Safety Consultant, The Kicklighter Group

TapRooT® User Success Stories from Healthcare & Industry - Linda Unger & Barbara Phillips (facilitators)
MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

Process for Running a Healthcare Root Cause Analysis - Tommy Garnett, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc. & David Davis, Founder and Vice President, The Patient Safety Solutions & Consulting Company, Inc.

Innovative & Creative Solutions - Michele Lindsay, Principal Consultant, P2, Canada

Planning Your Improvements

In addition to these sessions focussed on healthcare performance improvement, there are general sessions for cross industry lessons learned and inspiration.

These General Sessions include these talks:

Lt. Col. Ralph Hayles (retired), Gulf War Veteran, Lessons Learned from Friendly Fire

Nikki Stone, Olympic Aerial Skiing Gold Medal Winner, Overcoming Setbacks to Achieve Olympic Success

Carolyn Griffiths, UK Rail Accident Investigation Branch Chief Inspector, Lessons from Setting Up an Independent Accident Investigation Organization

Ed Frederick, Exelon Nuclear (Board Operator at TMI during the accident), The Accident at Three Mile Island - An Insider’s Perspective

Marcia Wieder, Doctor of Dreams, You Can Make Improvement Happen

But that’s not all. There are exceptional opportunities to network with industry leaders from the healthcare industry and from other high reliability industries (aviation, nuclear power, military, refining, and many others).

So don’t hesitate to sign up for this guaranteed, amazing Summit of performance improvement leaders.

See:

http://www.taproot.com/summit.php

for registration information.

The Air Accident Investigation Branch’s official web page for the investigation of the 777 crash at Heathrow is:

http://www.aaib.dft.gov.uk/publications/special_bulletins/s1_2008___boeing_777_236_er__g_ymmm.cfm

The International Herald Tribune had an interesting article on the progress of the investigation into the crash of the 777 landing at Heathrow. See:

http://www.iht.com/articles/ap/2008/02/19/europe/EU-GEN-Britain-BA-Crash-Landing.php

Dr. Mark Chassin, new President of the Joint Commission, has an ambitious goal. His goal is to make healthcare delivery meet the same high reliability standards as the best high-reliability industries. Who are these “best” high-reliability industries? Speaking during a January 31, 2008, teleconference, he identified the aviation and nuclear power industries as today’s best high-reliability organizations.
Why is this important?

If you are at a hospital and you would like to learn best practices to improve patient safety AND network with people from the aviation and nuclear power industries (as well as industry leaders oil industry, mining, and manufacturing), where should you go?

Answer: The TapRooT® Summit on June 25-27 in Las Vegas, NV.

Plus, if you aren’t already a TapRooT® User, you should attend the TapRooT® and FMEA for Healthcare Root Cause Analysis Course on June 23-24, also in Las Vegas.

This is the best place to learn high reliability best practices that cross industries and can revolutionize patient care.

For more information, see:

http://www.taproot.com/summit.php

And while you are there, watch the videos from previous Summit attendees to see what everyone is talking about.

And check back at this blog tomorrow for a complete run-down on the Medical Error Reduction Best Practices Track at the TapRooT® Summit.

(Lt Col Ralph Hayles - left)

For those that investigate accidents and incidents, Lt Col Ralph Hayles story is immensely interesting.

Involved in a “friendly fire” accident at the start of Gulf War I, Lt Col Hayles was singled out for blame, discipline, and public vilification.
His “accident” was similar to many others. A combination of mistakes and equipment failures that led to a fatal result. And like many others, the last person to touch it (in this case the trigger) is blamed for all of the consequences.

To read his story see:

http://books.google.com/books?id=2tI8erYfxbwC&pg=PA8&lpg=PA8&dq=wall+street+journal+ralph+hayles&source=web&ots=j79QgRdLFK&sig=SW0sWVXDrmF2gbS85v5NiPVa2xY#PPP1,M1

Better yet, attend the Summit and hear Lt Col Hayles tell his story. Learn the impact of an investigation and discipline gone awry.

For more Summit information and registration, see:

http://www.taproot.com/summit.php

If your improvement ideas include improving equipment reliability and maintenance at your facility, then you should plan to be in Las Vegas on June 25-27 at the TapRooT® Summit.

Why?

Because the Summit has a track focussed on that topic and the track includes “Bloch Day.”

What is Bloch Day?

Heinz Bloch is a worldwide recognized equipment reliability expert with over 20 books on equipment reliability and maintenance topics. For example:

Heinz is even listed in Wikipedia:

http://en.wikipedia.org/wiki/Heinz_P._Bloch

Heinz Bloch, and his son, Ken Bloch, equipment reliability engineer at Flint Hills Refining, will share their latest ideas for improving equipment reliability and investigating equipment failures.

Their sessions will fill all four Equipment Reliability and Maintenance Best Practice Sessions on Thursday of the Summit. That makes Thursday … Bloch Day!

Their talks include:

How to Become Best of Class in Equipment Reliability by Maximizing Uptime - Heinz Bloch, Consulting Engineer, Process Machinery Consulting

Best of Class in Equipment Reliability: Part II - Heinz Bloch, Consulting Engineer, Process Machinery Consulting

Examples of Extreme Equipment Failure Investigations - Ken Bloch, Reliability Engineer, Flint Hills Refining & Heinz Bloch, Consulting Engineer, Process Machinery Consulting

Using TapRooT® to Solve Complex Equipment Problems - Ken Bloch, Reliability Engineer, Flint Hills Refining

And this day is just one day of the three day Summit. Other Equipment Reliability and Maintenance Best Practice Sessions at the Summit include:

Engineering Methods to Improve Equipment Reliability - Dave Thompson, President, RAMsoft Ltd., UK

Maintenance Best Practices - Mark Olson, Reliability Consultant; & Ken Reed, Senior Associate, System Improvements



Culture Shift Secrets - Changing Systems to Shift Cultures Towards High Performance - Kevin McManus, President, Great Systems!

Evaluating the Effectiveness of Corrective Actions - Brian Hennesey, First Energy, & Michele Lindsay, Principal Consultant, P2, Canada

Planning Your Improvements (facilitated by TapRooT® Instructors)

You will also hear from 5 Keynote Speakers.

(Keynote Speaker Nikki Stone - Olympic Gold Medalist)

But there is even more…

Before the Summit, you can attend a special 2-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course by Ken Reed. This course teaches a combination of TapRooT® and Heinz Bloch’s best equipment troubleshooting techniques. For more information about this course, see:

http://www.taproot.com/courses.php?d=4

Or you can attend the Equipment Reliability Techniques Course by Dave Thompson, President, RAMsoft Ltd., UK. For more information about this course see:

http://www.taproot.com/courses.php?d=20

To register for the Summit and one of the courses or to get more information, see:

http://www.taproot.com/summit.php

The web site has information about the Summit Reception and Golf Tournament; videos of past Summit attendees sharing their experiences; travel and accommodation information; complete Summit schedules, and even a frequently asked questions (FAQs) page.

Don’t miss out on this guaranteed learning experience. Register today!

I was reading root cause related articles when I came across this one by a doctor: