Root Cause Analysis Blog

In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

The TapRooT® Summit has 10 “Best Practice Tracks” focussed specific topics. One of those topics is:

Safety and Risk Management Best Practices

The purpose of this posting is to provide those interested in safety and risk management with a little better idea of the talks and discussion sessions they will experience if the attend the Safety & Risk Management Best Practices Track at the TapRooT® Summit.

Here is a list of sessions with a brief description of each session:

1. Hazard Recognition: The First Step in Safety & Risk Management - Peter Berkholz, Engineering Manager, Capability Resources

Peter will discuss practical strategies to identify hazards in the workplace and methods to get employees to spot and correct problems.

2. CHANGE

Dealing with Obstacles that Make Change Difficult - Hal Curry, Consultant, hal Curry & Associates

Managing the Risks Associated with Change - Malcolm Gresham, Principal Consultant, Practical Solutions Group, Australia

All safety improvement programs involve change. Hear these two talks that discuss change, obstacles to change, and risks associated with change.

3. Root Cause Analysis of Major Accidents

Lexington Airport Runway Mix-Up - Ken Turnbull, Consultant & TapRoot® Instructor

Cameco Cigar Lake Mine Flood - Mark Wittrup, Cameco

Investigating Fatalities - Mario Chacon, Cal OSHA (invited)

Those interested in safety can learn a lot from the accidents of others. This session focusses on three different discussions about major accidents. First, Ken Turnbull will share how TapRooT® can be applied to public information about an accident to analyze it and learn lessons. Next, Mark Wittrup will present the results of a TapRooT® investigation of an expensive mine flooding accident. Then, Mario Chacon from Cal OSHA will share lessons from fatality investigations.


4. Advanced Behavioral Management: Developing a Modern Safety Culture - Bob King, Director of HSE Training/Consulting, Woodland Grange, UK and Neil Roberts, Consultant, Woodland Grange, UK

Safety culture is a big topic in many industries (nuclear power, oil and refining, aviation, …). Instead of hearing the same perspectives that we have all heard, we decided to bring a fresh look at the topic from Woodland Grange in the UK. Bob King and Neil Roberts will share their experience and advice on developing and establishing a “modern” safety culture.

5. Panel Discussion: Is There a Tradeoff Between Process Safety and Industrial Safety - Panelists: Miles Kajioka (ConocoPhillips), Valarie Barnes (US NRC), Bob King (Woodland Grange), and Ken Turnbull (Consultant, previously with Texaco)

The explosion at the BP Texas City Refinery caused many to question their Process Safety Management programs. In a sworn deposition, the Process Safety Manager at BP Texas City implied that resources were diverted from process safety and used to improve industrial safety. The implication was that in any plant with limited budgets, any investment in industrial safety could be seen as taking resources away from process safety. The panel will provide their views on this “tradeoff” and discuss with participants things that can be done to make programs complimentary rather than competitive.

6. TapRooT® User Success Stories From Healthcare and Industry - Facilitators: Linda Unger and Barbara Phillips

Three TapRooT® Users (to be determined closer to the Summit) will share recent successes improving performance by applying the TapRooT® System. Learn from the best practices of others and apply their ideas to improve performance at your facility.

7. The Good, The Bad, and The Ugly: Rating Improvement Programs and Incident Investigations - Tom Brower, Consultant

Is your program Good, Bad, or Ugly. Rate it and see. Compare your program to others at the session. And learn techniques to rate your company’s incident investigations.

8. Senior Executive Involvement in Safety

Bringing Safety to the Corporate Board - Dave Prewitt, VP, FedEx

What the Corporate Board Needs to Know About Safety - Bob King & Darby Alan, Woodland Grange, UK

What does the Corporate Board need to know about safety? With new corporate manslaughter laws in countries around the world, perhaps more than they currently know. Part of the Chemical Safety Board’s investigation of the explosion at BP’s Texas City Refinery implied that senior management and the Corporate Board needed to know more about safety and the impact of budget decisions upon safety. because of these issues, we invited Dave Prewitt, VP at FedEX, and Bob King and Darby Alan of Woodland Grange in the UK to speak about getting senior management, and even the Corporate Board, involved and aware of safety.

