Rackspace, a web hosting company, had a 45 minute outage on June 29th. An Article in Web Host Industry Reviews says that they are going to perform a root cause analysis of the event.
Analyzing the root causes of web outages can be very similar to other outage analyses that people do using TapRooT®.
For example, BellSouth used TapRooT® to review 911 outages, long distance network outages, and local service outages.
Another high reliability computer service provider, Tandem Computers who was later bought by HP, used tapRooT® to analyze network and computer reliability issues/outages.
It really is amazing how even with different technologies, the same proven techniques can be used to find the root causes of human error and equipment failure.
If you would like to learn advanced root cause analysis to analyze service problems, attend a TapRooT® Course. For more information, see:
Here’s an article from Abu Dhabi about a second fatal accident involving a child and a school bus. It’s interesting because the writer discusses the hierarchy of Barriers (we call them Safeguards in the TapRooT® System) and how they can be used when developing corrective actions. You usually don’t see this level of understanding of root cause analysis in a newspaper article or letter to the editor.
Someone asked me yesterday how they could justify the cost of the Summit to their boss. “After all”, they said, “We’re in a giant downturn and everybody is trying to cut, cut, cut. How can I justify the cost to come to the Summit?”
There are three reasons that it is important to attend the Summit even in the current recession (which is ending sooner than you think).
Reason 1: It’s a Great Investment Especially in Bad Times
When money is tight, every dollar counts.
We can’t waste money on a “boondoggle” conference.
Now the good news. The Summit isn’t a boondoggle (although you will have fun while you learn).
Many companies have designated their application of TapRooT® as business critical. And thus keeping their staff up to date on the latest root cause analysis best practices is also business critical. So they allow attending the Summit even in tough times.
So the Summit isn’t a waste of money. Instead, it is a guaranteed investment in the future of your company.
Reason 2: You Can’t Afford Two Years Without Improvement
Many companies put their improvement plans on hold this year because of budget constraints.
If all companies did this, then maybe a single year’s slip wouldn’t seem that bad. But here’s the bad news: They DIDN’T.
Some companies have invested in improvement this year and they are pulling ahead.
If you don’t have an aggressive improvement plan for next year - you’ll be left in the dust.
The Summit is an outstanding place to network, learn the most recent best practices, and talk to experts to develop your improvement plan for 2010.
Your goal will be to catch up with your 2009 goals and leapfrog ahead in 2010.
The improvements you achieve will more than pay for all your conference costs and more.
So you can’t afford to wait to attend the 2010 Summit because by then, you will be too far behind to hope to catch up.
Reason 3: Attending the Summit Can Help You Make Short Term Improvements That Contribute Immediately to the Company’s Bottom Line
The Summit isn’t just about long-term improvements. There are lots of quick fixes and great ways to save effort and money immediately.
Applying the best practices that you learn in a single investigation could produce dramatic savings that immediately add to your company’s bottom line.
One of the attendees at a past Summit told me that a single idea that he got on the first day was going to save his company over a million dollars on a project that they were working on.
Now I can’t guarantee a million dollar idea on the first day for everyone. But we do hand out sheets of paper with $10,000 bills printed on them for people to take notes. The idea is that every time you hear something that can save your company money, you write it down. At the end of the Summit you decide which of these ideas can save your company the most money and you develop a plan to implement the ideas when you return to work.
I’ve seen people with dozens of $10,000 Idea sheets. Their problem was trying to decide between all the great ideas they had. After all, there is only so much one person can accomplish (which is why you should bring a team to the Summit - but that’s a different article).
Therefore, if you really want to save money and help your company make it through this recession - the Summit should be an essential part of your plan.
WHAT ARE YOU WAITING FOR?
See your boss, get permission to attend, and get registered!
This is your company level Process Behavior Chart for LTI’s…. since you see no Special Cause Indicators is this good?
Careful…. what happens if you break these numbers down (aggregate) by different departments that have different levels of risk? Let us say that your Electrical Department’s LTI’s (see the Process Behavior Chart below) went up while your Supply Department Numbers went down?
Guess what… not knowing what your numbers truly say could mean a lost opportunity. In this case this could mean an electrocution the next time around. Had you taken our Trending Course and collected your TapRooT® investigated Root Causes you could then take your numbers down to the next level and Pareto your top Root Causes to know where to start looking for system level issues.
“What can I learn from my accident/incident/near-miss statistics?”
Next ask:
“How am I analyzing my statistics?”
Then ask:
“Why are all these statistics reactive (backward looking)?”
Then ask:
“What could a trend that is proactive (forward looking)?”
If these questions make you think (you don’t already have answers translated into well functioning programs), you should consider attending the pre-Summit course titled:
If you would like to meet with Bill Sirois, COO of Circadian Technologies, stop by his booth at the Exhibit/Reception at the TapRooT® Summit. You can discuss the origins of this new way to manage fatigue and how fatigue may be affecting your workers.
The Chemical Safety Board has updated their website with a more powerful search function and access to numerous hi-resolution photos of various accident investigations. The home page is here. One way to prevent accidents is to learn from your own mistakes. However, it is even better to learn from the mistakes of others. The CSB has some outstanding information available for use in your own training and lessons learned programs. Don’t miss out on this important improvement resource.
If you like the article, you should think about attending the TapRooT® Summit and sitting in on Bill Sirois’ (COO of Circadian Technologies) talk titled:
“How Fatigue Impacts Human Error“
In fact, you might be interested in the whole Behavior Change and Stopping Human Error Track!
So you are trying to implement a Behavior-Based Safety program at your facility. You feel it’s a way to get the work force engaged in their safety programs and make improvements. Unfortunately, your employees have heard that BBS is just a new management method of shifting blame to the employees, instead of having management fix facility safety problems. You’re worried that you will develop an “Us versus Them” environment. What can you do to make the transition to an effective improvement program?
Try using TapRooT® techniques to show your workforce that you really are interested in improving the site safety culture. Give them examples that show you are not just playing the blame game:
1. Whenever you must perform an incident investigation using TapRooT®, try to get the workforce involved. If there is a union presence, you should consider including them as members of the investigation team. In this way, you can show that your TapRooT® investigation is not out to assign blame, but to only gather unbiased facts. Names are kept out of your SnapCharT®s, Root Causes are found by strict adherence to the Dictionary®, and Corrective Actions are assigned that directly address the Root Causes that were discovered. Investigator biases are not introduced into the process.
2. Use TapRooT® for proactive audits. By ensuring that you are applying Corrective Actions to actual Root Causes, you’ll find your Corrective Actions will be targeted at the real problems, with no finger-pointing.
3. In traditional BBS, you teach your employees to point out when someone commits an unsafe act. The intent of this is to involve the workforce in self-correcting small problems before they lead to larger incidents. However, some employees feel that this is just a way for management to have the workforce blame each other for problems. This is not the intent of BBS, but it can be perceived that way. As an alternative, you should encourage the workforce to use TapRooT® Safeguards Analysis techniques to point out not just unsafe acts, but also unsafe conditions. These situations would be equivalent to missing Safeguards. This lets the employees look for problems not just with their peers’ behaviors, but also with their work environment as well. Since management is responsible for safe working conditions, this gives the workforce the opportunity to point out Potential Improvement Opportunities for both themselves and management. Stated a different way, it gives both the individual worker and management the opportunity to improve the working situation.
Behavior-Based Safety was initially conceived to help the workforce help themselves. The perception seems to have morphed into a blame-oriented system, which was never the intent. By using TapRooT® to show unbiased investigation techniques and Corrective Actions, you’ll be able to implement an effective improvement program.
