Root Cause Analysis Blog

The Navy must have changed a lot since I was in it.

Here’s a quote from an Associated Press article printed in Military.com:

“A Navy inspector general report said investigators had substantiated that Graf assaulted subordinates (pushing one, grabbing another and once throwing wadded-up paper at another Sailor) and that she regularly verbally abused subordinates by publicly berating them, belittling them and using profane language.“

A Navy CO using profane language and berating crew members in public … sounds like the first ship I was on in 1980.

And, of course, assault should never be tolerated. But the female CO, Captain Holly Graf, (pictured above) pushed someone, grabbed someone, and throws a wadded up piece of paper at someone? This hardly seems like serious offenses. But perhaps it does show a lack of judgment. After all, the CO’s job on a ship is quite serious and there needs to be a certain amount of formality and separation maintained to maintain good order and discipline. Grabbing sailors (or officers) and throwing things at them isn’t setting a good example for your crew.

Then there is the drag racing.

I’ve seen two ships line up side by side to run a one mile race. We won! Our nuclear powered cruiser beat a gas turbine powered cruiser.

The AP story said this about the drag race:

“One sailor said that during the race, aimed at boosting morale, the McCain got ahead of the Cowpens and began drifting to the left into the path of the Cowpens. Though the report did not question that the race took place, it said the allegation of “hazarding a vessel” was unsubstantiated.”

One sailor said?

If every CO was relived because they swore, had sailors that didn’t like them, or even made occasional judgment failures (grabbed a sailor), we probably couldn’t keep our fleet at sea. But maybe there’s more to this story than what was printed in the Associated Press article?

I decided to look a little further and did a Google search on “Captain Holly Graf”.

WOW! What an eyeful! Lot’s more information was posted on-line about how bad Captain Graf was!

Of course you can’t believe everything you read on-line, but … read the comments at this blog:

http://www.susankatzkeating.com/2010/01/captain-holly-graf-plows-down-whale.html

Then a picture of the “drag race” at this blog site:

http://www.militarycorruption.com/hollygraf5.htm

(Can’t tell if it is photoshopped or not.)

And a legal review of the charges against Captain Holly Graf:

http://admiraltymaritimelaw.blogspot.com/2010/03/navy-inspector-generals-report-on-holly.html

After reading the material available, I would conclude that Captain Graf was an awful person to work for and a terrible leader. The Navy is lucky that no one was killed as a result of her leadership failings. (Having your crew be scared to talk to you is a great way to get a ship into deep trouble.)

But some of the charges seem silly. Guilty of having a Junior Officer play a Christmas Carol on the piano at a Christmas Party at the CO’s house? Or another charge that a Junior Officer walked the CO’s dog willingly? Come on.

But what about Navy leadership? How did she get to such a position of power? Why weren’t her poor leadership traits detected earlier?

Man or woman, I don’t care. Men and women can be great leaders. Or not.

Poor leaders at sea can have dreadful consequences. Our sailors deserve good leadership. Seems like the poor leadership qualities of Captan Holly Graf might indicate a generic problem with the way that leaders are developed and promoted inside the Navy. Certainly this isn’t the first “bad CO” that I’ve heard about. Perhaps a more in-depth analysis is required?

Plenty to dig into when analyzing the root causes (and generic causes) of a poorly led ship.

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An article in Federal Computer Week says that a Congressional Panel has recommending expanding the DoD Office of Performance Management and Root Cause Analysis.

The office and the new Performance Assessment and Root Cause Analysis (PARCA) Czar, are the result of the Weapons System Acquisition Reform Act of 2009.

To find out more about the recommendations and the role of the new acquisitions PARCA Czar, see the article at:

http://fcw.com/articles/2010/03/10/defense-acquisition-reform-panel-recommendations.aspx

By the way, don’t you just love military acronyms … PARCA Czar … What a hoot!

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We discussed the use of checklists in the medical industry in a previous blog entry.  Yesterday, CNN’s Sanjay Gupta interviewed Dr. Peter Provonost, a medical researcher at Johns Hopkins University.  He was selected in 2008 as Time Magazine’s Top 100 Most Influential People.  He had a great discussion on the use of checklists in medical industry, specifically hospitals.  He mentioned a statistic that there are over 30,000 preventable deaths each year in the US due to inadvertent infections that could be mitigated by the use of simple checklists.  He said that consistent use of checklists in the medical industry would save more lives than any other single medical therapy currently being developed.  Quite a statement!  Something as cheap and as inexpensive as implementing simple checklists could save more lives than many of the more expensive therapies now under development.
What do you think?  With so much research indicating the benefits of checklists, why have they not yet come into widespread use?

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While performing your PROACTIVE TapRooT® Root Cause Analysis, you observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. He lifts 30 pipes an hour 3 times a day from a rack waist high to a pallet placed on timbers floor level. This task used to be performed by two loaders before recent lay offs, so you go to the Root Cause category of Excessive Lifting and see these two questions in the Root Cause Tree Dictionary:

* Was the issue related to excessive lifting or force to move an object?

* Did the task require repetitive motion (lifting, twisting, bending, etc.) that lead to a musculoskeletal problem?

Since this is a Proactive Assessment there are no issues yet, so your are asking what is the worse issue that could occur by the lifting movements above? Now what does excessive mean? What would excessive lifting, twisting and bending be? We could bring in an external Ergonomic Expert… or we can use a simple calculation ourselves first?

A simple calculator: http://www2.worksafebc.com/calculator/llc/liftlower/Default.htm

A little more technical: http://www.osha.gov/SLTC/etools/electricalcontractors/additionalreferences.html

NIOSH 1991 Lifting Calculator. Centers for Disease Control and Prevention (CDC), National Institute of Occupational Safety and Health (NIOSH), 208 KB ZIP*.

As you start doing these calculations, you should also see another Root Cause under Human Engineering start becoming very apparent: Arrangement / placement.

A question that comes to mind from the Root Cause Dictionary is:

* Did poor arrangement, placement, or situation of equipment, displays, or controls contribute to an issue?

So with these new found calculators and a better understanding of just a little bit of the Root Cause Tree Dictionary is this task a risk or not:

” You observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. This task used to be performed by two loaders before recent lay offs.”

Post your response!

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*******************************************************

NTSB SAFETY RECOMMENDATION

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National Transportation Safety Board

Washington, DC 20594

February 23, 2010

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NTSB Safety Recommendations R-10-1 and -2

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The National Transportation Safety Board makes the following recommendations to the Federal Railroad Administration:

Require the installation, in all controlling locomotive cabs and cab car operating compartments, of crash- and fire- protected inward- and outward-facing audio and image recorders capable of providing recordings to verify that train crew actions are in accordance with rules and procedures that are essential to safety as well as train operating conditions. The devices should have a minimum 12-hour continuous recording capability with recordings that are easily accessible for review, with appropriate limitations on public release, for the investigation of accidents or for use by management in carrying out efficiency testing and systemwide performance monitoring programs. (R-10-1)

Require that railroads regularly review and use in-cab audio and image recordings (with appropriate limitations on public release), in conjunction with other performance data, to verify that train crew actions are in accordance with rules and procedures that are essential to safety. (R-10-2)

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http://www.ntsb.gov/Recs/letters/2010/R10_001%20_002.pdf

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The complete recommendation letter is available on the Web at the URL indicated above.

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I saw an interesting article at nuclearmatters.co.uk about a speech given by Judith Hackitt discussing the potential to have process safety accidents with multiple fatalities because of short-term business pressures. I thought it was a good speech that the article was based on, but that there were a couple of inaccurate impressions that needed to be corrected. So I left this comment:

I like Judith’s statement but there two slightly incorrect facts in her comments …

1) Judith said: “… lack of injuries and near misses is no guide whatsoever that all is well in process safety terms…”

BP Texas City DID NOT have a good safety record.

They were killing people almost every year. They may have kidded themselves into believing that they were improving safety (a little under-reporting can go a long ways) but they had an unacceptable rate of fatalities. These fatalities were proof that something was wrong.

Also, they had previous process safety incidents and near-misses on the very process that exploded that indicated problems and that were not corrected.

Thus, at least for BP Texas City, they should have seen this accident coming and prevented it. They had warnings. All they had to do was listen, find the root causes, and act.

2) Judith said: “Short-term business pressures drove BP to cut capital expenditure at its Texas City plant by deferring projects and failing to monitor the subsequent impact of this. This had a dramatic impact on the repair and maintenance programme at the site and was a significant factor in the catastrophic explosion in 2005.”

The cost cutting at the Texas City refinery was not short term.

It started before BP bought the refinery. BP should have known that they would have to INCREASE spending to make up for cuts prior to the Amoco sale to BP. Instead, BP continued to cut spending right up until the accident. That makes it five, six, or perhaps even seven years or more of underfunding safety and maintenance.

The Texas City refinery under Amoco/BP had backlogged safety corrective actions that were a decade past due when the accident occurred. Therefore, this was not just a one or two year budget cut problem. It was historical underfunding of a high risk process. Short-term business pressures may have caused this underfunding in any one year but the impact was long-term and establish a culture of shortcuts and a “make it work” mentality.

Reasonable management should have been able to see that this game of process safety Russian roulette can’t go on forever. Eventually, someone has to “pay the piper.”

The fact that management can get away with underfunding safety and maintenance for several years without an accident is what makes taking shortcuts so tempting. This is especially true when managers are quickly promoted so that they don’t stick around to see the impact of their business decisions on performance at a complex facility (like the Texas City refinery). The wrong lessons (we can cut costs without noticeable impact) are reinforced as the market (and benchmarking surveys) rewards those with the highest production and the lowest costs. Management is not required to understand or face the long-term impact of their decisions.

Therefore, I still believe that many executives have not learned the lessons that:

1) You must work diligently to learn from your experience (they think Texas City was a surprise when it should not have been a surprise).

2) There is a point below which you should not cut the budget on a high-risk enterprise.

You must have strict standards that can’t be compromised and you have to say, “No - We won’t continue to operate without support for these safety initiatives.”

If management (especially senior management and corporate boards of directors) fails to learn these lessons and continues to operate high risk facilities as if they were any standard manufacturing plant, we (society) are doomed to see accidents with causes like those that caused the explosion at Texas City again.

Lest one thinks that this is only a problem for refineries and chemical and oil industry facilities, look no further than the Davis-Besse reactor vessel hole for a near-miss that was only prevented by the regulator saying “No” to a utility request to cut inspection requirements again.

No high hazard industry is immune to the temptation to get buy with less and the failure to listen to the warnings of operating experience.

Best Regards,

Mark Paradies

What do you think?

Has management learned the budget and operating experience lessons from Texas City?

Have they established strict standards and drawn a funding line that can’t be crossed?

Are they interested and actively promoting analysis of operating experience, advanced root cause analysis, and prompt implementation of corrective actions?

Or have things gone back to business as usual?

After all, the five year anniversary of the Texas City refinery explosion is just around the corner.

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I don’t usually post all the construction fatalities that happen in the US (or the world). Why? There are just too many.

But here is a link to a recent Fox News story about a double fatality cause by a trench collapse.

These don’t have to happen. We know how to stop these fatalities. No new science needs to be invented. Each trench collapse fatality is a needless loss of life.

