Having trouble getting away from those old, standard corrective actions that don’t seem to last? 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.
Michele Lindsay will be teaching “Get ‘Outside the Box’ Corrective Actions” at the 2010 TapRooT® Summit (October 27-29 in San Antonio, Texas).
Michele has been a certified Instructor for the TapRooT® System since 1998. As an “outside of the box” thinker, Michele was formally trained in creative thinking techniques in 1994. Recognizing innovation as a key competency in the “new” economy and the challenges and limitations of improvement teams to come up with effective and innovative solutions to problems, Michele leads and facilitates improvements with teams. She a Certified Instructor of the Six Thinking Hats™ and teaches an Innovation and Creative Thinking Workshop that helps individuals and teams break out of the limits of day to day thinking.
Learn more about Michele and our other speakers on our website!
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.
Dennis Osmer, former Worldwide Head of HSE, will be teaching “Communicating with Management About Risk” at the 2010 TapRooT® Summit (October 27-29 in San Antonio, Texas). If you attended the Summit last year, you may remember his presentation, “Pursuit of World Class EH&S” (if not, you may view the presentation here). In 2010, he will be back to 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.).
Dennis is a TapRooT® Instructor with over 40 years of industrial experience - the last seven years of his career as the World Wide Head of Health, Safety, Environment (HSE) and Emergency Management at CIBA Vision (a business unit of Novartis). There, he was responsible for the HSE activities for all of CVs operations (14 supply chain sites, 37 sales and marketing group companies, 11,000 employees on 3 continents). He has a pragmatic approach to developing and implementing HSE strategy which balances employee safety, environmental protection and business needs. He is a recognized expert with a track record of delivering performance.
His most recent activities were with Pandemic Preparedness, energy efficiency improvements, auditing, due diligence, new site start-up and HSE strategies for world class performance. While with a different business unit, he was the deputy chief of an industrial brigade and part of a community outreach program.
Dennis has an MBA in general management and finance from Fairleigh Dickinson University, and a BA in mathematics from the same university.
What’s the most effective way to learn how to communicate with management about risk? Attend the 2010 Summit! View our schedule of best practice sessions and hand pick one that answers your most pressing questions today!
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?
Learn the answers to 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.
Kevin McManus is the President of Great Systems! and provides performance improvement coaching from his office in Rainier, Oregon. He is a TapRooT® instructor, and has served as an Industrial Engineer, Training Manager, Production Manager, Plant Manager, and Director of Quality during his 29 year business career. He has served as an Examiner and Senior Examiner for the Malcolm Baldrige National Quality Award for ten years. Kevin also writes the monthly Performance Improvement column for Industrial Engineer magazine and is a regular speaker at a variety of regional and national events.
Kevin has taught many innovative Best Practice sessions at the annual Summit, including 8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement (View presentation) and Finding Time for Process Excellence - No Fuel, No Progress (View presentation).
Don’t miss an opportunity to set-up and sustain a continuous improvement system at your facility! LEARN MORE about the 2010 Summit!
Linda Unger & Michele Lindsay facilitated a TapRooT® User Best Practice Sharing Session at the 2009 TapRooT® Summit. The video below shows one of the best practices that was presented by Stephen Wagner for his group. Watch and learn …
Keeping connected with TapRooT® Users is an important part of my job. It helps me get new ideas about root cause analysis and incident investigation; ways to improve human performance; and ways to improve TapRooT®.
In the past we’ve worked on keeping connected at the TapRooT® Summits, by our newsletters, by this blog, and through our TapRooT® Advisory Board.
Now we are working on keeping connected by new technology - social networking. I’m using the business social networking site - LinkedIn - to connect with both potential and existing TapRooT® Users.
I started this new way of staying connected back in August when I started my LinkedIn account. About the same time, Chris Vallee, who also works at SI, started a group for TapRooT® Users (TapRooT® Root Cause Analysis Users & Friends).
