Root Cause Analysis Blog

(click on pictures to enlarge)

(Ken Turnbull & team receive the TapRooT(R) Cup from Mark Paradies)



Ken Turnbull’s team (Ken, Chuck Selman, Damian Shaw, and Jeff Cooper) trounced the competition in the 2006 TapRooT(R) Summit Golf Tournament.

They shot a 66! They chipped in for a birdie! They were unstoppable…

I thought my team was doing OK when we came in with a 1 over 73. Sorry … We were WAY OFF the pace.

Ken Turnbull’s team turned in a score of 6 under (the next best team was Brian Locker’s All Canadian Team - 3 under).

The course - Bent Creek Golf Course near Gatlinburg, TN - was designed by Gary Player and rewards accuracy - not distance. There was water and sand galore. These seemed like a magnet for my ball.

Dana Smith won both the Closest to the Hole and the Longest Drive trophies. Great job Dana!

We had several novice golfers (Yes- their first time on any golf course) and everybody had a GREAT time!

PLAN FOR 2007

For those planning for the 2007 TapRooT(R) Summit Golf Tournament, it will be on Friday afternoon, April 28, at the The Republic Golf Club in San Antonio. (See http://www.ichotelsgroup.com/h/d/cp/1/en/hd/satps)

This is a new course (rated best new course in 2003 by Avid golfer) that rewards long hitters - it has wide fairways and large greens. So practice your distance game and come to hit (the longest hole is 624 yards with three others over 543 yards). For the course layout see: http://www.republicgolfclub.net/Default.aspx?tabid=786

For more pictures, click on the continuation link below…

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Bill Sirois gave an excellent talk on a new tool that Circadian Technologies is building to help accident investigators analyze accidents and see if fatigue is a possible cause. The new technique is called FACT and is being tested to establish it’s scientific validity.

Click on the pdf below to see the slide from Bill’s talk.

Have you wondered about establishing a “Just Culture” and reducing blame from your investigation environment?

Jim Whiting gave an excellent talk at the TapRooT(R) Summit about the difference between no discipline and a Just Culture.

Of course it is better to attend the session than to just see the slides, but they are attached below for those who are interested.

Blame2.ppt

Another talk from the Summit is posted below.

To see Kevin’s web site visit:

http://www.greatsystems.com

During the Summit, many users were interested in finding out what custom tables other users have added. As more people discover the power of Equifactor(R), more ideas for custom tables come up. When you develop a custom table for a piece of equipment, let me know! I’d like to share your experiences with other users. In addition, after a careful peer review, these custom tables can be added to our software during the next revision. We can do this for any table that has wide-spread use across multiple industries.

Have you found unique symptoms (and remedies) for some of our already-established tables? Let me know. We can incorporate those experiences, too.

Another great talk in the area of equipment reliability was Tom Byerly’s presentation about advanced technology to improve reliability. To see the PowerPoint, click on the link below…

TapRooT - Latest in Research & Best Practices.ppt

Brian Locker gave several well received talks at the 2006 Summit. Here is one talk (pdf format - click on it to open).

I’m writing this posting to provide a place for Summit Attendees to comment on their experience.

I had many people tell me that this Summit was:

1) The best Summit they ever attended,

2) The best conference they ever attended,

3) Something that they will make every effort to attend in the future. (They said “I can’t believe I’ve missed this in the past!”)

But I wanted all attendees to have a place that they could post comments and let me know what they thought.

So I’m posting this entry and I’ll e-mail all the attendees so that they can comment here.

Thanks

Mark

On Thursday, Jim Whiting gave an excellent talk that really did get people to see “safety” differently - from a risk management perspective…

Of course, you really had to be there to hear the talk … but here is the PowerPoint. Just clik on the link below.

Main Session -2.ppt

Kevin is a Baldrige Examiner and in this talk he shared best practices from his experience.

For more writing by Kevin, see his web site:

http://www.greatsystems.com

How does advanced root cause analysis fit into a Lean program?

That was the topic of the attached pdf presented at the TapRooT(R) Summit by Kevin McManus. (Click on picture below)

For more writing by Kevin see:

www.greatsystems.com

As I told attendees, I will be posting the Summit papers on the blog when the authors pass them along to me.

Here is a paper about Equipment Reliability & Root Cause Analysis by Brian Murray of SKF. (PowerPoint format)

Reliability and Integrity Management 1-1.ppt

Back in the office today. I’ll try to complete my summary of the Summit and post more of the talks today and the rest of this week. So check back later this week for more info.