9. Planning Your Improvements - Facilitated by TapRooT® Instructors

A session that allows time for you to develop your improvement plans, get them reviewed by an experienced TapRooT® Instructor, and then benchmark them with other Summit participants.

Beyond the Safety & Risk Management Best Practice Trach sessions, there are five interesting Keynote speakers:

Marcia Wieder, Nikki Stone, Lt Col Ralph Hayles, Carolyn Griffiths, and Ed Frederick. For more information about their talks, see:

http://www.taproot.com/keynote_speakers.html

So if you are interested in improving safety and managing risk, sign  up for the TapRooT® Summit and register for the Safety & Risk Management Best Practices Track. See:

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

Also consider attending one of these related courses prior to the Summit:

• Risk Management Best Practices
• Innovation & Creative Solutions
• Hazard Recognition Best Practices

For more information about these courses, see:

http://www.taproot.com/pre-summit_courses.html

Some call it a vision. Some call it a dream. But every improvement program needs a goal. Do you have a vision of what performance would look like if you could achieve the ideal state at your company? Achieving that vision is what Marcia Wieder, America’s Dream Coach, is all about. As the closing Keynote Speaker at the TapRooT® Summit, she will show you how to achieve your dreams and make your vision a reality.

To hear a little of the type of advice America’s Dream Coach will provide at:

http://www.dreamcoach.com/video/0405_speaker_demo.wmv

And attend her talk: You Can Make Improvement Happen

To register for the 2008 TapRooT® Summit, see:

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

Dr. Beverly Chiodo, Professor at Teas State University, was a Keynote Speaker at the 2007 TapRooT® Summit. It is very unusual for us to have a Keynote Speaker back. There are so many interesting speakers and we want attendees to come back year after year to get new points of view. But so many attendees in 2007 asked us to have Dr. Chiodo back, and to have her expand on the topic of Character Based Behavior Change, that we had to break with our past rules and invite Dr. Chiodo to return.

First, Dr. Chiodo will repeat last year’s talk, “Character Driven Success,” in the 2:40 Human Error Reduction & Behavior Change Best Practice Session on Thursday. People who saw the talk last year as a Keynote who would like to see it again, should sign up for this session. If you didn’t see her talk last year and you want to know what the buzz is all about, get to this session!

Then on Friday, Dr. Chiodo will go beyond last year’s talk with a follow up talk in another Human Error Reduction & Behavior Change Best Practice Session. The talk, titled “Changing Behavior by Praising the 49 Character Traits” is for anyone truly interested in ethical, effective methods to change behavior and who wants to hear interesting, practical advice.

To learn more about this  blockbuster Summit, the great networking, and the best practice sharing (including videos from attendees at the 2007 Summit), see:

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

(S1W Prototype)

(Not everything is excitement in the Nuclear Nayy - Shutdown RO at S1W)

I can still remember when I first heard about the accident at Three Mile Island. I was on a bus heading out to S1W (a Nuclear Navy Prototype Reactor in the desert in Idaho). I was partly snoozing and the bus driver had a transistor radio playing. The music was interrupted for breaking news. The commercial nuclear power reactor at Three Mile Island was having some sort of problem - perhaps a meltdown! The on-the-scene reporter was interviewing a farmer near the plant. He said his cows weren’t acting right and that morning he could “…taste the radiation…”.

Ed Frederick, Keynote Speaker at the TapRooT® Summit,  was a member of the Control Room crew at the onset of the Three Mile Island Unit 2 accident on March 28, 1979. The decisions made, and actions taken by Mr. Frederick and the rest of the crew on that morning resulted in a partial meltdown of the reactor core. The accident is the only General Emergency and evacuation associated with nuclear power in the United States. The accident at TMI was the subject of intense public interest and is still remember each year in television news.

But the accident at TMI happened back in 1979. What could we possibly learn that’s new from such an old accident?

