Last year, a Delta employee lost his leg when it was crushed by the wheel on a jetway in Knoxville, Tennessee.
I had a little extra time waiting for my flight to Atlanta from Knoxville last Friday so I asked the gate agent about the accident and what had been done to prevent a repeat. She said they were now required to have a spotter to make sure that no one got near the wheels while the jetway was moving (the wheels aren’t visible from the jetway controls).
That’s a Human Action Safeguard.
She also said that no one is allowed to use the stairs or get near the wheels while the jetway is in motion. That was already true when the accident happened but it was re-emphasized to everyone after the accident.
That’s a rule “quasi-Safeguard” that requires human action (compliance) to work.
Thus, a near-fatal accident had two human action related Safeguards that are meant to prevent recurrence of the accident.
Here is a graphic from our root cause analysis training…
Now let’s evaluate the corrective actions used to prevent a possible future fatality using the graphic above…
First, we made a rule that required a spotter during moving of the jetway. This is a human action related Safeguard implemented through a rule. That is the second weakest type of corrective action (#5).
Reemphasizing a rule that previously failed (the second corrective action used) is a training related human performance Safeguard and is the weakest corrective action to prevent recurrence of the accident (#6).
What do you think? If you had a serious accident (lost leg due to crushing) and it had the potential to be fatal, would two weak corrective actions be enough?
Maybe we should start at the top of the hierarchy in the figure above and see what is the strongest reasonable Safeguard that we can employ is…
1. REMOVE THE HAZARD
The Hazard in this case is the jetway weight and moving pinch point when the jetway is in motion. This is difficult to remove. (At least I can’t think of a way to do it.)
2. REMOVE THE TARGET
With current aviation operations, people are required to direct the plane while parking, unload baggage, refuel the plane, etc. Perhaps someday this will be done robotically, but for now, removing people from the jetway environment seems unlikely.
3. GUARD THE TARGET
This one is possible. See this photo below from Frankfurt …
They have implemented a guard to keep people away from the wheels.
Is it 100% perfect? No. People can go around the guard (jump over it?).
Is it better than warning people to be careful?
Yes!
So I sent the photo above to the Knoxville airport management. We’ll see if there are changes in the future to implement a stronger Safeguard to the potentially fatal Hazard.
ARE WE DONE?
NO!
This corrective action (if implemented in Knoxville) only fixes one small set of Hazards – jetway pinch-points in Knoxville. This Hazard exists at airports around the world.
For corrective actions to the Generic Root Cause, Delta would need to get airports around the world to guard the Hazard.
Next time you board a plane at your local airport, see what kind of Safeguard is in place. If you don’t see any, send the airport management (you can usually find a “contact us” link at the airport’s web site) a link to this posting.
ONE MORE THING TO LEARN
How do you develop corrective actions? Do you start at the top of the Safeguard hierarchy and work your way down or do you start at the bottom and work your way up?
Your investigators should have their corrective actions evaluated to see how effective they will be. For potentially fatal accidents, I would recommend using the top three strongest on the list and sometimes allow the fourth if somehow the top three aren’t possible.
The bottom two can be allowed in combination with the top 4, but I would never allow them to be the only corrective action if a fatality was possible.
Stop taking the easy way out. Learn a lesson from this accident (and the corrective actions). Improve your corrective action process by using the strongest possible corrective actions.
The Sun reported that damage to the Costa Fortuna, previously blamed on a collision with a whale, may have been caused by the vessel hitting rocks (running aground) in May of 2005 near Sorrento, Italy.
I don’t think that I’ve ever seen a major accident with fatalities that didn’t have a previous incident that could have been investigated, learned from, and thereby prevent the follow on accident IF they had applied advanced root cause analysis and implemented SMARTER corrective actions.
“A TVA spokeswoman told the Chattanooga Times Free Press that the construction ‘stand down’ ordered to start at noon Wednesday was to continue ‘until the errors discovered are clearly communicated to all personnel.’”
Will communicating the “errors” really improve performance?
A TVA spokesperson said:
“TVA had not yet determined if the mistakes were due to carelessness but a ‘root cause analysis’ was being conducted.”
Carelessness as a potential “cause”?
TVA’s top executive, Tom Kilgore, said:
“When workers return to the site on Monday, they will join foremen and supervisors to review an error that occurred in December that had the potential for fatal consequences and that was identified earlier this week at Watts Bar Unit 2. Also to be reviewed is a second incident that occurred this week which could have resulted in a severe injury or worse if it had happened under slightly different circumstances.”
That tool box safety meeting shouldn’t take too long. From the report, they don’t know the root causes yet. All they seem to know is that two mistakes were made. I guess “foremen and supervisors” will just tell employees to “be more careful” and not to make errors. Then everything will be OK.
After that, employees will be willing to cooperate in an open and revealing root cause analysis. Especially when they know that management is looking for those who may have been careless.
We all know that the best way to keep people from being careless is to fire those who are found to be careless. If you fire careless people frequently, everyone will be happy and careful!
Another quote from the article:
“Nuclear Regulatory Commission Region 2 spokesman Roger Hannah said Friday that such work stoppages at nuclear plants are ‘not uncommon’ and probably occur every two or three years. Hannah said they are ‘not exclusive to the nuclear industry.’”
Wonder why they need a stand down every two or three years if they have an effective performance improvement program? I guess people need to be reminded to be more careful every two or three years.
Maybe we should just schedule these stand downs in advance? We could call it human performance preventive maintenance. Every two years we would give people a day off to think about being more careful and “Presto!” … no more human errors.
Or even better! Rate people on their potential for carelessness on a scale from 1 to 10. Then every year fire the worst 10%-20% of the careless employees!
Do these actions sound like the Deming Red Bead Experiment to anyone? If you don’t know what the Red Bead Experiment is, see the following videos…
Now read these quotes:
NRC’s “…Hannah declined to speculate about any possible penalty for TVA. He said TVA would assess both nuclear safety and workplace safety issues.”
And …
“The problems were discovered in routine TVA inspections and follow heightened NRC scrutiny on other TVA nuclear plants.”
Ahhh… now we are getting to the “root cause” of the stand downs.
It will look like management is doing something.
Management would hate to look like they are doing nothing.