Thanks

Mark

When I left off at the last report we were just starting the Bob Nelson Talk on Rewards…

Bob gave a great presentation that got everyone thinking about how to motivate employees and change behavior with rewards. The talk included research results and practical examples. Plus we all participated in an exercise that really demonstrated the power of attitude.

The next session I went to was the Best Practices for Fast Analysis of Small Problems.

Sanjay Gandhi, TapRooT(R) Instructor from Kenya, gave a talk that really turned into faster/more efficient investigations of all size.

Sanjay gave 10 tips for faster/better investigation that was similar to the paper I posted on Efficient/Effective Root Cause Analysis.

Best Practice for Fast Analysis of Small Problems 04-07-2006.ppt

He also passed out the most recent edition of a paper I wrote on The Curse of Apparent Cause Analysis (click on document below).

After that session, all attendees started the Planning Session. Six breakout sessions were held where attendees planned their top three improvements so they could get started implementing when they returned to their site.

From there, I went to the TapRooT(R) Summit Golf Tournament. A great time was had by all (more in a separate posting about this).

We finished with the awarding of trophies about 7:30 PM and I was off to dinner with about 6 attendees and then back to the hotel (about 10:30).

What a full and fun day!

I’ll pass on more about the Saturday session later.

Thanks

Mark

What a day! (Thursday)

I made my first posting yesterday (Wednesday) and never got a chance to make another posting.

Right now I’m trying to get this written before Bob Nelson talks about rewarding employees.

Yesterday I started out giving a talk on human performance models and then Jim Whiting challenged people to STOP staying that they “are safe” or that they support “safety at any cost” and start recognizing that ALL human activity has some amount of RISK. We must assess the risk, manage the risk, decide which risks are unacceptable, …

Next I was the speaker at a session about Critical Human Action Profile and analyzing human error. We looked at a fairly simple valve mis-positioning error using CHAP and Reason’s Model of Slips-Lapses-Mistakes. This “simple” error was one of the major contributors to the Giant Refinery fire. Who would have thought that a simple errors could have ignited the spirited discussion that we had about the RIGHT way to lock out and drain a pump!

After another great lunch, I went to two talks on investigations. One was by Steve Hawkins of TN OSHA about lessions learned from fatality investigations. The next was Mark Kaszniak, a Chemical Safety Board investigator. He talked about the BP Texas City Explosion. After Mark finished talking, I started thinking that the BP Texas City Refinery disaster could have happened to anyone in the refining industry (I’ll write more about this if I get the chance next week).

Next, was an outstanding session on best practices used by TapRooT(R) Users to investigate problems. First four users shared best practices from their facilities. Then all the attendees in the breakout (about 80) got together in groups of 10 and compared best practices at their sites. They then selected a best practice from their group and shared it with the rest of the groups.

Then we went back to hear a keynote speaker - Mike Kelley, VP of TODCO. What an inspiring talk about a Vision for Corporate Improvement! You could feel the emotion, sincerity, and commitment in his voice.

Then there was a Panel Discussion. Topic? “What is the most important factor in leading an investigation.” Each of six panelists (Mark Kaszniak, Ken Turnbull, Brian Locker, Steve Hawkins, Jim Whiting, and Mike Kelley) had to pick one factor that they deemed “Most Important” and explain in five minutes or less WHY they thought it was most important. They then answered questions from the attendees about their opinions. … It turned out to be quite thought provoking.

That was the end of the official day. But I was immediately drawn into a conversation that lasted for an hour. We retired to the hotel’s lobby bar for further discussions that lasted almost two hours until karaoke started. With about 60 Summit attendees in the bar, the party started. We had great fun and more discussions of a wide range of topics. It was 11 PM when I decided that I needed sleep and, for me, the fun had to end.

What a day!

I’ll try to sum up Friday when I get a chance and also post some of the papers presented by the speakers.

Thanks

Mark

As asked, here is a pdf of the talk I gave this morning on human error and modeling human error.

(Call me at 865-539-2139 if you are interested in this talk.)

Thanks

Mark

I just came from the Investigations Best Practices Session (Ken Scott/CJ Blacklund/Dennis Ward). Great info. I can’t cover all the good info in a short note so I will just pass along one “nugget”…

Dennis Ward talked about the value of looking at common causal factors from multiple accidents rather than looking at one accident at a time. The result? Multiple improvements to the FAA’s process for certifying pilots. A really impressive story that Dennis says he will be back to report on the results as private pilot safety improves.

