Root Cause Analysis Blog

The March TapRooT(R) Friend / Experts e-Newsletter has been posted at:

http://www.rootcause.net/

This month’s e-Newsletter includes the following topics:

- WORLD CLASS ROOT CAUSE ANALYSIS



- THE CURSE OF APPARENT CAUSE ANALYSIS - DISCUSSION

- WHAT’S IN THE FEBRUARY/MARCH ROOT CAUSE ANALYSIS BLOG?



- MINE SAFETY AND TapRooT(R)

- WILL A SAFETY STAND-DOWN CHANGE PERFOREMANCE?



- MARK PARADIES TEACHES TWO COURSES IN EUROPE IN MAY: GOTHENBURG, SWEDEN / AMSTERDAM, NETHERLANDS



- LAST CHANCE TO REGISTER FOR THE 2006 SUMMIT

- THINGS TO DO IN GATLINBURG - BEFORE/AFTER THE SUMMIT

- WHERE CAN YOU GET ROOT CAUSE ANALYSIS TRAINING?

- SIGN UP FOR A 5-DAY COURSE BEFORE APRIL

- J.O.K.E OF THE MONTH

Those attending the TapRooT(R) Summit (April 5-8, 2006) will get a chance to hear Dr. Bob Nelson - the Guru of Rewards - talk about ways to use rewards to get the behavior you want from employees.

Dr. Nelson sent me 11 articles that Summit attendees might want to read either prior to or after the Summit. I am posting them here so that you may download the pdf’s and read them.

Just click on the papers to see the PDF’s.

Dump The Cash

Top Ten Ironies of Motivation

You Want ToMAYtoes, I Want ToMAHtoes

Give Generation X a Chance and a Challenge

Long-Distance Recognition

Click on the link below for more…

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The March 2006 Root Cause Network(TM) Newsletter has been posted on-line.

What is in this issue?

• Accidents - What’s Going On???
• Each Week Learn from an Accident
• The Curse of Apparent Cause Analysis
• 2006 Root Cause Training
• Blackhawk Down
• Rewards - The Secret of Success
• SKF + TapRooT(R) + Equifactor(R) = Improved Equipment Reliability
• Trending Incidents
• Don’t Miss This! TapRooT(R) Summit
• Pre-Summit Courses

I’ve already had several comments on “The Curse of Apparent Cause Analysis” article. It’s short, but worth reading (especially if you have the urge to shortcut good root cause analysis to save time).

I was reading an e-mail about performance improvement in the medical industry and came upon a new term “SBAR.”

I did some searching and came up with the following link that describes the technique well:

http://www.errormedicine.com/SBAR_report.pdf

The idea applies to any industry where trouble calls are made to people not at the site of the trouble.

Interested in more ideas about improving communications or reducing medical errors? Then consider attending the TapRooT(R) Summit on April 5-8, 2006, in Gatlinburg, Tennessee.

Communication Improvement: At the Summit Vincent Phipps will present Communication Techniques to Stop Human Errors from 1-2:20 on Wednesday. His talk will cover practices that go beyond the standard three-way communications techniques.

Stopping Medical Errors: Also at the Summit there is a whole track on stopping medical errors. for more information see:

http://www.taproot.com/summit.php?sched=1

and click on buttons on the left labled “Medical Error Reduction Track” to display the schedule for that tracks.

For a Summit Brochure (pdf) click here.

Click here to visit the Root Cause Newsletter(TM) Newsletter Archive.

We’ve just posted the February 2006 TapRooT(R) Friends/Experts e-Newsletter.

Topics in this newsletter include:

- PROACTIVE USE OF TapRooT(R)



- CREATIVE SOLUTIONS

- ROOT CAUSE ANALYSIS BLOG HAS EXCELENT TOPICS IN JANUARY/FEBRUARY



- RISK MANAGEMENT

- QUALITY IMPROVEMENT BEST PRACTICES



- TapRooT(R) TO EXHIBIT AT IOSH CONFERENCE IN LONDON



- SKF + EQUIFACTOR(R) + TapRooT(R) = IMPROVED EQUIPMENT RELIABILITY

- NEED TapRooT(R) - NOT BLAME

- CHUCK HOPKINS REMEMBERED



- CSB REQUESTS COMMENTS ON EVIDENCE PRESERVATION RULE

- SPECIAL ONCE A YEAR COURSES IN APRIL



- YOUR MOST IMPORTANT DAYS FOR PERFORMANCE IMPROVEMENT ARE IN APRIL

- WHERE CAN YOU GET ROOT CAUSE ANALYSIS TRAINING?

- SIGN UP FOR A 5-DAY COURSE BEFORE APRIL

- J.O.K.E OF THE MONTH



To get this newsletter sent directly to your e-mail, register at:

http://www.taproot.com/contact.php?news=1

I thought this was interesting and can be helpful to users who need to publish information to the web or for any organization that uses PDFs for document distribution.

The National Security Agency (NSA) has issued guidelines for how to remove extraneous data from Microsoft Word and other documents prior to publishing them as Adobe PDFs.

Read the paper here. (PDF)

How does the Chemical Safety Board decide which accidents to investigate and which accidents aren’t worth investigating?

Here is a link to a pdf that explains their process:

http://www.csb.gov/news_releases/docs/CSBIncidentScreeningReport.pdf

Brian Locker, one of our Canadian TapRooT(R) Instructors, forwarded this notice of a job opening to me.

The forestry industry in BC had 41 fatalities in 2005. The result so far has mainly been negative press.

But the BC Provincial Government is now hiring a special coroner to investigate forestry deaths and make recommendations to improve forestry safety.

Those interested should apply using the form above.

A full time coroner to investigate forestry deaths … This seems like the ultimate in reactive root cause analysis. But at least they are starting something.

Frank Wright of Jacobs Engineering sent me this link:

http://www.co.arapahoe.co.us/citizeninfo/Vehexp.doc

According to the police report in the linked document, it seems that the car’s owner thought that bringing a balloon filled with acetylene to a Super Bowl party would add to the celebration.

But this was not to be a Super Sunday for this jokester … The balloon exploded in the car.

The results are pictured above.

At first I couldn’t decide if this should be the Monday Accident or the Friday Joke. But blowing up your own car and then getting arrested (see the police report at the link) … this just had to make the joke category.

Perhaps readers can use this event to once again caution employees that horseplay and practical jokes can go seriously wrong. Even though no one was killed by this stupidity, an even worse accident could have been the result if the balloon was ignited in a house full of people.

The announcer says that this “unfortunate accident” was caused by a “combination of circumstances.”

How do you understand the combination of circumstances that lead to an unfortunate accident?

You must understand “what happened” before you can understand “why it happened.”

That is why we draw a SnapCharT(R) to graphically show the sequence of events before we use the Root Cause Tree(R) to find the root causes of the Causal Factors that combined to cause an accident.

Want to learn more about the TapRooT(R) Process?

1. Read more at:

(How Do You Use TapRooT(R) Paper)

2. Attend TapRooT(R) Training.

3. Attend the TapRooT(R) Summit.

Where can you find back editions of the Root Cause Network(TM) Newsletter?

Try this link …

This report is so massive that it will take weeks to digest it all.

The following files were downloaded from the BP Web Site. There is also a BP press release about the report. They are placed here for the convenience of readers.

BP Final Report on Texas City Refinery Explosion

Click below for the appendices…

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Here is the document if you missed the link in the article.

DIFCMOD-1.xls

This replaces the previous broken link.

A TapRooT(R) User, Lee Dobry, e-mailed me these comments about the Procedures article that I wrote on November 9. He has some great ideas to think about and a useful procedure evaluation tool in the format of an excel spreadsheet.

Click on the link below to read Lee’s ideas and download a copy of the spreadsheet.

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If you attended the ‘05 TapRooT(R) Summit, you heard Scott Waddle, former CO of the submarine USS Greeneville, tell about the collision with the Emime Maru (a Japanese fishing vessel that was training high school students) and the impact on his life.

I tried to find the NTSB accident report prior to the Summit and I couldn’t find it on the NTSB web site.

However, a TapRooT(R) User sent me the report, so I thought I would post it here.

The ‘06 TapRooT(R) Summit is on April 5-8, 2006. Click here to see the outstanding key note speakers we have scheduled to speak at the Summit.

One more note. If you want to see what it looks like when a submarine breaks the surface when performing and emergency blow, click on the video (.avi format) below:

Another paper in Spanish from Marco Flores, one of our Spanish Speaking TapRooT(R) Instructors.

(Basado en: The 7 Deadly Sins in Incident Analysis de Mark Paradies)

Marco Flores, one of our Spanish speaking instructors sent this paper to be posted for our Spanish speaking readers.

How do you trend your performance data?

Can you tell the difference between normal random variation and a real, significant trend?

Can you prove that a trend is significant (good or bad)?

Do you know the special techniques needed to trend infrequently occurring data (like accidents, incident, sentinel events, quality problems, equipment failures, and almost all root cause analysis data)?

Do you know when to use Pareto Charts to spot areas begging for improvement and when NOT to use Pareto Charts?

I gave a presentation (Trending, Root Cause, & Performance Improvement) at the last VPPPA Conference about the problems with trending and some advanced trending methods. A pdf of the presentation is attached below. Click on it and see if you are interested in learning more. If you are, please sign up for the next Advanced Trending Course in Gatlinburg, Tennessee, on April 3-4, 2006. For more course information, click here.

Jim Whiting, our Australia TapRooT® Rep, sent the attached PDF alert about Fire Extinguisher Hazards.

Mark

NOTE: This is a Microsoft Word file
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NOTE: This is a PDF file
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NOTE: This is a PDF file
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This article caused considerable controversy in the construction industry. It was originally published in the Root Cause Network Newsletter but was picked up by industry publications as well. The linked document is in a PDF format.