The TapRooT® Root Cause Analysis Users and Friends group now has 165 members and is the largest LinkedIn group for people interested in root cause analysis.
As of January 1, my LinkedIn profile has over 700 connections (individual people I am linked to and get updates from) and I’m also a member of about 50 groups.
If you would like to link up with me, see my LinkedIn profile at:
I am up in Vancouver this week to certify two new instructors; meet Megan and Kevin from the Vancouver Airport Authority:
Our Train the Trainer process allows licensed companies to certify instructors to teach the two or three day TapRooT® course for their employees. Once you have certified instructors, you can train as many people as you like. This is a great option for organizations that want to train large amounts of people. See more pictures from the trainer certification course:
For more information on our Certified Instructor Program, click HERE, then give us a call at 865.539.2139 to get started.
TapRooT® Instructor, Boris Risnic, is fluent in three languages: English, Spanish and Portuguese. He has worked for Otis Elevator Brazil - United Technologies Co. and Ford Motor Company - Brazil. Boris has participated in more than 50 incident investigations worldwide utilizing TapRooT® techniques, and has worked actively to implement TapRooT® and safety training for more than 3000 employees at Otis Elevator in Brazil, Chile, Uruguay, Argentina and Mexico. Boris holds a B.S. in Industrial Engineering - Electronics.
Kevin McManus is the President of Great Systems! and provides performance improvement coaching from his office in Seattle, Washington. He has served as an Industrial Engineer, Training Manager, Production Manager, Plant Manager, and Director of Quality during his 23 year business career. He served as an Examiner and Senior Examiner for the Malcolm Baldrige National Quality Award for six years. Kevin also writes the monthly Performance Improvement column for Industrial Engineer magazine and is a regular speaker at a variety of regional and national events.
Meet Kevin at the 2009 TapRooT® Summit!
Kevin will be presenting 8 Reasons Why People Don’t Report Problems & 8 Solutions to Improve Employee Involvement at the 2009 TapRooT® Summit. There are many cultural, and in turn systemic, reasons why people don’t report equipment failures, human errors, near misses, and accidents. Unfortunately, unless work systems are changed to help reduce this cultural challenge, organizations will find it difficult to achieve widespread, and lasting, change. This presentation will give Summit attendees the chance to examine the approaches they currently have in place for listening to, and learning from, their people. An interactive exercise will be used to help them identify those employee feedback barriers that may exist in their own organization and to help them evaluate possible solutions for removing those barriers and increasing their employee engagement levels.
Kevin is co-facilitating a session about how TapRooT® is being utilized to promote best practices within the Pharmaceutical, Food and Manufacturing industries, and co-presenting the Analyzing 230 Environmental Incidents in 5 Months best practice session with Buck Griffith.
Also, Kevin will present Finding Time for Process Excellence - No Fuel, No Progress. He will discuss how most people want to support an organization’s process improvement efforts, but they often don’t have enough time built into their jobs to work on projects, learn new skills, or serve on a team. At the same time, they are wasting time each day attending meetings, processing e-mails, and misusing the limited project and process analysis time that they do have. Kevin’s presentation will include an interactive exercise designed to help you eliminate non-value added time and better utilize your process improvement time investments.
So many information-packed, interactive sessions to choose from! LEARN MORE about the 2009 Summit on our website: http://www.taproot.com/summit.php
Ken Turnbull is a Consultant and TapRooT® Instructor with an impressive resume of worldwide experience. Ken specializes in developing proactive measurements for safety programs, coaching executives in demonstrating management commitment to safety, and doing root cause investigations.
He worked for Texaco for 32 years and led many accident and incident investigations as Texaco’s Corporate Safety Manager. He used and taught the TapRooT® method for over eight years at Texaco and was instrumental in convincing executive management of Texaco the importance of reporting and determining the root causes of all incidents, including near misses.