A stand down makes them look like they are doing something.
The more people stand down, the more dramatic the effect.
Thus, a stand down may keep the NRC from descending upon a nuclear utility.
If NRC management starts to believe that TVA has multiple troubled plants with multiple reasons for concern about human performance and human reliability, that could result in a special inspection. A special inspection is bad. When multiple regulators descend upon a nuclear utility, they always find things that need to be improved. If too many areas need improvement, the NRC could order reactors shut down until the “culture” is changed.
An NRC ordered shut down is bad news for the utility. “Changing the culture” can take years, cost millions of dollars, and result in many managers being fired. That’s much worse than the impact of a simple stand down for a few days. Thus, a stand down is a cost-effective way to keep the NRC happy – at least for a while – even if the stand down has no lasting impact on human performance.
Is there a better approach?
How about honest recognition of mistakes big and small? Once the mistake is recognized, management could require a thorough, effective, advanced root cause analysis of any problem that could result in significant impact on plant safety, personnel safety, radiation exposure, environmental performance, or plant performance. Management could then insist upon the development and implementation of effective (SMARTER) corrective actions. Part of those corrective action could include effective communications about what happened and why it happened (the real root causes) to all employees that are impacted by the issue or the corrective actions.
What if you really want to stop having stand downs (and the incidents that cause management to call for stand downs)?
Management needs stop being REACTIVE by being PROACTIVE.
Management needs to shift from reactive root cause analysis to advanced PROACTIVE root cause analysis and stop problems before incidents happen. (We teach how to do this in our 5-Day TapRooT® Course.)
I’d recommend that TVA stop blaming workers (calling them careless) and start finding and fixes the real root causes of problems. Rather than a show stand down for the NRC, use effective advanced root cause analysis – both reactively and proactively – to improve performance and avoid issues that require stand downs every few years.
Show stand downs haven’t resulted in improved performance in the Nuclear Navy or the nuclear power industry (as evidence by the fact that they are repeated over and over again) and they should not be accepted by the NRC as effective management action. Rather, knee-jerk use of a stand down should be seen as a sign of weak management. Management that does not know how to improve human performance.
Avoid this scenario at your facility. Make sure that your management understands how to use advanced root cause analysis both reactively and proactively. Get your advanced root cause analysis program effectively implemented and then continue to improve it every year. And this advice is not just for nuclear utilities. Rather, it applies to every industry where mistakes may cause major accidents – oil, refining, chemical plants, aviation, railroads, shipping, pipelines, pharmaceutical manufacturers, mining, hospitals, …
Where can you learn best practices to continuously improve root cause analysis and human performance? Start at the 2012 Global TapRoot® Summit in Las Vegas on February 29 – March 2. See the schedule for all nine Summit Tracks at:
I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.
The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.
Sources of Root Cause Analysis Failures by Mark Paradies is published by:
Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.
What is it that produces a safe environment with safe workers? Is it people with the right attitude… is it a reduced risk environment… or is it both? Do we need reward or punishment… or both? How do different cultures interact successfully to work safely? What is the best environment for a person to work in physically? How does one know?
Listening to a radio show recently about people trying to get out of debt, the host said this, “it is not the math that got them in the situation it is the behavior; that is why changing the behavior is the first step.” It was in reference to people who wanted to know why the had to pay off small debts first and not the large credit cards with high interest.
Point being, that the more one practices a behavior, the higher the probability that the behavior becomes habit. Providing a better environment with the right tools increases the ability to perform the behavior. It is with this in mind that the sessions below were put together:
Wednesday
Proactive Prevention of Injuries and Accidents Due to Human Error
Ergonomic and Human Performance Improvement
Working Across Languages and Cultures
Thursday
Changing Behavior By Praising the 49 Character Traits
Criminal Prosecution of Accidents
Using Training Simulation to Improve Human Performance
Design for Reliable Performance
Friday
Using FACT to Measure & Analyze Fatigue (Both Reactive & Proactive)
Planning Your Improvements
The course and the Human Performance and Behavior Change Best Practice Track make a great one-two punch for improving human performance. Plus, you will save $200 off the course fee when you attend both.
Don’t miss the remarkable knowledge available in the course and the Summit. Register today!
WHAT!?! You haven’t written down your goals and developed metrics?
Get HOT!
Writing down your goals makes achieving them much more certain.
And “What gets measured, gets done!”
Don’t let important improvement initiatives get forgotten in the daily crunch to get things done.
One more idea …
Use the comment field to leave a couple of your better improvement goals and metrics here. Others can see them and get inspired to make more improvement happen at their facilities. We’ll all help each other to be challenged to get better.
Are you involved in performance improvement efforts in the healthcare industry? Then you should be planning to attend the 2012 Global TapRooT® Summit Track titled:
Healthcare Quality, Patient Safety, and Sentinel Event Best Practices
Most conferences about improving patient safety, healthcare quality, and reducing sentinel events are strictly organized by and attended by healthcare professionals. This provides good sharing of best practices within the healthcare industry, but does not provide networking or benchmarking outside the healthcare industry.
The TapRooT® Summit provides both in-industry networking/benchmarking and cross-industry/cross-functional networking/benchmarking. Here’s one healthcare industry patient safety professional talking about her experience at a previous Summit:
(.wmv format. Click above to play)
But what about the 2012 Global TapRooT® Summit? There are several sessions at the 2012 Global TapRooT® Summit that have a strictly healthcare focus:
What does increasing expectations for healthcare quality and patient safety mean to your improvement efforts?
Response lessons learned from the Joplin Disaster.
Using electronic medical records to improve healthcare quality and patient safety.
Using Baldrige criteria to achieve performance improvement.
These provide opportunities to network and benchmark with healthcare professionals.
Plus, there are also sessions that span industries and disciplines:
Criminal prosecutions of accidents.
Developing a fatigue risk management plan.
Positive Contributions in facilitation and management interactions.
But that’s not all. The Keynote Speakers also provide lessons learned and best practices that cross industries.
For example, Astronaut Ken Mattingly, of Apollo 13 fame, talkes about Lessons Learned from Apollo 13 and Space Shuttle Operations.
And Dr. Beverly Chiodo talkes about Character Driven Success and how it can help your improvement program.