Here’s a video demonstrating a collapse…

And here’s a trench cave in that occurred while an Oregon OSHA Inspector was filming…

Luckily the man “in-the-hole” was not killed in the second example. But many are not as lucky.

Back in 2003, I wrote an article called “Stop the Sacrifices.” It was an emotional appeal to the construction industry to stop these needless deaths. It caused a lot of controversy.

Perhaps the construction industry has improved since them. I know that some companies have. But others continue to put peoples’ lives at risk by promoting shortcuts (or at least turning a blind-eye to their workers’ taking shortcuts) and not promoting best practices to keep people safe.

If you are responsible for construction work and trenching, take a moment to review what you are doing to keep workers safe. A new sewer line or a broken water pipe isn’t worth someone’s life.

If you would like to learn more about best practices to improve safety, consider attending the 2010 TapRooT® Summit. The Safety & Risk Management Track has these Best Practice Sessions that will give you ideas to improve performance:

Improving Incident Investigation & Safety in the BW Fleet

Communicating with Management About Risk

Ahead of the Law: OSHA Enforcement Problems & Solutions

Using TapRooT® for Regulatory Compliance

How Does Your Corporate Culture Effect Your Investigations?

Advanced Ideas for Corrective Actions

Be a Safety STAR: How a VPPA Program & TapRooT® Can Be Combined for Excellent Safety Performance

Quality In Life & Work

Planning Your Improvements

Go to the Summit web site to see all the schedules for all the Best Practice Tracks and see which track will help your company’s performance the most.

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Many people have asked me to repost the talk that I gave at the 2008 TapRooT® Summit about TapRooT® and Safety Culture/Organizational Culture. So here it is in a pdf format…

FindingCultureIssuesPOSTED.pdf

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Donald Wheeler is expert that I trust for trending advice. I took his three commercial courses on statistical analysis and adopted his methods to use in root cause analysis trending. We use his book in our Advanced Trending Techniques Course. So this article that outlines the history of one of the major techniques we teach is very interesting … at least to me!

See:

http://www.qualitydigest.com/inside/quality-insider-column/individual-charts-done-right-and-wrong.html

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Several people have asked me:

I thought…

I thought that I would provide the guidance by breaking up the suggestions by the 7-Step TapRooT® Reactive Investigation Process that is detailed in Chapter 3 of the TapRooT® Book (Copyright 2009, used here by permission).

NOTE: If you don’t understand the terminology or reasons for the management actions below, it could be that you need more TapRooT® Training!

TapRooT® 7-Step Reactive Investigation Process

STEP 1

So let’s start with Step 1: Planning the Investigation - Getting Started.

Since we are just getting started, there is nothing for management to review. However, management does have several responsibilities.

a. Management needs to set criteria for what gets investigated. This should be documented in the site’s incident investigation procedure. Management should then make sure that all incidents are reported and investigated. Occasionally, management will identify an incident that doesn’t meet the criteria, but still, in their opinion, deserves a complete investigation and root cause analysis.

b. Management should make sure that their site is prepared for investigations. This includes having an investigation procedure, trained investigators, and investigation review process, and trained management. See the TapRooT® Book (Chapters 3 and 6 and Appendix A and C) for more information.

c. Management should ensure that evidence is preserved for the team.

d. Management should make sure they they have assigned an adequate investigative team to perform the investigation and that the team has all the resources and support that they need. Depending upon the seriousness of the investigation, the team may include independent facilitators or coaches to help the team and outside experts for technical guidance. Management should assign an independent (not from the organization involved in the incident) Team Leader for all but the most minor investigations. The Team Leader should be thoroughly trained (probably in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course).

e. Management should agree to an initial investigation scope (although the team should have the freedom to enlarge the scope based on the facts discovered during the investigation).

STEPS 2 & 3

Next, come Steps 2 & 3. I include these together because the main aspect that management will be reviewing is the team’s SnapCharT® with the incident’s Causal Factors. Management should make sure that:

a. The team has a detailed, logical SnapCharT® that is based on the evidence (facts) about the incident. Each Event and Condition should have a factual bases and not be an assumption (unless the reason for not verifying the assumption is adequately explained).

b. The evidence cannot support alternative scenarios.

c. All facts (not just those that supported this sequence of events) were considered.

d. Each Event includes the “Who did what” or “What did what” to clearly indicate the action that occurred.

e. ALL Causal factors have been identified (including those that were a “catch” for an error). May want to consider the using Safeguard Analysis to check the completeness of the Causal Factors.

f. The Causal Factors are the big picture causes of the incident and are not root causes. (They meet the definition of a Causal Factor and are at the “most general” end of the “So What?” chain.)

g. All Causal Factors have the associated information about them grouped together under the Causal Factor.

h. Only job positions (not people’s names) are used on the SnapCharT®.

i. Emphasis adjective are not used on the SnapCharT® (just state the facts - quantified when possible).

j. The Causal factors are repeatable and sufficient to cause the Incident.

STEPS 4 & 5

Next come Steps 4 & 5 - finding the incident root and generic causes. For these two steps, management should ensure that:

a. The team took each Causal Factor though the Root Cause Tree®.

b. Each root cause has evidence to support the finding and that the evidence provides a “Yes” answer to one of the questions in the Root Cause Tree® Dictionary.

c. The evidence is on the team’s SnapCharT®.

c. Management System root causes were considered.

d. The team checked for previous similar incidents and previous ineffective corrective actions.

e. Generic causes were considered for each root cause that was discovered.

f. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) was considered in analyzing the root causes’ generic causes.

g. There is evidence to support the finding of generic causes.