Ken is a CSP, a former member of the NFPA 30 Committee, a former member of the Technical Steering Committee of the Center for Chemical Process Safety and a former Chairman of the API Safety and Fire Protection Sub-Committee. He has taught courses in the USA, Canada, Scotland, and Africa.
Meet Ken at the TapRooT® Summit!
Ken will be sharing his expertise at the 2009 TapRooT® Summit in Nashville, Tennessee, October 7-9, 2009. He will be co-facilitating the Panel Discussion: Some Less Than Obvious Lessons Learned from the BP Texas City Refinery Explosion with Mark Paradies, David Lynn, and Mike Kelly.
Ken will also be presenting Advanced Ideas for Defining Causal Factors. “When you are doing a root cause analysis (RCA) it means that your customer did not manage risk to their satisfaction,” said Ken. “Causal factor determination is actually a qualitative risk analysis that should be done early in the RCA to make evidence gathering more efficient. This session will show how qualitative risk analysis should be used to determine causal factors.”
The Investigation and Root Cause Analysis track at the 2009 Summit includes this informative best practice session, but you can also choose this session by creating a Custom track! Don’t miss the opportunity to join Ken and other world-class experts in Nashville, Tennessee this October!
Michele Lindsay is always developing new ideas that inspire and empower others, like the popular 2-day course, Innovation and Creative Solutions, (2009 TapRooT® Summit, October 5-6 in Nashville, Tennessee). She is the type of leader that keeps people “in the know” to give them the tools they need to go back to their facilities and create an exciting future.
Michele has been a Certified Instructor for the TapRooT® System since 1998 and has consulted, investigated and taught using this tool to a long list of companies that include: NASA, ExxonMobil, Pfizer, Exelon, First Energy, Ontario Hydro, PetroCanada, GE and Fluor. She has taught hundreds of TapRooT® courses and thousands of students throughout Canada, USA and Europe.
Michele is Principal of Performance Potential or P², a company whose vision is to help organizations and individuals access their potential. By helping clients understand their problems and come up with innovative solutions, P² can help access the potential that lies within all organizations.
Michele has always been an “outside of the box” thinker, but was formally trained in creative thinking techniques in 1994. Recognizing the challenges and limitations of improvement teams to come up with effective and innovative solutions to problems, Michele became a Certified Instructor of the Six Thinking Hats™ that includes Lateral Thinking tools by Edward De Bono. These creativity tools and techniques have helped hundreds of organizations improve existing processes and develop breakthrough ideas to move them closer to their performance potential.
Prior to opening her own consulting practice, Michele worked at Ontario Hydro in the Corporate Heath & Safety Department. She has a B.Sc (specializing in Human Kinetics) from the University of Guelph. She currently resides north of Toronto, Canada, with her husband and two daughters and is an avid sports enthusiast, playing basketball, hockey, baseball and golf.
Michele will be presenting The Keys to Successful Safety Culture Change and TapRooT® User Best Practice Sharing Forum at the 2009 TapRooT® Summit. In this first presentation, join her for an interactive discussion and exercise to further explore the topic of cultural transformation that yields “super-performance.” Uncover the keys to transforming and creating a culture of excellent performance in BOTH safety and production. Using a real life example of an organization that was cobbled together from 10 different competing companies, review the steps that were taken to create a company that excelled in its field. Take away valuable lessons learned during this amazing transformation to a super performing company.
In the TapRooT® User Best Practice Sharing Forum, Michele looks at how TapRooT® is being utilized to promote best practices at your facility. Come prepared to discuss these and other issues as we seek to promote operational excellence!
Steve Swarthout is President and Senior Partner of Performance Improvement of Virginia, Inc. He has 40 years of engineering/equipment troubleshooting experience and has taught TapRooT® to thousands of people. He has held a Senior Reactor Operator license at a commercial nuclear utility and facilitated over 100 incident investigations.
