Come and learn best practices in Safety & Risk Management at the 2010 TapRooT® Summit. Sign up for this track and be part of these remarkable best practice sessions. (Read bios of the presenters on the Summit website):
How Does Your Corporate Culture Effect Your Investigations? The culture that exists within your company greatly effects the success of any investigation and subsequent corrective actions..
Brian W. Tink and Brian A. Tink will show you some ways to quantify & identify your current corporate culture. The session will conclude by suggesting how you can use this information to strengthen your organizational/safety culture, allowing you to develop and execute more effective corrective actions that will, in turn, lead to desired and significantly improved business results. . Communicating with Management About Risk: Effectively communicating HSE risks to senior management is critical. Their support for resources (time and money) is necessary to implement actions that reduce risk. Strong visual communications and other techniques are needed to get the message across in a way that leads to action and increased credibility for HSE issues. One of the keys is to present HSE information from a business perspective.
In this session, Dennis Osmer, former Worldwide Head of HSE will review development of several risk communication techniques (risk assessment in terms of organizational impact & degree of control vs. probability & severity, use of site risk analysis, score cards, involvement in accident notifications, etc.).
Ahead of the Law: OSHA Enforcement Problems & Solutions: What is the latest in the world of safety compliance? Join Dave Janney and learn what OSHA has been citing, current inspection emphasis programs, the A-Z’s of the Site Specific Target Program, and inspection and citation handling tips..
Using TapRooT® for Regulatory Safety Compliance: Learn how one of the world’s most sucessful airlines is driving safety compliance by using TapRooT®. Dave Janney, System Improvement’s Senior Associate and former FAA Liason at Delta Air Lines will provide framework for the regulatory compliance environment in the industry, and Rick Diamond and Joe Fresquez from Southwest Airlines will discuss how SWA is using TapRooT® in the regulatory oversight function in its aircraft maintenance division.
Improving Incident Investigation and Safety in the BW Fleet:BW Fleet Management are responsible for the management of a large fleet of Bulk Carriers, Oil and Gas Tankers. Although they are a recognized leader in the Shipping Industry, in 2008 they decided more needed to be done..
Capt. Vibhas Garg and Malcolm Gresham will present how BW Fleet Management’s search for a better way to analyze incidents resulted in them implementing TapRooT®. This presentation will discuss the challenges overcome when implementing the system. It will also cover how the introduction of a company Risk Management Framework will contribute to future improvements.
Advanced Ideas for Corrective Actions: In this best practice session, Dan Damaan will present how to use risk to rank corrective actions. The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization.
Richard Mesker will also talk about using extent of condition/common cause/generic cause analysis to build complete corrective actions during this session.
Be a Safety STAR: How a VPP Program & TapRooT® Can Be Combined for Excellent Safety Performance: Learn how some leading companies used TapRooT® to improve their OSHA VPP (Voluntary Protection Programs) processes and get some ideas how you can leverage the capabilities of TapRooT® with Melva Luckie-Oni, Dave Janney and Dan Phillippe..
Quality in Life and Work:Quality Improvement can be applied to your personal life and your business. It’s sequential—inside out, not outside in. George Burk was critically burned and severely injured, the sole survivor of 14 passengers in a military plane crash.
Learn how several of W. Edward Deming’s 14 Points for Quality Improvement assisted him in his recovery, rehabilitation and transformation from victim to survivor. Hear and learn how you can apply several of Deming’s points—to help you and help you assist others to achieve success in life and business.
Attend the Improvement Program track at the 2010 TapRooT® Summit (learn more about the presenters on the Summit website). The specific sessions for this track include:
Self Improvement for Your Future: In response to a declining job market in 2009, we offered a Career Development Track at the Summit in Nashville, Tennessee. It was so well received, we decided to offer a best practice “mini course” in career development for 2010. Register for this session and join Dave Janney, Brad Towe and Barb Phillips as they present not only how to end 2010 on a professional high note, but also how to make 2011 the best professional year ever!
Dr. Beverly Chiodo is returning to the Summit to speak about Character Driven Success and how to change behavior by praising the 49 character traits:
Character Driven Success: You will learn to:
* Motivate people to respond nobly to life’s challenges.
* Express specific ways others have benefited your life and the life of your organization.
* Discover the secret of “going the second mile.”
* Create an environment which builds rapport and team spirit.
The purpose of this session is to broaden your understanding of what makes communication powerful and effective. Dr. Chiodo will challenge you with a new perspective on how to motivate others to excellence.
Changing Behavior By Praising the 49 Character Traits
The purpose of Dr. Chiodo’s presentation is to enlarge your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
As you participate, laugh, and refine your ability to speak and write, you will learn to influence and motivate others. Your life will be changed as Dr. Chiodo teaches you how to empower others.
How To Set-Up and Sustain a Continuous Improvement System
How do high performing organizations design their continuous improvement systems?
How do these organizations use and improve their continuous improvement systems over time?
What options exist for setting up a high impact continuous improvement system?
What types of teams do you need?
Kevin McManus will answer these questions, while also providing an overview of the tools and processes necessary to implement and sustain a continuous improvement system that meets your needs in a value added manner.
Mark Paradies will be presenting Lessons Learned about Excellence & Safety from Admiral Rickover on this track.
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In the best practice session, “What are Your Proactive Performance Indicators?” the difference between reactive and proactive measures will be explained with examples. Attendees will also have the opportunity to share the proactive measures that they have found useful.
“How TapRooT® Fits into ISO” is also a best practice session on this track, as well as “Using Training Simulation to Improve Performance” presented by Mario Paquette and Gerald Perrier.
Attend a track dedicated to improving investigation, troubleshooting and root cause analysis at the 2010 TapRooT® Summit (learn more about the presenters on the Summit website). The specific sessions for this track include:
Success Stories from TapRooT® Users
Jason Laws will present “Beyond Safety: Using TapRooT® Tools to Improve Other Business Processes” during the best practice session “Success Stories from TapRooT® Users.” Two other great presenters are coming to share as well — Steve DiCarlo will present “Implementing TapRooT® at Cogentrix” and David Burns will present “Improving Investigation Efficiency & Effectiveness at Marathon’s Catlettsburg Refinery.”
Legal Aspects of TapRooT® Investigations will be presented by Karen West, Senior Legal Counsel, Health Safety & Environment at Talisman Energy Inc.
Lifecycle of an Incident: An incident is like an iceberg, with the most visible part being the investigation and associated corrective actions. Often ignored below the surface are how an organization needs to prepare for an incident, how they respond to it and how they recover from it. In the session, Keith Recsky will show us how these can all be tied together using the PDCA (plan, do, check, act) cycle, with continuous improvement opportunities ready to be discovered when conducting an effective post incident review looking at this never ending life cycle.
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Investigation Ideas:Patrick Fortune will present “Best Practices for Implementing TapRooT® into an Existing Incident Management System.” Patrick will be speaking on the “exhilaration and tribulations” of incorporating TapRooT® into an existing Incident Management System. Expect to take away some Best Practices and even some learnings from Patrick’s mistakes, giving you the freedom not to repeat them yourself! Patrick describes his focus as a mix of “speaking truth to power, no matter what the consequences” and “let’s work the problem people.”
Dennis Ward will also present how to improve performance by analyzing multiple aviation accidents for common causes during this session.
Ideas for Leading Investigation Teams: Once you attend a TapRooT® course and learn how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? In this talk, Ken Reed will discuss:
Preparations required before an incident occurs
The first steps when you receive that phone call
How you actually use the TapRooT® tools during the course of a real-world investigation
TapRooT® User Best Practice Session: Linda Unger, Michele Lindsay and Michelle Youngwill lead this session on user best practices...