I’m now sitting in the Certified TapRooT(R) Instructor Workshop listening to Linda Unger share ideas to improve TapRooT(R) Training conducted by instructors at licensed TapRooT(R) User sites. There is a new revision to the 2-Day TapRooT(R) Incident Investigation and Root Cause Analysis Course.

One of the ideas is a SMARTER Corrective Action form to help people develop … SMARTER Corrective Actions!

After this I’m off to the Keynote Talk … “Better Communications to Improve Safety, Quality, Productivity, & Morale!” Vincent Phipps of TLC is an excellent presenter and I’m looking forward to his talk.

I’ll try to get some brief videos of sessions and some pictures tonight - NO GUARANTEE - because we also have a reception that starts at 5 PM and goes until …

Hope that next year you can be here.

Mark

Just left Brian’s session after an excellent talk on maintenance management and root cause analysis.

For me, the statistics on failure - especially the “caused” failure by maintenance activities - was an eye opener.

Seems that we would be better off just keeping our hands off stuff.

That is where condition monitoring comes into a maintenance strategy.

For Brian’s slides, click on the attached PowerPoint below.

Reliability and Integrity Management 1.ppt

Next is lunch and then another set of breakouts - I’m attending the Investigations & Corrective Action Program Best Practices session.

More reports later.

Thanks

Mark

Wow!

Just left Mike Durant’s talk. Very emotionally moving and right on target for our world situation and our individual corporate improvement programs.

One small part of the message was Mike’s advice on achieving Mission Success:

- Leadership

- Resources

- Tactics

- Training

- Planning

Mike received a sincere standing ovation from the audience and then signed books for the Summit attendees.

I’m off to an equipment reliability session by Brian Murray of SKF … more later.

Thanks

Mark

Students are back in class learning on the second day of the pre-Summit Courses.

(Bethany Butler attending the Advanced Trending Techniques Course)

(Ray Mays and Mike LeMay discuss trending issues at a break.)

(Attendees in the How To Interview & Gather Information Course organize their SnapCharT(R))

(Ed Skompski discusses SnapCharT(R) with students.)

(Proactive Exercise in the 2-Day TapRooT(R) Course - using the computer to help find root causes.)

(More 2-Day TapRooT(R) Course attendees discussing root cause analysis.)

(The communication exercise in the 2-Day Course … “You said WHAT?”)

(”OK Nikki - Here’s what you need to do…)

(Equifactor(R) Course attendees listen to Steve Swarthout explain Heinz Bloch’s troubleshooting techniques.)

(Katherine - cup of coffee in hand - is much more relaxed … )

(Becky is smiling now because she is ready for the Summit set-up that starts this afternoon. A record number of attendees (over 175 at last count) will arrive tomorrow morning. That means that Becky’s busiest 24 hours are just about to begin!)

The thunderstorms passed through last night and the hotel was in great shape for the beginning of the 2006 Summit … the Pre-Summit Courses.

(Katherine busy coordinating courses - Wow! What a day!)

This morning about 125 people arrived for the seven pre-Summit Courses:

(Nikki directing people to their class)

(Ed … telling people where to go.)

2-Day TapRooT(R) Incident Investigation & Root Cause Analysis

(Ken Turnbull teaching.)

(Class discussion … What IS the Root Cause? … or Root Causes???)

(Linda giving class exercise instructions.)

2-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting & Root Cause Analysis

(Students working on a problem.)

Advanced Trending Techniques

(Kevin McManus teaching.)

(Working on an exercise for trending course.)

Creative Solutions

(Michele working with the Creative Solutions Class.)

(Attendees working on a creativity exercise.)

How To Interview & Gather Data

(Ed teaching.)

Risk Analysis & Management Best Practices

(Jim Whiting - Australian Risk Management Expert - teaches risk analysis best practices.)

Stopping Human Error

(Joel Haight teaches class … more than “just say no” to human error…)

Initial reports from attendees indicate a very successful start to the week.

(Attendees discussing the morning’s work.)

(Natalie - On-Site TapRooT(R) Course Coordinator who is attending her first TapRooT(R) class.)

Lunch Photos

More Photos … Click on Continue Link

(more…)

This week the Root Cause Analysis Blog will be different.

We will be bringing you up to date coverage of the TapRooT(R) Summit.

I will try to drop you notes about sessions I attend and we are going to try to post at least a couple of summary videos of a couple of sessions to give you a flavor for WHAT YOU MISSED!

Because if you are reading about the Summit, you probably aren’t AT THE SUMMIT.

The people at the Summit are too busy:

• sharing root cause analysis best practices,
• learning operations/maintenance/safety/quality best practices from industry leaders,
• and hearing from world renowned experts

… They just don’t have time to read the Root Cause Analysis Blog this week.