Steve is presenting Using Nuclear Industry Analysis Concepts in Healthcare Industry Sentinel Event Investigations at the 2009 TapRooT® Summit. This session will examine how to determine generic causes and how to look for other potential problems which might not have been identified in the initial investigation. There will be examples from the medical and non-medical field. Participants are invited to bring an investigation, which they will use to evaluate for generic concerns.
If you work in healthcare, the opportunity to bring an investigation for free evaluation is just one reason to sign up for the Eliminating Hospital Sentinel Events Track at the Summit in Nashville, Tennessee, October 5-7, 2009!
Have you heard about the Summit track for Spanish speaking TapRooT® Users? TapRooT® instructors Marco Flores (Monterrey, NL Mexico), Arturo de la Garza (García, NL Mexico) and Piedad Colmenares (Bogota, Colombia) will be presenting on this excellent best practices track at the 2009 TapRooT® Summit. View the track schedule here (click on the “Spanish Speaking TapRooT® Users” button on the left):
From his youth, Marco Flores has dedicated himself to exploring the limits. During his school days in 1965, he was a member of the International Society of Interplanetary Studies, and the University Society for Experimental Rocketry. While at M.I.T. pursuing a Master’s Degree in Aeronautics and Astronautics, he was part of the Innovation Center and the Commission for Hispanic Rights, dedicated to defending the human rights of the Spanish-speaking prisoners in Massachusetts. While at the Innovation Center he produced the famous “Phantom Potential Racer” and the “Automatic Banana Peeler” that took center place in the news in Boston, and was interviewed by Eye Witness News for the banana peeler, and by Boston Public Television on the impact of automation on rural unemployment in Latin America and migration to the United States.
For 25 years he worked in the development of technology, start-up and troubleshooting for direct reduction plants worldwide.
Today he is the President of TECMEN, a consulting company dedicated to developing solutions material handling and processes under extreme conditions that go from automated “taco” shell handling, to high temperature components applied to chemical and nuclear processes. He has produced multiple worldwide patents for different companies. He has traveled extensively, spending most of his time between Australia, Germany and South America.
He has been a TapRooT® Instructor for seven years and is co-translator of the TapRooT® course materials into Spanish and Portuguese, and has frequently applied the TapRooT® method for innovation, project planning, and systematic failure and accident analysis.
He paints, writes poetry and wrote a play on the role of women in Mexican History.
Certified TapRooT® instructor, Arturo de la Garza Guajardo has a B.S in Chemical Engineering from Nuevo Leon State University and an advanced degree in Industrial Engineering. He has received designation as a Certified Safety Professional from the Mexican Council of Risk Prevention, Num 029.
Since 2000, he has been working as an independent consultant in safety and risk prevention, auditing different industrial operations.
He also has experience as Associate with ProSecurity Technologies as Safety and Security Director in projects for PEMEX Servicios Marinos in Tabasco, Mexico and ING Insurance Company.
He has served as Auditor for LAMOSA Plants and as Corporate Safety Manager at CEMEX, as well as Corporate Safety & Security Director at Grupo Cydsa, Safety & Security Superintendent at Petrocel and Industrial Relations Manager at Cyanaquim.
In June 2007, Piedad Colmenares started a consulting firm, HSEQ Soluciones Integrales, providing services to national companies with emphasis in Occupational Health in Bogotá, Colombia. In 2006, she worked as a Consultant for Occupational Health Division of the General HQ – Military Forces Health System. From 1990 – 2006, Piedad served in the Colombian Navy, was promoted up to Lieutenant Commander, and held the following positions: Director Occupational Health Department, Director of Statistics Division of the Navy Health System, Director of Occupational Health of Naval Medicine Center in Bogota, Director of Bacteriological Laboratory at the Naval Medicine Center in Bogota, and Director of Bacteriological Laboratory at the Naval Hospital in Cartagena.