(Picture of Three Mile island)

Look at the various “facts” that are available at various places on the internet:

http://americanhistory.si.edu/tmi/
http://www.nucleartourist.com/events/tmi.htm
http://www.tmia.com/

http://www.pbs.org/wgbh/amex/three/

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/tmi.htm

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/aftermath.htm

http://www.washingtonpost.com/wp-srv/national/longterm/tmi/whathappened.htm

http://video.google.com/videoplay?docid=8348815263023489062

http://www.threemileisland.org/

http://www.uic.com.au/nip48.htm

http://en.wikipedia.org/wiki/Three_Mile_Island_accident

http://www.nrc.gov/reading-rm/doc-collections/fact-sheets/3mile-isle.html

(Picture of damaged core)

The causes for the accident at TMI and the experiences related by someone who was “investigated” after the accident are just as applicable today as they were back in 1979. And they are applicable across industries around the world. That’s why I’ve been asking Ed to speak at the Summit for years - the lessons are important for everyone who is interested in investigations and performance improvement to learn. And this year Ed will share his inside view of the accident and the aftermath.

Ed will also conduct a Best Practices Session that allows investigators to practice their skills by drawing and revising a SnapCharT® based on what they “know” and answers from the person involved - Ed Frederick.

For more information on the rest of the sessions and Keynote Speakers at the Summit and to register, see:

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

Next week I’ll be at the IOSH Conference in Telford, England.

Why am I attending?

To hear some interesting talks and to promote advanced root cause analysis to improve safety in the UK.

If you want to talk about root cause analysis, drop by our booth (A 12 - near the entrance) and say Hi!

Hope to see you there…

Mark

The TapRooT® Summit has a Best Practices Track focussed on improving Corrective Action Programs. The specific sessions for this track include:

• “Outside the Box” Creative Solutions
• Evaluating the Effectiveness of Corrective Actions
• Using TapRooT® to Evaluate Common Cause and Extent of Condition
• Better Corrective Actions by Using Corrective Action Tools
• Management & Performance Improvement
• How to Get and Keep Management Support
• The Good, The Bad, and The Ugly, Rating Your Improvement Program and Incident Investigations
• Root Cause Analysis of the Accident at Three Mile Island

For more information about the Summit, including the five blockbuster Keynote Speakers, see:

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

Carolyn Griffiths is the Chief Inspector of the UK Rail Accident Investigation Branch.

The UK RAIB is an independent investigative organization that by law investigates the UK’s railway accidents and incidents. The purpose of their investigations is not to apportion blame or to enforce laws, but rather to improve railway safety and prevent future accidents. For questions about the UK RAIB see:

http://www.raib.gov.uk/about_us/index.cfm

Carolyn is a Keynote Speaker at the TapRooT® Summit in Las Vegas on June 25-27. She will speak about her experiences starting up the UK RAIB in 2004/2005 and some investigation lessons learned from the RAIB’s initial investigations.

What can you learn?

Every investigator or head of an investigation organization can learn from the experiences of others. In talking to Carolyn, I found that her approach to getting good investigations, the training she requires for her investigators, and the challenges of getting investigations completed were all interesting topics to hear about.

That’s what’s great about the Summit. You will not only hear the RAIB’s Chief Inspector talk, but also, you will have the opportunity for one-on-one conversations to ask questions, share best practices, and make a new contact in your network of professional associates.

For more Summit information and to register, see:

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

As a TapRooT® and Equifactor® instructor for System Improvements, I get the opportunity to meet quality, engineering, safety, manufacturing, operations and medical company experts from around the world. In two or five days these experts learn the basics of the TapRooT® System for finding the root causes of problems PLUS some attend one day of Equifactor® Equipment Troubleshooting Technique for root cause failure analysis of equipment problems. These are grueling days of lecture and hands on application that does not allow much time to teach people the science behind good root cause analysis. Just as important, I do not get to show people why being an expert in your field of work can actually impede your investigation due to “tunnel vision” of the mind.