Frankly, I don’t know how I am going to take time to write about the Summit. Because I will be busy learning and sharing.

But I will try.

And when you see a small sample of what is going on … You can start to plan to attend the TapRooT(R) Summit in 2007.

It will be held in San Antonio, Texas, on April 25-28, 2007.

So put the dates in your planner and get your 2007 travel and budget requests in … because you will find attending is well worth the effort and you will wonder … “Why didn’t I go to this before?”

Yes, some who have seen me play might think that my golf game is a joke…



Perhaps that is why Michele, a TapRooT(R) Instructor from Canada who will also be playing in the tournament, sent me this joke in an e-mail (was she trying to psych me out?):

List of Top 10 Caddy Comments:

#10 Golfer: “Think I’m going to drown myself in the lake.”

Caddy: “Think you can keep your head down that long?”

#9 Golfer: “I’d move heaven and earth to break 100 on this course.”

Caddy: “Try heaven, you’ve already moved most of the earth.”

#8 Golfer: “Do you think my game is improving?”

Caddy: “Yes sir, you miss the ball much closer now.”

#7 Golfer: “Do you think I can get there with a 5 iron?”

Caddy: “Eventually.”

#6 Golfer: “You’ve got to be the worst caddy in the world.”

Caddy: “I don’t think so sir. That would be too much of a coincidence.”

#5 Golfer: “Please stop checking your watch all the time. It’s too much of a distraction.”

Caddy: “It’s not a watch - it’s a compass.”

#4 Golfer: “How do you like my game?”

Caddy: “Very good sir, but personally, I prefer golf.”

#3 Golfer: “Do you think it’s a sin to play on Sunday?”

Caddy: “The way you play, sir, it’s a sin on any day.”

#2 Golfer: “This is the worst course I’ve ever played on.”

Caddy: “This isn’t the golf course. We left that an hour ago.”

. . And the #1 best caddy comment:

Golfer: “That can’t be my ball, it’s too old.”

Caddy: “It’s been a long time since we teed off, sir.”



One lucky fact … There are no caddies at the TapRooT(R) Summit Tournament!

Hope to see you there!

(PS: We need two more golfers to round out the field of 40 in this the third TapRooT(R) Summit Golf Tournament. To register call Becky or Katrina at 865-539-2139.)

Just a week and a day until the TapRooT(R) Summit Golf Tournament.

(Brian’s winning team last year - I’m the tall one handing out the trophy)

The office handicappers have it a close three way race between defending champion Brian Locker (with a new team), Ed Skompski (with a strong set of teammates), and Linda Unger (also with a strong team). However, office gossip is often wrong so don’t be disheartened if your team wasn’t the pre-tournament favorite.

For team pairings and tee-times, see the list below. (Click on the “Continue reading” link below.)

(more…)

HELP US SET A RECORD

If 4 more people sign up for the TapRooT(R) Summit we will surpass last year’s record attendance.

I know several people who told me they were coming still have not signed up (can you spell p-r-o-c-r-a-s-t-i-n-a-t-e?).

If you are thinking about attending - STOP THINKING and SIGN UP!

Click here to register.

One of the sessions at the TapRooT(R) Summit will be a presentation by one of the CSB investigators about their investigation of the BP Texas City Refinery Explosion. Read below about the continuing investigation and I hope you can make it to the Summit to hear more…

The following message is from the United States Chemical Safety and Hazard Investigation Board, Washington D.C.

CSB Investigation Continues as Texas City Marks First Anniversary of BP Refinery Explosion

Washington, DC, March 23, 2006 - On the first anniversary of the refinery explosion at BP Texas City that killed 15 people and injured 170 others, the U.S. Chemical Safety and Hazard Investigation Board (CSB) is continuing to investigate many aspects of the disaster. The Board expects to issue its final report on the accident, including a determination of root causes and new safety recommendations, at a public meeting in Texas City in late 2006.

(more…)

I haven’t had any time to work on the blog this week (to busy with Summit prep). But I couldn’t let a Friday go without a joke.

This joke is from a past TapRooT(R) Summit. One of the attendees told me:

“Remember - no one is completely useless … They can always be used as the bad example!”

TapRooT(R) Summit - Gatlinburg, Tennessee - April 5-8, 2006

For those who prefer to wait until the last minute, NOW is the time to register for the TapRooT(R) Summit.

Why should you be in Gatlinburg, Tennessee, on April 5-8?

Because:

You need to hear the great speakers who will inspire you to greater achievements.