Police Tips for Leading Investigation Teams: TapRooT® UK Instructors Alan Smith and Mhorvan Sherret, the Directors of Matrix Risk Control (UK) Ltd, and former senior Detectives, provide unique and insightful police tips for leading investigation teams..
Leading Successful Investigations – Drawing on UK Experience: Dr. Bill Nixon from the Health and Safety Laboratory in the UK is coming to share tools and tips for leading successful investigation teams, how they were applied to a major investigation and how they impacted the outcome.
Mark Paradies organized the first Summit (held in 1994) because, after attending, and even helping organize, many conferences between 1983 and 1994, he saw a need for a conference with a focus on performance improvement, human error, incident investigation, and the latest improvement technology. The conference that was NOT oriented toward research and PhD discussions (although this is valuable). The first meeting was oriented toward practical applications that could be implemented at industrial facilities and in service organizations.
The other purpose of that first Summit was sharing information and ideas across industry and organizational boundaries. This couldn’t be done by one professional organization (with a safety, quality, or equipment focus) or by an industry oriented trade group (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …).
And even for that first Summit, we wanted to have international participants.
What a challenge. We didn’t have a society to organize, publicize, and pay for a meeting. But people needed the knowledge, the best practices, the learning, …
So the first Summit was organized and held in nearby Gatlinburg, TN (with 33 participants).
It was before digital photos and videos so we don’t have a visible record of the lessons that were learned. But after it was over … we knew that we had to do it again.
1995 – Orlando – 72 participants.
Disney was a great place to hold the Summit. And with more than twice as many people attending, we started to invent ways to maximize the networking.
Orlando was also the first Summit to include a pre-Summit TapRooT® Course (our standard 2-Day).
1996 – Nashville – 85 participants.
Our social activity? The Grand Ole Opry.
More people … more benchmarking. Also, this was the first Summit with a session dedicated to medical errors at hospitals (an idea ahead of its time).
1997 – San Antonio – 105 participants and growing strong.
The first Texas Summit. It included more, better networking, some great speakers, and our first reception/party.
This was also the start of “special” pre-Summit courses (additional topics beyond our 2-Day TapRooT® Course).
1998 – Dallas – 119 participants.
The Southfork Ranch hosted the 1998 Summit. A JR look alike attended the Summit party where everyone had a great time.
This Summit was also the start of TapRooT® Users presenting their Success Stories. A great way to share best practices.
Because we hold the Summit every 14-16 months, after the Summit in the Autumn of 1998, we skipped 1999 Summit and held one in the Spring of 2000.
2000 – Gatlinburg – 125 participants.
A Shuttle Astronaut Mike Mullane explained the first Shuttle disaster and what Summit attendees had to do to achieve excellence.
The great speakers and breakout sessions gave attendees lots to talk about.
2001 – Galveston – 133 participants.
Two days before the Summit, a Tropical Storm dropped 2 feet of rain! Lesson learned: Don’t hold the Summit on the Gulf coast in late June!
Once again, we had several great keynote speakers.
Plus there were 11 pre-Summit courses to choose from. These pre-Summit Courses give professional accident investigators a way to learn new skills and refresh skills that they don’t get to use very often.
(Band at the reception.)
2002 – Gatlinburg – 140 participants.
(Mark at opening talk.)
Participants enjoyed the great speakers …
Great best practice sharing …
Participants said it couldn’t get any better. But it did.
2003 – Dallas – 155 participants.
Back to the Southfork Ranch,
This was the Summit with the first TapRooT® Cup Golf Tournament – something that has become a fixture of Friday afternoon at the Summit and a part of the great networking that every Summit includes.
We also had the first TapRooT® Advisory Board Dinner.
And we had a great reception/party!
On the serious side, we had excellent sharing of knowledge and best practices…
2005 – San Antonio – 169 participants.
Back to San Antonio again.
Wow! What amazing Keynote Speakers, networking, and best practice sharing. The Summit that couldn’t get better hit a new high. (Don’t tell Mark Paradies that it can’t be done.)
Above is a picture of the participants listening to the start of Scott Waddle’s talk. He was the CO of the submarine USS Greeneville when it collided with the Emime Maru (a Japanese fishing vessel). Most of the audience was in tears by the end of his talk. Wow! Powerful!
The Advisory Board went on a Riverwalk cruise (we are doing it again this year).
And our golf tournament was held at The Quarry Golf Club (where we are holding this year’s tournament). Half of the course plays around the outside of an old stone quarry. The other half is down in the quarry. A very interesting course to play!
2006 – Gatlinburg – 175 participants.
Back to Gatlinburg and the Smoky Mountains – this time in the early spring (the leaves were just starting to bud).
The best Summit so far. Each year we build upon the successes of the past while adding new ideas to improve the best practice sharing and networking.
(Panel Discussion Debate)
Look at the networking and best practice sharing …
And this was the first Summit Golf Tournament that the Canadian Team was not victorious. Instead, Ken Turnbull’s team had the lowest score.
2007 – San Antonio – 224 participants.
We’ve found that San Antonio is a great place to hold the Summit. So we are back again in 2007.
Once again, great speakers, networking, best practice sharing, and fun!
The Summit is a well-oiled networking/benchmarking/best practice sharing machine!
And again, we had a great reception!
And how about the golf?
The Canadians won again …
2008 – Las Vegas – 259 participants.
The 20th Anniversary of System Improvements …
The first Summit we’ve ever held in Las Vegas was a real winner!
First there was touches of Vegas with Elvis and showgirls.
But before the Summit started, there was great learning in the pre-Summit courses …
And during the Summit there was serious networking, best practice sharing, and learning from great Keynote Speakers…
Then we played golf in 100 + degree Fahrenheit heat. But the Canadian team still won!
2009 – Nashville – 221 participants.
We held the 2009 Summit in the midst of the Great Recession. Who would have guessed that it would be the third biggest Summit of all times.
We had amazing Keynote Speakers …
And the networking and benchmarking – the best ever! Maybe you can tell from these pictures …
Then there was the reception …
And the TapRooT® Advisory Board Dinner …
And the almost rained out TapRooT® Summit Charity Golf Tournament …
And Mark Paradies’ team finally won (beating the Canadians)!
And the charity golf tournament raised $2,700 for an abused women’s shelter.
2010 – San Antonio – ??? participants.
What’s in store for the 2010 Summit in San Antonio (October 27-29)?
Here’s what we know:
There will be amazing Keynote Speakers …
For the background on these Keynote Speakers, see:
There will also be great knowledge sharing, networking, and best practice sharing … Picture yourself in San Antonio at the Summit talking about the biggest problems that face your site with some of the world’s best performance improvement experts and a great bunch of very smart peers. Here are some of the experts that are scheduled to participate in the best practice sessions that you could discuss your “potential improvement opportunities” with:
Dr. John Grout – Mistake Proofing Expert
Mark Paradies talking about Admiral Rickover’s culture
for process safety & excellence.
Heinz Bloch – Equipment Reliability Expert
Dan Verlinde – TapRooT® Software Program Manager
Dr. Beverly Chiodo – Behavior Change & Character Expert
Brian Crawford – Flight Safety Officer, ExpressJet Airlines
Captain Vibhas Garg – Sharing a Best Practice for Incident Investigation
Jennifer Mounce – Coaching Expert
Major General Doug Rich – Command Surgeon – Air Mobility Command
George Burk – Airplane Crash Survivor
And that’s just a sample. There are 87 best practice breakout sessions with more than one speaker/facilitator in many of the sessions. For all of the Best Practices Session leaders, see:
Finally, there is the TapRooT® Charity Scramble Golf Tournament being held at The Quarry Golf Club where we will see which team can claim the coveted TapRooT® Cup.
