Root Cause Analysis Blog

(Investigators gone wild!)

SPARE TIME INVESTIGATIONS

I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!

(Spare time maintenance.)

SOMETHING FOR NOTHING

Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

- Poor investigations & corrective actions

- Repeat incidents

- Increased risk of big accidents

- Risk of regulatory action after a big accident or because of repeat incidents

- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

- Overworked, disheartened investigators

- Investigators trying to dodge investigation assignments

- Disenchanted employees who look at investigations as a waste of time

- Inaccurate investigation statistics

- Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.

(Climb the ladder to work on the roof. A reasonable assignment?)

REASONABLE ASSIGNMENTS

If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

HOW MUCH WORK?

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”

(Benchmarking at the Summit.)

BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES

Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!

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

Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.

As a TapRooT® root cause analysis instructor and a Six Sigma Black Belt for System Improvements, Inc., I ask the question in this article’s title to numerous safety leaders from multiple industries. What do you think the typical responses are before they attend a TapRooT® course…..

1. No Lost Time Injuries
2. No Fatalities
3. No Near Misses

What’s wrong with these answers? After all, to be best in class for safety you must report these types of numbers. What if I asked your company’s safety leader the following question… “what did you do wrong today to cause this person to get hurt?” This is basically the same question as above except now the safety leader has to answer that the safety department was not successful at the end of the day.

The point is that that the above answers are what are called “lagging metrics”. It’s too late to know what was done wrong or even what was done right! Think about it… when a a fatality occurs the investigation team must exert a lot of effort and time to understand what happened, why it happened, and how to prevent it from happening again. Prevention….. if only the team had understood the everyday problems and root causes that were present before the incident occurred in this area of the business.

Did you know that it takes less time to perform a TapRooT® audit in predetermined areas of company and hazard risk than it does do perform a post incident investigation? So the question to ask again is “how do I know I was successful today in safety?” Your answer could be, “based on a predetermined risk assessment, we lowered the high risk areas in fall protection from 70% to 60%!”

For for ideas about proactive TapRooT® audits, call us at System Improvements, Inc. at 865.539.2139 or even better, attend the TapRooT® Summit in June and see how other top industries are using our proactive audits. Below is a list of proactive opportunities. See you in June.

* Safety & Risk Management
* Human Error Reduction & Behavior Change
* Corrective Action Programs
* Proactive Improvement, Operational Excellence, and Lean/Six Sigma
* Medical Error Reduction
* Equipment Reliability & Maintenance
* Investigation & Root Cause Analysis
* Management & Measuring Performance
* Certified TapRooT® Instructor
* TapRooT® Software Techniques & Administration

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).

Company travel policies are strange.

For example, some companies don’t allow travel to Las Vegas for conventions or meetings.

Why? The only answers that I’ve heard is that these companies believe that employees won’t work (or learn) in the “What Happens in vegas Stays in Vegas” environment that is portrayed on TV.

We’ve had courses in Las Vegas for years and can report that students who attend there learn just as well as students in other venues. But that still doesn’t satisfy some corporate policy makers.

So here is a new idea…

If your corporate travel approval team says no travel to Vegas … suggest that you attend with a chaperone. Ask your boss to attend with you to make sure that you both spend your work time productively learning all the best practices available at the Summit.

The two of you can make plans for developing your improvement program at the “Planning Your Improvements” session on Friday of the Summit.

Policies shouldn’t stand in the way of improvement. Don’t let an arbitrary rule stop the progress of your improvement program. get signed up for the Summit NOW!

Register at:

http://taproot.com/summit-single.php

Attend the TapRooT® Summit and in addition to ideas that could save your company millions and prevent accidents and injuries, you could win a prize!

What kind of prize?

Just for being on-time for the sessions on the first day, you will become eligible to win an iPhone. (And there will be more prizes too…)

Also, if you were the “neatest” 50s/60s attire to the Summit Reception (Elvis will be there), you can win an iPod Shuffle.

Later in the week there will be additional iPods and other prizes.