Also, there is a panel discussion of senior managers (Gerry Migliaccio, Senior VP at Pfizer; Vicki Hollub, President & General Manager of OXY Permian CO2 Business Unit; and Zena Kaufman, Divisional Vice President of Global Pharmaceutical Operation at Abbott Laboratories) who will discuss “What Does Senior Management Want from Incident Investigations and Root Cause Analysis?”
This is just a sample of the sessions, for the complete TapRooT® Summit schedule, see:
I know you will find the information you take home motivational and valuable. That’s why we provide the following Summit guarantee: Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.
With a guarantee like this one, you have nothing to lose and everything to gain!
Here’s what some participants had to say about the pre-Summit courses they attended…
Then sign up for the Leading Performance Improvement Best Practices Track at the Summit. You will experience five great Keynote Speakers, eight Best Practice Sessions, and a final session where you will plan your improvements.
The Best Practice Sessions for the Leading Performance Improvement Track are:
How Pfizer Achieves Operational Excellence
What is Culture and How Do You Identify and Solve Culture Problems
What Does Management Need to Know About Process Safety Improvement
Designing Your Continuous Improvement Program
Developing a Fatigue Risk Management Program
Criminal Prosecution of an Accident
Response Lessons from the Joplin Disaster
TapRooT® Implementation Success Stories
But that’s not all. If you choose to, you can customize your Summit experience by choosing to replace some of these sessions with sessions from the other eight tracks, including:
Changing Behavior by Praising the 49 Character Traits
The Day 29 Miners Died: The UBB Mine Explosion
Developing Great Investigators
TapRooT® Implementation, Investigations, and Process Improvements
TapRooT® Users Share Root Cause Best Practices
The 7 secrets of Incident Investigation & Root Cause Analysis
Positive Contributions in Facilitation & Management Interactions
Investigation Process Best Practices
Working Across Languages and Cultures
Using Baldridge Criteria to Achieve Performance Improvement
Don’t miss the sessions that will help you develop a world-class performance improvement program. Get registered today. See:
Last July, a train crash in China killed 40 people. According to CNN, the Chinese government has decided to punish 54 people for their roles in the accident. The story quotes the state-run Xinhua news agency as saying:
“According to a final investigation report, the train crash was caused by major design flaws in train operating equipment, relaxed safety controls and poor emergency response to equipment failure.”
The story also said that the probe:
“…exposed that the Ministry of Railway and the Shanghai Railway Bureau had failed to act properly after the accident and were unable to disclose relevant information on issues of social concern, leaving a negative social influence,”
So who lost their jobs or were disciplined? They include:
Liu Zhijun, the country’s former railway minister
Zhang Shuguang, the railway ministry’s deputy chief engineer
Xu Xiaoming, Guangzhou Railway Group Chairman
Miao Weizhong, China Railway Signal & Communication (CRSC) Deputy General Manager
Zhang Haifeng, Railway Signal Design Institute Chairman
No decision has been made about criminal charges.
No for my question…
If firing people improves safety, shouldn’t China have one of the best safety records in the world? It seems that every accident in China is followed by firings, discipline, and criminal prosecutions. But this doesn’t seem to make performance better.
This course is only offered once a year … so don’t miss out! You will learn advanced trending concepts that will help your management understand what their root cause analysis data is telling them.
The NTSB has decided that texting, e-mailing, or even chatting on a cell phone is too dangerous to be allowed.
Therefore, they are recommending that states pass laws that prohibit all use of electronic devices except those that aid the driver (like a GPS).
NTSB chairman Deborah Hersman said, “No email, no text, no update, no call is worth a human life.”
In one article, Jonathan Adkins, a spokesman for the Governors Highway Safety Association, said the recommendation was a “game changer” but said that, “States aren’t ready to support a total ban yet, but this may start the discussion.”
What do you think? Is a total ban (including all cell phone use) the right answer?
What about other activities that cause distractions?
Sometimes I wonder about the number of things that are now illegal.
Let me know your thoughts by leaving a comment here.
Jay Branson of Delaware OSHA wrote a great article in the December 2010 issue of Process Safety:
“Regulatory Initiative for Improving Process Safety Performance.”
Two key items about incident investigation from the article are:
1. “A key element of process safety is the incident investigation following both severe accidents and near-misses.”
Mr. Branson also writes:
“…investigations become an important part of continuous improvement…”.
This may seem obvious. After all, incident investigation is part of the OSHA PSM regulation. But many (see the next section) don’t do good incident investigations/root cause analysis and miss golden opportunities to avoid major accidents.
2. Mr Branson second comment that I would like to highlight is:
“…there is a wide range of quality of incident investigations.”
Mr. Branson writes that in their regulatory experience (Delaware),
“Some small facilities do not have the expertise
to conduct adequate root cause investigations.”
On the other hand, he writes:
“…large companies may blame the operator rather than admit to management system failures…”.
Of course, we believe in the importance of incident investigation and root cause analysis as a part of any continuous improvement program (not just PSM). The reason we developed TapRooT® was that we saw many programs at big, medium, and small companies that need improvement.
One might have thought that by now, big, medium, and small companies would have found out about TapRooT® and improved their investigations and root cause analysis.
That got me thinking…
Maybe we need to enlist your help?
If you have friends, colleagues, or acquaintances that haven’t discovered TapRooT®, it’s time you had a talk with them.
For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.
Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.
Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.
It was a pleasure to teach and work with this group personally in Hyderabad, India.
If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February. Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.
Dr. Gary Becker, an award-winning economist, spoke at a recent meeting that I was lucky enough to attend. One of the things he mentioned (and is famous for developing) is the idea of “Human Capital.”
Many economists calculate ways to optimize capital. Usually, this capital is money spent for plant facilities (hardware).
But Dr. Becker emphasizes a different type of capital – people or Human Capital.
He asks what companies are doing to:
• Improve human capital?
• Optimize human capital?
• Focus human capital?
• Keep human capital?
• Use human capital to its best advantage?
It seems that many companies forgot about the important investment they had in human capital. They downsized with a vengeance out of fear of the “Great Recession.” Now they find they have a shortage of qualified workers. They can’t find the skilled people they need and they find that the skilled workers they have aren’t loyal after watching coworkers get cut loose in bad economic times.