STEPS 6 & 7

The final management jobs in Steps 6 & 7 are to ensure that sufficient corrective actions are adopted and implemented to prevent recurrence of this incident and, if applicable, similar incidents. Therefore, management should ensure that:

a. Each root cause/generic cause has a corrective action.

b. The corrective action is SMARTER.

c. The investigation team considered the recommendations in the Corrective Action Helper® (check their recommendations against the Corrective Action Helper®).

d. For a significant incident’s root causes, Type 1-4 corrective actions are used (see below). Preference should be given to removing the hazard if possible, next removing the target, and then guarding the target.

(From the TapRooT® Book. Copyright 2008. Used by Permission.)

e. Any corrective action that includes a “re” should be questioned. (For example: retrain, remind, and re-emphasize.) “Re” corrective actions are just repeating actions that didn’t work in the past. Why do we expect them to work now? Also, note that if the corrective action is counseling an employee to remind them about rules or procedures, this is “re” corrective action and should not be used alone, but must be combined with other behavior change techniques.

f. Reject any corrective action that includes these words - Ensure, Assure, Insure, Make Sure - unless the team can explain how they will make sure that the change occurs (and this additional information should be included in the corrective action to make it specific).

g. Corrective actions that are studies be carefully evaluated to see why the study has to be delayed and can’t be completed before the investigation is concluded. (Examples of studies are: Investigate, Evaluate, Consider, Analyze.)

h. Any corrective actions that require behavior to change have considered what factors are causing current behavior and how these will be removed and what rewards/incentives and punishment will be clearly linked to the desired behavior to make it occur.

i. Training is not used as punishment or to embarrass an employee.

j. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) were considered in developing corrective actions and are documented on the SnapCharT®.

k. The people responsible for implementing the corrective actions and the people impacted by the corrective actions agree that the corrective action will be effective.

l. Corrective action will be sufficient to eliminate significant risk or if additional Safeguards or process redesign need to be considered because the risk is so significant.

m. Corrective actions are assigned to the appropriate individual/organization for implementation.

n. The organization responsible for corrective actions has adequate resources to implement the corrective action by the assigned due date.

o. The corrective actions are tracked, and if significant enough, verified, and validated. Management should periodically be updated on corrective action status, especially overdue corrective actions.

p. Significant corrective actions are periodically checked (audited) to ensure their continued effectiveness.

q. Significant corrective actions that may impact other facilities are shared within a corporation.

r. Names of employees are not used in the report.

s. Emphasis adjective are not used in the report (just state the facts).

t. Pictures are used effectively to help explain what happened in the report and presentation.

u. Rewards are given for good investigations.

v. Evidence and reports are retained to meet any legal requirements.

Not every one of these “management must” items must be performed by a manager for each investigation. Management can set up systems , review teams, or review boards to help ensure the quality of investigations.

- - - -

Now for your comments … What do you think? Additions? Deletions? Modifications?

And how is your site doing to make sure the TapRooT® Process is being used correctly, efficiently, and effectively?

By the way, many of the points above originally were shared as best practices at the TapRooT® Summit. If you would like to keep up with the latest TapRooT® best practices, attend the 2010 TapRooT® Summit in San Antonio on October 27-29.

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In 1935, the most experienced test pilot crashed the most advanced airplane, the Boeing 299. The papers said it was too much plane for one man to fly. As it turns out, it wasn’t “too complicated” – rather, there was just too much to remember. Too many controls to remember to set. Set something wrong (or forget to set it) and the plane would not fly. Flying had grown too complex to depend on a person’s memory.

The answer was simple: a checklist. Actually, four checklists. At first, pilots resisted. But it’s hard to argue with the evidence that checklists really helped avoid common errors and kept planes from crashing. Now, aviation checklists are a staple of the professional pilot.

I would argue that medicine became too complex to rely on doctors’ or nurses’ memories long ago. Hospitals need to adopt the best practices that are the staple of high performing organizations (for example, aviation or nuclear power). It is far past the time that standard practices and checklists should have been adopted to stop sentinel events. Especially when a twelve-year study published in the January 2009 issue of the New England Journal of Medicine shows a 40% reduction in accidental deaths when hospitals use checklists.

That’s just one of the best practices that should be adopted immediately to improve performance in the complex environment of a modern hospital. Where can you learn more? Try a TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. Then attend the TapRooT® Summit in San Antonio (October 27-29) for more best practices to improve performance. You could be part of the movement to save thousands of lives every year by applying known best practices to improve healthcare quality and patient safety.

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Part 2, as promised, is a discussion on our TapRooT® Users and Friends LinkedIn Group.  This begins with a question asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.

“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”

My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.

Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don't put in don't dead head or run a pump dry. I've been doing this too long to expect that.]

That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.

Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.

Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.

Thanks All,

Jason

Now the rest of the discussion from the TapRooT® Users and Friends LinkedIn Group

Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor

ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!

First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!

At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.

The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.

First attack at the problem:

1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM

2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)

3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?

4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.

So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.

After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.

Posted 1 month ago | Delete comment

Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.

For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.

Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?

That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:

- Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
- Was he using the right tool? Did we provide him with the right tool?
- Was the right person performing this job?
- Was this job really required in the first place?
- Do supervisors ever watch their people do this particular job? Why not?
- Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
- Was the worker properly trained for this task?
- since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?

I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.

I also know that sometimes we think that people should already know these things. There are 2 possibilities:

1. The person really didn’t know (to cut away from himself)
- Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
- This is when my discussion above comes into play.

Hope this helps a little.

Posted 1 month ago | Reply Privately | Delete comment

Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.

I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.

My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.

Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.

So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.

The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.

Once again. Thanks guys. I appreciate the feedback.