These prizes help us keep the sessions on time and our our way of thanking you for your participation and timeliness.

For complete Summit information, see:

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

A press release from the UK Rail Accident Investigation Board:

The RAIB is carrying out an investigation into a derailment of a Docklands Light Railway train near Deptford Bridge station on 4 April 2008.

At 05:27 hrs on 4 April the 05:19 hrs service from Lewisham had just left Deptford Bridge station, and was traveling towards Greenwich, when it struck an object on the track and was derailed by the second axle of the first bogie. The front of the train came to a rest 88 meters after hitting the object. There were no injuries to the 59 persons on board the train and all were evacuated safely back to Deptford Bridge station.

The train, which was the first train of the day from Lewisham, was under automatic operation. The object on the track was found to be a steel drilling template that had been in use during engineering activities the previous night.

The RAIB’s investigation into the derailment is independent of any investigations by the safety authority.

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website:

http://www.raib.gov.uk

- - -

The Chief Inspector for the UK RAIB is Carolyn Griffiths. She is one of the Keynote Speakers at the TapRooT® Summit being Held on June 25-27 in Las Vegas, Nevada. For more information about the Summit and for registration, see:

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

Kay Gallogly, Founder, The 42 Group, LLC

Kay is an organizational effectiveness consultant in the nuclear power industry. Focus areas are incident investigation, human performance, and safety culture. She has been investigating incidents since 1992. Prior to starting her own company Kay worked for Exelon for 13 years in a number of capacities including six years of technical fieldwork. She has a BA in Organizational Management and an MBA.

Kay will be presenting IEEE Root Cause Analysis Standard and Using TapRooT® to Evaluate Common Causes, Extent of Condition, and Extent of Cause at the Summit.

Kay Gallogly, Founder of The 42 Group will be presenting IEEE Root Cause Analysis Standard at the 2008 TapRooT® Summit on Wednesday, June 25 at 10:30 a.m.

This segment will provide an update on IEEE Recommended Practice for the Investigation of Events at Nuclear Power Plants. At present a working committee of nuclear industry representatives is composing a guide to conducting and reporting event investigations. The update will include an overview of the process and the practices that have been identified as key elements of an investigation in this important initiative.

Marco Flores will be presenting the following case study during the Spanish Sessions at the 2008 TapRooT® Summit. The sessions will be held on Friday, June 27.

Ken Reed, Equifactor® Program Manager, and Mark Olson, TapRooT® Instructor, will be presenting “Maintenance Best Practices” on the Equipment Reliability and Maintenance Best Practices track at the 2008 TapRooT® Summit. The session will be held on Friday, June 27, at 9:15 a.m.

From Ken:

Times, they are a-changin’! Discuss how the shift in manufacturing and training philosophy has affected the way we view our maintenance departments, including the way they are organized and utilized. This is an interactive discussion on current trends in maintenance practices, so plan on bringing your own observations to the table.

Ken Reed

Mark Olson

I previously wrote a blog entry about the wrong kidney being removed from a cancer patient.

Yesterday, I read an AP article with the following quotes:

“Twenty-four wrong-site surgeries were reported to the Minnesota Department of Health between October 2006 and October 2007. Two were at Methodist, but Carlson said they were relatively minor compared with last week’s error: a needle biopsy on the wrong lung, and a diagnostic exam of the wrong bronchial tube.”

“Kathleen Harder, a University of Minnesota researcher, said medical errors of this magnitude are rare but do happen.”

“Medical errors” certainly are NOT rare. The question is: “How rare are high consequence medical errors?”

The answer is: “No one knows.”

Why?

Because their is no national law that requires the reporting of high consequence medical errors to a central reporting agency.

Thus all statistics are a guess.

On top of that, to avoid liability errors may disguised as normal deaths. I read a sad story about a family being told that “every possible had been done” to save the life of their grandmother. They chose not to have an autopsy performed. Later, they found out that she had been administered large doses of blood thinner that may have contributed to, or caused, a fatal hemorrhage in her brain. The death would have been a natural death in the statistics. It would have gone unreported. Yet, the family now believes it was a covered up medical error that was detected by a nurse (a family member) reviewing the medical records.