She became a Naval Officer Graduate–Lieutenant of the Administrative Corps in 1987 at the Colombian Naval Academy and received her Postgraduate on Occupational Health from Universidad Jorge Tadeo Lozano in 2001.
Meet our instructors at the 2009 TapRooT® Summit, Nashville, Tennessee, October 7-9, 2009 as we seek to promote operational excellence around the world!
Brian Locker is the president of KnoW Problem Inc. in Ontario, Canada. Brian has considerable experience working with a number of industries, nationally and internationally. Starting in Health Physics, Brian spent twenty years at Ontario Hydro, a large electrical utility in Ontario. This included eight years as a manager of safety.
Brian then spent four years working for the Canadian nuclear regulator, the Atomic Energy Control Board. In 1996, Brian was introduced to TapRooT® and began working with System Improvements, teaching the process and carrying out investigations for clients in North America and throughout the world. Brian also provides leadership coaching and regulatory oversight services.
Brian (along with TapRooT® instructor Brian Tink) will be teaching a course that offers innovative ways for Improving Your Organization’s Safety Culture. This 2-day course is designed for persons in all industries and is only offered once this year: October 5-6, 2009, Nashville, Tennessee (just prior to the 2009 TapRooT® Summit).
Another exclusive opportunity to learn from Brian’s experience is during his Summit best practices session. Brian will be presenting Leadership for Doing Things Right. If you schedule the Improving Your Organization’s Safety Culture course with a Summit track, you will receive $200 off of an entire week of business critical training, networking and good fun!
In his Summit session, Brian suggests that “Employee Communications” is the single most important root cause on the tree as it is the key that unlocks all of the other root causes. This knowledge comes from 30 years of practical experience investigating hundreds of incidents, large and small. If any or all of the following are occurring in your organization:
Management’s employee communications program fails to communicate management’s concerns for quality workmanship, safety, and the environment.
Management fails to provide proper examples and rewards for quality workmanship, good safety performance, and environmental stewardship in the organization.
Management’s verbal/written communications and actions are inconsistent, and therefore do not support excellence in safety, environment, and quality.
Management’s communications and actions are not clear with respect to the organization’s risk tolerance.
Low morale or a feeling from personnel that “management doesn’t care what I do right; they only notice me when I do wrong,” contributes to many issues.
Employees frequently take shortcuts because they do not have a “do it right the first time” attitude or because the push to meet production goals overrides all other spoken goals.
this course is for you!
Have you signed up for the Summit? Don’t miss the opportunity to learn new strategies that revolutionize performance at your facility.
Mimosa Mining in Zimbabwe Certified two instructors to teach the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
Our instructor in Africa, Sanjay Gandhi, taught the course with them. The two instructors that were certified are Nick Manjoro (HE Manager) and Shadreck Manjoro (SHE Superintendent).
Here’s some pictures from the course…
(That’s Sanjay on the left)
If you want to become a Certified TapRooT® Instructor at your site, see this link for the requirements:
Ken Scott worked for the Mine Safety and Health Administration (MSHA) as an Instructor at the National Mine Health & Safety Academy. He developed MSHA’s Accident Investigation Training Program, and investigated many mining accidents including mine explosions. Ken is a Certified Mine Safety Professional. He has a BS in Agriculture, and a MS in Safety (Mining).
Ken will be leading an Accident Presentation Crandall Canyon Coal Mine Disaster at the 2009 TapRooT® Summit.
This presentation is an overview of the tragic coal mine accident that occurred at the Crandall Canyon coal mine, Utah, in August 2007. The disaster involved two events and lead to the total deaths of six miners and three rescue workers. The first event resulted in the deaths of 6 miners when the overstressed coal pillars suddenly failed during mining activities, violently expelling coal from the barrier pillars into the mine openings. The mine pillar failure was so violent that it was recorded as a seismic event of 3.9 magnitude and was felt more than 3 miles away. The second incident occurred ten days later during rescue efforts when another mine failure occurred. The second mine failure, “outburst”, incident lead to the death of three rescue workers and the injury of six others. The miners that died during the original mine failure have never been recovered.