Posted 1 month ago | Reply Privately | Delete comment

Response from: Christopher Vallee, Senior Associate and TapRooT® Instructor

Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.

As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?

Steps of the process:

1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.

Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.

2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).

Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.

3. Shops have floating experts identified for employees who need a little help.

Problem: The new are training the new. The senior employees are too busy to.

So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .

Have senior employees attend training with new employees to help all do right.

Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.

Posted 1 month ago | Delete comment

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Here’s a link to an interesting article titled “Where Process-Improvement Projects Go Wrong“:

http://online.wsj.com/article/SB10001424052748703298004574457471313938130.html?mod=wsj_share_twitter

It makes some good points that we’ve had in Chapter 6 of the TapRooT® Book since 2008.

If you are looking for ways to keep your improvement program progressing (especially if you are using TapRooT®), consider attending the TapRooT® Summit on October 27-29 in San Antonio. You get great, fresh ideas to make your program better and to keep people involved. For details, see:

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

(if the new web site isn’t up yes, it will be soon!)

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The story is titled:

What is it with the Washington Metro?

And it talks about the safety and budget issues at WMATA.

I guess that putting the bus driver in jail after the accident last year (or was it two years ago?) didn’t stop the accidents at WMATA.

The blog writer at the Baltimore Sun pins his hopes on the NTSB. But in my book, only management can really change safety after they fully understand the root causes of the problems.

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The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”

The story also said:

“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“

Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!

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Several states passed laws prohibiting the use of hand-held cell phones. Did these laws work? (Reduce accidents?)

No, according to a study by the Highway Loss Data Institute reported on by Top News.

According the the study/story, the rates where a ban has been passed mirror those of neighboring states with no law. Thus no decrease was seen by having a criminal penalty for hand held cell phone use.

Almost everyone agrees that drivers can be distracted by cell phone use so why didn’t this bans work? Here are some of my ideas…

1. Hand held cell phones is only one of many distractions.

2. Enforcement - people still use their phones.

3. People use phones in hands fee mode and are still distracted.

Have other ideas why this ban doesn’t improve accident statistics? Leave them here as a comment.

One more note …

I was over in the UK recently. They have all sorts of laws to make a driver pay attention. One of the big stories was a man who got a ticket for blowing his nose while he was stopped in traffic. The officer thought he was not “in full control of his vehicle.”

Next, making sneezing illegal while driving…

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The story in The Daily Press says:

“A new round of construction problems on U.S. Navy vessels built by Northrop Grumman Corp. have spawned yet another investigation into the nation’s largest Navy shipbuilder.

Northrop, already under fire for widespread yet unrelated welding problems that surfaced two years ago at its Newport News shipyard, now faces quality issues at its Gulf Coast yards in Avondale, La., and Pascagoula, Miss., the Navy said Thursday.

All Gulf Coast vessels built by the company over the last several years are under investigation for a host of problems, including improper welds and defective engines and lube-oil systems, the Navy said.“

Other bad press for Northrop Grumman Shipyards include:

• More bad welds on submarines
• Engine problems on the USS New York
• Inspector files false reports on 13 Navy ships

Sounds like they need better root cause analysis and better corrective actions! Maybe it’s time they took a TapRooT® Course?

Poor quality over an extended period of time is an indicator that your problem reporting and corrective action programs aren’t working. Applying the same old corrective actions of blame, counseling employees, more training, and making procedures longer doesn’t solve quality issues. People stuck in the blame game need a systematic investigation process that finds the true root causes of problems and the solutions.

TapRooT® does that with proprietary, copyrighted systems and training, and patented software that comes with a money back guarantee. Nobody else stands behind their system like we do. And that’s just one of the reasons that industry leaders choose TapRooT®.

If you are interested in thorough investigation of quality problems with effective corrective actions, consider sending some of your quality professionals to a 5-Day TapRooT® Advanced Team Leader Training public course. See:

http://www.taproot.com/courses.php?d=2

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Bloomberg published a long article detailing alleged safety problems at commuter (regional) airlines. The story is titled:

Fatal Flying on Airlines No Accident in Pilot Complaints to FAA

To read the whole story, see:

http://www.businessweek.com/news/2009-12-30/fatal-flying-on-airlines-no-accident-in-pilot-complaints-to-faa.html

The real question the story brings to mind is … “How do executives and managers strike the right balance between costs and safety?”

What do you think? Leave a comment here.

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I saw an interesting blog post today. Darren Greenwood talked about how major IT failures are often caused by human failures. The article, “Fail or succeed, it’s the human factor ,” is short, but insightful. Read it and see.

What can I add? Whenever the human factor is involved, you need to go beyond blame to find the real, fixable, root causes of the failure. Then you can stop the problem from happening again and again.

What else can I add? TapRooT® is the advanced root cause analysis tool that includes expert systems to help you dig into the root causes of human errors and find effective fixes.

Do you need TapRooT® Training? See:

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

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On July 31, 2009 we started a TapRooT® Root Cause Analysis Users and Friends Linkedin Group, to promote more opportunities to update your expert contact list and ask questions from TapRooT® Clients, Instructors, and their Friends. We add people everyday and would like to see it continue to grow and become a valuable resource for you with each additional question and answer session.

To promote the group’s value, here is one of two discussions that I will share in the upcoming weeks. For more, you will have to join. This discussion was started by Mark Ralls, HSE Manager at Production Services Network. Here is his Linkedin Profile if you want to connect: Mark Ralls

One other interesting point is that while this Q & A only contains 10 posts, Mark let me know that numerous experts contacted him offline, which is great!