Why do I say that these accidents didn’t have to happen? Because when you apply advanced root cause analysis after an accident, you almost always find multiple best practices that, if they had been applied before the accidents, could have prevented the accident.
Also, a proactive audit, observation, near-miss program using advanced root cause analysis could have identified and fixed these problems BEFORE the accident occurred.
These facts make needless deaths all the more tragic.
According toa story in Army Times, Defense officials will be charged with performing a root cause analysis of major cost overruns in military acquisition programs. Here’s the parts of the story dealing with root cause analysis:
“Under the conferees’ proposal, the department would be required to ‘perform a root cause analysis’ on each breaching program.”
“Further, the House-Senate bill, if approved and signed by the president, would require the secretary to designate one defense official in charge of conducting program-specific performance studies and ‘root cause analyses.’”
“The summary says this official would be ‘responsible for issuing guidance related to performance assessment for acquisition programs and for analyzing the root causes of poor performance, including reviews conducted after Nunn-McCurdy breaches.’”
We all know that some forms of root cause analysis are no more than a witch-hunt looking for someone (usually down the chain of command) to blame. This has been true in many military accidents. If you were at last year’s Summit, you heard thefirst hand account (from Lt.Col. (Ret.) Ralph Hayles)of a Army cover-up during an investigation into a friendly-fire accident. Or you can read the bookSilent Knightsby Alan Diehl to find out how facts are covered up to keep system problems causing military aviation accidents from being exposed (and fixed). Or you can look into the botched 1989 Navy investigation of the explosion of a gun turret on the USS Iowa (that killed 47 sailors). Or more recent investigations that have been discussed here:
[You might look at the list and assume that the Navy has the worst root cause analysis. I think the preponderance of posts about the Navy is because I'm a Nuclear Navy veteran and I watch press stories about the Navy more closely and post more about them.]
But let’s assume that the military can get beyond the blame game (the Military Healthcare System has gone beyond blame and adopted TapRooT® to make significant patient safety improvements). The next fault in many root cause analyses is using root cause analysis system that is too simple. Examples? 5-Whys, Fishbones, Cause-and-Effect, and Fault Trees. See some reasons why they are too simple here:
So what should this new military directorate do? What system is robust enough to handle potentially politically sensitive cost overrun investigations? As a reader of this blog, I hope you already know the answer.
TapRooT® has already been proven effective in many industries for a wide variety of types of problem solving/root cause analysis. I can still remember talking to the former Commanding Officer of the USS Greeneville,Scott Waddle, after he attended 2-Day TapRooT® Course. [You may remember that Scott was blamed for the collision of the USS Greeneville with the fishing vessel Ehime Maru (nine crew members of the Ehime Maru died). He also spoke about the collision at the TapRooT® Summit in 2005.] What was his comment about using TapRooT® to investigate military accidents? He was amazed. He started to see the system causes that were involved in the collision of the USS Greeneville and the Ehime Maru. He could see that the blame that was placed on him and the guilt that he felt after the accident were insufficient to improve the system that caused these types of accidents. He was amazed that such powerful technology - TapRooT® - wasn’t already being applied by the military to stop accidents and save lives.
Unfortunately, the military has not changed much since 2005. The blame culture still exists. Cover-ups still happen. Lives are still being lost needlessly. But if the military adopted real, advanced root cause analysis - major improvements are possible. Especially with the support of Congress. Maybe real positive change in the defense procurement system - change based on advanced root cause analysis … TapRooT® - could actually occur. Change that saves taxpayers money … potentially saves troops lives … and increases our defense stature. That could beanother real success storyabout the effective application of TapRooT®.
The first of the “15 Questions” on the TapRooT® Root Cause Tree® asks:
“Was a person excessively fatigued, impared,
upset, bored, distracted, or overwhelmed?”
Even though the questions in the Root Cause Tree® Dictionary help answer the question, assessing fatigue has always been difficult.
Now there is help.
About three years ago, I had a meeting with the management team at Circadian Technologies and helped convince them that they could take some complex, proprietary models that they used to assess fatigue and simplify them for use by company accident investigators.
They agreed to give it a try. After several years of R&D and testing, they now have a tool that usable and FREE.
What can it help you do? How about answering the following questions:
What is the probability that an individual was fatigued at the time of an incident/accident or operational deviation?
Was his/her fatigue the proximate cause of the incident/accident/operational deviation?
What was the source of excess fatigue risk (if any)?
At what level of the Fatigue Risk Management System did the fatigue risk originate?
What percent of my company’s incidents/accidents/operational deviations are caused by a fatigue impaired employee?
What is the cost of employee fatigue impairment at my company?
Answering these types of questions should be a high priority for any company with 24 hour operations, but especially for:
Hospitals
The transportation industry (aviation, maritime, trucking, mass-transit, rail, and bus)
Refineries
Nuclear plants
Oil platforms
Mines
Military operations
Pharmaceutical manufactureres
DOE sites
Really, any commercial or government facility with significant risk if a person makes an unexplained mistake.
But there’s more good news.
Bill Sirois, COO of Circadian Technologies, will be at the Summit to explain how to use FACTS and to help explain the effect of fatige on human performance.
To sign up for the Summit and Bill’s important sessions, see the Summit web site:
Here’s one more thing to think about. “Unexplained” human error costs industries billions of dollars a year. Many of these costs may be attributed to fatigued employees. Because employers don’t have a way to judge if employees are making mistakes because they are fatigued, they don’t take effective corrective actions to solve this problem.
By attending the Summit and learning about this new, free tool, you could potentially save your site millions of dollars when you can accurately identify fatigue as a cause of human error.
Thus, if you think you might have fatigued employees (and anyone in the industries I’ve listed above SHOULD be thinking of this possibility), you should get signed up for the Summit now and make sure that you attend Bill’s session (Wednesday in the third breakout from 2:40-3:55 and Thursday in the sixth breakout from 2-2:20).
The New York Times reports that after an accident that killed 25 people and injured 130 more, the Metrolink Board of Directors has voted to authorize $975,000 to install hidden video cameras on Metrolink commuter trains.
Last year train engineer Robert Sanchez ran a “red light” and hit an oncoming Union Pacific freight train. He was “texting” when he should have been driving the train.
Now Metrolink wants better forensic evidence to perform better investigations of accidents, incidents, and near-misses. The new cameras are a step in that direction.
What do you do to make incident investigation evidence collection and interviewing better? Have you thought about this important piece of an accident/incident investigation?
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Also, if you are interested in improving your incident investigations, consider attending the Investigation and Root Cause Analysis Track at the TapRooT® Summit in Nashville on October 7-9.
What will you learn?
First, you will see three accident presentations that will help you learn best practices from the presenters (including how to investigate multiple accidents to learn generic lessons).
Second, hear two best practice investigations from TapRooT® Users. Dennis Ward, from the Alaska Medallion Foundation, will share his experience using TapRooT® to find common causes of aviation accidents. Next, Ron Pryor of Alcoa will explain how TapRooT® was used in a Kaizen project to improve product quality.
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
3 rules for improving investigation questions,
who to get someone to share more information, and
how to confirm understanding.
Fourth, learn if your investigation system is “The Good, The Bad, or The Ugly” and what you can do to improve it.
Fifth, attend the one-and-only session where TapRooT® Users share their best ideas … the TapRooT® User Best Practice Sharing Forum. You will participate in a session that is always rated as one of the most helpful to TapRooT® Users who are looking for innovative ways to make investigations more efficient and effective.