Ken will also be facilitating the Mining Best Practice Sharing session.
Don’t miss this opportunity to meet Ken in Nashville, Tennessee, October 7-9, 2009. Learn more about our Instructors and Best Practice Presenters on our website!
Heidi Reed has over 25 years of experience as a health, safety and environmental professional. She currently holds a Certificate of Safety Management with the American Society of Safety Engineers. She has been an accomplished Regional Health, Safety, Environmental Manager for a major international corporation and has an extensive background in managing and mentoring US-based construction and general industry health, safety and environmental programs. Heidi has successfully utilized TapRooT® to analyze the root cause of incidents and to develop strategic corrective action plans for mitigation of jobsite hazards.
Currently, Heidi is a TapRooT® instructor and a health, safety and environmental consultant specializing in program and safety technician development.
What Everyone Needs to Know about Preparing Emergency Drills
Heidi will be presenting Using TapRooT® to Prepare for Emergency Drills during the Safety Improvement Ideas session the 2009 TapRooT® Summit.
Do your employees know how to respond to emergencies?
Does your company have a methodical and consistent means of planning and implementing emergency drills on an annual basis?
TapRoot® software and proactive training can be used to design a plan for employees to improve their understanding of the importance of drills and of their roles and responsibilities. By plotting ideas and sample emergencies within the Spring and Summer Planning SnapCharts®, the drill can easily move from a Table Top or Functional Drill to the Autumn SnapChart® where observations of the drill will define strengths and weaknesses in the actual emergency response. SnapCharts® can be used to:
• Define the purpose and scope of the drill;
• Define the ground rules for the drill;
• Outline procedures for each position;
• Add new and more challenging problems to the scenario;
• Set up separate drills for various locations, business units, or company functions;
• Designate auditors for each stage of the drill;
• Track strengths and weaknesses as Significant Issues, SafeGuards, etc. in the Autumn SnapChart®.
People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator. But it’s always nice when you are a new investigator to start off with some easy incidents before diving into a politically sensitive accident or a legally difficult fatality. Plus some investigations are better when facilitated by an outsider. Therefore, here are some suggestions of when to ask for help facilitating, investigating, and analyzing the root causes of an incident.
Legal: Could this accident end up in court? If so, you need the help of your company’s attorney. They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.
Customer Dispute: It’s always tough when a customer has a problem and blames your product/service. What do you do if you think that the product/service was OK but instead, the customer’s actions caused the problem? Root cause analysis could be a big help. But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective.
Union Issue: Ever had an investigation that gets contentious with a union? This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement.
Just Learning: TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations. What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.
Overwhelmed: Too many accidents to investigate? Augment your staff with outside facilitators to help investigate incidents and provide your investigators with valuable feedback.
SI has 40+ experienced TapRooT® investigators around the world to provide help when you need it. Contact us at the link above or call 865-539-2139.
Richard Mesker has over 20 years of experience in Power Plant Operation, Electric Utility, Safety, Radiation Protection, Power Plant Water Chemistry Programs and Utility Safety Management. Richard oversaw the safety program for a fortune 250 company with multi-state locations. Richard is a graduate of the US Navy Nuclear Power Program. He received a Bachelor of Science degree in Business from the University of the State of New York and performed graduate studies at the University of South Florida in Industrial Hygiene and Safety Management. He currently resides in Florida, and is a certified safety professional, certified utility safety administrator, occupational health and safety technician, and registered with the national radiation protection technologists. Richard is qualified to teach many OSHA courses including OSHA 10 and 30 hour construction and general industry certification.
His current and past affiliations include the Nuclear Industrial Safety and Hygiene Association (NISHA), the Southeastern Electric Exchange, Accident Prevention Section and the American Society of Safety Engineers (ASSE).
