Once a year we offer a special class that teaches the TapRooT® Software called “Getting the Most from Your TapRooT® Software.”
This year the course is in Las Vegas on June 23-24.
This course is an intensive review of the TapRooT® Version 5 Enterprise (web) Software including:
- installation,
- configuration,
- data migration (from Version 4),
- administration,
- best practices,
- custom reports, and
- future release information.
Learn all the capabilities built into the amazing TapRooT® Software.
If you are a TapRooT® Power User or Software Administrator, don’t miss this course. Sign up at:
Portland, Oregon opened its doors to 30 employees from various industries attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis course. If you have never attended a TapRooT® public course and want to, who might you be be sitting next to? Here are the companies that attended our Portland course:
U.S. Mint
Intel Corporation
Alaska Airlines
Tidewater
Sause Bros.
Virgin America
Duke Energy Corporation
Southern California Edison
Lawrence Berkeley National Laboratory
Tyco Thermal Controls
Intrepid Potash
…. Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) teaches the difference between facts and events.
…. good investigation teams communicate and stay focused.
…. no blame… just the facts during the what phase of investigation.
…. facts…. facts… facts; you get it right here and your root causes and corrective actions stay connected to the true problems.
…. we teach…. you learn…. you practice …. we guide.
The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is the world’s premier root cause analysis training. On top of that, it’s an amazing value. Why do I say that?
1. TapRooT® is the root cause system chosen by industry leaders worldwide. This course teaches all the TapRooT® root cause analysis tools. For a few success stories from users, see:
- innovative, yet proven methods to change behavior,
- how to present investigation results to management,
- how to avoid common mistakes when trending addcident/incident data,
- advanced corrective action development techniques, and
- proactive performance improvement.
3. Attendees receive the patented TapRooT® Software. The course fee is only $2395. The software alone costs $1495. That makes the 5-Day TapRooT® Course an exceptional value.
Our special offers make the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training an even more outstanding value. The special offers include:
1. Prior Course Attendee Discount: Prior 2-Day TapRooT® or 3-Day Equifactor® Course attendees get a $500 discount off the course fee.
2. Licensed Site Discount: Attendees from a licensed TapRooT® Site/Com¬pany qualify for the $500 discount.
3. Multiple Course Attendee Discount: If you sign up 3 or more people at one time for a 5-Day Course, you get a $100 discount for each person.
The maximum discount is the $500 discount plus the $100 discount.
If your folks qualify, they could attend the 5-Day TapRooT® Course for just $1795 each. These special offers make the 5-Day Course an even greater value! For course info, locations, and dates, see:
This week we have a full 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Knoxville. I was teaching with Linda Unger, VP at SI, on Monday and too these “action” photos of the class listening, learning, and participating.
Why are so many people from industry leading companies attending TapRooT® Training? Because TapRooT® is so effective finding and helping people fix the root causes of problems. Also, our courses are interesting, fun, and effective.
Marco Flores, one of our Spanish speaking instructors, taught a TapRooT® Refresher Course for TapRooT® Users at Occidental in Columbia (pictured below). With the new TapRooT® Book coming out in April, now is the time to schedule refresher courses for your TapRooT® Users during the summer. Use the CONTACT US button above or call 865-539-2139.
Just one final exercise left and these students will be ready to tackle tough incident investigations, quality issues, equipment failures, and plant upsets.
It’s morning in Amsterdam and the class is hard at work on their first SnapCharT®. By the end of the week they will be ready to investigate difficult accidents, incidents, quality problems, and equipment failures.
For those that aren’t aware, I am the Summit Chair and with the help of the TapRooT® Advisory Board, the Track Chairs, the staff at System Improvement, and previous year Summit participants (that a lot of help!), I plan the TapRooT® Summit.
I also hand pick the courses that are offered prior to the Summit - this year on June 23-24. I pick these courses based on the experience I have with performance improvement programs around the world. My goal is to put together a world-class selection of courses that will help people solve their toughest problems.
Each year I bring back some old favorites and some brand new courses.
The old favorites are based on previous attendance and feedback.
The new courses are based on requests from participants and problems that I observe in my extensive travels.
This year there are three new courses:
1. Hazard Recognition Best Practices
2. Engineering Equipment Reliability Techniques
3. TapRooT® and FMEA for Healthcare Root Cause Analysis
There are also, eight returning veterans:
1. Advanced Trending Techniques (10th year)
2. Innovation & Creative Solutions (2nd year)
3. Stopping Human Error (5th year)
4. Risk Management Best Practices (5th year)
5. Interviewing and Evidence Collection (3rd year)
6. Getting the Most from Your TapRooT® Software (2nd year)
How often do you review your corrective actions for unintended consequences? If you see “bugs” in your corrective action board, think about attending one of our TapRooT® root cause analysis system courses, training that helps solve problems both reactively and proactively. We can show a proven SMARTER process before a corrective action becomes another incident.