I’m not a person that favors large government regulatory initiatives. And I’ve seen many government programs go astray. But unless the healthcare industry can come together to establish effective reporting and improvement programs, a large government lead regulatory initiative will surely be the eventual result.

If you are interested in efforts to reduce medical errors, you should participate in the TapRooT® Summit in Las Vegas on June 25-27. There is a Best Practice Track dedicated to medical error reduction. And you can network with experts inside the medical field and from a large variety of other industries. The cross industry networking may be the only hope for accelerated improvement in the healthcare industry. After all, as Sam Levenson quipped:

“You must learn from the mistakes of others. You can’t possibly live long enough to make them all yourself.“

If you are in the medical industry leading an improvement effort, don’t miss this once a year chance to learn from others.

-

Last week I spent a couple of days working on the IEEE Root Cause Analysis Standard for Nuclear Power Plants. The picture about is four of the collaborators “relaxing” after a hard day of standard development.

Kay Gallogly (second from the right), founder of The 42 Group, will be describing the progress made so far at the TapRooT® Summit in Las Vegas (June 25-27). See: http://www.taproot.com/summit.php for more information about her talk and the rest of the Summit.

Read this history of the TapRooT® Summit to understand why the TapRooT® Summit has developed into a highly rated, blockbuster event - our history of continuous improvement.

You will also understand why we decided to hold the TapRooT® Summit, what the Summit is, why you will want to attend to help your company turbo-charge performance.

Don’t confuse the TapRooT® Summit with the many excellent courses we sponsor each year. After all, what is the difference between a Summit and a course?

Although the Summit shares the TapRooT® name with the courses, the focus of the Summit is quite different. This quick Summit history lesson will show you the difference between the Summit and our great root cause analysis courses.

HOW THE SUMMIT STARTED

I organized the first Summit in 1993 (to be held in 1994) because, after attending, and even helping organize, many conferences between 1983 and 1994, I saw a need for a conference with a focus on performance improvement, human factors, incident investigation, and the latest improvement technology. A conference that was NOT oriented toward research (although I appreciate good research). A meeting oriented toward practical applications that could be implemented at industrial facilities and in service organizations.

Wow! That’s a mouthful!

I also saw that there was MUCH to be gained by sharing information and ideas ACROSS INDUSTRY BOUNDARIES.

Thus this summit could not be held by one professional organization (with only a safety, quality, or equipment focus) or by a society oriented toward one industry (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …). And it had to be international — as most companies were expanding to worldwide operations.

This was a problem.

I had to start from scratch to organize, publicize, and pay for a meeting that needed to be held, but didn’t have an already established audience nor did I have a conference staff.

Some (Linda) said I was nuts!

But I knew it needed to be done. And nobody else was going to do it. So I become a conference organizer.

SUMMIT HISTORY

So in 1994 we held our first Summit in Gatlinburg, TN (with 33 participants).

It was a start. We learned a lot.

Feedback was very favorable.

And we decided to do it again.

1995 - Orlando - 72 participants.

At this Summit we started to figure out how to make the networking really special. That’s one of the things we’ve continued to improve as the Summit grows. Perhaps that’s why participants frequently remark about the valuable, new professional contacts and friends they make at the Summit.

(We went to Disney on Saturday after the Orlando Summit.)

1996 - Nashville - 85 participants.

Benchmarking became even a bigger part of the Summit.

Also, this was the first Summit with a session dedicated to medical errors at hospitals - an idea that was ahead of its time.

(We had a night at the Grand Ole Opry.)

1997 - San Antonio - 105 participants and growing strong.

Our first of many Texas Summits. We learned to make the networking even more enjoyable and how to get people together for a reception/party to continue networking in an informal environment.

(The Alamo in San Antonio)

After San Antonio in 1997, we decided to make the schedule about every 15 months to rotate the seasons. So our schedule would shift and occasionally “skip” a year. Thus Dallas was in the Fall of 1998, but we skipped 1999.)

