Root Cause Analysis Blog

I was so busy at the 2008 Summit that I really didn’t have a chance to take a break from Sunrise to Sunset.

That’s why I didn’t provide minute to minute reporting on what I was learning at the Summit – I just didn’t have a chance to write.

I did take some notes and I thought that readers might be interested in what I learned. Therefore, I will share my “A-Ha’s” here for everyone to read.

1. I learned from Darby Allen that 5-10% of all profits are consumed by the costs of accidents and incidents. The costs include hidden costs. For example:

• Fines
• Legal
• Investigation
• Productivity Loss
• Retraining
• Lost Production/Missed Orders
• Sullied Reputation
• Hidden Equipment Damage

2. I learned from Dave Prewitt that senior management needs a single source (a single database) that has all failure data and costs in it. This includes audit findings. That senior management can then use the data to build an organization that is resistant to disaster because they proactively ensure that systems are safe.

3. I learned from Lt. Col. Hayles that big organization naturally tend to cover up senior management failings and look for scape goats when big things go wrong. That this is a natural part of “protecting the mission of the organization”.

4. I received lots of good ideas about TapRooT® and the TapRooT® Software from the TapRooT® Advisory Board Meeting.

5. I really enjoyed the great people at the Summit and had a wonderful time at the Reception/Birthday Party where I got a chance to catch up with two old friends – David Busch and Kevin O’Connor.

6. I learned from Carolyn Griffith that the UK Rail Accident Investigation Board spends 7 months training one of their new investigators. Also, that a “no blame” policy is a major part of their investigations.

7. I heard many user best practices at several best practice sharing sessions including the TapRooT® User Best Practices Session run by Linda Unger and Michele Lindsay. I’ll try to do a separate write up of these later.

8. I learned from Chris Vallee (Six Sigma Black Belt and TapRooT® Instructor) that SnapCharT®s and Swim Lanes can be combined into a powerful Lean/Six Sigma tool.

9. That even though I had studied the accident at Three Mile Island extensively, I could learn much more by listening to an operator who was at the panel (Ed Frederick).

10. I learned from Marcia Wieder that dreams and visions are similar and that fear is the biggest roadblock to achieving your dreams (vision).

11. That I need to practice if I am going to play golf!

I also learned so things in general about the Summit that others should know about…

1. That there were many outstanding sessions that people told me about (and that I wanted to attend) but that I couldn’t go to. Therefore, bring several people from your facility to cover all the applicable sessions that you want to learn from.

2. That you should come early and stay late. This helps you learn more.

Start by attending one of the many pre-Summit courses.

Next, come down early in the morning and have a leisurely breakfast while networking with other participants.

Don’t plan to leave early. Plan to stay over Friday night and leave Saturday morning.

3. That people love to share best practices. We had 10 Best Practice sharing sessions at the 2008 Summit that were focussed on allowing participants to share their knowledge with others. These were some of the highest rated sessions of the Summit because the calibre of the attendees at the Summit is so exceptional.

4. That people love to be inspired. Speakers that inspire are always highly rated. Heinz Bloch, Marcia Wieder, Nikki Stone, and Beverly Chiodo inspired their audience and helped people leave the Summit energized to make a difference when they returned to work.

5. That even with a crowd that is as enlightened at people at the TapRooT® Summit, it is hard not to blame people for mistakes. This became apparent after Lt Col Hayles talk. Some of the people I spoke to just could get by his mistake when he pulled the trigger in a friendly fire incident. They could see how he was set up for the accident by factors beyond his control. And that to prevent future friendly fire accidents, you must go beyond “being more careful next time.”

6. That a hot room for one is a cold room for another. Temperature is an individual preference.

Here are some things I already knew, but were reinforced by the Summit:

1. We have great clients that are industry leaders. I’m always impressed by the discussions we have and how willing participants are to share their best practices.

2. I have a great staff that knows what they are doing, plans well, and handles unexpected changes with panache (style, grace, and a flair for excellence).

3. That even the best in any industry can learn from others. Even the best companies can improve.

4. That even companies with the most to learn, have best practices that others can learn from.

5. That some of the most eye opening lessons come from outside your industry (if you can translate from their terminology to yours).

6. That having a good time and learning are not mutually exclusive activities.

7. That TapRooT® really is an exceptional root cause analysis tool that is changing the way the world solves problems.

8. That EVERY facility and company that uses TapRooT® should have someone at the Summit. We guarantee that what you learn will produce a return on investment at least 10 X the cost of your attendance or you get your money back. So start planning to attend in 2009!

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