But have you heard the old saying:
“Better late than never.”
Even companies that didn’t think about the value of human capital during the recession should start thinking about it now.
Ask yourself…
“What are we doing to maximize human capital?”
Here are two action items to add to the list of things your company should be doing:
1.Get people trained to solve problems using TapRooT®.
2.Improve your TapRooT® Investigators’ skills by sending them to a pre-Summit course and the TapRooT® Summit.
The TapRooT® Training and the Summit will produce an amazing return on your human capital investment. The skills learned will be immediately useful for improving performance.
For more info about TapRooT® Training and the 2012 Global TapRooT® Summit, see the TapRooT® web site:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
The picture above is from a airport jet bridge in Frankfurt, Germany.
If you look at the ground level you can just make out the wheels that carry a very heavy load.
You might also notice that they have a guard to keep people away.
Why did I notice this?
Because last year at the Knoxville airport a Delta employee was run over by these wheels. It totally crushed one leg.
There was no guard when the accident happened. Instead, Delta had a policy that all employees should be clear before the jet bridge was moved and stay clear while in motion.
Obviously, this administrative control (SPAC in TapRooT® lingo) failed (SPAC Not Used).
However, a physical guard might be a better safeguard than an administrative control.
Next time I get a chance I will have to see if the corrective action from the Knoxville accident was to add guards on the Knoxville jet bridges.
I had several new TapRooT® Users with safety backgrounds contact me lately to tell me how much TapRooT® influences them in their job.
In addition to helping them find the root causes of accidents, incidents, and near-misses, they said that it helps them:
- make decisions,
- target audits,
- plan improvement efforts,
- explain why safety rules are needed,
- see hazards that they previously might have overlooked,
- understand why rules may be broken (or ignored).
- develop new ideas for effectively enforcing safety rules, and
- have better discussions about safety with others who have also been trained in TapRooT®.
This got me thinking …
Should everyone involved in safety be trained in TapRooT®?
What do you think? Would TapRooT® Training help others involved in safety in their daily jobs?
Then I thought one step beyond that …
Isn’t everyone involved in improvement in one form or another?
Perhaps everyone should be trained in TapRooT®?
Let me know your thoughts by leaving a comment below.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
To answer it, you have to consider the advantages that being the best bring to those who achieve excellence.
1. Reputation. One of the biggest advantages of being the best is the reputation that comes with being the best. The best sports teams enter the playing field with a clear advantage. They set the tempo of the game. They make the other team play to their strengths and emphasize the opponent’s weaknesses.
2. Culture. The reputation of being the best tends to breed an excellence culture. People in the organization won’t accept second best. This culture helps the best stay the best. And that’s an invaluable advantage.
3. Avoiding Complacency. It’s easy to become complacent when you are at the top. That’s why true leaders are constantly striving to be better. They know that excellence is a continuing journey. They can’t rest on their laurels.
Some may think that constantly striving to be better is a cost of being the best. But it is actually a hidden advantage. People who work at the best companies don’t waste time justifying their efforts, arguing against false cost savings, and dealing with the turmoil of constant downsizing and needless reorganizations.
4. Cost Savings. Being the best is cheaper than being second best (or last). This is a counter-intuitive result of being the best. How does this work?
If something does go wrong, the best are better equipped to deal with the emergency. This is in part due to government regulators and the public “cutting them slack” because of their excellent reputation.
Be the Best. Learn the strategies of the best. Where? At the 2012 Global TapRooT® Summit in Las Vegas on February 29 – March 2.
“How is TapRooT® different from other root cause analysis tools?“
While answering the question, I concluded that it was the wrong question. The question should have been:
“Why is it that so many industry leaders have chosen TapRooT®
to be their standard for finding and fixing the root causes of problems?“
It’s not what makes TapRooT® different … It’s what makes TapTooT® clearly superior that should be the focus of the question and my answer.
Some people just don’t get this line of questioning. They say things like:
“Every techniques has its advantages and disadvantages.“
They just don’t understand that people can’t be trained in every technique.
Companies can’t afford to train everyone to be a guru problem solver.
Companies need a “best answer.” A root cause system that has been intelligently designed to meet the needs of the people in the field. People doing real investigations. A system they can adopt as a standard.
The techniques in this standard system need to be “human factored” – designed with the limitations and capabilities of the users in mind.
TapRooT® Design
When designing TapRooT®, Mark Paradies and Linda Unger not only used the human factors expertise that Mark brought to the development, but also worked with outstanding human factors experts (including Dr. Charles O. Hopkins and Smoke Price).
They human factored the TapRooT® System to make it usable. That makes it superior.
But the development efforts didn’t stop there.
Mark got reviews and comments from safety and reliability experts from a number of industries including aviation (Jerry Lederer, father of aviation safety), nuclear power and nuclear weapons (Larry Minnick, nuclear plant safety expert, and Paul Haas, DOE human factors & safety expert), and the oil/petrochemical business (Heinz Bloch, equipment reliability guru).
That’s Jerry Lederer on the left in 1926. I met Jerry in 1990.
Those named are just a sample … not an exhaustive list. There were many more TapRooT® Users who helped in the early TapRooT® development efforts.
This made TapRooT® grow beyond one philosophy – beyond a single industry perspective.
Investigation + Root Cause Analysis
All this knowledge helped us develop not just a root cause analysis system, but something more … an investigation and improvement process that includes built-in human factored root cause analysis and troubleshooting tools.
When people tack root cause analysis on to an already completed investigation, they are missing the power of the techniques to help the investigator collect and evaluate investigative information.
That’s why TapRooT® is not just root cause analysis. TapRooT® is root cause analysis meshed with troubleshooting, an investigation process, and performance improvement processes (both reactive and proactive).
The whole system is made to work together seamlessly.
That’s different and superior!
Don’t Start Off Looking for “Why?”
I don’t want to give away all the secrets that make TapRooT® superior, but I will share a few more that should help people trying to decide if they should attend TapRooT® Training.
First, unlike many root cause analysis tools (think 5-Why’s or any cause-and-effect based system), TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.
That’s a key difference.