Sign up for the golf tournament here (registration is separate from the Summit registration):
A man operating a loader accidentally crushed another worker. He was prosecuted for breaches of the Australian Mining and Quarring Safety and Heath Act 1999.
He was found guilty and given a sentence of 8 months in prison (suspended) and a fine of $13,437.70 to pay for investigation and court costs. The article said that, “Neither the SSE nor the Operator nor Contractor were charged.”
Here are the “key messages” from the lawyer in Australia that wrote the article:
“Ensure you have a robust health and safety management system, regardless of your industry. It needs to be documented and it needs to be followed through, so the reality of what you do matches what’s contained in the documents.”
“Employers need to be able to demonstrate that employees are trained in and understand the system. If employers can show that and something goes wrong, they are in a defendable position. It also minimises the possibility of things going wrong.”
“Take swift action when employees do the wrong thing. If an employee breaches the safety system, do not hesitate to take severe action against them. In other words, employers should be considering discipline and termination. Courts view such breaches very seriously, and so should employers.”
What do you think?
Were the root causes discovered?
Were all the lessons learned that should have been learned?
Would you be sure that this accident won’t happen again?
How would you approach this accident?
Leave a comment here about your approach to this accident. And then think about …
Would you be ready for a fatality investigation at your facility?
Would you know how to handle all the aspects (including police issues) of a fatality investigation?
Perhaps you should consider attending the pre-Summit Course:
UK TapRooT® Instructors Alan Smith and Mhorvan Sherret, the Directors of Matrix Risk Control (UK) Ltd, and former senior Detectives, provide a course that will help you prepare for the worst by participating in realistic police interviews and investigation scenarios. It’s a great chance to get prepared just in case something bad ever does happen.
This course is only offered in the US just prior to the Summit and attendance is limited, so sign up today.
The EHS & Safety News America reported that a safety manager was indicted for one count of involuntary manslaughter after a fatality at a facility in Ohio.
For an individual. involuntary manslaughter carries a maximum penalty of up to five years in jail and a $10,000 fine.
Two TapRooT® trained former detectives will share information you need to know about dealing with the aftermath of a fatality.
After the course (October 25-26 in San Antonio), consider attending the TapRooT® Summit to learn best practices to prevent fatalities at your facilities. For more Summit information, see:
The TapRooT® Summit has a Best Practices Track focused on improving Corrective Action Programs (learn more about the presenters on the Summit website). The specific sessions for this track include:
Getting “Outside the Box” Corrective Actions
Having trouble getting away from those old, standard corrective actions that don’t seem to last? Michele Lindsay will help you get a glimpse on how to best use your most valuable resource, your intellectual capital in coming up with corrective actions that are new, different and effective. Tap into the creativity that we all have, but often can’t find in this fun, fast moving and innovative session.
Using TapRooT® for Regulatory Safety Compliance
Learn how one of the world’s most successful airlines is driving safety compliance by using TapRooT®. Dave Janney, SI Sr. Associate and former FAA Liason at Delta Air Lines will provide framework for the regulatory compliance environment in the industry, and Rick Diamond and Joe Fresquez from Southwest Airlines will discuss how SWA is using TapRooT® in the regulatory oversight function in its aircraft maintenance division.
Sticky Corrective Actions
In this session, learn:
1) Corrective Action Best Practices from PCS
2) A Consultive Process for Corrective Action Development
Making Bad Corrective Actions SMARTER
Kevin Palardy and Ralph Brickey will present how to make bad corrective actions SMARTER.
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.Advanced Ideas for Corrective Actions
In this session, Dan Daamen will present Using Risk to Rank Corrective Actions.
The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization..
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Corrective Actions for Culture Problems (Fixing Employee Communications NI + More)
Michele Lindsay, Brian A. Tink, and Brian W. Tink are the presenters for this informative session. Have you created some corrective actions that look great on paper, but when implemented have had little or no effect? You may be missing a very important, yet often overlooked, aspect to your organization … its culture. Organizational culture has been proven to have a measurable and significant impact on safety, job performance, and the organization’s bottom line. Find out how you can create corrective actions that can improve your performance while positively shaping your organization’s culture.
Closing the Loop: Corrective Action Effectiveness Reviews
Heidi Reed and Barry Baumgardner will show how to close the loop with Corrective Action Effectiveness Reviews.
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Coach for Improved Corrective Action Development & Implementation
Executive Coach Jennifer Mounce is returning to the Summit for the second year. Participants walk away from this session with coaching skills and a coaching model that can be used in any work environment to support improving human performance in the workplace.
Come and learn best practices in Behavior Change and Stopping Human Error at the 2010 TapRooT® Summit. Sign up for this track and be part of these dynamic best practice sessions. (Read bios of the presenters on the Summit website):
Combining TapRooT® with INPO’s Error Prevention Tools to Improve Human Performance
Rob Fisher and Ron Pryor will discuss how Alcoa Davenport Works improved performance by using TapRooT® tools to identify vulnerabilities, and known error reduction techniques to reduce the probability of events related to human errors.
Influencing Without Authority
Chris Vallee will be leading this interactive lecture and workshop. Ever heard these statements:
If only management would do the right thing!
The employees will not follow the rules unless being watched!
If the EHS/HSE department were not placed under XXXX in the Organization, I could get something done!
Management supports every corrective action after an incident happens.
Guess what? You have more control and influence than you realize:
1. Learn about influence Networks that make sense (it is not always about the job title).
2. Learn how to perform a Stakeholder Analysis (it is amazing how different this is from your actual company’s organizational chart).
3. Discuss live examples where it worked.
4. Decide what your next step is to influence without authority.
Practice Fixing Human Performance & Behavior Problems: An Interactive Exercise Session
Chris will also be leading this workshop … a time to put it all together. Here’s what attendees will work on:
1. Listing burning issues and discussing:
What’s been tried
What worked
What did not work
2. Based on what’s learned that week, you’ll identify what may be the gap between the issue AND solution.
Be prepared to dig deeper than the surface
Work with your industry AND outside industry peers
Work with the available* Behavior and Human Error presenters
(* some presenters are only present the day of their presentation)
Plan a follow up session
Coaching Skills to Sustain Behavior Change
Executive Coach Jennifer Mounce is returning to the Summit for the second year. Participants walk away from this session with coaching skills and a coaching model that can be used in any work environment to support creating behavioral change in the workplace.
Human Factors & Behavior Change Best Practices
Ralph Brickey will be presenting Ideas for Changing Behavior When Working Outside Western Culture. This session will explore issues of working with conflicting cultural thought when seeking to establish norms for investigations and implementing change in other cultures. Through a simple exercise participants will first examine a few of their own western “norms” and then apply these in a case study involving an investigation of a confined space incident that resulted in the deaths of two workers in an eastern culture.
But that’s not all for this session, Tom Brower will also be presenting Practical Human Factors Lessons Learned.
Measuring Fatigue Using FACT
Rainer Gutkuhn from Circadian Technologies will be presenting this best practice session. There is now a global body of scientific evidence that shiftwork in the 24/7 workplace is a high risk occupational safety exposure, and that the development of Fatigue Risk Management Systems (FRMS) has emerged as the internationally accepted standard for managing the inherent costs, risks and liabilities of shiftwork. This session will review the new ANSI standard for FRMS in refining and petrochemical industries, as well how the other industries as diverse as Aviation, Railroads, Mining and Utilities are implementing Corporate FRMS systems as a continuous improvement process. It will also provide examples of fatigue management tools that can provide the analytics needed to ensure the success of programs for optimizing shiftworker health, safety and quality of life.