Richard has experience with OSHA investigations, injury/fatality investigations, root cause determination, working with labor on investigations, site audits, training, procedure development and program oversight.
Richard will be leading a session about how TapRooT® fits into proactive improvement at the 2009 TapRooT® Summit. Come and meet Richard and our outstanding group of Best Practice Presenters from around the world in Nashville, Tennessee, October 7-9, 2009.
TapRooT® instructors Tommy Garnett and David Davis will be presenting a 2-day Pre-Summit course, TapRooT® and FEMA for Healthcare Root Cause Analysis on October 5 and 6, 2009 in Nashville, Tennessee. TapRooT® Users will learn to use tools to perform JCAHO required healthcare FMEA as part of proactive risk reduction/performance improvement program.
Learn team-based, systematic, proactive approaches to identify how a process or design can fail, why it fails, and how to make it safer. These techniques can be applied to find and fix the root causes of issues to improve patient safety & stop healthcare sentinel events before they happen.
David Davis
Dave Davis is a Certified Nurse of the Operating room, and a Registered Nurse and retired U.S. Army Lieutenant Colonel. He has an MS in Nursing Services – Administration, and an MS in Operating Room Nursing. He is a previous consultant in infection control & disease epidemiology for the U.S. Army and is Certified as a DoD Healthcare TapRooT® Instructor.
Tommy Garnett
Tommy Garnett has 20 years of experience in Patient Safety & Risk Management. He is a Registered Nurse, a Certified Trauma Nurse, and a Flight Nurse. Tommy graduated from the American Institute of Medical Law, and is a licensed and Board Certified Healthcare Risk Manager. He is also Certified as a DoD Healthcare TapRoot® Instructor.
Have you heard about the eye-opening 2009 Summit track planned for healthcare professionals, Eliminating Sentinel Events? If you are interested in real issues of human performance in the medical industry and why people make mistakes and cause sentinel events, you want to be sure to register for this track!
Tommy Garnett will be presenting “A Near Miss Medical Gas Incident” during the Healthcare Root Cause Analysis Presentations. “To do or not to do a Root Cause Analysis, that is the question!” said Tommy. Other business critical sessions Tommy will be co-presenting are “Using Nuclear Industry Analysis Concepts in Healthcare Industry Sentinel Event Investigations” and “Healthcare Performance Improvement.”
Tommy has 20 years of experience in Patient Safety & Risk Management. He is a Registered Nurse, a Certified Trauma Nurse, and a Flight Nurse. Tommy graduated from the American Institute of Medical Law, and is a licensed and Board Certified Healthcare Risk Manager. He is also Certified as a DoD Healthcare TapRoot® Instructor.
Learn more about sessions planned for the Eliminating Sentinel Events track on the Summit Schedule page!
Sanjay Gandhi is the Director of Nutek Solutions Ltd. in Nairobi, Kenya. Sanjay has 16 years of experience in corporate Health, Safety and Environmental consulting, auditing and training. He is the Chairman of Kenya Occupational Safety and Health Association, and Chairman of Kenya Petroleum Sector Environment Committee. Sanjay has a BSc in Civil/Structural/Environmental Engineering and has been a Certified TapRooT® Instructor since 2004.
Sanjay will be one of the facilitators of the Refining, Petrochemical/Chemicals, Pipelines, & Terminals Best Practice Sharing session at the TapRooT® Summit. How is TapRooT® being utilized to promote best practices within the Refining, Petrochemical/Chemicals, Pipelines, & Terminals industries? How are root causes being tracked to evaluate effectiveness of investigations and corrective actions? Come prepared to discuss these and other issues as we seek to promote operational excellence!
How can you become the best in 2009, in spite of all of the gloom and doom economic forecasts? Attend the 2009 TapRooT® Summit and meet our world-class instructors! The best way to rise to the top during a downturn is to refresh your skills with the latest in best practices!