One of the big drawbacks of many systems is that people using them jump to conclusions about why something happened before they understand what happened. It’s a natural human tendency. In fact, the more knowledge about a problem someone is, the more likely they are to think they automatically know the answer.
In TapRooT®, an investigator’s first goal is to build a complete SnapCharrT®.
A SnapCharT® visually shows what happened and as much information as can be gathered about the factors that surrounded what happened before one starts looking for root causes.
Users find this initial focus a major advantage because it helps them avoid the “blame trap” and the trap of jumping to conclusions.
Expert System Helps Investigators See Beyond Their Current Knowledge
The next major advantages of TapRooT® is the way TapRooT® looks at root causes and the tool used to guide investigators to the root causes of the problems causal factors.
In TapRooT®, we realized that accidents aren’t quite like falling dominoes. In fact, most accidents have multiple causes that existed prior to the accident and just never came together in the exactly wrong fashion at one point in time to cause the accident. Sometimes people call this coincidence “bad luck.” Engineers and statisticians may think of using Monte Carlo methods to simulate the seemingly randomness of real life.
Because of this, TapRooT® encourages investigators to identify all the causal factors and to find each causal factor’s root causes. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each causal factor that contributed to an accident.
Think about this as multiple opportunities to improve performance by improving multiple defenses to keep accidents from happening.
The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. Nobody has anything close to our tree.
Most of the development effort of the Root Cause Tree® was focussed on helping people in the field find the causes of human performance (including behavioral) problems.
The Root Cause Tree® is unique in the guidance it gives investigators in analyzing human performance issues including an expert system to start the troubleshooting of human errors, the categorization of best practices that is embedded in the tree, and the guidance for each category built into the Root Cause Tree® Dictionary.
Some say that the goal we set out for the Root Cause Tree® is impossible to achieve. We wanted to capture 90 – 98% of the root causes of human error in the categories on the tree. They say that it is impossible to include ALL the causes of human error in a model. Instead, they say that one should start out with an open mind and analyze each problem from scratch.
There are two problems with this argument.
First, the human brain thinks categorically. For example, the language we use to describe an accident is based on words (categories). So even if you try to start with an open mind, your brain is already categorizing.
We have found that the vast majority of investigators have not had specialized training in human factors. Therefore, they don’t know what they should be looking for (they don’t have the categories in their brain). This makes it almost impossible for them to identify the causes of human errors and develop effective corrective actions.
That’s why they revert to the standard answers of blame (counseling and discipline solutions), training, and, when all else fails, writing a procedure. It’s not that these answers are always wrong. It is that these answers are just a small fraction of what needs to be done to improve human performance. And the Root Cause Tree® provides a much more complete answer.
Second, we never said the Root Cause Tree® has all the answers.
The Root Cause Tree® is just the best list we’ve ever seen. We think it is closer to the 98% end of the scale than to the 90% end. And we know it is much more complete than the answers in the models carried in the heads of the people who come to our training. Thousands of users that we train each year tell us that TapRooT®’s Root Cause Tree® expands the universe of problems they can find and solve …. It does not restrict their problem solving efforts.
Having designed TapRooT® and spent over 20 years improving it, I could go on with other major and minor advantages that we’ve worked so hard to incorporate into the TapRooT® System. But I’ll stop here with one more reason that TapRooT® is superior…
Continuous Improvement
We started with a great design but we didn’t stop.
We search for and implement ideas that make TapRooT® ever better, including ideas from international experts and our TapRooT® Advisory Board (60+ people from industry leading companies).
Better training, better software, and better techniques.
Continuous improvement keeps TapRooT® the state-of-the-art in root cause analysis and makes it superior.
TapRooT® as Your Root Cause Analysis Standard
Of course, there are more advantages to using TapRooT® – reasons that industry leaders around the world have standardized on just one method of root cause analysis. But by now you are probably thinking…
“Why haven’t we standardized on TapRooT® yet?”
Seems like a great idea.
Get started by attending one of our public TapRooT® Courses.
Attend a TapRooT® Course. Go back to work and apply what you have learned. If you don’t find root causes that you previously would have overlooked and if you and your boss don’t agree that you develop better corrective actions that are more effective, just return the course materials and any software supplied and we will refund the entire course fee.
That’s how confident we are that you will feel the difference.
TapRooT® isn’t just different, it’s superior.
Already Using TapRooT®? Get Better!
How do those that already use TapRooT® keep up with the newest TapRooT® improvements to sustain their programs and build on their success?
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Had a great meeting learning about behavior based safety applications in Europe.
The meeting was hosted by Diageo in Dublin. Diageo makes Bailey Irish Cream and Guinness (among other world famous drinks).
The meeting included tours of the Baileys Irish Cream production facility and the Guinness Warehouse (an international tourist destination in Dublin).
Employes of Diageo shared their stories of success and safety and health managers from around Europe shared their ideas about behavior based safety and safety improvement in general.
Why does Mark (President of System Improvements) travel to Europe to attend a meeting on health and safety? Because we at System Improvements think it is important to incorporate the latest international best practices and ideas into TapRooT®. That’s why you will see key System Improvement employees at conferences around the world. We believe that keeping up with the ideas that are developing in health and safety, quality, equipment reliability, and human factors is the only way to make sure that TapRooT® stays the state of the art in root cause analysis.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
“The distracted tugboat pilot who crashed a barge into a sightseeing “duck boat,” killing two tourists, was sentenced Tuesday to a year and a day in prison for his role in the incident, federal prosecutors said.”
The story also said:
“Devlin admitted that he was distracted by his cell phone and laptop for an extended period of time before the collision, that he piloted the Caribbean Sea from its lower wheelhouse where he had significantly reduced visibility and that he did not maintain a proper lookout or comply with other essential rules of seamanship, according to federal prosecutors.”
But there is more …
“The morning of the accident, on July 7, 2010, Devlin’s 6-year-old son was undergoing routine eye surgery when he experienced complications including a laryngospasm — which led to partial oxygen deprivation for eight minutes. Devlin’s wife said she panicked and called her husband, who was at the controls of the tug at the time, according to KYW.”
And even more …
“The sightseeing “duck boat” was anchored in the shipping channel after being shut down because the boat’s operator saw smoke and feared an onboard fire.”