You need to network with others with similar problems who are willing to discuss their lessons learned.

You need to benchmark your best practices against the best practices of others.

You want to learn state-of-the-art performance improvement techniques from world recognized experts.

For the complete Summit schedule see:

http://www.taproot.com/summit.php?sched=1

And then register at:

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

Sunrise over Gatlinburg

Is Your Workforce Aging?

Will this cause increased or decreased injuries?

How do you need to change the way work is done?

What should you be doing to cope with this phenomenon?

There is a session at the TapRooT(R) Summit that may help you decide what to do:

Joel Haight of Penn State will present -

“Strategies for Reducing Human Error &

Injury when your Workforce is Aging”

There is still time to register for the Summit. See:

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

Those attending the TapRooT(R) Summit (April 5-8, 2006) will get a chance to hear Dr. Bob Nelson - the Guru of Rewards - talk about ways to use rewards to get the behavior you want from employees.

Dr. Nelson sent me 11 articles that Summit attendees might want to read either prior to or after the Summit. I am posting them here so that you may download the pdf’s and read them.

Just click on the papers to see the PDF’s.

Dump The Cash

Top Ten Ironies of Motivation

You Want ToMAYtoes, I Want ToMAHtoes

Give Generation X a Chance and a Challenge

Long-Distance Recognition

Click on the link below for more…

(more…)

What is World Class Root Cause Analysis?

TapRooT(R) of course!

But there is more to it than that.

In addition to TapRooT(R), World Class Root Cause Analysis requires:

- A strategy for your improvement program

- A written improvement plan

- Trained resources (great people) to perform the analysis

- An improvement program owner to make the process work

- Middle and senior management support

- Advanced trending techniques (need database for this)

- Strategies for collecting and disseminating lessons learned

- Aggressive implementation of improvements (corrective actions)

- Management and supervisory support of behavior change initiatives (corrective actions)

- Specialized help for difficult problems

- Continuous effort (you are never “good enough”) and continued nurturing

- Processes to insure good, consistent investigations

- Rewards for good investigations and corrective action implementation

That’s my short list … what can you add to it?

This whole topic comes from an e-mail I received that I will share here.

Bob Cargill of TransAlta wrote:

- - -

Hi Mark - Last year one of the members of our corporate reliability group

attended a maintenance conference in Tampa Florida where a reliability

program scorecard workshop was offered. One of the aspects in the

scorecard was a KPI for RCFAs which indicated that investigations be

started within 72 hours of incident occurrence. Are you aware of any other

KPIs that would give us an understanding of the hallmarks of a world class

RCFA program? We already have TapRooT but we would like to enhance the

system that works with the software.

Thanks!

Regards,

Bob Cargill, RET

Reliability Specialist

TransAlta Utilities Corporation

Alberta Thermal

Duffield, Alberta

Canada

- - -

I replied to Bob that I would post his question in the e-Newsletter and here on the Root Cause Analysis Blog to see what feedback TapRooT(R) Users could provide.

So to post your comments below (click on the Comment link).

I also told Bob:

- - -

Two other ideas …

1. We have a session at the Summit on Best Practices for Corrective Action Programs and Root Cause Analysis and this topic could easily be added to the agenda for that session. Are you planning on attending the Summit? It really is the best place to network with other TapRooT(R) Users and find out what the best of the best are doing. For more summit info see: http://www.taproot.com/summit

2. I am working on a update to the TapRooT(R) Book and will add that to the topics to research and add to the book. We are going to discuss the book update at the post-Summit (Saturday) TapRooT(R) Advisory Board meeting.

Would you like to join the Advisory Board and attend the meeting? I could use more maintenance ideas on the board. I’ve pasted the original e-mail charter for the Adviory Board below so that you can see what it is about. Let me know what you think.

Thanks

Mark



- - -

For readers who are interested, I am looking for some new members for the TapRooT(R) Advisory Board. So if you are interested, please drop me a note.

Now please click on the comment link and provide me with your ideas about Key Performance Indicators and Measures of a World Class Root Cause Analysis Program.

Thanks

Mark

We’ve had a change of plans on the Equipment Reliability & Maintenance Best Practices Session.

Jeff Hammons from Parsons will not be able to present so we have been lucky to get an excellent talk that will be VERY interesting.

Ken Turnbull, TapRooT(R) Instructor and retired Safety Manager for Texaco, will present a talk on the fire at the Giant Refinery.

Why will this be interesting to those interested in equipment reliability and maintenance?

Because this accident was initiated by an equipment reliability problem.