1998 - Dallas - 119 participants.

We started having TapRooT® User present the results of their work in Success Stories. A great way to get best practice sharing started.

(We had a JR look-a-like. He didn’t look like the picture above. More like JR after a binge!)

2000 - Gatlinburg - 125 participants.

This was the start of the outstanding Keynote Speakers that wowed participants.

(Linda and Mark with our keynote speaker - a Shuttle Astronaut that discussed the first Shuttle disaster.)

2001 - Galveston - 133 participants.

Two days before the Summit, a Tropical Storm dropped 2 feet of rain! Lesson Learned: This is the last time we will schedule a Summit on the Gulf coast in late June!

This year we also started expanding the pre-Summit course selection. We’ve grown from 3 courses to choose from in 2001 to 11 to choose from in 2008.

(Band at the reception.)

2002 - Gatlinburg - 140 participants.

The networking and best practice sharing took a step up. And the reception was outstanding! Participants said it couldn’t get any better. But it did every year.

(Mark at opening talk.)

2003 - Dallas - 155 participants.

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.

(Linda at dinner with participants on Thursday night.)

2005 - San Antonio - 169 participants.

Wow! What amazing Keynote Speakers, networking, and best practice sharing. The Summit that couldn’t get any better has hit a new high.

(Audience 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 - it was quite powerful.)

And golfing at the Quarry was also a high point.

2006 - Gatlinburg - 175 participants.

The best Summit so far. Each year we build upon the successes of the past and add new ideas to improve the best practice sharing and networking.

(Panel Discussion Debate)

This was also the Summit where we learned that smaller hotels promote better networking. People get lost in mega-complexes. Therefore, we try to hold Summits in nice, affordable, middle-sized hotels with convenient facilities.

2007 - San Antonio - 224 participants.

Participates were blown away by the Keynote Speakers and how well the Summit was organized. The Summit is a well-oiled networking/benchmarking/best practice sharing machine!

To hear what past participants have to say about the Summit, click on the videos at the bottom of the Summit home page:

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

And for 2008?

For the first time we will hold the Summit in Las Vegas!

When? June 25-27.

We expect 300 participants.

Will you be there?

Get your hotel reservations early!

Keynote Speakers include:

Marcia Wieder
Ralph Hayles
Nikki Stone
Carolyn Griffiths
Ed Frederick

Best Practice Tracks include:

• Investigation & Root Cause Analysis
• Proactive Improvement, Operational Excellence, & Lean/Six Sigma
• Equipment Reliability/Maintenance
• Human Error Reduction & Behavior Change
• Safety & Risk Management
• Corrective Action Program
• Medical Error Reduction
• Management & Measuring Performance
• TapRooT® Software Techniques & Administrator
• Certified TapRooT® Instructor

For complete details, see the Summit web site home page at:

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

So how has all this experience helped us create a Summit with unparalleled networking, benchmarking, and best practice sharing as well as exciting, motivating, practical Keynote Speakers?

First, we build upon the experience of each year to make each Summit better than the last. After each Summit we hold a lessons learned review. We review all the participant critiques. We discuss things that were a success and things that could be improved. And we come up with new ideas to try the next year. And we document ideas that worked that we want to continue. Since I have been involved in every Summit since 1994, I bring a wealth of history and experience to the planning process that helps each year get better.

Second, my full time job is looking for ways to improve performance and sharing that information about the new technology and ideas that I find. I learn things in the many TapRooT® Courses that I teach. I learn things at the half-dozen conferences I attend around the world (last year included conferences in Ireland, Italy, the USA, and England). I learn things from the TapRoot® Advisory Board Members (60 people) and TapRooT® Users around the world (tens of thousands of people). I learn things from the 26 TapRooT® Instructors - all highly qualified performance improvement experts - from around the world. Perhaps that why my e-mail box is overflowing.