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.
Stopping human errors should be a prime part of any improvement program. And learning about human error reduction and behavior change best practices is what the Human Error Reduction and Behavior Change Best Practice Track at the TapRooT® Summit is all about.
Here are the sessions and speakers that make up the track:
Character Driven Success - Dr. Beverly Chiodo, Texas State University. Dr. Chiodo was one of the most highly praised speakers at last year’s Summit. So we brought her back this year to speak about changing behavior in two sessions. Don’t miss her inspiring, insightful, and useful techniques that you can apply to get Character Driven Success.
Changing Behavior by Praising the 49 Character Traits - Dr. Beverly Chiodo, Texas State University in Safety
Advanced Behavioral Management: Developing a Modern Safety Culture - Bob King, Director HSE Training/Consulting, Woodland Grange, UK, & Neil Roberts, Consultant, Woodland Grange, UK. Advice on achieving a modern safety culture from two highly regarded UK safety experts. The Human Design Spec - Minimizing Human Error While Working in a 24/7 World - Bill Sirois, VP, Circadian Technologies. When analyzing the causes of human eror, do you consider fatigue? What can you do to reduce fatigue and thereby reduce human error. Bill will share effective ideas and the latest research to help people reduce errors in 24/7 operations.
Latest Human Performance Improvement Ideas from the Institute of Nuclear Power Operations - Tom Kriesel, Senior Evaluator, INPO. Hear the latest ideas that are helping the nuclear industry achieve outstanding human performance.
Human Performance Improvement Research - Valerie Barnes, US Nuclear Regulatory Commission. Val Barnes, human performance researcher, will share the latest human performance research issues being investigated by the US Nuclear Regulatory Commission.Human Performance Improvement:
1) Proactive Human Performance Improvement - Chris Vallee, System Improvements. Why wait for accidents to point out human performance improvement needs? Look for human performance problems (and their root causes and corrective actions) proactively.
2) Exelon’s Error Free Performance Tool - Renee Jourdin, Exelon. Techniques that prevent errors are used to achieve “error free” performance during utility maintenance/repairs. Find out how you could adopt these techniques to reduce human error.
Innovative & Creative Solutions - Michele Lindsay, Principal Consultant, P2, Canada. Do you keep using the same old corrective actions to improve human performance? Try innovative techniques to develop effective, creative solutions. Michele will share ideas from her highly praised two day class.
Planning Your Improvements -This session provides you with the opportunity to organize the best practices that you have learned into an sure-fire improvement plan. Get expert advice from experienced TapRooT® Instructors and benchmark you plan against the plans from other industry leaders. These sessions are in addition to the General Session talks by these great 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
But there’s one more thing that may interest you. There are courses on Monday/Tuesday before the Summit. The Stopping Human Error Course by Joel Haight, ‘05 ASSE Outstanding Safety Educator, teaches advanced techniques to analyze and stop human errors. This is more than an academic course. Dr. Haight brings 19 years of oil and petrochemical industry experience (including overseas operations) to this course. Learn the latest human factors research and practical, industrial approaches and get the book Human Error Reduction and Safety Management.
Of course, Stopping Human Error is just one of the Pre-Summit Courses. Other potential courses that may interest you include:
Innovation & Creative Solutions TapRooT® & FMEA for Healthcare Advanced Trending Techniques Stopping Human Error Hazard Recognition Best Practices Getting the Most from Your TapRooT® Software
Risk Analysis & Risk Management How to Interview & Gather Evidence Equifactor® Equipment Troubleshooting & Root Cause Analysis TapRooT® Incident Investigation & Root Cause Analysis Equipment Reliability Techniques
For more information on the Summit and the pre-Summit Courses, see the Summit web site at:
A story in CIO magazine says that a survey (by the consulting firm Deloitte of 100 technology, media, and telecommunications firms worldwide) listed “Human Error” as the leading cause (75% of the time) of security failures.
If this is even remotely true, these firms need advanced root cause analysis - TapRooT® - to analyze their human error incidents and find the real root causes of “human error.”
As we see it, human error isn’t a root cause. It is a starting point to dig into the cause of the human error. We see most human errors as Causal Factors and use the Root Cause Tree® to dig into the real, fixable root causes of the problems that cause the human error.
Unless you find the real root causes of human error, it’s doubtful that you will develop effective fixes. Without effective fixes, the problem will continue to trap people even if they are trying to be careful.