_________________________________________

What do you measure? Mark Ralls, HSE Manager at Production Services Network and a TapRooT® Client

_________________________________________

From Dennis Osmer, Owner, Osmer & Associates, LLC, and a TapRooT® Instructor

Sounds like time to move into predictive measures such as training time, number of near misses, inspections, management audits, etc.

Posted 21 days ago | Reply Privately | Delete comment

____________________________________

From Jason Laws, Plant Manager at Gulbrandsen Technologies and a TapRooT® Client

We do measure Near Misses. We audit for proper safety on a bi-weekly, weekly basis in the Plant, and we document our TRIR.

I have never been a fan of using Total Recordable Incident Rate as a sole predictor of safety. I have to dig it up, but there was a good article on this awhile back in CEP.

We also measure process non-conformance. High temp alarms, pressure excursions, etc. I have come from a background that focused on the trips, slips and falls. Those are important, but the “catastrophic loss of life, property and capital” may not be predicted or prevented by these type of metrics.

Unfortunately, most of our current work is done as a reaction to an incident. We have incident database where we keep Pareto Charts for our Investigation findings. Currently, we track 4 types of incidents investigations: mechanical failures, quality issues, customer issues, safety incidents ( or near incidents).

Each sub group is broken down in to 3 Pareto Charts. 1. The Human Performance area. 2. The Near Root Cause. 3. The Root Causes discovered.

We couple these with a dollar cost or serious multiplier. This has helped to focus our resources on the performance areas that are causing us the most trouble, or what you might call our “general and systemic root cause usual suspects.”

Resources are as limited as they have ever been. This screening tool takes time to develop, and it takes active and quality investigations. We then follow them up with TapRoot(R) audits and CHAPS focusing on those key problem areas. We try to use this to focus our limited resources to the largest affect.

Our goal is a Total Process Improvement across the board. The Safety Triangle is Well Know. However, I like to think of it as a Total Performance Pyramid. One side is the Safety Triangle. The other Two are Quality and Performance. As we can reduce the size of each triangle (with fewer non-conforming events ) the size of each triangle should reduce. If we can run a stable plant, then the need to hurry is reduced then I believe the size of the safety triangle would also reduce with fewer recordables and overall improved safety.

This spreads the responsibility for safety and performance improvement as well as metric collection across departmental lines. These metrics will come from several departments that have the responsibility of developing and executing corrective action programs.

Now this may need a change in corporate philosophy and management by-in that Improvement goes beyond safety and the HSE department alone. It’s one way that we have been trying to collect the most effective metrics with as low an demand on our limited resources.

Posted 21 days ago | Reply Privately | Delete comment
____________________________________

From Christopher Vallee, TapRooT® Instructor and System Improvements, Inc. Senior Associate

Thanks Dennis and Jason for answering Mark’s post.

Here are a few links to presentations on metrics during the summit. What ever you measure (x1, x2, x3) changes to them should be tied into lagging indicators (y1, y2). If the x’s change and you see now change in LTI’s or Near misses thne you need to dig deeper.

http://www.taproot.com/wordpress/2009/10/30/how-to-target-audits-for-better-performance-improvement/

http://www.taproot.com/wordpress/2009/10/30/trending-with-the-taproot%C2%AE-v5-software/

http://www.taproot.com/wordpress/2009/10/19/how-taproot%C2%AE-fits-into-proactive-improvement-hazard-and-risk-analysis/

Posted 20 days ago | Delete comment

____________________________________

From Jason Laws, Plant Manager at Gulbrandsen Technologies and a TapRooT® Client

Chris, enjoyed the slides. Looks like I am working a manual path with my version of the software. I will try to get my Company to embrace the enterprise version. Right now, running my Plant as a pilot version. So, I am getting buy with the single user licenses.

If I can make it to San Antonio, I will try to sit in on some of the ver-5 sessions.

I also like your cube example in the second presentation. It may borrow the analogy to supplement my pyramid example.

Posted 20 days ago | Reply Privately | Delete comment

____________________________________

From Mark Ralls, HSE Manager at Production Services Network and a TapRooT® Client

Here is a list of things we currently measure. As you can see there are proactive, predictive and reactive measures.

____________________________________

From Dennis Osmer, Owner, Osmer & Associates, LLC, and a TapRooT® Instructor

MARK –
an impressive list — you might consider additionally: training time, emergency & BC drills, process risk analysis, site risk analysis & attitude surveys — in the past, I’ve used a collection of measurements that would change every 14 to 16 months (with notification & education of course)
best wishes for your continued success
dennis

Posted 20 days ago | Reply Privately | Delete comment

____________________________________

From Christopher Vallee, TapRooT® Instructor and System Improvements, Inc. Senior Associate

Mark,
Agreed an impressive list of metrics… now the test. Do you have an x1 + x2 + x3 = Y understanding of your proactive measures and their impact on lagging indicator changes?

Say I have a moderate near missing rating (lagging indicator) and it increases or decreases, can I say which proactive changes (increased or reduced) correlated to the near miss rating?

If you stopped certain improvement programs would this show an impact on your lagging indicators?

Chris

____________________________________

From Mark Ralls, HSE Manager at Production Services Network and a TapRooT® Client

Good question Chris. No we don’t. I think that is a direction we need to go.

Posted 19 days ago | Reply Privately | Delete comment

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The US Nuclear Regulatory Commission has issued a draft Safety Culture Policy Statement for comment.

The draft requires all nuclear material licensees (companies that operate reactors and that use or manufacture nuclear material) should demonstrate a positive nuclear safety culture. But how?

Here’s an idea…

One of the characteristics of a positive safety culture outlined in the draft policy statement is:

“The organization maintains a continuous learning environment in which opportunities to improve safety and security are sought out and implemented.”

The policy statement then includes examples. One example is:

“Personnel seek out and implement opportunities to improve safety and security performance.”