Ken will show how Hienz Block’s Troubleshooting Tables (part of the TapRooT(R) Software) could have been used PROACTIVELY to prevent this accident.

Link to Case Study by CSB of Giant Refinery Fire:



http://www.csb.gov/metatraffic2/track.asp?mtr=http://www.csb.gov/completed_investigations/docs/Final%20Giant%20Case%20Study.pdf

If you have waited until the last minute to register for your hotel room at the Summit, you may find out that the hotel has filled up (certain nights are full).

You may be able to wait a couple of weeks and as other room blocks expire, get a room. So ASK the hotel if you can be put on a WAITING LIST.

My other recommendations are as follows:

1. Cheap ($55-$49), Clean Hotel with small rooms. Just Down the hill (steep hill!) about 1 mile from the Park Vista Resort Hotel (where the Summit is). If I remember right, free parking and internet…

Gatlinburg Microtel

http://www.microtelinn.com/reservations/locationdetail.asp?FacId=15

2. Cabins in the Mountains around Gatlinburg (requires drive on narrow, twisty roads each day but great views). Links to cabin rental companies …

http://www.jacksonmountain.com/

http://www.sunsetcottage.com/

http://www.heartlandrentals.com/

http://www.mountainchalets.com/

Cabins will be more memorable. Microtel will be cheaper.



If you rent a cabin, make sure it is near GATLINBURG (not Pigeon Forge). There is often heavy traffic between Pigeon Forge and Gatlinburg.

As usual for any conference we have had some speaker modifications for the TapRooT(R) Summit.

First, Ed Skompski will replace Dana Barclay teaching the 2-Day Collecting Information and Interviewing Course.

Next, Ken Scott will be replacing Dana Barclay at the Investigation and Corrective Action Program Best Practices Session.

Third, either Ed Skompski or Evan Erwin will be replacing Steve Dashper at the software sessions.

So far all other sessions and courses are on track!

The driver knows that it was a bad day (more pictures at the link below).

What is the cost of this kind of accident?

• Damage to the bridge.
• Damage to the equipment.
• Damage to the trailer.
• Damage to the cab.
• Driver injuries.
• Other drivers injured?
• Lost time at a construction site (equipment never got there).
• Lost time of people stuck in traffic because of the accident.
• Lost time of people stuck in traffic because of repairs.
• Management attention diverted to the lawsuits (there will no doubt be some).
• Emergency response.
• Increased insurance premiums.

What is the root cause of the accident? Who knows … it’s unlikely that anyone will ask!

But we already know the most likely corrective action … Fire the Driver!

And here is an amazing thought - the fired driver is probably the only one who learned a lesson. He learned a lesson not because he was fired, but because he was the one who hit the bridge.

So what can you learn from this accident?

First, do you know the costs of accidents at your facility?

Do you know how much “human error” cost your company last year?

If you don’t know these costs how can you decide how much you should invest to prevent these costs in the future?

Second, do you know when you should use discipline after and accident and when you should NOT use discipline?



If you are interested in this topic, consider attending the “Just Culture” session at the TapRooT(R) Summit. Jim Whiting, Australian Safety and Risk Management experts will be sharing ideas that may change your company’s approach to discipline.

Finally, the people who investigate this accident will probably attribute it to “simple human error.” But this simple result probably won’t help them understand the real causes of the accident or practical solutions to prevent these accidents in the future.



If you are interested in the real root causes of human error, I would suggest three things.

1. Attend the 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training.

2. Attend the Stopping Human Error Course on April 3-5, 2006, in Gatlinburg, TN.

3. Attend the Human Performance and Behavior Change Best Practices Track at the TapRooT(R) Summit, April 5-8, 2006.

Hope to see you at one or all of these sessions…

For more pictures, click below.

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Will you be in the picture of the winning team at the 2006 TapRooT(R) Summit Golf Tournament?

Above is a picture of Brian’s “All Canada” winning team from the 2005 TapRooT(R) Summit Golf Tournament (I’m the one handing out the TapRooT(R) Cup to Brian).

Brian’s team has won for two years in a row. This year several teams are planning to knock off Brian’s team to take the cup home.

If you haven’t signed up for the Summit or the tournament, there is still time. But don’t wait. We are limited to 10 teams and the slots are going fast. Register for the Summit and the tournament today!

(Ed’s Team at 1st tee in 2003)

How do you evaluating the effectiveness of your incident investigations and root cause analysis?

If you would like to learn best practices, benchmark with industry leaders, and brainstorm even better techniques, the attend the “Evaluating the Effectiveness of Your Incident Investigations” Breakout Session at the TapRooT(R) Summit (April 5-8, 2006, in Gatlinburg, TN).