Using Mistake Proofing to Stop Human Error
Dr. John Grout will present how significant injuries are avoided and dollars are saved by companies around the world when they implement simple ideas that either eliminate the chance for a mistake to occur or make a mistake easy to detect. This concept (and the techniques that generate these simple fixes) is called Mistake-Proofing. It is also known as Poka-Yoke (pronounced POH-kah YOH-kay). This session will help you find practical, effective ways to remove the opportunities for error. What will you learn?
· Why we make mistakes
· Basic concepts of mistake-proofing
· Where mistake-proofing works well and where it does not
· Where mistake proofing fits in your quality or safety toolbox
· How to create poka-yokes that solve quality or safety problems
Lesson Learned About Human Factors & Generic Causes from Recent Airline Incidents
Brian Crawford and Ken Turnbull will present this session about recent airline incidents and lessons learned.
Have you noticed that on the Summit Schedule Page we have a track called “Special Topics”? This is “technically” not a track, but options — and we know you love options to your schedule. As always, you can pick a track, and if there is a best practice session within that track that you are not interested in attending, you have the ability to modify that session by clicking the “modify” button and changing to a different session on another track, but this year we are adding even more topics that are not part of any particular track, they are just Special Topics to give you more choices for a customized schedule to fit your needs. Here are the Special Topics:
Medical TapRooT® Instructor Update
Prioritizing Improvements
Sustainable Development
What Does Management Need to Know About Root Cause Analysis (Discussion Session)
Asset Management Problems and Solutions
Solving Equipment Reliability Problems
PowerPoint Tips & Tricks
Know the Law When Dealing with MSHA After a Serious Accident
If you have questions about modifying your Summit track schedule, or choosing a special topic, call us at 865.539.2139 or e-mail us at info@taproot.com.
Have you put off registering for the 2010 Summit because you are not sure which track to register for? It’s a tough decision with nine best practice tracks to choose from! But October 27th will be here before you know it, so don’t procrastinate! We’ll be posting detailed track information every Tuesday and Thursday to help you with your decision.
Meanwhile, here is some information to help you — but keep in mind each track is completely customizable, (i.e., you can replace any best practice session with a session from another track by simply clicking the “modify” button, and this year we also have special topics you can choose from that are not related to a specific track):
Behavior Change & Stopping Human Error
Register for this track if you are interested in learning these best practices:
Combining TapRooT® with INPO’s Error Prevention Tools to Improve Human Performance
Influencing without Authority
Coaching Skills to Sustain Behavior Change
Human Factors & Behavior Change Best Practices
Measuring Fatigue Using FACT
Using Mistake Proofing to Stop Human Error
Lesson Learned About Human Factors & Generic Causes from Recent Airline Incidents
Practice Fixing Human Performance & Behavior Problems: An Interactive Exercise Session
Planning Your Improvements
Corrective Action Program
Register for this track if you are interested in learning these best practices:
Getting “Outside the Box” Corrective Actions
Closing the Loop: Corrective Action Effectiveness Reviews
Sticky Corrective Actions
Using TapRooT® for Regulatory Safety Compliance
Making Bad Corrective Actions SMARTER
Advanced Ideas for Corrective Actions
Corrective Actions for Culture Problems (Fixing Employee Communications NI + More)
Coach for Improved Corrective Action Development & Implementation
Have you started your planning to attend the TapRooT® Summit? Now is the time to plan the trip to get the best airline fares.
BEFORE you schedule anything, PLAN to stay for the final speaker – Jeff Skiles, who was the co-pilot on the Miracle on the Hudson. He will speak from 10:35-11:35 on Friday, October 29.
What does that mean? You should plan to stay in San Antonio on Friday night and fly back home on Saturday (or maybe even Sunday).
San Antonio is a great place to visit and we will be posting things to do and places to see (beyond the Alamo) in upcoming blog posts. We’ve already posted hotel information (and other travel info) here:
“Safety Culture” has been a topic of increasing interest since the term was first used in the report on the Chernobyl accident.
In 2004, the Institute of Nuclear Power Operations (INPO) published “Principles for a Strong Nuclear Safety Culture.” It outlines INPO’s expectations for utilities to maintain a strong, positive safety culture. See the document here:
From the INPO report, the principles for a strong nuclear safety culture are:
1. Everyone is personally responsible for nuclear safety.
2. Leaders demonstrate commitment to safety.
3. Trust permeates the organization.
4. Decision-making reflects safety first.
5. Nuclear technology is recognized as special and unique.
6. A questioning attitude is cultivated.
7. Organizational learning is embraced.
8. Nuclear safety undergoes constant examination.
These are similar to the Nuclear Regulatory Commissions work on nuclear safety culture, a sample of which is contained in this document:
Organizational learning (which includes root cause analysis) is my favorite safety culture topic. Here’s a quote from the above NRC document:
“The organization maintains a continuous learning environment in which opportunities to improve safety and security are sought out and implemented. For example, individuals are encouraged to develop and maintain current their professional and technical knowledge, skills, and abilities and to remain knowledgeable of industry standards and innovative practices. Personnel seek out and implement opportunities to improve safety and security performance.”
I added the bold to the text. And let me highligft it even more…
How do YOU demonstrate a good safety culture? For organizational learning, how do YOU:
Maintain your skills?
Remain knowledgeable of industry standards?
Learn new innovative practices?
And do you do this ONLY in your industry or do you look for learning across industries to find best practices?
Those who have attended the Summit and one of the pre-Summit special courses know that it’s a great place to maintain and advance your skills, network across industries, and learn best practices from around the world.
Therefore attending the Summit is a great way to show that you are supporting a strong safety culture.
Don’t contribute to a bad safety culture … Sign up for the Summit today. Register here:
I was talking to a root cause analyst the other day and they couldn’t see how budget cuts could cause a major accident (like BP Deepwater Horizon or BP Texas City). I had trouble explaining it because the cause-effect relationship is not direct.
Then I was talking to someone that wanted to attend the TapRooT® Summit. They said they couldn’t attend because the company had a new initiative to “cut costs.”
That got me thinking …
What if that person needed to attend the Summit because they were going to learn some best practice that could improve performance at their facility and prevent a major accident? If they don’t attend, they don’t learn. Then the accident is NOT prevented. Cost cutting has caused a major accident and nobody will ever know.
If you were thinking about attending the Summit but have had trouble because of budget cuts, ask again. Don’t let a budget cut stop you from your destiny – attending the Summit to prevent a major accident at your facility.
That small saving by not attending the Summit might be an expensive mistake that costs your company millions (or even billions) of dollars.
FACTS is an online diagnostic expert system to help investigators and companies readily determine if human fatigue may have been a causal factor in an accident/incident.
ABOUT CIRCADIAN®
CIRCADIAN® provides Fatigue Risk Management Systems, Shift Schedules, Software, and Training & Publications to solve the challenges of the 24/7 workforce.
FACTS is a web-based investigatory tool that helps users determine if human fatigue may have been a causal factor in an accident/incident. Developed by the world’s leading experts in sleep, fatigue, and circadian rhythms, FACTS generates results that correlate well (r = .91) with conclusions reached by experts who investigated NTSB and other industrial accidents.
Fatigue is one of the most pervasive yet under-reported causes of human error-related accidents, incidents, and injuries in both the industrial and transportation sectors.