Experts who are now using TapRooT®, have learned how to investigate with an open mind based on tons of research in human and workplace system interactions. But with all the knowledge our experts bring to the table why was this a limiting factor before TapRooT® use? After presenting at the ASQ Automotive Conference in Michigan this February, audience members wanted to know more about root cause tool limitation and expert use of rules-of-thumb. So if you want to understand more of our thinking processes in problem solving and why we have a tendency to assume we know why an incident occurred before we really know what occurred, link to the paper below.

“Why ask why when you should be asking what?”

Winning an Olympic Gold Medal sets you apart. You are the best on the planet at your event.

But Nikki Stone’s story goes beyond being the best. She showed exceptional dedication & persistence to come back from a career-ending injury (that prevented her from standing, much less skiing).

Why is Nikki a TapRooT® Summit Keynote Speaker? Because people leading performance improvement initiatives need to overcome obstacles that seem insurmountable.

After being inspired by Nikki’s determination and courage, these obstacles won’t seem so large. You can achieve success!

Don’t miss Nikki’s Keynote address. And talk to Nikki one-on-one at the Summit reception.

To see an interview with Nikki, click on the YouTube video below:

A new survey by the National Sleep Foundation shows that on average, people get 40 minutes less sleep each night than they need for optimum performance. Also, about 1/3 of the folks surveyed said they fall asleep or become very sleepy while working.

Why are people so short on sleep? Researchers think that people are working more and still want to maintain their off time with family and friends. Therefore, they sleep less.

What are the effects of sleepiness on workers and how do you evaluate fatigue as a cause of human error and accidents? That’s one of the topics in the upcoming TapRooT® Summit (Las Vegas, June 25-27).

Bill Sirois, VP and COO of Circadian Technologies, will be presenting three sessions on fatigue and the investigation of fatigue as the cause of accidents. The sessions are:

Human Error Reduction & Behavior Change Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 World

Investigation & Root Cause Analysis Best Practices Track:

• FACTS - Computerized Analysis of Fatigue as a Cause of an Incident

Medical Error Reduction Best Practices Track:

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment

For additional Summit information, see:

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

To download, click on:

http://www.hss.energy.gov/CSA/CSP/camp/reports/Camp_1stQtrFY08.pdf

Click here to listen to Kevin…

The main thrust of a comment by Mayor Daley in Chicago seems to be that if you punish enough people, future accidents will be prevented - or so an article in the Chicago Tribune implies…

At a news conference the paper quotes Major Daley saying:

“I don’t manage the CTA, [CTA President] Ron Huberman does. Any time you have an accident, you have an investigation. Then you have the proper penalties for the individual, and discipline, and that’s what they have done. They have allowed this to be thoroughly investigated, and they are not afraid of the outcome. The outcome shows there were deficiencies, and they have corrected it.”

The article states that Huberman, who appeared with Daley at a South Side news conference on an unrelated subject, said that heads rolled after the accident. He is quoted as saying:

“The director in charge of this group has been replaced. The manager in charge of this group has been replaced. The supervisor has been replaced. And the foreman has been replaced. Everyone was held ultimately accountable for this.”

The article says that the NTSB’s investigation concluded that the derailment in a stretch of Blue Line subway was caused by the CTA’s “ineffective management and oversight of its track inspection and maintenance program and its system safety program, which resulted in unsafe track conditions.” Bob Chipkevich, Director of the the NTSB’s office of railroad, pipeline and hazardous materials investigations, said the CTA’s track inspection and maintenance were the worst he had ever seen at a U.S. transit agency.

The article also mentioned that Huberman stated that:

“Significant changes have been put into place, new auditing functions have been put into place … and new technology has been put in place.”

He also said:

“You have a brand new team. This was the result of the 2006 derailment. … We have accelerated many changes, and they are in place today, making it a safe system.”

So what’s the answer? Replacing people or accelerating changes and new technology? Was it the people (who are now gone) or the politics that caused the problems? Was the poor maintenance, faked reports, and bad surveys caused by four bad people or was their a culture that caused poor performance? Did the culture change or did we just put new people into the old culture?

More stories about this accident are available at:

http://www.suntimes.com/news/metro/552146,ntsb091107.article

http://www.chicagotribune.com/news/chi-ntsb_websep12,1,3577989.story

http://www.ctatattler.com/2006/07/fire_closes_blu.html

http://www.ctatattler.com/2006/05/anatomy_of_a_tr.html

http://cbs2chicago.com/video/?id=24432@wbbm.dayport.com

http://www.ntsb.gov/Pressrel/2007/091107.htm

http://www.ntsb.gov/events/2007/Chicago-IL/presentation.htm

I will be exhibiting and attending the 44th National Irish Safety Organization Annual Health & Safety Conference in Killarney on October 11-12. If you will be attending, please stop by our booth and I’ll demonstrate how TapRooT® works. In addition, you can get your very own Spin-A-Cause™ - the worlds fastest root cause analysis system.

I’m off to the IEEE/HPRCT Human Factors and Power Plants Conference in Monterey, CA. The conference starts on Monday so don’t look for my regular posting (I’ll try to post anything interesting that I observe).

What am I talking about at the conference? Two topics…

Improving and Existing Root Cause Analysis and Corrective Action Program - Tuesday, 10:30 - 12, in San Carlos 1 room

Positive vs. Negative Enforcement - Which Promotes High Reliability Human Performance - Wednesday, 8:30 - 10, in San Carlos 2 room

If you are attending, stop by one or both of my sessions and say Hi!

See the link below for an AP story on incidents at a nuclear fuel plant in Erwin, TN.

http://www.chron.com/disp/story.mpl/nation/5069951.html

I know that reporters have to make their stories readable, but does the author, Ducan Mansfield, have to be so sensational?

Words and phrases like:

“three-year veil of secrecy”

“could have caused a deadly, uncontrolled nuclear reaction”

“revealed”

“stinging letter”

seem to be used to sensationalize administrative action to keep national security issues secret while releasing information about incidents at the Nuclear Fuel Services plant.

If the author wanted to, he could have used this sensational headline:

“Environmental Activists Disregard National Security
in Hopes of Damaging the Nuclear Industry”

What can incident investigators learn from this? Don’t think that your incident investigations will receive fair and balanced coverage.

Environmental activists and reporters may have an agenda. Whether the agenda is to get a story published or to damage a company, regulatory agency, or industry, may not be clear - but it makes little difference if your company’s reputation is damaged in the process.

Sometimes investigations of accidents border on the bizarre.
The attached PowerPoint has been around the internet several times but I still find it amazing.

Where is my Dozer.ppt
click above to open PowerPoint

Imagine performing the root cause analysis of this strange accident…

If you attended the 2007 TapRooT® Summit, it would have been hard to miss this guy:

Kevin McManus taught several informative breakout sessions, including:

Analyzing Frequently Occurring Quality & Downtime Problems

Best Practices from the Malcolm Baldrige National Quality Award

How to Develop a High Performance Work Culture

And in his spare time at the Summit, he also worked in these breakout sessions:

Incident Investigations - Best Practices

as well as the Improving Quality and Processes, Panel Discussion: Comparison of Root Cause Techniques and Lean Root Cause Analysis breakouts.

He also co-taught a pre-Summit course, Advanced Trending Techniques. Best of all, he has agreed to come back and share his experience and wisdom with our 2008 Summit attendees (but we have promised not to work him so hard!).

Kevin is the President of Great Systems! and provides performance improvement coaching from his office in Seattle, Washington. He has served as an industrial engineer, Training Manager, Production Manager, Plant Manager, and Director of Quality during his 23 year business career. He served as a Examiner and Senior Examiner for the Malcolm Baldrige National Quality Award for six years. Kevin also writes the monthly Performance Improvement column for Industrial Engineer magazine and is a regular speaker at a variety of regional and national events. No wonder he has so much to share!

Thank you, Kevin, for your hard work and dedication to changing the way the world solves problems!

Below is a note I received from Summit Speaker, Bill Sirois. (Bill Sirois is Senior Vice President and Chief Operating Officer of Circadian Technologies, Inc. (CTI). You may contact him through his website: www.circadian.com.) ~ Barbara

While we all know intuitively that fatigue is frequently a root cause of today’s accidents and injuries, it is still being grossly under-reported as a causative factor. This is because we are not collecting the necessary data to identify fatigue as the real culprit. Plus, it is much easier to blame “behavior” as the cause of human error. For example, the truck driver who recently crashed into the Bay City Bridge in Oakland at 4:30am was cited for speeding, rather than the more likely scenario that he simply nodded-off during the low point on the human biological scale. Moreover, his entire life’s history is being scrutinized to find just cause that he was simply a “bad apple” to begin with. Yet, the fact remains that there is a 15 times greater likelihood of an accident between 3am and 6am than at any other time of day (DOT, 1995). It has to do with our human design specifications (i.e. circadian rhythms), and most of us have known that for a long time. Just how to prove it in an industrial or transportation accident is another matter. That’s where FACTS comes in.

In the meantime, please let me know if you have any questions on the FACTS System, or if you have any incidents that you would like to have analyzed for fatigue as part of the research and development effort.

[Please click the icon below to view Bill’s Summit presentation.]

Here are a few more ideas shared at the TapRooT® User Best Practices session (with Linda Unger, Michele Lindsay and Jade Washmon):

“If an incident appears to be easy to resolve, immediately assign one person to investigate. If the assigned person finds the incident is more complicated, then form a team.”

“Follow through with corrective actions. We developed a system with e-mail notification. Three individuals are assigned to follow-up to make sure corrective action is implemented.”

“Corrective Actions Team: take your corrective actions back to management before the final report is complete.”

“Review process for each investigation. Use a TapRooT® quality checklist - making sure leadership is trained in TapRooT® so when management reviews the checklist, they know what they are looking for.”

“Be efficient with utilization of investigative teams. Establish a goal of the investigation that is thorough, efficient and objective. Cover all bases on data collection: 1) Go see the equipment/facility involved (example, walk to the pothole, check visability); 2) Collect all paper for the incident (example: reports, records); 3) Meet all people involved (conduct interviews); 4) Review recordings (request security videos). Last but not least, recognize your team’s work!”

Jim Whiting discussed different risk analysis methods used to estimate hazards in his Summit talk, “Using Risk Analysis as a Pre-Job Evaluation/Pre-Job Briefing Tool” (as well as how to choose the most effective risk control option!). Click below to download a copy of Jim’s papers:

All safeguards are not created equal.

In Jim Whiting’s Summit talk, he showed attendees how to identify and strengthen safeguards for proactive improvement. For more information about using safeguard analysis, download Jim’s presentation below:

After writing hundreds of reports, Mike Rodriguez shared an experienced based presentation at the Summit, “Writing the Report - Do’s and Don’ts.” Take this opportunity to download a copy of his handout below to keep as a handy report writing reference:

Single User, Multi-User, Corporate Multi-User — choices, choices — how do you weigh your options? Ed Skompski’s presentation at the Summit helped attendees make an informed decision. But if you missed Ed’s presentation at the Summit, “Comparing Individual User, Workgroup, and Enterprise TapRooT® Software - Which is Best for Your Company?” — you can view his papers below:

Six Sigma methodology focus is implementation of a measured-based strategy that focuses on process improvement and variation reduction through the application of Six Sigma improvement project. But any process improvement in healthcare demands knowledge of how its systems affect patient care. Harry Wetz and David Davis presented “Six Sigma/Lean Healthcare” at the Summit. To view their papers, see the icon below:

Six Sigma Quality

Kaizen Event Summary - Medication Administration

System Improvements has been working since the mid-90’s to help healthcare facilities perform better root cause analysis and adopt advanced strategies to stop human error. Continuing that work, David Davis, Tommy Garnett and Ed Skompski presented and facilitated ideas for “Healthcare Best and Worst Practices for Root Cause Analysis” at the TapRooT® Summit. Below is David and Tommy’s handout for the presentation:

If you are at a healthcare facility and need to learn advanced root cause analysis or would like to learn best practices to stop medical errors, see our course info and our upcoming announcements about the 2008 TapRooT® Summit on this blog.

Summit attendees who signed up for the “Stopping Medical Error” track learned best practices in infection control. David Davis and Dr. Will Sawyer presented “Stopping Nosocomial Infections” at the TapRooT® Summit. If you missed this excellent presentation about infection-control, click below to view David’s papers:

Lessons from History . . . Modern Day Techniques . . . Marco Flores presented all in his Summit presentation, “Becoming Creative - Techniques from Great Thinkers.” Find out the techniques used by great thinkers to drive their creativity by viewing Marco’s handout:

SMARTER is an acronym that stands for:

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

Each corrective action should be reviewed for each of the letters in SMARTER. Sanjay Ghandi and Steve Swarthout presented how to accomplish this using the SMARTER Matrix at the TapRooT® Summit.

Click below for a copy of Sanjay’s handout for this presentation.

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This Summit session drew upon current nuclear industry initiatives to highlight recognized best practices in conducting incident investigations. The industry initiatives include an IEEE Recommended Practice on incident investigations, Corrective Action Program Owners Group working conference objectives, and industry experience. Our presenter, Kay Gallogly, provided current industry thinking on practices that are ready to implement as well as pit falls to avoid in managing an effective incident investigation process.

Click the link below to download a copy of Kay’s presentation.

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Troubleshooting mechanical equipment can take many forms. There are many methods being used, with varying degrees of success.

What makes your ace troubleshooter so good?

How can we make our entire troubleshooting team that productive?

Ken Reed showed us how to build a successful troubleshooting strategy in his Summit presentation, “Developing an Equipment Troubleshooting Strategy.”

Click the link below to view Ken’s presentation.

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How many times have you had an equipment failure occur, only to have the operators tell you:

Oh, yeah, it never has worked right.

Many would say this is a nuisance issue, sometimes costing a little extra for repeat repairs, but not worth a full investigation. At the Summit, Ken Reed presented how implementation of this philosophy is a roll of the dice, sometimes resulting in disastrous consequences.

Click below to receive a download of Ken’s handout at this presentation.

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Try to build a nuclear power plant in someone’s back yard, and you’ll witness how communities come together to fight something they perceive as extremely dangerous. And yet, at the submarine base in Groton, CT, there may be as many as 18 nuclear reactors within a quarter mile of each other, in various stages of operation and maintenance. Why is there no public outcry over this “dangerous” situation? Admiral Rickover has put in place a program that has endured over 30 years. In his Summit presentation, “Rickover’s Legacy - Safety & Equipment Reliability,” Ken Reed told us what made Admiral Rickover’s program endure, while the civilian program has, until quite recently, languished.

Click below for a download of Ken’s presentation.

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Equipment troubleshooting is an art. It requires logic, focus, and system expertise to successfully conduct equipment fault analysis and repair. Troubleshooting electrical and electronic devices takes this one step further. Ken Reed’s presentation at the Summit, “7 Step Method for Electronic Troubleshooting,” reviewed troubleshooting strategies that can be employed when faced with electronic equipment failures. Click the link below to download a copy of Ken’s presentation.

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Why is it important to get management involved in your investigation program?

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Hazard Identification and Risk Analysis are internationally recognized pro-active safety tools that can take an organization’s safety program to the next level. Job Safety Analysis is one way to translate that hazard and risk information into task specific steps that help the employee recognize and avoid the risks inherent in certain jobs. The challenge has always been to provide an end product that is useful enough that employees not only understand it and use it but also know how to revise it when situations change.

Dan Stevenson’s Summit presentation, “Combining Process Mapping of Procedures with Job Safety Analysis,” outlined one organization’s successful effort to develop immediately available procedures for all critical tasks that provide useable information about the risks of the task and the tools needed to reduce the likelihood of personal injury or damage to equipment. This Procedure Mapping process proactively uses the familiar TapRooT® tools and introduces other simple tools to provide a very, user-friendly process that is easily used by all employees.

Click the link below for a presentation of Dan’s 6-step overview of this process.

~ Barbara

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