Michele Lindsay and Brian Locker will facilitate this session that will help you to evaluate your investigation efforts.

Have you voted yet?

Vote for your 10 favorite sessions at the TapRooT(R) Summit.

Here’s the list of sessions to choose from.

In the Company of Heros - Mike Durant, Blackhawk Down Pilot

Better Communications to Improve Safety, Quality, Productivity, & Morale! - Vincent Phipps, TLC LLC

Challenging the Way North Americans Manage Safety - Jim Whiting - Risk@Workplaces, Australia

Getting Beyond Slips, Lapses, Mistakes, and Latent Errors - Mark Paradies, President, System Improvements

A Corporate Vision for Performance Improvement - Mike Kelly - VP Operations at TODCO

Panel Discussion: What is the Most Important Factor in Leading an Investigation - Mark Paradies, President, System Improvements - Moderator. Panel: Mike Kelly, VP TODCO; Brian Locker, Consultant, TapRooT®; John Carpenter, Safety Manager, Intel; Ken Turnbull, retired Safety Manager, Texaco & Consultant, TapRooT®; Jim Whiting, risk@workplaces, Australia; Steve Hawkins, Assistant Administrator, Tennessee OSHA; Mark Kaszniak, Chemical Incident Investigator, CSB

Rewards - The Secret of Success, Bob Nelson, Guru of Rewards

Leadership Skills to Enhance Human Performance - Brian Locker, Consultant, TapRooT®

Communication Techniques to Stop Communication Errors - Vincent Phipps, TLC LLC

Strategies for Reducing Human Error & Injury when your Workforce is Aging - Joel Haight, Penn State

Analyzing Fatigue as a Cause of Errors - Bill Sirois, Sr. VP & COO, Circadian Technologies

Understanding Human Error by Using Critical Human Action Profile - Mark Paradies, President, System Improvements

Using Technology to Reduce Human Error - Joel Haight, Penn State

Using Mistake Proofing as a Corrective Action to Prevent Slips and Lapses - John Grout, Campbell School of Business

Measuring the Effectiveness of Your Improvements - Joel Haight, Penn State

Holding Live, Interactive Safety Meetings on the Web - Dr. Don Lighter, CyberCE

A UK Best Practice - The Safety Case - Terry Callan, C Safe T, Ltd

ZERO Accidents - Best Practices to Attain Outstanding Safety Performance - Thaddeus Allen, Fluor Corporation

Process Safety Best Practices from the Nuclear Navy - Ken Reed, System Improvements

TapRooT® User Best Practices - Linda Unger, VP, System Improvements & Michele Lindsay, Consultant, TapRooT®

Establishing a Just Culture/No Blame Environment for More Effective Investigations - Jim Whiting Principal, risk@workplaces, Australia

Investigation/Corrective Action Best Practices - Dana Barclay, President, Dana Barclay, Ltd.

Learning More from Multiple Aviation Accidents - Dennis Ward, Medallion Foundation,

Management Involvement in Corrective Actions - C.J. Backlund, LANL

Best Practices for Getting & Keeping Management Buy-In - Brian Locker

Ranking the Risk of Your Incidents & the Importance of Your Corrective Actions - Linda Unger, VP SI, Jim Whiting, Principal, risk@workplaces, Australia, & Ken Turnbull, consultant, (enforcement), + TapRooT® Users

Evaluating the Effectiveness of Your Investigations - Michele Lindsay & Brian Locker

Innovative Thinking & Creative Corrective Actions - Michele Lindsay, Consultant, TapRooT®

Regulatory Investigations - Lessons Learned from Fatality Investigations - Steve Hawkins, Assistant Administrator, Tennessee OSHA,

Regulatory Investigations - BP Texas City Refinery Explosion Investigation - Mark Kaszniak, Chemical Incident Investigator, CSB

Best Practices for Fast Analysis of Small Problems - Sanjay Gandhi, Nutek Solutions, Ltd, & Jim Thatcher

Using the Root Cause Tree® and Managing Corrective Actions in the New TapRooT® Software - Mike Casada, Consultant, TapRooT®, & Evan Erwin, IT Support, SI

TapRooT® Certified Instructor Workshop - Linda Unger, VP, SI

Using SnapCharT® for Process Mapping - Bryce Donaldson, Ophion Risk Management

TapRooT® Software: Single User, Workgroups, or Enterprise Edition - Which is Best for Your Company? - Ed Skompski, Partner, SI & Frank Garcia, Persistech

Installation Best Practices for TapRooT® Software - Frank Garcia, Persistech & Steve Dashper, Software Engineer, SI

BuildingYour Own Custom Reports in Access, Excel, or Crystal Reports - Frank Garcia, Persistech

Linking the TapRooT® Software to Other Databases - Frank Garcia, Persistech

Answering the Unanswered Questions about TapRooT® Version 5 Software - Ed Skompski, Partner & Software Project Manager; Frank Garcia, President Persistech; Steve Dashper, Software Engineer, SI; Evan Erwin, IT Support, SI

Then copy and paste your choices in the comments sections here…

Also see how others have voted at the same site.