Because fatigue is difficult to detect (i.e., no blood, urine or breathalyzer test exists to identify it) companies have a difficult time quantifying the true impact and cost of fatigue in their operations.
To bridge this gap, CIRCADIAN® created an online diagnostic expert system to help investigators and companies readily determine (by standardizing criteria and with high probability) if human fatigue may have been a causal factor in an accident/incident.
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One additional note …
One of the developers of FACT will be at the TapRooT® Summit to share information about the technique and how to use it.
This presentation is in the Changing Behavior and Stopping Human Error track from 10:40-12 on Thursday, October 28.
What does it take to maintain your TapRooT® Instructor certification? Every two years you must attend the TapRooT® Summit and one of the pre-Summit Courses.
Why? Because instructors need to understand the latest improvements in TapRooT® & not let their improvement skills rust away. TapRooT® Instructors are training the leaders of performance improvement in their companies. They need to continually sharpen their skills. After all, Capt. William Rodriguez said:
“If you’re not peddling, you’re going downhill.”
The Summit provides the knowledge that TapRooT® Instructors need by sharing the latest best practices as well as getting the latest 2-Day TapRooT® Course PowerPoint® slides (update your TapRooT® Course License).
But what about the pre-Summit Course? See the list at:
Instructors will especially appreciate the Advanced TapRooT® Techniques Course that teaches advanced ideas for defining causal factors (the hardest part of the TapRooT® System). They will also want to attend the Getting the Most from Your TapRooT® Software Course to learn the new Version 5 TapRooT® Software and the great new interface that reinforces the 7-Step Investigation Process that they teach in the 2-Day Course. Or they might pick one of the other courses that is really focused on a problem that their site is experiencing.
No matter what course you pick, you will learn skills that will help you lead your company’s improvement effort and you will maintain your TapRooT® Instructor Certification.
Then, of course, there is the Certified TapRooT® Instructor Track at the Summit. Linda Unger and I work hard to make sure that it includes very special session to help TapRooT® Instructors improve their skills and become even more valuable assets to their company.
This year the TapRooT® Certified Instructor Track includes:
TapRooT® Instructor Update (you get the new PowerPoint slides)
Legal Aspects of TapRooT® Investigations
What’s New in the TapRooT® Software
What Makes a Good Instructor Great?
Ideas for Leading Investigation Teams
TapRooT® User Best Practices
Police Tips for Leading Investigation Teams
Leadership Responsibilities for Each Step of the TapRooT® 7-Step Process
Planning Your Improvements
And don’t forget the five great Keynote Speakers that include Jeff Skiles, the Co-Pilot who helped land the “Miracle on the Hudson.”
Plus there are many chances for networking, benchmarking, and having fun.
Go to the Summit web site to get more information and to register:
I asked: “Do we need to wait for the completion of the Presidential Commission’s investigation to learn from the BP Deepwater Horizon Accident?”
OK … I know I will make some people mad with this answer but … Here’s the answer none-the-less.
NO – WE DON’T NEED TO WAIT TO LEARN.
First, let me say that as the many official investigations continue, we will learn more about the technical details of what happened. The equipment failures that cause the failure of the blowout preventer. The details of the tests that were performed and misused to justify replacing the mud with seawater. The design basis for the well design and construction decisions that turned out to be inadequate to prevent a blowout.
These are things that we will learn with time.
Thus, people aren’t completely wrong when they say – “Wait until the official investigations are completed.” “We don’t want to jump the gun and jump to conclusions without the facts.”
That’s sentiment is well and good.
But, they are missing my point.
We already know enough about some parts of the accident to be able to learn some important lessons. Lessons that we need to learn RIGHT NOW.
The first, and biggest, thing we can learn is that SAFETY CULTURE MAKES A DIFFERENCE.
We already knew that drilling in deepwater is dangerous. We knew this before the BP Deepwater Horizon accident. We certainly know it now.
The risk of a failure in deepwater is more than the risk of drilling on land or in shallow water. The deeper you go, the more complex it gets. Also, the higher the technology that you use. These facts make it more important to understand what makes a high reliability organization tick – what produces a good safety culture for these demanding environments.
I think everyone will agree with the previous paragraph.
Yet, BP did NOT take extra precautions in designing or constructing the well being drilled by the Deepwater Horizon. In fact (and we know this to be a fact from testimony already given), they didn’t take precautions that other companies take and are “standards” for drilling in deepwater.
What shortcuts did they take? Here are five that I think have already been proven:
1. The choice of the cheaper, but less safe design using a single liner for well completion. BP says this design had longevity advantages. But it was mainly FASTER and CHEAPER. This choice obviously was not about safety first. A well that experiences a catastrophic failure doesn’t need to be designed to last longer.
2. Using too few hangers to center the casing. I’m not a drilling expert but the experts TOLD BP that the six hangers were WAY TOO FEW and would make it almost impossible to get a good cement job.
3. Failure to circulate the mud fully prior to cementing. Fully circulating the mud is required by an API standard. Not circulating the mud fully was a safety shortcut (but it saved them time and, therefore, money).
4. Failure to run a cement bond log. If this was a standard well and everything had gone right, you might skip this safety step. But on a well that is deep, with a single casing, with too few hangers, and with a bad first test, skipping this test was inexcusable. They were leaving safety to luck. And they ran out of luck that day.
5. Failure to deploy the casing hanger lockdown sleeve. I haven’t heard why this wasn’t done. But BP and the Coast Guard/MMS investigators already know about it. I just haven’t been able to find the testimony (which is on line).
These are facts.
Of course, BP argues that MMS approved these shortcut. But errors at MMS don’t mean that BP was right and had a safe well design. The mistakes at MMS, if and when they occurred, are just additional failed safeguards that allowed the accident to progress.
Therefore, I’m not saying that these are all the shortcuts. There are MORE.
I’m saying that these shortcuts are sufficient to prove that, at least for this well’s safety, BP’s practices WERE NOT to make safety the highest priority.
The question remaining is … “Is this the BP culture or were the people drilling this well ‘outliers’ – rouge engineers and supervisors who were working outside BP’s culture.”
This is where I make a fairly safe assumption.
This well was so deep and so important that it couldn’t (and shouldn’t) slip underneath the radar of BP’s management. Fairly senior management (maybe not the CEO, but certainly some high up folks) must have known about the design decisions. In fact, I believe investigators will be able to show significant management pressure to get the well complete and move on to the next well. This pressure – without enough consideration for safety as an overriding priority – is the current safety culture at BP.
Thus even though they talk about ” …focusing on safety like a laser” and “We don’t do anything unless it is safe.” … the reality, which is reflected by the practices in the field, is quite different.
When I heard the BP America President say in Congressional testimony that:
“We don’t do anything unless it is safe.”
I knew that he didn’t really understand safety. Why? Because safety is never absolute. Everything we do has some risk.
Therefore, we can learn NOW. We can learn that SAFETY CULTURE IS IMPORTANT.
And there are important lessons that are common practice in high reliability organizations that all organizations facing high risk, high complexity operations must learn.
How do I know about these lessons?
I worked in a high reliability organization. The Nuclear Navy. And I “got it.”
I also studied human factors and organizational design and I understand why a high reliability organization function successfully.
But obviously, not everyone gets it.
I say obviously because repeated major accidents are proof that somebody doesn’t get it.
Therefore, from the “evidence” of their repeated serious accidents, I conclude that BP senior management doesn’t get it.