Multiple causal factors and probably multiple opportunities to avoid this fatal accident.
Now the question:
Will Prison Time Keep Future Accidents From Happening?
The story ended with:
“Lawyers who represented the families of the two victims released a statement in July saying the families ‘are gratified that federal prosecutors have acted to hold one of the responsible parties accountable in this tragedy that should have been avoided.‘”
Should we seek prison time for those involved in accidents?
Two people who have faced criminal prosecution will discuss their personal experience in the “Criminal Prosecution of Accidents” session in the Leading Performance Improvement Track. To see the track schedule, click on the button for that track at:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” your Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
The UK Rail Accident Investigation Branch has published a report about a train derailment in Summit Tunnel, near Todmorden, West Yorkshire, UK.
Here’s the summary from their press release:
In the early hours of 28 December 2010, a passenger train was travelling from Manchester to Leeds when it struck a large amount of ice that had fallen onto the tracks from a ventilation shaft in Summit tunnel. All wheels of the front bogie were derailed to the left in the direction of travel causing the front driving cab of the train to strike the tunnel wall. The train remained upright and once it had stopped, the train crew took action to protect the train and raise the alarm. About three hours later, the passengers and train crew had been led out of the tunnel by the emergency services. No injuries were reported, while the train suffered damage to its cab windscreen, a coupler, bodywork and underframe. There was minor damage to the track.
The ice formed as water, seeping through the lining of a ventilation shaft, froze during a long period of freezing temperatures. This ice fell onto the track after a thaw which started on 27 December 2010. The train, which was the first to pass through the tunnel in over three days due to the Christmas holiday period, then collided with it. A combination of factors led to this accident:
the risk of ice, particularly ice falls onto the track, was not identified before the train service resumed so the train was allowed to enter Summit tunnel while running at its maximum permitted speed; and
the routine maintenance regime did not identify excessive ice in the tunnel and no additional inspections were carried out.
The RAIB has made five recommendations, all directed to Network Rail.
The first recommendation relates to how water in Summit tunnel is managed.
The second is about identifying those structures which are at risk from extreme weather and then checking they are safe to use after periods when no trains have been running.
The third calls for the potential hazards due to extreme weather and thaw conditions to be taken into account in Network Rail’s weather management processes.
The fourth calls for training and information to be given to staff who need to carry out the additional inspection of structures that are at risk in extreme cold weather.
The fifth relates to the management of safety related information (and details of actions taken) that is passed from Network Rail’s buildings and civils – asset management function to other parts of the company.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Also, see this link for information about the Fatigue Risk Management Course that Circadian Technologies is providing prior to the 2012 Global TapRooT® Summit being held in Las Vegas:
“The brass still doesn’t know why a dozen Raptor pilots blacked out and one fatally crashed, prompting the May 3 no-fly order. Officials suspected the oxygen system aboard the $300-million, radar-evading superfighter. Ground crews starting up the jets in sealed, garage-like hangars might also have been a factor. After months of study, the Air Force still can’t say for sure.”
The Air Force has decided that they know enough about the failures to resume flight. Air Force Chief of Staff General Norton Schwartz ” … ordered careful monitoring of the jets and their pilots as the F-22 training system slowly cranks back into gear over a period of months.”
Have you ever had this happen? An accident investigation where you could not find root causes?
What kind of advice would you give the Air Force (or anyone else) who had trouble finding the root causes of a serious problem that could cause additional fatalities and the loss of high dollar assets?
By getting childhood immunizations, kids avoid serious diseases. Even adults know to get flu shots to avoid most of the misery of the flu season. That’s prevention!
Of course, prevention requires effort. You have to get the shot. And sometimes there’s a minor reaction (a sore arm, headache, or mild discomfort). But overall, the effort and pain are worth it. You avoid the disease.
What does this have to do with accidents? The analogy of vaccination to prevent a disease is a proactive improvement program to prevent an accident. So let’s look at ways to become proactive and get immunized against accidents.
Step 1: Define the Disease
Before you develop a vaccine, you need to understand the virus. In proactive improvement, you need to understand what you are trying to prevent. For example, you can’t just say you want to improve safety. You have to be more specific. Are you trying to prevent fatalities? Are these fatalities caused by industrial hazards or process hazards? That makes a difference in the type of proactive improvement program you develop because industrial accidents and process accidents don’t have the same types of causes.
To define the disease, look at the causes of past serious problems at your facility and at similar plants in your industry. Also, consider experience from other industries. Even though they produce a different product or service, they may have similar hazards or equipment. And every industry shares at least one commonality – people. Thus, major accidents in a large variety of industries can help you learn about the diseases that your plant may face.
Step 2: Develop a Vaccine Proactive improvement “vaccines” are proactive efforts to spot problems & fix them before accidents happen. They can be “desk-based” exercises (for example, an FMEA or a HAZOP). Or they can take place in the field (a behavior-based observation or an audit).
I prefer the field-based assessment activities because they tend to be “reality based.” That is, they tend to catch bad practices in the field that desk-based exercises tend to overlook.
Developing a good observation, assessment, or audit program is difficult. People may put on a show. Observers may not know what to look for. To get ideas about setting up a truly effective, proactive improvement program that uses root cause analysis to develop effective improvement ideas (corrective actions for observed problems), read Chapter 4 of the TapRooT® Book. You will learn best practices you can apply.
Step 3: Get Your Shots!
A vaccine can’t work if it isn’t administered. And a proactive improvement program can’t work if the proactive improvement activities aren’t performed.
Corrective actions have to be implemented or they can’t work. I’ve seen major accidents that could have been prevented by corrective actions that had been developed, approved, and were waiting to be implemented. Getting a corrective action added to the list of backlogged corrective actions won’t stop an accident!
Problems won’t solve themselves. Just like parents have to get their kids to the doctor to get their shots, management has to watch over the proactive improvement program to make sure the activities are happening, the tools are being used effectively, and the corrective actions are getting implemented.