I was reading an e-mail about performance improvement in the medical industry and came upon a new term “SBAR.”

I did some searching and came up with the following link that describes the technique well:

http://www.errormedicine.com/SBAR_report.pdf

The idea applies to any industry where trouble calls are made to people not at the site of the trouble.

Interested in more ideas about improving communications or reducing medical errors? Then consider attending the TapRooT(R) Summit on April 5-8, 2006, in Gatlinburg, Tennessee.

Communication Improvement: At the Summit Vincent Phipps will present Communication Techniques to Stop Human Errors from 1-2:20 on Wednesday. His talk will cover practices that go beyond the standard three-way communications techniques.

Stopping Medical Errors: Also at the Summit there is a whole track on stopping medical errors. for more information see:

http://www.taproot.com/summit.php?sched=1

and click on buttons on the left labled “Medical Error Reduction Track” to display the schedule for that tracks.

For a Summit Brochure (pdf) click here.

If you have already attended the 5-Day TapRooT(R) Course but you would like to learn MORE advanced investigation and root cause analysis skills, what should you do?

Attend the Advanced Investigation Skills Track at the TapRooT(R) Summit on April 5-8, 2006, in Gatlinburg, TN.

First, you can attend the following sessions to provide advanced root cause analysis and incident investigation skills:

• Investigation/Corrective Action Best Practices
• Best Practices for Managing Investigations with Potential for Litigation
• Innovative Thinking and Creative Corrective Actions
• Evaluating the Effectiveness of Your Investigations
• Analyzing Fatigue as a Cause of Errors
• Best Practices for Fast Analysis of Small Problems
• New SnapCharT(R) Software

You will also hear the following Keynote Speakers and Sessions:

• Panel Discussion - What is the Most Important Factor in Leading an Investigation
• Mike Kelley - VP, TODCO - A Corporate Vision for Performance Improvement
• Bob Nelson - Guru of Rewards - Rewards, The Secret of Success
• Mark Paradies - President of System Improvements - Getting Beyond Slips, Lapses, Mistakes, and Latent Errors
• Jim Whiting - Principal, risk@workplaces - Changing the Way North Americans Manage Safety
• Mike Durant - Blackhawk Down Pilot - In the Company of Heroes
• Vincent Phipps - TLC LLC - Better Communications to Improve Safety, Quality, Productivity, and Morale!

And if you want even more, attend the pre-Summit Course (April 3-4) titled “How to Interview and Gather Evidence“.

This special opportunity only happens once this year so don’t miss your chance, register today!

Maybe this was a marketing ploy or an “I did exactly what he told me” example of malicious compliance. But it does remind us that inadequate communications can lead to mistakes.

Of course, TapRooT(R) Users know that the Root Cause Tree(R) covers these kinds of errors. But sometimes we would like to learn more about preventing communication mistakes. That’s exactly what Vincent Phipps of TLC LLC will talk about at the TapRooT(R) Summit.

So if you are interested in Communication Techniques to Stop Human Errors, attend Vincent’s talk from 1-2:20 on Wednesday and learn practices that go beyond the standard three-way communications techniques.

For a complete Summit Schedule see:

http://www.taproot.com/summit.php?sched=1

and used the buttons on the left to display the schedule for particular tracks.

For a Summit Brochure (pdf) click here.

To answer this question, please look at the Summit web site and scroll through the various tracks at:

http://www.taproot.com/summit.php?sched=1

Then I would like you to comment on this e-mail and let me know what you think are the 10 best sessions (the ones you would most like to attend).

Of course voting on this is very difficult for me. I’m the one who scheduled ALL the sessions. And I will be giving several sessions.

So first let me say that I am not voting for my own sessions (modesty?) and I had a hard time picking the following but here are my 10 Best (not in any particular order):

1. In the Company of Heroes, Mike Durant, Blackhawk Down Pilot.

For the rest, click below.

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Efficient root cause analysis should be what every comp