What can I do? I’m going to share what I know with anyone willing to listen and learn. BP if they are willing. Or any other company that faces potentially catastrophic damage if they are not highly reliable.
At the 2010 Summit in San Antonio on October 27-29, I will provide two presentations that takes learning about safety culture and performance improvement to the next level.
The first talk is a Keynote address to the entire Summit audience titled:
“Taking Improvement to the Next Level”
I already have part of this presentation developed but I’m adding to it daily. If you are responsible for improving safety, quality, equipment reliability, or production, you need to be at this talk.
The second talk is much more focused on safety culture and the secrets behind a high reliability organization. It is titled:
“Lessons Learned About Excellence & Safety From Admiral Rickover”
This presentation takes the PhD complexity of safety culture and high reliability organizations and makes it understandable and practical. This presentation details what’s made the Nuclear Navy work for all these years. It’s the secrets that Admiral Rickover understood (and many others in the Navy didn’t understand).
This second presentation is part of the Improvement Program Track. if you are interested in high reliability organizations and safety culture, make sure to sign up for it when you register for the Summit.
So, here is my overall advice …
Don’t wait to learn.
Start reviewing the facts that are available now and learn as much as you can as fast as you can.
Also, plan to attend the Summit in October (register now). The lessons you can learn there are too important to miss. They can help you save lives, your company’s reputation, and all sorts of headaches.
Dr. Beverly Chiodo has been invited to speak about Character at the 2010 TapRooT® Summit!
Dr. Chiodo is a professor in the Department of Management at Texas State University. Dr. Jerry Supple, former President of Texas State, said she has won every teaching award the university offers, and she’s been recognized for her teaching effectiveness at the state and national levels as well. In 1996, she was featured as “Hero of the Day” by CBS national TV program — This Morning. In 1997, Beverly was named “The Best Business Professor in the Nation” by the National Business Education Association. She has published widely in her field and is a frequent presenter at seminars and conferences.
Beverly earned her BBA degree from Baylor University, her MBA from Texas Tech, and her Ph.D. from Texas A&M. She is known by her students as the “Doctor of Encouragement.” Beverly says that her teaching philosophy can be summed up in the proverb which says, “A wise teacher makes learning a joy.”
This is Dr. Chiodo’s fourth year to appear at the Summit. Don’t miss the chance to hear these talks — as busy as she is, this may be the last chance you have to hear her at the Summit!
Here is some information about Dr. Chiodo’s sessions:
Character Driven Success
You will learn to:
* Motivate people to respond nobly to life’s challenges.
* Express specific ways others have benefited your life and the life of your organization.
* Discover the secret of “going the second mile.”
* Create an environment which builds rapport and team spirit.
The purpose of this session is to broaden your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
Changing Behavior by Praising the 49 Character Traits
The purpose of Dr. Chiodo’s presentation is to enlarge your understanding of what makes communication powerful and effective. Dr. Beverly Chiodo will challenge you with a new perspective on how to motivate others to excellence.
As you participate, laugh, and refine your ability to speak and write, you will learn to influence and motivate others. Your life will be changed as Dr. Chiodo teaches you how to empower others.
Have you looked at the other world-class speakers on the “Improvement Program” track? Check out our track schedules on our Summit Schedules page: http://www.taproot.com/summit.php?t=schedule
Outstanding leaders know that accountability is vital and it extends to other internal core values such as honesty, competence, courage, compassion and honor. Outstanding leaders “wear” these core values like a coat draped around their shoulders because the core values are first and foremost personal, then professional … inside out, not outside in. Here are a few ways to “wear” those core values (traits).
“The glory of great men must always be measured against the means they have used to acquire it.” ~ Francois de la Rochefoucauld, writer
Uphold your values. “If you don’t have principled leaders, the other stuff doesn’t matter,” said Frances Hesselbein, President of the New York based Leader-to-Leader Institute. In the final analysis, when all is said and done, the character, integrity, honor and quality of the leader will determine the organization’s results.
“The first thing a great person does is make us realizethe insignificance of circumstance.” ~ Ralph Waldo Emerson, poet
Be consistent. To be a truly great leader you know that means you can’t pick your spots. Regardless of the circumstances or situation, you can’t be a little dishonest or choose to have a bit less integrity today. When you choose to slide, even a little, from your internal core values, it’s easier to slide a second and third time. Then slowly but surely, you ‘slide’ farther and farther away from them. The result is it becomes more difficult to return to the internal core values you once held. It then becomes a “The Law of Self-Fulfilling Prophecy” and you break them again and again. It then becomes second nature.
“Actions start another’s trust like a starter starts a car.” ~ LT. Col Lynn Allen, USMCR (Ret)
Focus on results. That’s the best way to hold people accountable says Blythe McGarvie of Williamsburg, VA based LIF Group. Only reward staff based on the results they achieved and only when their work is successful but not if they miss their goals. Don’t base any rewards or acknowledgements on effort alone.
Be concise. Clearly and often enunciate your organization’s values; publish them in newsletters, reports and on plaques and other similar visual reinforcements. The most effective way is to share the values with employees and visitors at every opportunity.
Become the benchmark. People listen to the leader in the ‘conference room’ but watch them in the ‘hallway.’ They respond more to what the leader does than what the leader says he or she’s going to do. A leader’s actions must be congruent with their words; his or her actions are seamless and transparent. No difference between how they act in their personal lives and how they act at work.
“Leadership is a matter of how to be, not how to do,” says Hesselbein. “When they see you live and believe what you say, morale goes up and productivity soars.”
Act. When the leader sees the values being ignored, skewed or not reinforced, they take the necessary action to make sure to hold themselves and everyone else accountable. That’s accountability!
Be visible. No matter the situation, the leaders must remain visible to the staff and employees. When there’s bad news, don’t hide in your office or under the desk. Don’t delegate the message. Be the messenger. Deliver the news yourself. Best way to do this is LBWA-O: Lead By Walking Around-Outside. Make that the way you lead … out front and visible.
“Innovation distinguishes between a leader and a follower.” ~ Steve Jobs, Apple co-founder
Remain focused. Establish goals that reinforce and stay true to the mission. Leaders run into problems when they deviate from their goals. Then it’s short step to compromise their core values.
“There is nothing worse than a brilliant image of a fuzzy concept.” ~ Ansel Adams, photographer
Ensure people feel vital and valued. This is accomplished through training and encouraging and supporting them to get involved in volunteering and philanthropy. This helps to add more purpose in their lives; knowing they are helping people in their community who are less fortunate.
Grasp the details. It’s important the leader knows the organization’s details … the numbers … people, financial, equipment and related resources. If you don’t know them or can’t understand them, they don’t seem reasonable or your presumptions don’t add-up, that should be a red flag. A bell should ring inside your head.
“Take care of those who work for you and you’ll float to greatness on their achievements.” ` H.S.M. Burns, oil industry executive
Captain George A. Burk will be presenting “Quality in Life and Work” on the Safety and Risk Management Track on Friday, October 29, 2010 at 8:00 a.m. at the Summit. The 2010 TapRooT® Summit will be held October 27-29, 2010 in San Antonio, Texas (with Pre-Summit Courses October 25-26). For more information about Captain Burk:
The Westin Riverwalk hotel offers spacious meeting rooms, a well laid-out facility that allows attendees to move around without bottlenecks and delays, as well as covered terraces where attendees can step out of the hotel to make a phone call or review notes while enjoying a Riverwalk view. Comfortable guest rooms and the many amenities including a pool, gym and spa make the Westin a wonderful retreat for an extended weekend stay and for your family or a friend to travel with you … not to mention the many attractions that San Antonio offers! View this video from our recent visit to San Antonio to learn more!