Third, I use the information from all these sources to plan an event that will help people improve performance. I screen speakers and work with presenters to help develop content that is educational and useful. I use the knowledge I’ve gained three decades of studies in human factors, engineering, root cause analysis, performance improvement, equipment troubleshooting, and healthcare error management to put together a one-time-only meeting that focuses on solving problems by using proven, effective techniques and promotes the sharing of new ideas by hundreds of performance improvement professionals from around the world that participate in the Summit.

Finally, I turn the production over to my skilled, dedicated staff. Every year scores of people stop me at the Summit to compliment me on the professionalism, helpfulness, and friendliness of my experienced staff.

Thus the Summit is so amazing because of the input and hard work of hundreds of people and the experience and creativity of the staff at System Improvements.

Each Summit is a once-in-a-lifetime chance to learn the performance improvement secrets that - if applied - will carry your facility to a best-in-class status. And each year the Summit is better than the last. Don’t miss this performance improvement event!

Neil Roberts will be presenting “Advanced Behavioral Management: Developing a Modern Safety Culture” on the Safety and Risk Management and Human Error Reduction & Behavior Change Best Practices Tracks at the TapRooT® Summit on Thursday, June 26 at 9:15 a.m.

The session will have the following objectives:

1. To demonstrate the benefits and limitations of safety climate and safety culture surveys as a precursor to the introduction of a safety culture change programme.

2. To outline and demonstrate the benefits of a holistic and advanced approach that would encourage change in an organization’s safety culture. This would include reference to four key areas:

(i) Management Leadership
(ii) Safety Performance Measurement
(iii) Safety Coaching
(iv) Safety Interdependence

3. To demonstrate that habitualization of front line safety behaviors has its limitations, but if we are to make a systemic and long lasting difference to culture we need to identify and encourage a change of management based behaviors.

Although the title includes the word “advanced,” any attendee will benefit.

Neil Roberts will be presenting “Advanced Behavioral Management: Developing a Modern Safety Culture” on the Safety and Risk Management and Human Error Reduction & Behavior Change Best Practices Tracks at the TapRooT® Summit on Thursday, June 26 at 9:15 a.m.

Neil’s background was originally in engineering (12 years). He became interested in Health and Safety when his father was seriously injured in a workplace accident in 1978. In 1991, his first involvement in occupational health and safety training occurred while employed at Water Training International. He ran intensive Deep Excavation courses and Confined Space courses at a purpose built facility in Derby (UK). He has been involved in occupational health and safety training for 18 years and joined Woodland Grange in the UK in 1995.

His current role is Senior Tutor at Woodland Grange and he delivers safety training courses at all levels (especially IOSH and NEBOSH courses). He is the Business Development Executive for Woodland Grange’s Modern Safety Culture programme. He has an involvement working with companies to develop their safety culture. Typical inputs would include safety climate surveys and interviews together with analysis of accidents and behavioral trends. Gap analysis recommendations are performed followed by the development of action plans, training workshops and programmes. He has been involved with many training events performed both in the (UK) and internationally.

Jose Gerard will be presenting: Como Evitar Accidentes de Trafico en Monterrey (How to Avoid Traffic Accidents in Monterrey) during the 2008 TapRooT® Summit Spanish Speaking Sessions planned for Friday, June 27.

Es una descripcion de las observaciones hechas durante muchos años de servicio en ambulancias y camiones de rescate urbano de los servicios medicos oficiales de emergencia en Monterrey y su area metropolitana, mientras tratamos de resolver los problemas que ya tiene la persona involucrada en un accidente de automovil.

This presentation includes Jose’s observations during his many years of service in ambulance and urban rescue trucks of the official emergency medical services in the metropolitan Monterrey area. Jose’s work includes resolution of problems encountered by persons involved in a car accidents.

A pesar de que la presentacion esta hecha para el area de Monterrey, las observaciones hechas aplican para casi cualquier ciudad en la que pueda pensar.

Jose’s observations apply to almost any other city you may think of (not just the Monterrey area).