Get More Ideas
If you have a proactive improvement program and you are looking for more ideas to strengthen your vaccine, I have two ideas…
1. Attend the Leading Performance Improvement Track at the Global TapRooT® Summit in Las Vegas on February 29 – March 2, 2012. See the track details at:
You get the call that there has been an incident that needs to be investigated. So, you begin mapping out the SnapCharT®, performing the root cause analysis or developing the corrective actions and this happens (Watch Video):
Never fails, too many Type “A” personalities in the room, and you are the one who has to facilitate the team. It does not matter whether you have a Type “A” or “B” personality, it can get ugly if it is not handled correctly, especially if someone was hurt (or worse) or if the company lost a lot of money. So what to do …
Here are a few facilitation hints:
1. Define who the team lead is upfront. (This prevents an Accountability NI issue.)
Note that the investigation facilitator does not have to be the one who is in charge. After all, the facilitator’s true role is to facilitate the TapRooT® 7 Step Root Cause Analysis Process, not necessarily the team members themselves. It can also help if the facilitator is a neutral person not familiar with the incident or process being investigated.
2. Allow all members to introduce themselves … often new people are introduced into an established team. The introduction gives a person, new or shy, the platform to speak up later.
3. While developing the SnapCharT®, (or time line for friends new to our process), ensure that all the people, equipment, and process actions that occurred are listed, whether people think they are an issue related to the incident or not. You can make a movie with a good time line of events.
Note that this enables the good actions of all members, divisions, contractors, clients and owners to be listed as well and removes some of the blame and finger pointing that can occur.
4. While using the Root Cause Tree Dictionary, Root Cause Tree and SnapCharT® to find Root Causes for your Causal Factors, it is never an “I am right ” or “You are wrong” discussion. Unknown to untrained TapRooT® team members, the facilitator has carried in the “Arbitrator”!
Great, another “A” type in the group you say? Well, yes and no, the “Arbitrator” is the Root Cause Tree Dictionary.
The Root Cause Tree has lots of experience and knowledge to gently nudge any group into the right choice. It comes with some explicit rules … facts, facts, facts! You select a root cause because it related to or impacted a particular Causal Factor. A Root Cause is not selected because you have already decided on what you want the corrective action to be. It is also not ignored because you think you cannot change it. Root causes are just the facts.
Here is an example of how the Root Cause Tree Dictionary arbitrates and removes the emotion for the Causal Factor of “Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.” This is just one of the Causal Factors for the Incident of a motor being damaged with lots of downtime costs.
Two team members are in a heated discussion as to whether the Operator could detect or could not detect the contamination while opening the valve …
One team member who believes that the Operator had the knowledge of the contamination in the line is focused on what was seen after the fuel supply system was opened up.
The other team member believes that the Operator could not see inside the system while opening the valve.
You, (as the facilitator), walk up to the arguing pair and without telling either member who may be right or may be wrong, you say, “Open up the Root Cause Tree Dictionary and tell me which fact (condition on the SnapChrarT®) matches the bullet in the Root Cause Tree Dictionary.” Now state the fact and say, “this relates to why the Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.”
By focusing on the facts as known by the operator at the time he was opening the valve, the contamination was unknown and not detectable. The contamination was identified after the fact and only after taking apart the manifolds and valve.
The “Arbitrator” saves the day again with emotions and opinions removed!
Try these steps and also let me know in the comment section, what else you have done to reduce bias and emotions during your investigation facilitation.
Then attend a TapRooT® Course to learn about SMARTER corrective actions.
Part of the SMARTER evaluation is to review the corrective action for unintended consequences.
But the person who develops the corrective action can’t do the review for unintended consequences. That needs to be dome by someone independent who really understands the process/job being modified.
Rest on your laurels. After all, your safety, quality, six sigma, lean, TPM, patient safety, or other improvement programs are good enough. You should leave well enough alone. Your company meets the minimum regulatory requirements (and maybe exceeds a few). Everyone has heard the saying:
If it ain’t broke, don’t fix it.
Sit back, relax, and wait for a crisis to cause you to jump into action.
What? Wait for a crisis? Sure. That’s what people who are complacent do.
Of course, during a crisis, heads may roll. Plant managers get transferred to “special projects.” Safety, operations, & maintenance managers get fired. And companies get a black eye from the negative press. You know the names of companies that have waited for a crisis to start improvement. They are famous (in a bad way) around the world. Ben Franklin would remind them that they are:
Penny wise; Pound foolish.
Think about the risks of waiting for a crisis to improve and you will decide that complacency is a bad idea.
How to Improve
To improve, you need a plan. It should be written, measurable, and sponsored by senior management. To be a sponsor, senior management must believe in continuous improvement of the improvement program. You must get the right senior manager sponsor and they need to see the plan as their plan. If the plan is their plan, they will pay attention!
Get Sponsorship
Why is getting sponsorship difficult? Because management has limited attention. A limited number of “silver bullets.” They must pay attention to the most recent crisis, plus the current hot topic from their boss. Plus, there are always budget troubles and production snafus to worry about.
Their crisis focus keeps them from being proactive and focusing on long-term improvement. They may forget what’s important, proving the saying:
When your up to your a##
in alligators, it’s hard to remember that the objective
was to drain the swamp.
If you’re lucky, you have progressive management that thinks ahead. They support, or even require, continuous improvement of improvement programs.
But what if you are unlucky? You must make improving the improvement program a crisis. That’s what I had to do when I was working at a plant where the plant manager said:
“I don’t need a prioritization system
to prioritize improvements,
I need a prioritization system
to prioritize my crises!”
I made improving the improvement program a crisis by having the regulator require it and then getting it tied to 50% of the executive’s annual bonus. If the improvement program failed to improve, he lost ½ of his bonus. Now that’s a crisis!
Program Analysis
What do you improve first?
Good question. To answer that question you need to network and benchmark state-of-the-art improvement programs to identify areas to improve.
I’ve heard people say, “We do Six Sigma. We don’t need to improve.”
Six Sigma was developed in the mid-80’s. That was before most people had even heard of the internet. Engineers graduating from college right now hadn’t even been born! Six Sigma programs need to be improved just like any other improvement program.
All managers in charge of improvement programs need to network with industry leaders to learn new tricks and refine their improvement systems.