The Canon City Daily Record recently published two articles about Summit best practice speaker, Capt. George A. Burk, United States Air Force (retired):
1. Reconnecting with The Past: Just six days shy of the 40th anniversary of the deadly airplane crash that claimed his father’s life, Daryl Robinson will meet the sole survivor of that crash — the last person who saw his father alive (read article).
2. Resilient Survivor: Almost 40 years ago, he was alone in a field, surrounded by explosive aircraft wreckage, listening to the “snap crackle pop” of the fire that was consuming the debris and nearby trees — the fire that had burned more than 65 percent of his body — and he realized death was imminent (read article).
And register for the Summit! Captain Burk will be presenting “Quality in Life and Work” on the Safety and Risk Management Track on Friday, October 29, 2010 at 8:00 a.m.
“HSE investigators discovered that the two drugs were stored in the same racking system, despite having almost identical packaging. They found that no proper management system was in place for the storage of the drugs, and warnings from earlier incidents had not been properly followed up.”
The story said that the mother had died needlessly.
What do you do to make sure that your root cause analysis and corrective actions for incidents are effective?
Would your facility have a “needless” death?
Should you be using TapRooT® and attending the TapRooT® Summit to learn ways to check the effectiveness of your root cause analyses and corrective actions?
Learn Best Practices in root cause analysis, safety & risk management, improvements, investigations, stopping human error, corrective actions, patient safety and more!
At some conferences, 90% of what you get is the networking. You meet some great people and take home some new “best practices” that you can apply at your facility.
At some conferences, 90% of what you get comes from the great keynote speakers. They inspire you to go back to work and accomplish even more.
At some conference, 90% of what you get is from the breakout sessions. The small group interactions, lessons learned, and best practice sharing in these smaller sessions can really be helpful in developing an improvement initiative.
Why can’t you have all three? Who knows. But finding all three together is really uncommon.
I attend a lot of conferences. Seven to ten a year. More than most people. (Who can afford the time?) But I do it to stay on top of the latest improvement initiatives. And here is what I’ve found. There is one conference that has all three every time it is held … The TapRooT® Summit.
You get the 90% networking and the 90% great keynote speakers and the 90% amazing breakout sessions that are the highlights of most conferences all in one conference.
That’s 90% + 90% + 90% = 270%!!!
170% more than your average conference.
Ok … You may think that Mark is going nuts. After all, what conference has 170% more than other conferences? Well then, lets look at each of the percentages for proof.
Part of the purpose of the Summit is to send you back to work inspired to to your best. Who is better to inspire you than Jeff Skiles, the co-pilot of the Miracle on the Hudson flight. As the Summit’s closing keynote speaker, Jeff will tell his amazing story that includes lessons of teamwork, adaptability, training, and preparation that helped them make it through that day. Don’t miss this chance to learn from his experience and shake his hand.
What does it take to keep young workers safe? Do these same lessons apply to all employees? That’s what you will hear about and think about when our opening keynote speaker, Candace Carnahan, tells her story. She learned a difficult lesson about safety at an early age. She will share that lesson with everyone at the Summit. It’s a message that anyone with young employees needs to hear. Don’t miss it!
Finding the root causes of your problems and developing effective fixes is only half the battle. If you want to really improve performance, you need to get the improvements implemented. That’s why I chose an improvement implementation expert, Don Harrison, to be a Keynote Speaker. He is President of Implementation Management Associates and the developer of the Accelerating Implementation Methodology (AIM). And Don will speak about one of the most difficult aspects faced by people leading improvement efforts … Getting Sponsorship Right. So if you need senior management support for your improvement program and getting improvements implemented, you can’t afford to miss his talk.
Everyone knows that blame is counter productive when trying to improve performance. But what if you we a patient at a hospital and you were almost killed? The sentinel event required extensive rehab so that your life was disrupted for almost a year. Would you be empathetic? Or would you want to strike back? Would you sue over the error? What if the hospital didn’t seem to be telling you the truth? Would this make you mad? As an investigator of accidents, you often have to deal with people who are impacted by the accident – either those who were hurt or those who are being seen as “at fault.” That’s why you need to hear Linda Kenney’s story. You will hear see Linda eventually understood what happened, learned to work with those who “caused” the damage, and took this event and made it into something positive (for her and for the people who “caused” the damage she suffered). It’s an amazing story that will get you to think beyond just the root causes of an accident to the impact accidents can have on people.
I’ll be one of the Keynote Speakers at the 2010 TapRooT® Summit. And I’ll be talking about an important topic for all TapRooT® Users – Taking Improvement to the Next Level. Over the past couple of years, I’ve come to understand that many TapRooT® Users attend their initial TapRooT® Training and expect that that is all they need to do to have excellent root cause analysis and an outstanding performance improvement program. But those people are wrong. They have taken an important first step, but the journey is still at it’s beginning. To achieve excellence, they need to do more. And that’s what I’m going to share. The steps one must take to achieve excellence in their performance improvement journey using TapRooT®. If you are a TapRooT® User somewhere along your journey to excellence, don’t miss this keynote address. And if you don’t use TapRooT®? The lessons are just as applicable. Don’t miss this keynote address.
OK … I think this gets more than 90% … I think it gets 100%. But, being one of the speakers, I may be biased. What do you think?
NETWORKING
I’ve had many TapRooT® Summit participants tell me that the networking at the TapRooT® Summit is the best they have every experienced at any conference they have ever attended. And I know the reason why. We work hard to make it the best networking conference on the planet.
What do we do? You’ll have to be there to experience it, but I’ll give you some clues.
First, we start out with a networking exercise to get each participant to meet a minimum of three new people that they share something in common with. I personally assign these introductions for every Summit participant.
(Reception) (Golf)
Next, we sponsor two events – the Summit Reception and the Summit Golf – to help people get to meet even more folks on an informal basis. Both are great ways to find new friends.
Third, we even make lunch a networking event by letting you pick your favorite TapRooT® Instructor (or maybe a TapRooT® Instructor that you have never met) to sit with at lunch.
Fourth, several of the best practice sessions are organized to encourge even more networking.
Fifth, there really are great people to meet at the Summit. Speakers and participants alike! And because the Summit is not a “mega-conference” … you really can find people and meet them (and shake hands with and talk to speakers).
And finally, because we emphasize networking so much, everyone participates in it and makes it easy. Introductions happen spontaneously. If someone doesn’t know you, they ask who you are and what you do. And you will find meeting new people easier and more fun than you ever have before at any other conference.
How do I know that I’m right about the networking being so good? Listen to what just a few of the attendees had to say (and this is just a sample – double click each video to play):
(Quicktime Format .mov)
(.mp4 format)
(.mp4 format)
Do you agree that this deserves a 100% score (not just 90%)? I do. But read on…
TECHNICAL/BREAKOUT/BEST PRACTICE SESSIONS
When we first started planning Summits back in 1994, we worked to make each of the technical sessions full of new best practices, great ideas, and sharing of lessons learned. As the Summit developed over the years and additional tracks were added (there are 9 tracks this year), we have continued to make these sessions full of content that people interested in the topics of each track need.
Just look at these tracks and then see the Summit Schedule and look at the sessions in the track that you think you would like to attend the most and see how applicable the sessions are to your improvement efforts:
Safety & Risk Management
Behavior Change & Stopping Human Error
TapRooT® Certified Instructor
Investigation, Troubleshooting, & Root Cause Analysis
Wow! They are some great tracks aren’t they. But there’s more. You can mix and match to customize your Summit experience. You can pick from sessions from several tracks to develop Your Track – just like you want it.