The 5-Day Course really gets into the causes and investigation of human error. It is based on advanced human factors knowledge derived from research from around the world. Where are these courses held? Here are some upcoming locations and dates:
Charleston, SC March 3-7
Galveston, TX March 10-14
Amsterdam March 10-14
San Antonio, TX March 31 - April 4
Knoxville, TN April 21-25
Singapore May 5-9
Aberdeen, Scotland June 9-13
Here’s some pictures from the course that Mark Paradies and Chris Vallee are teaching…
Chris teaching…
Class listening intently…
Group exercise - spirited debate and learning!
If you haven’t attended a TapRooT® 5-Day Course, you are missing an opportunity to learn advanced root cause analysis that can help your company improve!
This is just another example of the types of accidents that need thorough root cause analysis to make sure that the problems that caused the accident get fixed.
But let lesson from this accident might not be obvious to everyone. Why did this accident have to happen? A good proactive improvement program could have spotted this hazard and fixed it before anyone was hurt.
Proactive use of root cause analysis is a much more efficient and effective way to improve. It’s much better than waiting for accidents to point out safety problems for reactive root cause analysis.
If you are interested in proactive root cause analysis, there are two ways to learn more.
First, attend a 2-Day or 5-Day TapRooT® Course. You will learn to apply the highly acclaimed TapRooT® System to find root causes of accidents (reactively) or to find the causes of problems before accidents happen (proactive improvement).
Will the results of your root cause analysis be more of the same? You know what I mean … More Training, More Firings (or demotions), and/or More Procedures.
Or will you find the real root causes and develop effective corrective actions?
If you haven’t attended our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course, you need to soon to be ready to investigate accidents, incidents, quality problems, equipment failures, and other operational issues and find and fix their true root causes.
Where can you attend a course in the near future? You can have a course at your site (contact us by clicking here). Or you can attend one of our public courses:
Edmonton, Canada January 21-25
San Diego, CA January 28-February 1
London, England February 4-8
New Orleans, LA February 4-8
Singleton, Australia February 4-8
Halifax, Canada February 25-29
Vancouver, Canada March 3-7
Charleston, SC March 3-7
Galveston, TX March 10-14
Amsterdam, The Netherlands March 10-14
San Antonio, TX March 31-April 4
Knoxville, TN April 21-25
I read the following in the trade publication Machinery Lubrication (November 2007): A multi-industry study published by the National Research Council of Canada showed that particle contamination was the root cause of 82 percent of wear-related failures.
My first thought was … Where did they get these statistics? Very few companies do a formal root cause analysis of every equipment failure.
My second thought was … Particle contamination isn’t a root cause!
Particle contamination would be a Causal Factor - just the start of the root cause analysis process in the TapRooT® System. There could be many causes of the contamination.
Want to learn a systematic process for finding the root causes of equipment failures? Attend the 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Course.
You can schedule a course at your site for 10 or more attendees or send folks to one of our public courses:
Galveston, TX January 15-17
Lake Charles, LA January 23-25
Aberdeen, Scotland January 30-February 1
Edmonton, Canada February 20-22
Perth, Australia February 20-22
Melbourne, Australia February 27-29
Bogota, Columbia March 5-7
Calgary, Canada March 10-12
Houston, TX March 26-28
Christchurch, New Zealand March 31-April 2
Linda, Chris, Ken and I are teaching two 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course in Las Vegas this week. Ken will also be teaching the Equifactor® Equipment Troubleshooting techniques.
Teaching great courses isn’t all that we are doing in Las Vegas. Katherine, our meeting planner, also is here and we are planning the details of the TapRooT® Summit (Las Vegas on June 25-27, 2008).
I thought that I should let readers know what we are doing so that you can start your planning for the Summit. This isn’t planning for the technical sessions (that’s done and I’ll share that next month). This is planning for the location and the fun we are going to have.
First, we are at the Westin Casuarina at 160 East Flamingo in Las Vegas. The hotel is just a block and a half off one of the busiest intersections on the strip. An easy walk and you are at Bally’s, the Bellagio (and their fountains), and Caesars Palace.
The hotel is nice - great soft beds, double-headed showers, and a friendly staff. And the TapRooT® Summit rate ($155/night) is a good value.
The hotel has a small casino (compared to some of the mega-casinos). It will be easy to network with others attending the Summit.
What is there to do in the area at night after the Summit concludes? Tons.
Every time I come to Las Vegas I marvel at how much there is to do. The shows are amazing. Of course, there are the standard Vegas shows. But there are also Broadway shows, famous entertainers, magic, and comedy, including:
Toni Braxton
Cirque de Soleil (”O”, Mystere, Zumanity, KA, The Beatles-LOVE)