One great opportunity to demonstrate a site’s commitment to a positive safety culture is to have a team attend the TapRooT® Summit and implement best practices that they learn at the Summit. This demonstrates that personnel are seeking out and implementing “opportunities to improve safety and security performance.” Especially if you bring a couple of security folks with your Summit improvement team.

So, if you are planning how you can demonstrate to the NRC that you have a positive safety culture, don’t forget to explain how your improvement team attending the Summit is an example of efforts to maintain a continuous learning environment.

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Back in June of last year, I posted a blog entry on a WHO study of 8 hospitals that implemented checklists in hospitals:
(http://www.taproot.com/wordpress/2009/01/15/surgery-checklist-reduces-surgery-deaths/)

One of the researchers on this study, Dr. Atul Gawande, was interviewed on National Public Radio this morning (link here).  He went into even more detail and and provided further insight on this study.  He discussed how complicated and intricate the medical profession has become, and therefore instituted the use of checklists in the operating room in 8 hospitals.  He had some amazing (but not unexpected) findings:

“We get better results,” he says. “Massively better results.

“We caught basic mistakes and some of that stupid stuff,” Gawande reports. But the study returned some surprising results: “We also found that good teamwork required certain things that we missed very frequently.”

Like making sure everyone in the operating room knows each other by name. When introductions were made before a surgery, Gawande says, the average number of complications and deaths dipped by 35 percent.

How did the surgeons respond?

…when his team surveyed the doctors who used the checklist, “There was about 80 percent who thought that this was something they wanted to continue to use. But 20 percent remained strongly against it. They said, ‘This is a waste of my time, I don’t think it makes any difference.’ And then we asked them, ‘If you were to have an operation, would you want the checklist?’ 94 percent wanted the checklist.”

Checklists are a way of life in many critical, complex industries.  The airline, nuclear, and pharmaceutical industries all use checklists to some extent, but many in the medical community are still resistant.  We have even seen a reluctance to perform a root cause analysis for sentinel events.  Many people feel that, if they are using a checklist, they are perceived as not being an expert at their job.  And yet, Dr. Gawande had some amazing statistics concerning the sheer volume of information presented to physicians:

     - The average physician evaluates 250 primary diseases and conditions each year
     - These same patients have an additional 900 additional medical problems
     - The doctors prescribed over 300 different medications, 100 lab tests, and performed 40 different types of office procedures
     - In an ICU, the average patient requires 178 individual actions per day (administering drugs, suctioning lungs, etc)
     - Out of those 178 actions, 2 per day (~1%) were performed incorrectly
 
Sometimes, memory is just not enough.  When a sentinel event occurs, perform a TapRooT® analysis.  See how many times “no procedure” and “no standard turnover process” show up as root causes.

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After an investigation, we often put corrective actions in place that, at first glance, seem like they ought to fix our root causes.  These corrective actions put rules in place that, if followed, will have a high likelihood of preventing that incident from happening again.  The problem is that the corrective action has to be able to be consistently applied and monitored.  If this is not possible, then the corrective action will most likely be completely ineffective. 

Let’s take a look at some of the new cell phone laws that have been put in place over the last several years.  The AAA has put together a chart of various distracted driving laws (link here).  Here are a few:

1.  It is illegal to text while driving in Tennessee.
2.  In California, rental cars must have safe operating instructions for cell phones.
3.  In Massachusetts, cell phone use is permitted as long as it does not interfere with the operation of motor vehicle. The driver must also keep one hand on the steering wheel at all times.
4.  In New Hampshire, drivers are accountable for distractions that contribute to a crash.
5.  In many states, it is illegal for drivers with learner’s permits to use a cell phone.

Let’s take a look at the law that prohibits cell phone use by drivers with a learner’s permit.  Some states have expanded this to include any teen drivers, regardless of their license status.  The purpose is obvious:  We want young drivers to concentrate on their driving, so let’s put a law in place that gets rid of that distraction.

On the surface, this seems like a good idea, right?  We want to influence teen drivers to keep their cell phones off while driving.  But what is the reward these drivers receive for following the rule?  Using our Soon, Certain, Positive motivators, we can see that the reward for following the rule is extremely uncertain.  How do you realistically enforce this rule?  Do we expect law enforcement officers to see someone using a cell phone and then determine the age and license status of the driver before they pull them over?  Of course not.  The only way this law can be enforced is if:
1.  There has already been an accident or other rule violation AND
2.  The police have evidence that the person was actively using the cell phone while driving.

Therefore, this law will very rarely be implemented.

This type of rule is a reactive rule.  Only after an accident has occurred can the rule be applied, and then only if the violation can be proven.

So how can we make this law more effective?  We need to be able to proactively enforce the rule.  This means that there needs to be an easy way for law encorcement to know when the law is being violated.  By the same token, the drivers need to know that there is a good chance that they will be caught when they are violating the rule.  I recognize that we can’t make these laws perfect.  For example, we could put a jamming device in the car that prevents cell phone use whenever the car is running.  However, this is not a REASONABLE corrective action, and therefore is a poor rule.  However, we could make the law more effective by extending the law to ALL drivers.  Now law enforcement is much better equipped to proactively enforce the rule, before an accident actually happens.  When they see someone (anyone) using a cell phone while driving, they can enforce the rule.

Take a look at the other 4 examples I gave at the top of the post.  Can these rules be effectively implemented?  How could you make these rules stronger and more likely to succeed?  You should evaluate all of your corrective actions this way if you are to expect better performance.