But that’s not all. There are also “Special Topics” to choose from that are in addition to the sessions in the tracks. These Special Topics include:
Prioritizing Improvements (Mark Paradies)
What Does Management Need To Know About Root Cause Analysis (Kevin Palardy)
You can add these special topic sessions to your custom schedule to make the Summit even more significant to your improvement efforts.
To make this even more impressive, many of the speakers could have been Keynote Speakers. The problem is that we just have too many great speakers to fit them all into the five keynote slots. You might find dozens of the talks that are good enough to fill a Keynote slot, but here are some that I know would do the trick:
Bill Sirois: Measuring Fatigue Using FACT
Dr. John Grout: Using Mistake Proofing to Stop Human Error
Jennifer Mounce: Coaching Skills to Sustain Behavior Change
Brian Crawford: Lessons Learned about Human Factors & Generic Causes from Recent Airline Incidents
Karen West: Legal Aspects of Tap[RooT® Investigations
George Burk: Quality in Life & Work
Major General Doug Rob: High Performance Ideas for Leading Improvement
Brad Towe: Self Improvement for Your Future
Dr. Beverly Chiodo: Character Driven Success
Bill Nixon: Leading Successful Investigations: Drawing on UK Experience
Keith Recsky: Lifecycle of an Incident
And that’s just a sample. I can’t list them all or I’d list every session!
Again, don’t just take my word for it. Here is what people have to say about the quality of these sessions (in a .mp4 format video – double click to play):
Another 100%? I think so.
So maybe the formula should be:
100% + 100% + 100% = 300%
That makes the TapRooT® Summit 200% better than other conferences that you might attend.
That’s three times as good!
Even though you might not agree with my math … You get the idea.
So get the approvals you need and get signed up! You can’t afford to miss this Summit!
Ever attend a conference or training event, and walk away feeling like there was one piece of the puzzle that you really needed an answer to but you just didn’t get? We want to assure you that you won’t feel that way about the TapRooT® Summit!
Did you know that you can easily customize your Summit schedule so that every single session you attend is relevant to your most pressing issues? That’s right! You can choose a track (there are nine tracks), and then you can change one, two or more sessions within your track to make it a perfect fit. Not only can you jump over to any another track to choose a session that interests you, but this year we are offering “Special Topics” that you can also choose from.
Special Topics offer additional options this year (some of them are brand new) and include:
Know the Law When Dealing with MSHA After a Serious Accident
PowerPoint Tips and Tricks
Solving Equipment Reliability Problems
Asset Management Problems and Solutions
Medical TapRooT® Instructor Update
What Does Management Need to Know About Root Cause Analysis (Discussion Session)
Sustainable Development
Prioritizing Improvement
We think you’ll appreciate the opportunity to have more custom choices. Be sure to check them out when you register for the Summit
If you can only attend one conference/training this year — why not choose the one that will best fit your needs? The TapRooT® Summit! 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 Summit fee.
If you have questions about how to put all the pieces together, give us a call at 865.539.2129.
Technically, this is a little off the Riverwalk path, but still conveniently walkable from the hotel. Schilo’s (pronounced She-lows) is a San Antonio German delicatessen established in 1917. To walk there from the Westin Riverwalk (the 2010 Summit hotel), just go out the front door (street level) and walk one block toward the Alamo, then turn right on Commerce Street and walk a couple more blocks until you see the sign pictured below (on the right side of the street).
Some of the signature dishes include:
Potato Pancakes: German potato pancakes served with homemade applesauce
Reuben: Corned beef, sauerkraut, swiss cheese on grilled rye bread
Schilo’s Burger: Large patty on a french roll — you pick the toppings
Schilo’s Famous Split Pea Soup
This is a great place to grab a Shiner Bock, Spaten, Warsteiner or Pilsner Urguell (or maybe just a Bud Light … or homemade root beer) and a deli sandwich.
This is a popular place among locals as well, so be prepared to wait in line outside the door during peak hours (main dining room pictured below).
Eating at the bar has that fun, downtown vibe …
And if you eat in the back room, you will be joining some very interesting characters …
The guy below says, “Don’t delay, come eat at Schilo’s today!”
Seriously, this was one of our top picks for great grub when we were on the Riverwalk for the Summit site visit. We think you’ll like it too! Great, cheap comfort eats. The only thing we regret is not seeing the homemade cheesecake until we were on our way out the door. We won’t make that mistake again!
I hope you are taking notes. Don’t forget our other recommendation … more are to come!
We’ll join you in learning best practices in root cause analysis at the 2010 TapRooT® Summit (October 27-29, 2010 with Pre-Summit courses October 25-26).
Sometime people have an accident happen to them and nothing is learned. On the other hand, an accident can provide an opportunity to see problems in a different light.
Linda Kenney was the “victim” of a sentinel event. But the learning she has led after the sentinel event isn’t about how to prevent mistakes. Rather, she helped people see that doctors and patients, and their loved ones need support after these types of accidents.
The costs of an accident can go way beyond the direct costs. In this case, Massey will have a tough time recovering any kind of positive image after all this bad press. This will impact their stock price, borrowing, and hiring in the years to come.
Avoid major accidents. Get proactive in your safety improvement efforts. Attend the TapRooT® Summit and hear Mark Paradies tell you how to take your improvement efforts to the next level.
How Does Your Corporate Culture Effect Your Investigations? The culture that exists within your company greatly effects the success of any investigation and subsequent corrective actions..
Communicating with Management About Risk: Effectively communicating HSE risks to senior management is critical. Their support for resources (time and money) is necessary to implement actions that reduce risk. Strong visual communications and other techniques are needed to get the message across in a way that leads to action and increased credibility for HSE issues. One of the keys is to present HSE information from a business perspective. 
Ahead of the Law: OSHA Enforcement Problems & Solutions: What is the latest in the world of safety compliance? Join Dave Janney and learn what OSHA has been citing, current inspection emphasis programs, the A-Z’s of the Site Specific Target Program, and inspection and citation handling tips..
Improving Incident Investigation and Safety in the BW Fleet: BW Fleet Management are responsible for the management of a large fleet of Bulk Carriers, Oil and Gas Tankers. Although they are a recognized leader in the Shipping Industry, in 2008 they decided more needed to be done..
Advanced Ideas for Corrective Actions: In this best practice session, Dan Damaan will present how to use risk to rank corrective actions. The value of determining corrective actions and making recommendations is directly correlated to having senior leaders in an organization “buy in” and support implementing change. The fact of the matter that in today’s business environment that even competition within a company for funding is fierce. This session provides a high level view of business tools and approaches that can assist EHS professionals in providing effective justifications for proceeding with recommendations that provide an overall benefit for employees and the organization.
Be a Safety STAR: How a VPP Program & TapRooT® Can Be Combined for Excellent Safety Performance: Learn how some leading companies used TapRooT® to improve their OSHA VPP (Voluntary Protection Programs) processes and get some ideas how you can leverage the capabilities of TapRooT® with Melva Luckie-Oni, Dave Janney and Dan Phillippe..
Quality in Life and Work: Quality Improvement can be applied to your personal life and your business. It’s sequential—inside out, not outside in. George Burk was critically burned and severely injured, the sole survivor of 14 passengers in a military plane crash.
The Canon City Daily Record recently published two articles about Summit best practice speaker, Capt. George A. Burk
Ever attend a conference or training event, and walk away feeling like there was one piece of the puzzle that you really needed an answer to but you just didn’t get? We want to assure you that you won’t feel that way about the 