Sixth, learn how to use new, free on-line software to evaluate if fatigue was a cause of a human error. Bill Sirois, COO of Circadian Technologies will share this important, innovative software.
Seventh, learn new ideas for defining Causal Factors from Ken Turnbull, an experienced investigator and TapRooT® Instructor.
Eighth, Steve Hawkins, a very experience fatality investigator who is the Assistant Director of Tennessee OSHA, share the lessons he has learned in many investigation.
You will find that these sessions aren’t boring and dry. Instead, they are packed with ideas that you can use to make your investigations more effective and more efficient.
But these sessions are NOT the whole Summit.
There are five Keynote Talks that will provide even more information and motivation.
There are other Tracks that you can pick from to make your own custom Summit experience.
There are networking and social events to make the Summit fun and to help you add to your list of industry contacts.
Want more info? see this list of “frequently asked questions” …
So, if performing world-class accident/incident investigations to prevent future accidents is business critical to your company, I look forward to seeing you there!
CNN reported on causes of the crash of the Colgan Air flight in Buffalo, NY. The NTSB is investigating the crash that killed 50 people and many details of the investigation were discussed at a public meeting.
One controversial aspect of their discussions was that fatigue may have been a cause because of off-the-job sleep patterns of the two pilots. Read about it here:
My experience is that fatigue is often “under-investigated.” That’s one of the reasons that I scheduled Bill Sirois from Circadian Technologies give two talks about fatigue at the TapRooT® Summit.
The first talk is in the Investigation and Root Cause Analysis Track and is titled:
“How To Prove That Fatigue Was the Cause of an Incident.”
It will cover some new software that is available to investigators to prove that fatigue was a factor in poor human performance.
The second talk is in the Behavior Change & Stopping Human Error Track and is titled:
“How Fatigue Impacts Human Error.”
This talk will cover the impact that fatigue has on human performance and human error.
If you want to prevent dangerous human errors and be able to tell if fatigue is causing accidents at your facility, you need to hear these two talks.
It was part of the cause of the following accidents:
Challenger
Columbia
BP Texas City Refinery Explosion
Davis-Besse Reactor Vessel Hole (near-miss)
Chernobyl
Many think that establishing an appropriate corporate culture is the most essential cornerstone of maintaining a high performance organization.
What are you doing to understand, maintain, and improve the culture at your company?
Safety, quality, and equipment reliability improvement at your site might be impossible to improve without understanding and changing your corporate culture.
If you are interested in improving your understanding of culture and what you can do to change the culture at your company, there are some “must attend” sessions at the TapRooT® Summit (Nashville - October 7-9). Here’s the list…
First, attend the “Becoming the Best” session in the Safety Track. Dennis Osmer, who helped make a major change in corporate culture at Ciba Vision, will present “Pursuit of World Class EH&S.” Hear the lessons he learned that saved millions of dollars while improving injury and illness statistics.
In the same session, Brian Dolin will discuss “Systematic Safety and Process Safety Improvement.” Again, Brian brings tons of practical industry experience to efforts to improve safety that are dependent upon the culture of the organization. These first two talks will get your mind started on a journey to improved culture at your facility.
For the second breakout session, you need to choose between two informative talks. In the Safety Track you can hear Clare Solomon from the UK explain “Communicating Your Safety Message Effectively.” Her innovative and practical ways to get the message out are critical to any culture change program.
Or for this second breakout you may choose to hear Brian Locker’s talk: “Leadership for Doing Things Right.” Brian will discuss the differences he has observed first hand between organizations that excel and organizations that have major accidents. This is definitely a culture issue.
In the third breakout session, there is an opportunity to explore an issue that is a symptom at many sites with a troubled culture - people don’t report problems. You’ll jump over to the Safety Management Track and Kevin McManus, an expert in establishing business systems, will present: “8 Reasons People Don’t Report Problems and 8 Solutions to Improve Employee Involvement.” This talk really highlights effective, practical ways to get people involved in reporting problems (so they can be solved). This be a major improvement to a corporation’s culture.
The next talk that will really catch your interest is from Keynote Speaker Mike Kelley. He has practical experience establishing an amazing corporate culture as VP at TODCO. His Keynote talk, “Establishing a Culture that Promotes Super-Performance,” will share his vision for senior management in setting a high performance corporate culture. You will leave his talk more motivated and enthused to make culture change happen.
He will follow up the Keynote presentation with a breakout session (the fourth) in the Safety Track titled: “The Keys to Successful Safety Culture Change.” In this session he will get into the “how to” details of culture change. Mike speaks from real experience and you will appreciate his practical advice that he has used to successfully change culture in a high hazard industry (oil drilling).
In the fifth breakout session, you’ll transfer over to the Behavior Change Track to learn from Dr. Beverly Chiodo. Beverly is a management professor at Texas State University where she has won every teaching award they have. She brings her excellent presentation skills to her presentation: “Character Driven Success.” Understanding character is essential to establishing a positive, high performance culture. And nobody does a better job of explaining character than Dr. Chiodo. (PS: if you think a discussion of culture and character is boring, please note that Dr. Chiodo has received the highest ratings on this very session from past Summit attendees who say she is “awesome!”)
Next, in the sixth breakout session, Dr. Chiodo continues her discussion of character and culture with a talk titled “Changing Behavior by Praising the 49 Character Traits.” This is a practical talk about ways to apply Character Driven Success in the workplace. It is a real culture change tool.
In the seventh breakout session, we head “Down Under” to learn some culture change secrets from the Aussies who are presenting “Safety Improvement Ideas from Down Under” in the Safety Track. Greg Allan’s talk, “Measuring Safety Performance & Improving Safety Culture” is great advice for those who want to measure culture improvement.
The Thursday afternoon Keynote address from Dave Prewitt and Mark Paradies : “Systematic Management of Improvement.” Managers use systematic methods to obtain financial results. Mark and Dave will discuss ways that safety can be improved using systematic methods/tools.
Friday morning, John Miller, a personal accountability expert, will present “Personal Accountability.” Accountability is a critical element of culture and John’s inspiring talk will get you motivated to take accountability for improvement.
Next, in the eighth keynote session, John will get into the specifics of personal accountability in his presentation: “Practical Lessons for Applying Personal Accountability.”
The final breakout session is time to develop your culture improvement plan. You’ll have a little over an hour to develop your plan and have it reviewed by an experienced TapRooT® Instructor.
Wow! That’s a culture improvement extravaganza. If “culture” is important to your company, this custom program at the Summit is a must attend improvement event.
But wait, as they say on TV, “There’s more!”
Before the Summit there is a Pre-Summit Course (October 5-6) - Improving Your Organization’s Safety Culture.This course was developed by one of our Australian TapRooT® affiliates. For more info, see:
The final investigation reports are likely months away, so we should not jump to any conclusions. However, there are many things to consider here; manufacturer recommended training, company training processes, company oversight, FAA oversight, and fatigue. It’s easy to point the finger at the pilot but there looks to be a lot more to this one. It will be interesting to see what the final report reveals.
Living in Knoxville, I fly commuter airplanes all the time, and I feel safe. However, I also worked in the airline industry for 27 years and understand what these small carriers are up against. Financial pressure from the majors, trouble recruiting, and in many cases, less evolved management systems than the major carriers. As an aside, I worked for a company that ground handled Colgan back in the day some 28 years ago. They’ve been around a long time and that speaks to their ability to remain focused in an industry that has seen many come and go. Hopefully, Colgan, the FAA, and the NTSB can work together to make sure this never happens again.
I flew Colgan late last year and we aborted our takeoff in Houston due to engine problems. Not fun but I’m glad the pilot aborted!
If you want to ensure good management systems and training are in place, you should use TapRooT® proactively. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, we spend most of the morning on day 4 talking about proactive measures. We cover best practices throughout the rest of the course as well. Why not join us for the next course? Here is the schedule:
I recently read 11 nuclear plant trend reports. Not one had a mathematically valid way to trend. (One did come close.)
These 11 nuclear industry trend reports are not unusual … They are typical of trend reports from various industries.
This makes one ask: “Why do so many companies have trouble trending?”
Let’s look at specific problems in the 11 reports.
First, many “trend” reports showed no trends. Three of the eleven reports didn’t even have a single graph. They were just discussions of incidents and audits in a particular quarter with discussions of “trends” with no data.
Most of the reports that had graphs used simple bar and line graphs. Bar graphs with no timeline don’t really show “trends.” They are best used to look for the Pareto Principle and help to identify the biggest problems to attack first.
One report tried to use a mathematically based approach. They used a c-Chart with limits based on 3 times the square root of the mean of the data. But c-Charts require independent data with a constant area of opportunity – which is unlikely for incident data.
The most common error made in trending reports (and by management) is looking at the number of problems in one quarter and comparing them to the next quarter. If the number of problems goes down – that’s a good trend. If the number of problems goes up – that’s a bad trend. They tend to use straight-line approximations to “project the future” (as in the example below).
What’s wrong with this approach? Management starts reacting to noise rather than signals.
Some might say that there’s nothing wrong with trying to “fix things when they aren’t broke.” But they are wrong.
They don’t understand the cost of reacting to non-problems.
They don’t understand how employees get tired of the new improvement flavor of the week.
They haven’t thought about the negative cycle of blame, cover-up, and surprise that is all too common when major accidents occur.
What should people do? Where can they find out about the best practices in trending? First, they can read Chapter 5 of TapRooT® - Changing the Way the World Solves Problems. The new TapRooT® Book explains the problems with trending and the ways to implement best practices in performance measures and trending.
Would you like to go beyond reading? Then you should plan to attend this year’s Advanced Trending Techniques Course on October 5-6 in Nashville, Tennessee (just before the Summit).
What will you learn? First, you will learn why trending is needed and the basics of trending (including the proper way to apply Pareto Charts).
Second, you will learn the math behind Process Behavior Charts (the only chart you need to view trends over time). This math only requires addition, subtraction, multiplication, & division (no different¬ial equations).
Third, You will also learn special ways to use the charts to trend infrequently occurring accident data.
Finally, you will learn how to use your own trend data including how to improve the data and how to present it to management. Get more information about the course by clicking on the “Courses” button above.
Are you reading this blog overseas (not in North America)? Then you might be wondering, is the TapRooT® Summit worth the effort to convince management that overseas travel is worthwhile.
YES IT IS!
Buy why? Read on…
First, Certified TapRooT® Instructors are required to attend the Summit every two years to maintain their certification.
Why? To maintain and improve their TapRooT® teaching skills. Also, Certified Instructors from a Licensed Companies will take home the newest 2009 version of the 2-Day TapRooT® Course PowerPoint and instructor notes.
Second, there is an amazing amount of best practice sharing that takes place at the TapRooT® Summit.
Third, you will experience an amazing expansion to your worldwide network of contacts as you share ideas with experts and peers. People at leading companies from around the world attend the Summit. This amazing network of new friends will help you with your performance improvement ideas (and your career).
These are best practices from around the world that will help your business achieve world-class performance in human performance, equipment reliability, safety, and quality. The practical best practices that ateendees take home save thousands (even millions) of dollars (or Euros, Pesos, Yen, Pounds, Rupees, Yuan, Reals, Kronor, Rubles, …).
Fourth, you can learn from industry leaders and meet performance improvement gurus / celebrities that are speaking at the Summit. Visit http://www.taproot.com/summit and click on the speakers to see who will be there.
(Picture of just a small fraction of the over 60 presenters.)
Fifth, down-home hospitality.
Many visitors to the US only experience the big coastal cities: Los Angeles, New York, Boston, or San Francisco.
Or they may go to fantasyland (Orlando).
But they never experience the heartland. Nashville is in the heartland. It’s the home of country music and the capital of Tennessee. And our staff is known for making people feel at home.
Don’t miss this opportunity to experience the real heartland of the USA.
The Hospital Survey on Patient Safety Culture: 2009 Comparative Database Report has an interesting statistic.On average, 52% of hospital staff surveyed did not report any medical errors in their hospital over a 12-month period. The statistic is based on data from nearly 200,000 hospital staff from 622 hospitals nationwide.
Can an employee really go a year without making any mistakes? Very doubtful. Even with outstanding human performance on an well designed action, a person will make a mistake one in 10,000 tries. More normal performance is one error in 1000 tries.
So what do these stats mean? That errors are largely under-reported.
Before you criticize the medical industry, look at your facility’s statistics. How many error reports did you have last year. How many employees do you have. I’d bet that more than 50% of your employees never report a single error.
Have you ever thought about the costs associated with these unreported, uncorrected errors? It many be more than you think. The problem with under-reporting is that cheap opportunities to improve performance (near-misses) are being missed. Only big errors (to obvious not to be reported) are acted upon. So you have to think not only of the cost of the small errors, but of the cost of the big problems that could have been prevented.
Would you like to improve your near-miss reporting? Then there’s a session by Kevin McManus at the TapRooT® Summit that you need to attend:
“8 Reasons Why People Don’t Report Problems &
8 Solutions to Improve Employee Involvement”
Learn why people don’t report problems and practical things that you can do to improve your error reporting program to make it world-class.
And if you would like to learn how to analyze and prevent human errors, attend theStopping Human Error Coursebefore the TapRooT® Summit on October 5-6. This course is being completely redesigned for 2009 (more about this in later posts) but we know that you will learn practical ways to make major improvements in human performance at your facility. I’ll send you the latest details if you e-mail me by clicking on the “Contact Us” button at the top of the page.
2 openings - 1 in Quebec and 1 in Saskatchewan - Health And Safety Manager - 10 yrs exp
apply to jobs@entirehire.com
SAFETY MANAGER
Quebec Chemical company needs fluently bilingual French/English Safety Manager for plant
Saskatchewan location needs English - Safety Manager for plant
Position Summary :
The Safety Manager ensures site compliance with Government Regulations and Safety Standards, coordinates and maintains Site / Transport Emergency Response, Process Safety Management and Security Plans. (more…)
Next time you are busy justifying your accident prevention and root cause analysis efforts by concentrating solely on the monetary side of what an accident costs, read the story at this link:
Capability Resources of Australia will be presenting Improving Your Organization’s Safety Culture as a Pre-Summit Course October 5-6, 2009 in Nashville, Tennessee. This course is designed for persons, in all industries, interested in understanding and improving their organization’s safety culture. A full cross-section of people should attend including persons in safety, human resources, operations, maintenance, supervisory and management positions.
This course includes:
- An overview of various safety culture models (Professor Patrick Hudson, Professor James Reason and others)
- Why it is good business to improve safety culture
- Safety leadership practices
- The need to continually change measures and KPI’s to improve as an organization moves along the safety culture continuum
- Findings from other organizations
- Model and tools to measure and improve your organization’s safety culture
- Example of an organization’s survey result
You will gain a basic understanding of:
- What is meant by ’safety culture’
- Elements of a safety culture continuum
- A ‘measure’ of your organization’s safety culture (from your perspective)
- Tools to help improve your safety culture
This special course is only offered once this year! Register today!
We understand that for you to spend your valuable time away from work and fund attendance to an event like the Summit, you have to be able to show your organization the benefits. But what if you could improve your corrective actions and prevent recurrence of your biggest problems? How much would that be worth?
I’d like to discuss the sessions in the Corrective Action Program Track
and the benefits of them:
• In “Success Stories from the Field,” Dennis Ward will discuss “Improving Performance by Analyzing Multiple Aviation Incidents for Common Causes,” and Ron Pryor will present “Using TapRooT® in a Kaizen Project to Improve Product Quality,” showing how TapRooT® can be used proactively in conjunction with your quality improvement processes.
• In the “TapRooT® User Best Practice Sharing Forum,” Linda Unger and Michelle Lindsay will facilitate a user discussion so everyone can learn from each other. Two heads are better than one, so bring your best practices to share with the group.
• “The Good, The Bad, and the Ugly: Which Describes Your Investigations and Reports and What Can You Do To Improve?” Brian Tink and Tom Brower will lead a discussion and an interactive workshop to allow participants time to develop a quality improvement strategy for their company. Through examples from the session leaders and open discussion, the session will help you gain insight and develop some ideas you can implement when you return to your site.
• Dan Verlinde and Ed Skompski will present “Managing Incidents & Corrective Actions Using the TapRooT® Software,” covering Corrective Actions, Corrective Action Helper, and Corrective Action Status in the TapRooT® V5 Software, including user management of Investigations/Documents and Corrective Action Management.
• “Tools to Help Management Evaluate Corrective Actions,” facilitated by Dana Barclay and Ralph Brickey. If you could write just one corrective action that would prevent an incident, would this pay for your summit attendance many times over?
• Kevin McManus will present “8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement” to give you more ideas of how to unleash the power of employee involvement and good morale.
• “Improvement Effectiveness Measurement” will be presented by Dr. Joel Haight and Brian Tink. Learn how upstream measures are used to improve performance; more importantly, see how to show the link between these measures and the outcome of your safety activities so you know what is working and what is not.
• “Trending Using the TapRooT® Software” will be presented by Ed Skompski, Dan Verlinde, and Chris Vallee. This session will cover how to use your data for trending purposes in the TapRooT® V5 Software, including Corrective Action Status Reports, Root Cause Reports, the search function, and defining trending going forward.
That is a lot of value for $995! And that does not count the benchmarking with old and new friends from your and other industries. But WAIT! There is MORE:
You’ll meet in the morning and afternoon with attendees from all tracks to hear the keynote speakers:
• Dr. Joel Fish, Brian Tink, and Jim Thompson will talk about how just one root cause analysis changed an industry practice.
• E.D. Hill from Fox News will talk about “Lessons Learned from Success.”
• Mike Kelley will deliver an empowering talk called “Establishing a Culture that Promotes Super-Performance” where he will discuss his view that personal and professional growth are tied together and how they ultimately add to the success of the organization.
• Mark Paradies, our President, and Dave Prewitt will present thoughts on systematic ways to manage performance.
• Best selling author John Miller will open the day on Friday with a powerful talk on personal accountability.
These keynote talks provide a good balance of usable techniques, personal improvement, and motivation, and alone are easily worth the $995! How much would it cost to hire just one of these amazing speakers?
And by the way, there is one more thing – the last session you attend will be “Planning Your Improvements” where TapRooT® Instructors will facilitate attendees in developing action plans for when you return. The difference in success and failure can come down to one simple process; setting goals and following through to achieve them.
Be proactive! Tell your management that you want to attend the Corrective Action Program Track at the 2009 Summit. Write down the value to you of each of these sessions, and put some thought around the cost of human error in your business. What if you could reduce these costs just a small %? How much is the summit worth to you? I think you’ll agree, much more than the cost.
Don’t forget our guarantee: Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire fee.
P.S. - I would be remiss if I did not mention that it is also a great idea to come two days early and attend a two-day course at a cost of $1895 for a course and the summit (a $200 discount). See the list of two-day pre-summit course here:
“Human error was listed as the cause of 12 out of 34 incidents.”
“Equipment failure was listed as the cause of 17 out of 34 incidents.”
“Information that is missing includes the experience and training of the personnel involved in the accident; operator/contractor training and maintenance programs; job procedures; condition of the equipment; and maintenance and training records. We believe that this type of information holds the key to accurately identifying the causes of many accidents.”
“Right now the reports do an adequate job of telling us what happened, but they don’t do a good enough job of explaining why it occurred. In our opinion, MMS must significantly improve the method of investigating, analyzing, and reporting the root and contributing causes of accidents if MMS is going to use these reports in understanding why accidents occur.”
A patient suffering from pregnancy induced high blood pressure walks into an Acute Care Clinic 5 Day’s after giving birth with the following symptoms (1):
* Fatigue and weakness
* Rapid heartbeat
* Shortness of breath (dyspnea) when you exert yourself or when you lie down
* Reduced ability to exercise
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness
The patient is sent home after a lung x-ray and with medicine to slow her heart rate down. Six hours later she is admitted to the Emergency Room by ambulance with the following symptoms (1):
* Fatigue and weakness
* Irregular heartbeat
* Shortness of breath (dyspnea)
* Persistent cough or wheezing with white or pink blood-tinged phlegm
* Swelling (edema) in your legs, ankles and feet
* Lack of appetite and nausea
* Difficulty concentrating or decreased alertness
The patient is dropped off at the front desk to answer questions because she is able to sit up and speak. Finally the patient is paralyzed in order to be examined and the staff realize that she is having Congestive Heart Failure.
Two heart stops later, admission to the ICU and after fiver years, my wife, Babette, is doing okay… still gets tired but she did not need a new heart nor did she receive brain damage from lack of oxygen.
So what does this have to do with Root Cause Analysis and what I teach today…..
There must have been something “Different” with this patient… There must have been a recent “Change” in how to diagnose Congestive Heart Failure….
We have talked about performing a Change Analysis before on this site and we teach this in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader and Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis courses…. but what if you do not find a recent Change or Difference, how could you have prevented this from happening?
While the initial thought may have been these were abnormal symptoms (A Difference)…. the symptoms listed above are pulled directly from a well known medical clinic (1). Staff are trained to look for these issues and no Change was made recently in their processes.
So could you have proactively prevented my wife’s missed diagnosis and the findings listed below?
“Multivariable analysis showed that patients who presented to the emergency department with acute cardiac ischemia were more likely not to be hospitalized if they were women less than 55 years old.”(2) So is AGE enough of a a patient difference to understand what went wrong on January 5th, 2004?
The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! In all our TaprRooT® training courses proactive auditing is covered…. but what is the difference between a great audit and just watching someone work to see what policies and procedures they broke?
Go Out and Look (GOAL) and perform a robust audit. Knowing what you know now, what would you look for when auditing an examination of a patient in an Acute Clinic or the Emergency Room? Where would you start? What would you look for?
What critical Near Cause Categories could occur during this process in the timeline from Acute care clinic > ambulance > ER front desk ER > ICU (just to mention a few)…
Misunderstood Verbal Communication?
Turnover Needs Improvement?
No Communication or Not Timely?
Within each of these TapRooT® Near Cause Categories are Root Causes. So what would a Good Near Cause Category and Root Cause Best Practice look like…. the opposite of our definitions. By looking for these best practices during an Audit, you will find problems in you current unchanged process before it is too late.
So while performing an audit what is better and why… a surprise no notice audit or and a scheduled audit with plenty of notice…… I would love to see guests to the weblog and our TapRooT® students answer the above question.
After all The only major difference between an audit finding and investigation finding is timing and the severity of the outcome! Why wait! Join us and other leaders in the industry in an upcoming TapRooT® training course to learn more about effective proactive auditing. (more…)
The video below should remind us all that some worksites are more hazardous than others.
(click tp play - .wmv format)
The amazing part is that those nearest the hazards sometimes become complacent. After all, they live with the hazard day after day.
What does this have to do with root cause analysis?
First, you can apply root cause analysis proactively BEFORE any accident happens.
Two ideas that could have worked in this case are Safeguards Analysis and Equifactor®.
Safeguards Analysis
Before an accident happens, you can review any process and identify the Hazards, the Targets, and the Safeguards.
In this case, the energy being absorbed by the cable is one Hazard.
Someone reviewing this process could ask: “If the arresting system fails, what are the Safeguards to the energy in the cable?
This might identify potential Safeguards that need to be implemented to:
1) Reduce the number of targets.
2) Protect people who need to be nearby.
When I see all the people just standing around unprotected, I think this is an example where many targets (people who really didn’t need to be there) could be removed.
One other note. What was the Safeguard that worked for the “Yellow Shirt” that jumped the cable twice? His human performance (alertness) probably saved his legs. But one might ask, should we rely on this? Or should there be better Safeguards?
Equifactor®
Also, a reliability professional might use Equifactor® proactively to analyze potential failures in the arresting gear system to reduce the likelihood of failure. This would reduce the likelihood that the hazard (the energy in the cable) would be released.
Learn More
To learn more about Safeguards Analysis and Equifactor® and other TapRooT® root cause analysis techniques that can be applied proactively to stop accidents before they happen, attend a TapRooT® Course.
It is part of the transportation costs of things we buy.
It’s a portion of the cost of the food we eat.
Many of the oil companies are also TapRooT® Users. Therefore, I pay attention to the industry and the challenges the industry faces.
The last three weeks haven’t been good.
First, there was an announcement that efforts to start offshore drilling in the US would not be going forward.
Next, the Secretary of the Interior said he would stop Rocky Mountain oil shale production to “study” it some more.
Finally, the President released his budget which includes significant tax increases on domestic production of oil and gas over the next 10 years.
To me, the impact of these actions seems obvious. We are causing the price of gas to go up by discouraging domestic production of oil and gas through regulation and further increasing the price at the pump through taxation.
Some might hope that alternative energy sources will take the place of domestic oil and gas production. But they should be aware that the technologies that can provide the fuel we need (electric cars, fuel cells, and natural gas) are unproven and/or may not be developed in time (before the recovery occurs).
What will that leave us?
Skyrocketing prices at the pump when the recovery occurs.
Also, before the recovery occurs, the jobs that could have been created in the domestic oil and gas industry (and could have helped raise taxes to pay for our current surge in spending) will be lost.
Don’t get me wrong. I’m not saying that we should rape and pillage the environment. I think the domestic production of oil and gas can be done responsibly. And I think the government should incentivize our domestic oil and gas companies to develop new sources responsibly (perhaps some sort of decreased royalties based on excellent environmental performance of a site).
Also, I’m not saying that drilling and oil shale will come on line in the next 12 months. But we could be finding sources, adding to proven reserves, and combating rising prices by showing that we are serious about domestic production of energy.
Instead, I believe we will forgo domestic sources of energy and continue to use foreign oil. We will pay higher prices, send jobs and dollars overseas, weaken our economy, and hurt those who can afford increased fuel prices the least (the poor). And I really can’t understand why.
Sorry if you see this as a political rant, but I see it as a discussion of jobs in the US using our own local resources and a way to help us out of this economic slump.
I think of this as a performance improvement program for our economy.
I think we ALL should be doing all we can to turn things around and that includes the politicians in Washington.
If they don’t - we suffer. People should remember who did what when the price of oil goes back up to record levels. Big oil companies are often portrayed as robber barons. But the truth is that our own energy policy (crafted by politicians and bureaucrats in Washington, DC) is the real issue. If we don’t remember what politicians in DC do that cause the crises … they will never be held accountable.
- - -
NOTE:
I’m open to other ideas.
If you see things differently - or if you agree - please leave a comment to explain the way you see things.
The web site About.com has a page about airline accident rates. You can look up the top performing airlines (least accidents per mile flown) in North America, Europe, Asia-Australia, South/Central America - Mexico - Caribbean, or Africa/Middle East and an overall ranking.
China Airlines and China Eastern Airlines were tied at #88 for the worst record of those on the table (accident rate 4.52) and Delta Airlines was the best (accident rate -4.42). (Don’t ask me how they get a negative number - that’s just what the table says.)
The question to consider is …
Do these accident rates indicate future performance?
They are backwards looking statistics. Reactive. Should they be used to project future performance? Can the predict future accidents?
Many companies use reactive statistics to predict future performance. However, at the 2-Day Advanced Trending Techniques Course, we not only teach people advanced tools for trending statistics (including infrequently occurring accident statistics), but also, how to use proactive statistics to actually judge future performance without waiting for an accident to tell you how you are doing.
The course is based on the techniques that were developed by Walter Shewhart and are now used in Six Sigma programs. But we don’t take months or years to train you. We have taken just the techniques you need and built them into a two day class that anyone who can understand basic math (addition, subtraction, multiplication, and division) can use to accurately assess trends.
So the answer to the question above. Is:
NO
Only proactive trends can be used to predict future performance. The reactive statistics can only be used to confirm the proactive trends after the fact.
The next 2-Day Advanced Trending Techniques Course is in Nashville, Tennessee, USA, on October 5-6, 2009. This course is only offered once a year … So put the dates on your calendar and get signed up. To register, see:
For those trying to keep track of the billions BP has spent after the 2005 explosion that killed 15 people, you need to add another $180 million that BP has agreed to spend as part of an agreement with the Department of Justice and the EPA.
Linda Unger, VP at SI, was talking to a TapRooT® User. He mentioned that he was planning on attending the TapRooT® Summit in October of 2009. She asked:
“Are you going to have any problems getting approval
to attend in the current business environment?“
His answer:
“No. My part in incident investigations
is considered business critical.“
Is improving safety, quality, productivity, and maintenance by performing outstanding incident investigations “business critical” at your company? If not, why not?
Are cutbacks in a recession worth:
- A couple of fatalities?
- Losing a major customer over bad quality?
- Major cost over-runs because of mistakes in the process?
- Major plant downtime due to an unexpected equipment failure?
When you think of it that way, using incident investigations to improve performance is business critical.
That’s why you should be attending the TapRooT® Summit. The Summit is all about business critical best practices. Business critical best practices that your company can’t afford to miss. Business critical best practices to:
- Save lives
- Reduce risk
- Improve safety
- Change behavior
- Stop human errors
- Improve production
- Eliminate sentinel events
- Manage performance improvement
- Create effective performance measures
- Enhance equipment reliability and maintenance
- Maintain your TapRooT® Certified Instructor status
- Become a TapRooT® Software Super-User/Administrator
- Apply the latest root cause analysis and investigation techniques
For an overview of the Best Practice Tracks, see the schedule page:
Brainstorming is often successfully used to develop new ideas, increase employee moral and unfortunately… even to attempt to find Root Causes for problems. Lets start with the basics. Who should be sitting at the brainstorming table? When should brainstorming be used and more importantly when should it NOT be used? If you solve problems what can you use that has been successful?
So let’s start with roll call… say present if here:
Human Engineering Expert?
Procedure Expert?
Quality Control Expert?
Communication Expert?
Management Systems Expert?
Work Direction Expert?
Training Expert?
What… someone is missing? Who? Why would this matter you may ask? Let’s take a missing Training Expert. When is the last time a new training idea was suggested, developed and THEN handed off to the Training department to run with? Have you seen new training ideas getting stopped in their tracks because no one understood the process… after your brainstorming team invested all that time? After all, time is money. Why do we at System Improvements, Inc. think these are the right experts? Just take a look at our TapRooT® success stories and their companies’ return on investment and reduction of incidents.
One caution from experience, once you get the experts in the room you must also have a facilitator present to help the team keep the same perspective and reference. Try this if you don’t think so: ask everyone in a team to close their eyes and point North… which way do we go? TapRooT® has a way to solve arguments and to keep people on track, use our Root Cause Dictionary & Laminated Root Cause Tree. These tools will standardize your points of reference in your problem solving session.
When should brainstorming be used… Now that seems like it might be a tough question to answer, but it’s not. Use it when you first need to develop possible venture ideas, develop new ways to work a process or to communicate what others may have successfully done. Sometimes brainstorming can be used to develop corrective actions on GOOD problem Root Causes. System Improvements, Inc. has also developed a Corrective Action Helper® to use with our SMARTER technique. This guide includes best practice examples from multiple industries and includes references to allow you to dig even deeper.
When should brainstorming NOT be used… DO NOT use it to solve problems or to find Root Causes for problems. Why not you may ask? Brainstorming requires you to ASSUME that you know why a problem existed. Think about it, how many brainstorming sessions have you been in where you were called in as group for a company crisis… did it go a little like this:
“We are here today to solve the XYZ crisis. Write down your ideas on yellow stickies as to what the problem could be. We will affinitize these ideas and vote as a group on what the problem is and put a team on it to fix it.”
Whoa… how can you solve a problem when you don’t have the facts nor do you know the sequence of events of the problem you are attempting to solve? It CAN NOT be done from behind a table and you must GO OUT AND LOOK (GOAL)? If you are using brainstorming and other similar tools to solve your major issues and the problems continue to repeat or even get worse, then it is time to CHANGE. Look at our TapRooT® success stories and then talk to us at System Improvements, Inc. to see when the next Public class starts.
We in TapRooT® Courses, we teach a technique called Safeguards Analysis that can be used reactively in an accident investigation (to help identify Causal Factors and to help evaluate and develop corrective actions) or proactively in a process improvement program (to identify Hazards, safeguards, and Targets and improve system reliability).
Sometimes people have a hard time understanding what a Hazard is. Hazards in the terminology of Safeguards analysis are usually a form of ENERGY.
So looking at the picture above, identify the Hazard and Target.
Next identify the Safeguard that is keeping the Target safe.
I’ll post the answers in a couple of days as a comment.
NOTE: this Monday Accident and Lesson Learned is about an accident that has NOT happened. The lesson learned is that if we can spot the Hazards and the Targets and come up with reliable and perhaps even redundant ways to keep them separated (Safeguards), we can avoid accidents. And in most cases, we can do this proactively.
John Miller is our closing Keynote Speaker at the TapRooT® Summit (October 7-9 in Nashville, TN). I thought his article (below) was a great reminder of how important it is not to surrender our long term improvements to short term crisis - so I got permission to reprint the article here.
If you would like to find out more about John and his inspiring, helpful way of viewing personal accountability, attend the TapRooT® Summit. Until then, visit his web site at:
The man who brought me into the training industry in 1986, a terrific guy named Jim Strutton, always told me, “John, most organizations spend more money landscaping their grounds each year than developing their people!” Well, probably not always accurate, but given our current economic plight it sure could be. Yet the reality is this:
Now is the time to invest in people.
An immutable truth:
When tough times come, the training dollar is the last one budgeted
and the first one cut. Training is seen as “discretionary,”
even as some management teams chant
PEOPLE ARE OUR GREATEST ASSET!
Cutting training now would be as ludicrous as:
Allowing a teenager to get his license and begin driving his little sister to dance practice without ensuring, through responsible parental instruction, that he knows exactly how to do the job. Teaching a teen to drive safely is not optional. Right, parents?
Allowing the passengers on the plane that became a boat on the Hudson River to be served by pilots and flight attendants who didn’t have the skills to handle the crisis. Thankfully, their training wasn’t “discretionary.”
The Millers frantically knocking on the door of our neighbor Bruce÷a lieutenant in the local fire department÷at 2am because our house is on fire, and having him respond with, “Sorry, but our classroom training budgets have suffered deep cuts, so my team just isn’t ready for fieldwork. Good luck!”
Yes, I know, a bit absurd, but don’t doubt it for a minute: The economic situation we’re in right now is a lot like a house on fire. For some organizations, it is an emergency. And that is why we must train.
We need team members who are sharp, able, and ready to solve problems. Efficiency and effectiveness are paramount, while paying customers are rarer than ever. This is not a time for waste, nor the moment to lose buyers while believing there are a dozen more waiting in the wings to take their place. Because there are not. Too often organizations try to get through tough times with nothing more than empty words like these:
“Do more with less!”
“Be a team!”
“Adapt to change!”
“Get out there and sell!”
“You can do it; we believe in you!”
Or possibly you’ve simply been told to work harder.
Sorry, but lectures, motivational speeches, and platitudes are not enough. People need skills.
The good news is, some organizations seem to be on top of this incredible need for skill development. We’ve already seen a change in 2009. As I digress just a bit, this may sound like a commercial. So, my apologies in advance …
At QBQ, Inc., we do two things, both around personal accountability: Live QBQ! presentations (speaking) and provide a training program our clients facilitate in-house.
Our speaking revenue is dependent on client-held events. Currently, events are scarce. When the economy suffers, layoffs abound, and profits dim, this makes sense. Events stick out like sore thumbs and send the wrong message. It’s pretty conflicting to take a sales force to the Bahamas while home office positions are being cut.
But on the training side, we see growth. And that’s good, because training sends the right messages to people.
Training builds trust, loyalty, and confidence÷not to mention competence. It assuages fear and worry. In fact, one client firm went a step further. They took a class of 16 people through QBQ! training even though seven of the people had just been laid off and would be seeking employment elsewhere! Now that’s a merciful company and one that I could work for.
It’s also an organization that will be ready to compete when the economy turns. And make no mistake; all recessions go away. All sour economies rebound. So the only question is, will your people be prepared? They will be if you agree with the title of this message:
It’s time to train! John G. Miller Author of QBQ! and Flipping the Switch
With Kristin Lindeen QBQ! speaker/workshop facilitator
QBQ, Inc. Helping Organizations Make Personal Accountability a Core Value ˙
11368 Nucla Street, Denver, CO 80022
303-286-9900, Fax: 303-286-9911
Email: info@QBQ.com
The following press release is from the U.S. Chemical Safety Board, Washington DC:
Chairman Bresland’s New YouTube Safety Message Urges More Government Action, Increased Industry Vigilance to Prevent Catastrophic Dust Explosions
Washington, DC, February 4, 2009 - Marking the first anniversary of the Imperial Sugar explosion that killed 14 workers in February 2008, CSB Chairman John Bresland released a new video safety message today asking federal regulators and businesses to increase efforts to prevent combustible dust fires and explosions.
The safety message can be viewed on the CSB’s safety message channel, www.youtube.com/safetymessages, and the text can be also read on http://safetymessages.blogspot.com, an agency blog site.
In the safety message, Chairman Bresland noted that of eight catastrophic industrial dust explosions since 1995, all but one occurred during cold weather months. Four disastrous dust explosions occurred during the month of February alone.
‘Yesterday’s reports of a coal dust explosion near Milwaukee that caused injuries and damage underscore the danger from these accidents,’ Chairman Bresland said on the release of today’s message. Several contract workers suffered burn injuries from an explosion Tuesday morning involving a coal dust collection system at a power plant in Oak Creek, Wisconsin.
‘I call on all of industry to take this hazard seriously - during the winter months and throughout the year,’ Mr. Bresland said in the video. ‘And I urge the incoming leadership at OSHA to act upon the CSB’s recommendations from 2006 to develop a comprehensive regulatory standard for combustible dust.’
The CSB completed a major study of combustible dust hazards in November 2006, identifying 281 fires and explosions that killed 119 workers and injured 718 others. The CSB urged the U.S. Occupational Safety and Health Administration (OSHA) to develop a comprehensive regulatory standard designed to prevent dust explosions. OSHA has not issued a standard but has developed a program to increase enforcement of existing regulatory provisions.
On February 7, 2008, a catastrophic dust explosion destroyed the massive packaging plant at the Imperial Sugar refinery in Port Wentworth, Georgia, fatally burning 14 workers and injuring 38 others. In Senate testimony in July 2008, Chairman Bresland noted that the Imperial explosion and other major dust explosions would likely have been prevented if the companies had followed existing National Fire Protection Association (NFPA) recommendations for controlling dust hazards. Those measures - including appropriate equipment and building design, worker training, and rigorous dust-cleaning programs - should form the basis of a new regulatory standard for industrial workplaces, Mr. Bresland said.
‘Despite the efforts of NFPA, OSHA, the Chemical Safety Board, and many others, serious dust explosions and fires continue to occur,’ Mr. Bresland said in the new video. ‘As CSB chairman, my commitment is do everything possible to make these tragedies a thing of the past. Stronger, clearer regulations and more robust safety programs in industry will prevent most dust explosions - and save lives.’
The CSB is an independent federal agency charged with investigating industrial chemical accidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.
The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit our website, www.csb.gov.
For more information, contact Daniel Horowitz at (202) 261-7613 or Hillary Cohen at (202) 261-3601.
Viewers who can not access YouTube can download the video files for all safety messages and safety videos from a page within the CSB Video Room.
I was reading an article in a daily e-mail publication and an entry caught my eye. It said “Safety experts believe that about 20% of workers cause 80% of accidents”
It then went on to say that these “accident prone” employees were most likely:
Irresponsible, aggressive, and easily distractible people
Stoic “tough guys,” who work through any injury or illness and consider it a sign of weakness to do otherwise
Risk takers, who think accidents happen to other people and who are often young and male
Angry people, who let emotions distract them from their work because, as the old saying goes, they are “so angry they can’t see straight”
Shy workers, who don’t want to draw attention to themselves by reporting an incident or near miss
Tired people, including shiftworkers, whose lifestyles don’t give them enough energy or alertness to work safely
Disinterested workers, who frankly don’t give a damn about the job and simply don’t care enough to be careful
Wow! The article made me stop in my tracks and think…
First off, who are these “safety experts” who say that 80% of the accidents are caused by 20% of the workers and this makes them “accident prone”?
Of course a small percentage of workers cause most of the accidents. How could it be any other way? If 100% of the workforce was involved in accidents … Everyone would be injured!
Because only a small percentage of people are injured, people start thinking that they just had “bad luck.” But this isn’t right either.
The small percentage of employees being involved in accidents (”causing the accidents” as the article claims) is simply a result of modern safety systems that keep most of the employees safe most of the time.
Next, where could anyone get reliable statistics about the types of employees involved in accidents across the country that are categorized into the categories suggested above? I’ve never seen this type of report from National Safety Council, OSHA, or the Bureau of Labor Statistics. My guess is that someone made this stuff up - which could be why the data was completely un-sourced in the article.
What can you learn from this article’s lessons from accidents.
1. Don’t believe everything you read about safety. Look for the sources of statistics. “Experts believe” isn’t a good enough reference.
2. Think about statistics that are presented in articles. If they don’t seem right, they probably aren’t. Remember, over 50% of all statistics are made up (like this one).
3. Yes, a small percentage of employees are involved in accidents. But this doesn’t necessarily mean they are bad people. Stop looking to blame people (who caused this?) and start looking for system causes that you can correct to improve performance.
If you need a systematic process to find the human performance and equipment related causes of accidents and incidents, attend a TapRooT® Course and learn to apply the TapRooT® System to develop effective corrective actions to stop accidents and improve performance.
If you like the article, you should think about attending the 
Bill Sirois, COO of Circadian Technologies, will be at the Summit to explain how to use FACTS and to help explain the effect of fatige on human performance.
If you are interested in techniques to gather evidence and perform better interviews, you should consider attending the special, pre-Summit course titled:
Third, Vincent Phipps, communication expert, will discuss how to use communication skills when investigating an accident. His presentation will include:
There are other 
First, attend the “Becoming the Best” session in the Safety Track. Dennis Osmer, who helped make a major change in corporate culture at Ciba Vision, will present “Pursuit of World Class EH&S.” Hear the lessons he learned that saved millions of dollars while improving injury and illness statistics.
In the same session, Brian Dolin will discuss “Systematic Safety and Process Safety Improvement.” Again, Brian brings tons of practical industry experience to efforts to improve safety that are dependent upon the culture of the organization. These first two talks will get your mind started on a journey to improved culture at your facility.
For the second breakout session, you need to choose between two informative talks. In the Safety Track you can hear Clare Solomon from the UK explain “Communicating Your Safety Message Effectively.” Her innovative and practical ways to get the message out are critical to any culture change program.
Or for this second breakout you may choose to hear Brian Locker’s talk: “Leadership for Doing Things Right.” Brian will discuss the differences he has observed first hand between organizations that excel and organizations that have major accidents. This is definitely a culture issue.
In the third breakout session, there is an opportunity to explore an issue that is a symptom at many sites with a troubled culture - people don’t report problems. You’ll jump over to the Safety Management Track and Kevin McManus, an expert in establishing business systems, will present: “8 Reasons People Don’t Report Problems and 8 Solutions to Improve Employee Involvement.” This talk really highlights effective, practical ways to get people involved in reporting problems (so they can be solved). This be a major improvement to a corporation’s culture.
The next talk that will really catch your interest is from Keynote Speaker Mike Kelley. He has practical experience establishing an amazing corporate culture as VP at TODCO. His Keynote talk, “Establishing a Culture that Promotes Super-Performance,” will share his vision for senior management in setting a high performance corporate culture. You will leave his talk more motivated and enthused to make culture change happen.
In the fifth breakout session, you’ll transfer over to the Behavior Change Track to learn from Dr. Beverly Chiodo. Beverly is a management professor at Texas State University where she has won every teaching award they have. She brings her excellent presentation skills to her presentation: “Character Driven Success.” Understanding character is essential to establishing a positive, high performance culture. And nobody does a better job of explaining character than Dr. Chiodo. (PS: if you think a discussion of culture and character is boring, please note that Dr. Chiodo has received the highest ratings on this very session from past Summit attendees who say she is “awesome!”)
In the seventh breakout session, we head “Down Under” to learn some culture change secrets from the Aussies who are presenting “Safety Improvement Ideas from Down Under” in the Safety Track. Greg Allan’s talk, “Measuring Safety Performance & Improving Safety Culture” is great advice for those who want to measure culture improvement.
Friday morning, John Miller, a personal accountability expert, will present “Personal Accountability.” Accountability is a critical element of culture and John’s inspiring talk will get you motivated to take accountability for improvement.