David Davis is the Co-founder and Vice President of The Patient Safety Solutions Consulting Company Inc., specializing in healthcare solutions for Patient Safety & Risk Managers. He will be presenting in the Medical Error Reduction Best Practices Track at the 2008 TapRooT® Summit. David is presenting “Morbidity & Mortality Reviews (Hot Case Rounds)” and “Process for Running a Healthcare Root Cause Analysis.”

He is a Certified TapRooT® Instructor and the Southeast Region Quality Management and Accreditation Support Coordinator for Clinical Operations, Southeast Region Medical Command (SERMC) in Fort Gordon, Georgia. He worked for the U.S. Army: Winn Army Community Hospital in Fort Stewart Georgia as the Patient Safety/Risk Management Coordinator and was also the Patient Safety Program Manager for the U.S. Army: Dwight David Eisenhower Army Medical Center in Fort Gordon, Georgia. His experience also includes Chief/Perioperative Nursing, Infection Control Officer/Hospital Epidemiologist, Infection Control Nurse, Staff Development Officer/Senior Clinical Nurse, Head Nurse and Operating Room Nurse.

David was awarded Department of Defense 2006 Patient Safety Award for Most Innovative Solution to Address a National Patient Safety Goal and the Army Civilian Commendation Award for Excellence. He has been awarded many distinguished medals including Legion of Merit, Meritorious Service, Army Commendation, Army Achievement, Coast Guard Good Conduct, National Defense Service and Air Force Reserve.

Ken Bloch will be presenting “Using TapRooT® to Solve Complex Equipment Problems” at the 2008 TapRooT® Summit. This presentation is on the Equipment Reliability and Maintenance Best Practice Track and is scheduled for Thursday, June 25 at 2:40 p.m.

To solve a complex equipment problem you need to know what information to look for and where to find it. With over one hundred information sources in a typical production facility, this task is easier said than done. The session uses case histories to explain how TapRooT® is being used to isolate the evidence you need to solve complex equipment problems.

Heinz Bloch and Ken Bloch will be presenting “Examples of Extreme Equipment Failure Investigations” on the Equipment Reliability & Maintenance Best Practices Track at the 2008 TapRooT® Summit. This session with be held on Thursday, June 26 at 1:00 p.m.

A special failure category represents a combination of extremes (”Extreme Failures”). These failures have severe consequences, yet provide little (if any) physical evidence. You will examine several extreme failures to identify their similarities and shared anatomy. This understanding is being used to measure Extreme Failure Investigation effectiveness.

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

Here’s an interesting CBS News video on sleep, fatigue, and human performance:

One of our speakers at the TapRooT® Summit is Bill Sirois of Circadian Technologies. Bill will be speaking about fatigue and human performance. He will also share a scientific way to evaluate fatigue in an accident investigation (called FACT). For more Summit info, see:

http://www.taproot.com/summit

Here’s part II:

Here’s the Reporter’s Notebook:

Heinz Bloch will be presenting “How to Become Best of Class in Equipment Reliability by Maximizing Uptime” and “Best of Class in Equipment Reliability Part II” on the Equipment Reliability & Maintenance Best Practices Track at the TapRooT® Summit. The presentations are scheduled for Thursday, June 26, 9:15 a.m. to 10:25 a.m. and 10:40 a.m. to noon, respectively.

Here are the presentation highlights:

How to Become BEST-OF-CLASS in Equipment Reliability by Maximizing Uptime 

(a) Bearing protection issues that are vastly misunderstood
(b) Lube application issues the vendors will not admit
(c) Dual seal component improvements your “alliance partner” will not tell you about
(d) Resourcefulness practiced by BEST-OF-CLASS companies
(e) Cultivating vendor contacts

BEST-OF-CLASS in Equipment Reliability Part II

(a) Bid evaluation concepts your design contractor knows little about
(b) How to effectively manage reliability on New Projects
(c) Grooming talent and skills - why the contractor can not do this for you
(d) Little-known reliability management strategies that make a big difference 

Heinz Bloch is a worldwide recognized equipment reliability expert with over 20 books on equipment reliability and maintenance topics. 

If your improvement ideas include improving equipment reliability and maintenance at your facility, then you should plan to attend!  

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