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Here’s a link to an interesting article about research that indicates why texting while driving produces worse performance than talking or using a cell phone while driving. See:

http://www.ergoweb.com/news/detail.cfm?id=2422

For the original article that this research article (Text Messaging During Simulated Driving) is based on, see:

http://hfs.sagepub.com/cgi/rapidpdf/0018720809353319?ijkey=gRQOLrGlYnBfc&keytype=ref&siteid=sphfs

Don’t text and drive!

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While people were busy preparing for Thanksgiving, the Navy Times published an article about “integrity” issues in the Nuclear Navy.

The article brought up a “new” test cheating incident by sailors on the nuclear aircraft carrier Harry S. Truman. It also mentioned a test cheating scandal revealed earlier this year aboard USS Dwight D. Eisenhower (another carrier) and the 2007 chemistry scandal aboard USS Hampton (a fast attack submarine).

One of the most interesting parts of the article was at the end of the article. It said:

“Colgary and another retired nuclear-trained officer who asked not to be named said the “nukes” are generally good people who aren’t working against the system but can sometimes be pushed too hard by it.

“We try to find the root cause of problems instead of treating symptoms of the problem,” Colgary said. “Typically it comes down to personalities. You can get overwhelmed sometimes with maintenance, preparing for getting underway, preparing for deployment. And oh, by the way, you have to balance your life at home.”

That doesn’t excuse a lack of integrity in the nuclear Navy’s zero-defect mentality.

“You have to trust every watchstander on the ship,” Colgary said. “God help you if you’re in a time of war and these things are amplified even more.”

Colgary said the exam proctor who stopped the cheaters should be commended. “It would be just as easy for that proctor to turn his back and let it go,” he said.

For the eight sailors who were kicked off Truman, their Navy careers might already be over. McMichael said sailors who are stripped of their nuclear NECs essentially lose their rating. They must then try to transfer to another rating, if there is room for them. If the alternative ratings are fully manned, the sailor may have no place to go and be administratively separated from the Navy.

Getting caught cheating also made them significantly poorer very quickly. Nukes are eligible for retention bonuses up to $125,000, depending on their rates and qualifications.”

“We try to find the root causes of problems instead of treating the symptoms…” and “…typically it comes down to personalities.” You must be kidding!??

Let’s start looking for root causes other than “bad sailors” (personalities). What is the operating tempo? How short staffed (undermanned?) are these crews? How much more are they trying to do with less? How long can this “war footing” go on with too little budget and too few ships?

Even a good horse can be run into the ground if you push it long enough (”…’nukes’ are generally good people…”).

I can’t help but think there is more to the root causes of recent Nuclear Navy problems than just some bad young sailors (and, yes, some bad COs, Officers, and Chiefs).

Does anyone else have a comment on this?

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The US Department of Transportation fined El Paso Corporation $2.3 Million over a recent pipeline explosion that killed one person. (For more info, see the AP article at this link.)

Makes one wonder … how big a fine is enough?

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The PowerPoint below was sent to me several years ago by a TapRooT® User.

I’m sure all of the tips come from accidents and are lessons learned that could be shared with your employees.

If you have a good Holiday Safety PowerPoint with lessons learned that you would like to share, e-mail me at “info” @ “taproot.com”.

Thanks

Mark

SafeHolidayWish.ppt
(click to download a Holiday Tips PowerPoint)

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Toyota has been a the center of several recalls including rusty truck frames and uncontrollable acceleration. One blog even said they had “…fallen from grace…”.

Perhaps it’s time for Toyota to go beyond the simple root cause analysis of 5-Whys and start using advanced root cause analysis for these more difficult issues (or for all issues).

If you need to learn why 5-Whys should NOT be your preferred root cause analysis tool, see this article:

http://www.taproot.com/wordpress/2009/08/26/more-bad-root-cause-analysis-advice/

It has links to several articles that explain the drawbacks of 5-Whys and then you can see why Toyota might be having problems.

And if you become interested in advanced root cause analysis, see the course schedule here:

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

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All high performance systems need root cause analysis. They can use it reactively when things go wrong and proactively to keep things from going wrong.

Long ago we had our first “network reliability” people start using TapRooT® to improve network reliability. Our first customer was a company that supplied high reliability computer system for financial transactions. The next one ran a high reliability telecommunications network that included 911 call systems.

It seems they may be needing some advanced root cause analysis training in London.

Why?

They had to shut down trading on the London Stock Exchange because of a “technical glitch.”

Here what a story from The Star had to say:

“LONDON: The London Stock Exchange PLC halted trading for three-and-a-half hours on Thursday after a technical glitch prevented some customers from connecting to its systems.

The LSE, Europe’s oldest independent exchange, said taking trade offline was the only way to ensure a fair and orderly market after customers reported the connectivity problems in early trading.

The exchange is still looking into the root cause of the embarrassing outage - the second significant technical problem in just over a year - and said it was too early to judge the extent of the effect on trade or lost business.“

And this isn’t the first time this has happened. The story also said:

“Just over a year ago, the LSE experienced its worst outage in almost a decade when a software glitch was blamed for a 7-hour shutdown that angered customers on one of the busiest days of the year on world equity markets.

On that day in September 2008, the shutdown left many clients unable to cash in on a worldwide stock market boom that followed the U.S. government bailout of mortgage giants Fannie Mae and Freddie Mac.”

Think that’s a big problem? You betcha!

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Here is my Thanksgiving posting. I post it every year, lest we forget.

In America, today is a day to get together with family and friends and reflect on our blessings - which are many!

One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.

During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter - a fate shared by about half of the Pilgrim settlers.

The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.

With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship god in a way that they chose without government control and persecution.

Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.

The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.

Is this the root cause of Thanksgiving?

This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:

“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled wold have been thought great tyranny and oppression.”

William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.

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