Where can you find industry leaders in one place? At the Global TapRooT® Summit in Las Vegas on February 29 – March 2, 2012. The Summit is famous for bringing improvement experts, industry leaders, and people who want to benchmark across industries together. See the Summit details at:
All improvement programs need a state-of-the-art root cause analysis system. Improvement programs use root cause analysis both reactively (to solve problems) and proactively (with audits / assessments / observations to prevent problems from becoming incidents).
TapRooT® is the state-of-the-art in root cause analysis. It’s continuously improved. If you learned TapRooT® years (or a decade) ago, you’re behind the times! Catch up!
Next? Take the Advanced TapRooT® Techniques Course before the 2012 Global TapRooT® Summit and attend the Incident Investigation, Troubleshooting, and Root Cause Analysis Track at the Summit. I guarantee that you’ll leave with ideas to improve root cause analysis. We even end the Summit with a session to develop a plan.
Never Stop Improving
Don’t become complacent and let the next major accident happen at your facility. Do all you can to keep improvement progress happening. Resist complacency! As Winston Churchill said:
Never, never, never give up!
Make continuous improvement your top priority and know that success will follow.
Circadian Technologies has published a white paper titled:
The Advantages & Disadvantages of 12-Hour Shifts:
A Balanced Perspective
Their press release states:
“12-hour shifts remain a much-debated topic in 24-hour operations. Do they cost more than 8-hour shifts? Are they safe? What impact do they have on alertness, health and productivity?
CIRCADIAN®, the global leader in providing 24/7 workforce performance and safety solutions for businesses that operate around the clock, has collected considerable data on the benefits and complications of 12-hour shifts. The goal of this white paper is to provide you with a balanced perspective of 12-hour shifts – one that will examine the pros and cons from both a management and shiftworker perspective.”
Here’s the link to register to receive this report:
being held on February 27-28, 2012, in Las Vegas just prior to the TapRooT® Summit.
This training, being provided by Circadian Technologies, will help you:
• Design and implement a cost-effective Fatigue-Risk Management System
• Assess the risks and costs of fatigue in your business
• Determine safe staffing levels and optimal shift/duty patterns for your operation
• Train employees and supervisors to mitigate fatigue risk
• Improve employee health, safety, and quality of life
Also, the Summit (February 29 – March 2 in Las Vegas) has two sessions on fatigue as well as other sessions on improving human performance. Don’t miss it!
“Halliburton on Thursday filed claims against BP in Texas state court for negligent misrepresentation, business disparagement and defamation related to the Deepwater Horizon incident on April 20, 2010.”
Also:
“These allegations are based upon BP providing Halliburton with inaccurate information prior to performing cementing services on April 19, 2010, and BP’s use of and omission of that information in subsequent public statements, filings and governmental investigations, according to Halliburton officials.”
“Halliburton said it learned that BP provided Halliburton inaccurate information about the actual location of hydrocarbon zones in the Macondo well.”
Seems to me that it’s much easier to prevent an accident by using advanced root cause analysis to learn from operating experience than it is to litigate after an major accident. Maybe that should be the #1 lesson from the tragic Deepwater Horizon accident.
I learned about the techniques in Dr. Donald Wheeler’s excellent courses on the use of data in quality control. We took the lessons from Dr. Wheeler and applied them to infrequently occurring data (like safety data) and built a course to teach the methods to TapRooT® Users.
If you really like reading about trending I would suggest two reading assignments…
FIRST, read Chapter 5 of the 2008 TapRooT® Book (the black book).
If you prefer live instruction about trending and a chance to try the techniques and be tutored, plan on attending the pre-Summit 2-Day TapRooT® Advanced Trending Techniques Course on February 27-28, 2012, in Las Vegas.
At the course you will get a copy of one of Dr. Wheeler’s books and get a chance to use advanced trending techniques on real data. plus you will develop a plan to improve your data and make use of it to improve performance.
I was reading an article about industrial safety in the UK. They were trying to make a link between the budget cuts for the UK Health and Safety Executive and increased fatalities in the UK in from June 2010 to June 2011. The 16% increase in fatalities caused some to call for a change in policies by the government.
This started me thinking … What is a real trend?
Of course, to each of the 171 workers who were killed and their loved ones, each fatality was a disaster that needed to be prevented. But does the number of fatalities increasing from 147 to 171 represent a real trend or just common, everyday variation – noise in the system – that doesn’t really prove anything.
There is a way to tell. The math and trending techniques to judge trends was developed back in the 1920′s by Dr. Walter Shewhart. It’s the same mathematical techniques used by Deming to improve quality and most six sigma programs.
All one has to do is to develop a Process Behavior Chart (see Chapter 5 of the TapRooT® Book for examples of these charts and the math required) for the past 20 years or so of data from the UK. One could then calculate the standard deviation of the data from one year to the next and the chart’s limits would show if a statistically significant trend exists.
Of course, a trend would not prove the relationship between fatalities and UK HSE budget cuts. Other factors could be more important. For example:
The general increase or decline in economic activity.
Influx of non-English speaking workers, especially in more hazardous industries, into the UK.
Company budget cuts that influence safety performance.
Management attention shifting from safety performance to other activities (especially in a bad economy).
Changes in overtime after downsizing or layoffs.
That brings up another point about trends. The more statistics are “averaged” the less the statistics mean.
For example, what if we looked at industrial fatalities on a worldwide basis? What would year-to-year variation mean to us? Almost nothing. Increases in one country could be overshadowed by decreases in another. My belief is that national statistics are almost useless for improving performance. At best, they are a fairly insensitive barometer to the general trend of safety performance if viewed over a number of years. (in general, you will see a decrease in the numbers, but the progress probably won’t be even.)
That should start you to think about your statistics and how you are using them.
Corporate statistics aren’t as useful as site statistics. And breaking site statistics down by looking at statistics by work type can make the trends even easier to detect. Plus, once a significant trend is detected, one will be able to draw causal implications much more easily.
Do you want to learn the math behind using trends properly and then plan to apply trending to your company’s operations? Then sign up for the 2-Day Advanced Trending Techniques Course, February 27-28 in Las Vegas, being held before the TapRooT® Summit. For more course info, see:
Just click on the course link above to get more information and to register.
Also, Bill Sirois, COO at Circadian Technologies, will be providing two talks about fatigue and fatigue risk management at the TapRooT® Summit. For complete Summit info, see:
