Root Cause Analysis Blog

The video below reminds me of investigators who quickly jump to conclusions when analyzing root causes.

To view the video click on: DeadFly-2.wmv

How does your root cause analysis system help you avoid jumping to conclusions? TapRooT® Users have a systematic process that produces evidence driven investigations and fact based root cause analysis. Don’t assume you know the answer. Use TapRooT® to get:

• Repeatable

• Defendable

• Explainable

• Documented

• Evidence Driven

• Fact Based

Root Cause Analysis.

Click here to find out about our training and here to find out about our software.

I like to post the funniest, most applicable jokes here each Friday but I thought you might want a daily e-mail to cheer your day. If so, you can sign up to get a daily e-mail from Scott Adams, the Dilbert cartoonist, with the latest Dilbert cartoon.

Here’s the link to subscribe at:

https://members.comics.com/members/registration/showDilbertLogin.do?aid=1

And if you would like to see today’s strip, click here.

Click on the video below … Should you laugh or should you cry?

If you owned the helicopter, you would cry!

How do you find root causes?

Try this!

Here’s some bad instructions and comments …

On Sears hairdryer:

Do not use while sleeping.

(Gee, that’s the only time I have to work on my hair!)

On a bag of Fritos:

You could be a winner! No purchase necessary. Details inside.

(The shoplifter special!)

On a bar of Dial soap:

Directions: Use like regular soap.

(and that would be how?)

On some Swann frozen dinners:

Serving suggestion: Defrost.

(But it’s ‘just’ a suggestion!)

On Tesco’s Tiramisu dessert: (printed on bottom of the box)

Do not turn upside down.

(Too late! you lose!)

On Marks & Spencer Bread Pudding:

Product will be hot after heating.

(Are you sure? Let’s experiment.)

On packaging for a Rowenta iron:

Do not iron clothes on body.

(But wouldn’t that save more time?)

(Whose body?)

On Boot’s Children’s cough medicine:

Do not drive car or operate machinery.

(We could do a lot to reduce the construction accidents if we just kept those 5 year olds off those fork lifts.)

On Nytol sleep aid:

Warning: may cause drowsiness.

(One would hope!)

On a Korean kitchen knife:

Warning: keep out of children.

(hmm…something must have gotten lost in the translation…)

On a string of Christmas lights:

For indoor or outdoor use only.

(As opposed to use in outer space.)

On a food processor:

Not to be used for the other use.

(Now I’m curious.)

On Sainsbury’s peanuts:

Warning: contains nuts.

(but no peas?)

On an American Airlines packet of nuts:

Instructions: open packet, eat nuts.

(somebody got paid big bucks to write this one…)

On a Swedish chainsaw:

Do not attempt to stop chain with your hands.

(Raise your hand if you’ve tried this…)

On a child’s Superman costume:

Wearing of this garment does not enable you to fly.

(Oh go ahead! That’s right, destroy a universal childhood belief.)

I’ve seen these long ago (early 90’s) but found them at:

http://www.lotsofjokes.com/cat_122.htm

From many sources on the internet…

This is a bricklayer’s accident report that was printed in the newsletter of the English equivalent of the Workers’ Compensation Board.

Dear Sir;

I am writing in response to your request for additional information in Block #3 of the accident reporting form. I put “Poor Planning” as the cause of my accident. You asked for a more complete explanation and I trust the following details will be sufficient.

I am a bricklayer by trade. On the day of the accident, I was working alone on the roof of a new six-story building. When I completed my work, I found I had some bricks left over which, when weighed later, were found to weigh 240 lbs. Rather than carry the bricks down by hand, I decided to lower them in a barrel by using a pulley which was attached to the side of the building at the sixth floor.

Securing the rope at ground level, I went up to the roof, swung the barrel out, and loaded the bricks into it. Then I went down and untied the rope, holding it tightly to insure a slow descent of the 240 lbs of bricks. You will note on the accident reporting form that my weight is 135 lbs.

Due to my surprise at being jerked off the ground so suddenly, I lost my presence of mind and forgot to let go of the rope. Needless to say, I proceeded at a rapid rate up the side of the building.

In the vicinity of the third floor, I met the barrel which was now proceeding downward at an equally impressive speed. This explains the fractured skull, minor abrasions, and the broken collarbone, as listed in Section 3, accident reporting form.

Slowed only slightly, I continued my rapid ascent, not stopping until the fingers of my right hand were two knuckles deep into the pulley which I mentioned in Paragraph 2 of this correspondence. Fortunately, by this time I had regained my presence of mind and was able to hold tightly to the rope, in spite of the excruciating pain I was now beginning to experience.

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We’ve all had a bad corrective action program review meeting. Off the wall questions, last minute changes, unreasonable cost constraints, and more.

What did Dilbert face? See this link:

http://www.dilbert.com/comics/dilbert/archive/images/dilbert2916120060814.gif

Does this make you think of your last root cause analysis meeting when you arrived at the corrective actions approval?

What a beautiful car!

To see the rest of the story, click below.

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If your a pilot, you know it’s a bad day when…

Click on pictures to enlarge …

Click below for more …

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In California car parking is often tight. So the fully submersible mini-van was invented for those with a pool but no parking space.

If you get upset by reading jokes … don’t read jokes. If you get upset when you read this joke, REMEMBER …

ALL readers of this blog are ABOVE AVERAGE … so this joke doesn’t apply to you!

Michele Lindsay, a TapRooT(R) Instructor in Canada, sent the following joke:

The average woman would rather have beauty than brains,

because the average man can see better than he can think.

This made me think…

What does management really want when they ask for a root cause analysis?

They really want the problems to stop and the costs to be minimal. If no real change is required, that would be great.

It is our job to educate them that you can’t get something for nothing. Meaningful change requires work.

The question is … can we demonstrate the return on investment from root cause analysis that makes the whole process worthwhile?

I think we can. See http://www.taproot.com/about.php for Success Stories from TapRooT® Users. I think they demonstrate what is possible.

Once management understands that an investment is required, then the only question left is the ROI - which we NEED to demonstrate to prove that the effort is worthwhile.

Thus even for the joke - we need to demonstrate that the value is there - whether it is “men” or “management” - “beauty”, “brains”, or “return on investment”.

Prove your worth.

Is the joke …

“Why did the armadillo cross the road?”

OR

“What’s the root cause of the armadillo accident?”

OR

“Hey, what happened to my armadillo and hot sauce sandwich?”

Ken Reed - our Equifactor® expert - spent 21 years in the Nuclear Navy. He retired last year as a Master Chief on one of the newest submarines, the USS Seawolf. I suppose that is why he was so excited when he discovered this secret R&D photo for a new class of submarine/airplane.

(Click on picture to enlarge.)

(Click on picture to enlarge.)

OK - What is the biggest hazard to the unborn baby?

This is the Friday Joke but … it demonstrates that those closest to the problem sometimes don’t see the problem.

I thought the bucket brigade was obsolete until Ken Reed, one of our TapRooT(R) Instructors, sent me this picture.

(Click on picture to expand.)

Seems to me that evacuation would be the best idea….

(click on picture to enlarge)

(Click the picture to make it bigger so you will get the joke.)

Sent to me by Linda Unger, VP at System Improvements:

Was this a two for one sale or just common courtesy in New York (note that they both have New York plates)? I think the root cause was that they wanted to become the Friday Joke!

You won’t get this one unless you have attended a TapRooT(R) Course.

Could this be real?

It’s an Accident waiting to happen.

And the root cause would be???

This was definitely NOT a near-miss for the seagull.

Click on the movie below to observe the incident.

Then ask - What was the Hazard? - What was the Target? - What were the Safeguards?

Yes, I know this is a blonde joke but … was it the student or the teacher that was most wrong for this test question…

(Click on the figure above to enlarge.)

Yes, some who have seen me play might think that my golf game is a joke…



Perhaps that is why Michele, a TapRooT(R) Instructor from Canada who will also be playing in the tournament, sent me this joke in an e-mail (was she trying to psych me out?):

List of Top 10 Caddy Comments:

#10 Golfer: “Think I’m going to drown myself in the lake.”

Caddy: “Think you can keep your head down that long?”

#9 Golfer: “I’d move heaven and earth to break 100 on this course.”

Caddy: “Try heaven, you’ve already moved most of the earth.”

#8 Golfer: “Do you think my game is improving?”

Caddy: “Yes sir, you miss the ball much closer now.”

#7 Golfer: “Do you think I can get there with a 5 iron?”

Caddy: “Eventually.”

#6 Golfer: “You’ve got to be the worst caddy in the world.”

Caddy: “I don’t think so sir. That would be too much of a coincidence.”

#5 Golfer: “Please stop checking your watch all the time. It’s too much of a distraction.”

Caddy: “It’s not a watch - it’s a compass.”

#4 Golfer: “How do you like my game?”

Caddy: “Very good sir, but personally, I prefer golf.”

#3 Golfer: “Do you think it’s a sin to play on Sunday?”

Caddy: “The way you play, sir, it’s a sin on any day.”

#2 Golfer: “This is the worst course I’ve ever played on.”

Caddy: “This isn’t the golf course. We left that an hour ago.”

. . And the #1 best caddy comment:

Golfer: “That can’t be my ball, it’s too old.”

Caddy: “It’s been a long time since we teed off, sir.”



One lucky fact … There are no caddies at the TapRooT(R) Summit Tournament!

Hope to see you there!

(PS: We need two more golfers to round out the field of 40 in this the third TapRooT(R) Summit Golf Tournament. To register call Becky or Katrina at 865-539-2139.)

I haven’t had any time to work on the blog this week (to busy with Summit prep). But I couldn’t let a Friday go without a joke.

This joke is from a past TapRooT(R) Summit. One of the attendees told me:

“Remember - no one is completely useless … They can always be used as the bad example!”

Brit_Beach_Assault.wmv (for video, click on link to the left)

Some days you just shouldn’t get out of bed - or at least you should stay in the boat.

This video was passed along to us by Marty Locker who thought that TapRooT(R) Users might be able to appreciate that hazards (quick sand) aren’t always very visible.

Some people just can’t get enough stickies on their SnapCharT(R). But click below on the continuation link, and you will see an Investigation Gone Wild!

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This is serious so don’t laugh..

Chicken Little said … “The sky is falling, the sky is falling, let’s go tell the King!”

Instead, it turns out the only thing falling was the Chicken “Limbo” Game.

Imagine, a “limbo” game collapses when kids use it! Who could have guessed?

Amazing fact #2, kids get hurt when they play.

My kids had a Chicken Limbo (14 years ago now) and it fell over all the time. Of course, they also knocked things over all over the house.

And my daughter got hurt jumping off the bed (after I told her to stop jumping on the bed). It took three stitches to close the wound. Fourteen years later, she still has a scar on her forehead! Recall the BED! (Or maybe the window sill that she hit her head on…)

Here is the serious news about the recall:

- - -

Milton-Bradley is recalling about 461,000 Chicken Limbo Electronic Party Games after reports of the product collapsing unexpectedly, causing bumps, bruises, cuts and one fractured foot, U.S. Consumer Product Safety Commission officials said.

Milton Bradley has received 46 reports of the game unexpectedly coming apart and 23 reports of injuries.



Owners of the game should take it away from children immediately and contact Milton Bradley, based in East Longmeadow, Massachusetts, to receive a free repair kit, the CPSC said. The company can be reached at 1-800-245-0910, or at its Web site at www.miltonbradley.com

- - -

Product liability isn’t a joke but this may be taking things a liitle to far.

This has been a very busy week at SI and with the Summit coming up and my two week trip to Europe to teach a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course in Aberdeen, Scotland, and a 3-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting and Root Cause Failure Analysis Course in Brussels, Belgium, I need a lighthearted joke to get me ready for the weekend. So don’t be offended. Just click the black box (mpeg movie) above, watch and laugh.

And if you have more serious human performance problems to investigate, attend one or all of these courses/meetings:

• Attend the 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training.
• Attend the Stopping Human Error Course on April 3-5, 2006, in Gatlinburg, TN.
• Attend the Human Performance and Behavior Change Best Practices Track at the TapRooT(R) Summit, April 5-8, 2006.

Maybe this was a marketing ploy or an “I did exactly what he told me” example of malicious compliance. But it does remind us that inadequate communications can lead to mistakes.

Of course, TapRooT(R) Users know that the Root Cause Tree(R) covers these kinds of errors. But sometimes we would like to learn more about preventing communication mistakes. That’s exactly what Vincent Phipps of TLC LLC will talk about at the TapRooT(R) Summit.

So if you are interested in Communication Techniques to Stop Human Errors, attend Vincent’s talk from 1-2:20 on Wednesday and learn practices that go beyond the standard three-way communications techniques.

For a complete Summit Schedule see:

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

and used the buttons on the left to display the schedule for particular tracks.

For a Summit Brochure (pdf) click here.

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.

Here’s a PowerPoint(R) that you should try to find root causes.

It was sent to me by a TapRooT(R) User who says his management really likes it, so he would like to remain anonymous.

ProbSolvingFlowchart.ppt

Note that this is what blame in an investigation always leads to.

Watch this and laugh. It was sent by a TapRooT(R) User as an example of a “loss of situational awareness.”

Was this a near-miss or a slight hit?

What were the Safeguards that failed that allowed this funny incident to happen?

Do some quick root cause analysis … What were the root causes of the failure of the Safeguards that you believe should have been in place?

What Safeguards kept this accident from being worse? (What if there had been a large stone or an old muffler in the snow?)

What should the DOT do to avoid these incidents? Are your ideas based on root cause analysis or Safeguard Analysis?

What should the news crew do to avoid these incidents? Are your ideas based on root cause analysis or Safeguard Analysis?

Sometimes what seems like a funny mistake is really an opportunity for learning.

- - -

PS: If you have a good joke or funny video that relates to accident investigation, root cause analysis, or performance improvement - or if its just real funny and doesn’t relate to anything - send it to me via the info@taproot.com e-mail address.

Thanks

Mark

Everyone who performs investigations of accidents has probably done an interview and suspected that not everything they heard was true.

The Simpsons always have an over-the-top way of making a point. Here is a short clip that shows the genius of The Simpsons show and that gets the point across about interviewing honesty in a funny way.

A TapRooT(R) User sent it to me after he attended the 5-Day TapRooT(R) Course and learned the 14 Step Interviewing Process.

For more information about the 5-Day Course, click here.

Sometime people look straight ahead and they don’t see obvious safety hazards.

How many times have I heard:

“Its ALWAYS been that way.”

You may be the only one too see the hazard.

Do you ignore it or report it?

Do you allow it to exist or fix it?

Do you let others know when they are creating a hazard to themselves or others?

A TapRooT(R) User forwarded this to me and said that a friend had forwarded it to him.

Seems that to reduce corporate liability, the company had introduced a new policy that allowed only one alcoholic drink at corporate functions.

I think an engineer came up with this response…

I guess the company should have used SMARTER. Obviously, their corrective action was not Specific enough!

Steve believes in truth in advertising.

A nuclear industry TapRooT(R) User sent me this song with a holiday tune and a nuclear theme.

Some thoughts:

When is someone a candidate for “for cause” drug testing for off-the-job behavior?

What hazards would be created if this idiot made it to the highway?

Would three trips (or four) really cost that much gas?

How much does it cost to get your rear suspension completely replaced?

When will VW start building heavy duty pickup trucks?

And finally:

Who IS the guy sleeping patiently in the passenger seat?

A TapRooT(R) User sent me this “video” of a lego worker involved in an accident on what looks like a lego oil rig.

Remember - even toy workers need a safety improvement program!

Imagine you were assigned to figure out how the copier (equipment that costs more than $50,000) was broken.

No one seems to have any idea what happened.

No one admits they were involved.

The glass is broken and there is substantial damage to the scanning mechanism. Repair costs were more than $10,000.

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It’s FRIDAY and time for a JOKE!

Just when you thought of all the possible hazards when bungee jumping, watch this video, and THINK AGAIN!!!

Bungee_jump.wmv

I’m taking Friday off (my youngest daughter’s 16th birthday) so I decided to do the week’s joke a day early.

Look closely at the name of the company on the “sinking” van below.

Michele, one of our TapRooT(R) Instructors in Canada, sent me this video.

The video is suppose to be a real security video tape. I think it looks like a fake, but the point made about the lack of intelligence of the criminals is still funny.

Just call them Dumber and Dumbest.

break_enter.wmv

Michele Lindsay, one of our Canadian TapRooT(R) Instructors, sent me the following pictures in an e-mail titled, “Only in Canada”.

Have a good laugh…

For those who need labels for everything …

Several people e-mailed me that I had left out the fastest way to find root causes from my comments about ways to save time when investigating smaller incidents.

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A TapRooT(R) user sent me these pictures in an e-mail titled “Quit Complaining About Your Job.”

Click on them to make them larger.

NOTE: This is a Powerpoint file

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NOTE: This video is in MPEG format
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