One of the many Best Practice Sessions planned is: Becoming the Best: Pursuit of World Class EH&S. This session will be presented by TapRooT® Instructor, Dennis Osmer.
Dennis has over 40 years of industrial experience - the last seven years of his career as the World Wide Head of Health, Safety, Environment (HSE) and Emergency Management at CIBA Vision (a business unit of Novartis). There, he was responsible for the HSE activities for all of CVs operations (14 supply chain sites, 37 sales and marketing group companies, 11,000 employees on 3 continents). He has a pragmatic approach to developing and implementing HSE strategy which balances employee safety, environmental protection and business needs. He is a recognized expert with a track record of delivering performance.
His most recent activities were with Pandemic Preparedness, energy efficiency improvements, auditing, due diligence, new site start-up and HSE strategies for world class performance. While with a different business unit, he was the deputy chief of an industrial brigade and part of a community outreach program.
Dennis has an MBA in general management and finance from Fairleigh Dickinson University, and a BA in mathematics from the same university.
The presentation will provide some interesting thoughts on the pursuit of world class EH&S from this former global EH&S manager. During this dynamic session, Dennis will discuss reasons for EH&S change, key concepts and key systems that helped drive performance. He will highlight how, through continuous improvement over an 8 year period, an LTIR of 0.07 and a recordable rate of 0.79 was achieved.
What are you waiting for? Get refreshed and become the best! Choose your Best Practice Track for the October 2009 Summit in Nashville, Tennessee and meet TapRooT® Instructors from around the world!
If you are a Certified TapRooT® Instructor, you know that you must attend the summit and a pre-summit course at least once every two years. If you did not attend last year, it is really important that you sign up as soon as possible to make sure you keep your instructor status. If you did attend last year, you should still attend if at all possible to get the latest information and continue to build your knowledge base so you can be as effective as possible. Either way, we know you’ll have to justify your attendance to your organization, so I wanted to share some information on the track best practice sessions so you can see the value:
• Your first session will be the “TapRooT® Instructor Update,” where Linda Unger, Ken Reed, and Benna Dortch will update you on all things TapRooT® and provide the latest course materials for you.
• In “Success Stories from the Field,” Dennis Ward will discuss “Improving Performance by Analyzing Multiple Aviation Incidents for Common Causes,” and Ron Pryor will present “Using TapRooT® in a Kaizen Project to Improve Product Quality,” showing how TapRooT® can be used proactively in conjunction with your quality improvement processes.
• In “DISCovering How to Communicate After an Accident,” Vincent Phipps will enlighten us on the most common behavioral styles and how the way we interview can be adjusted based on those styles. If you have ever taken the DISC profile, you may understand what your personal style is, but Vincent will show us how to adapt our message to the different styles in others.
• Next you’ll get the latest information on software from Dan Verlinde, Ed Skompski, and Linda Unger in the session “What’s New in The TapRooT® V5 Software.“
• In the “TapRooT® User Best Practice Sharing Forum,” Linda Unger and Michelle Lindsay will facilitate a user discussion so everyone can learn from each other. Two heads are better than one, so bring your best practices to share with the group.
• Dan Verlinde and Ed Skompski will present “Managing Incidents & Corrective Actions Using the TapRooT® Software,” covering Corrective Actions, Corrective Action Helper, and Corrective Action Status in the TapRooT® V5 Software, including user management of Investigations/Documents and Corrective Action Management.
• In “Advanced Ideas for Defining Causal Factors,” Ken Turnbull will show how qualitative risk analysis can be used to help determine causal factors. We all know that a good root cause analysis can only be completed if good causal factors are identified, and this session will provide some valuable tips in this regard.
• “Making a Business Case for Improvement,” presented by…me. I will challenge you to take off your safety/quality hat, put on your sales hat, and show how much your efforts contribute to the organization so you can get the resources you need to be successful.
That is a lot of value! And that does not count the benchmarking with old and new friends from your and other industries.
But WAIT! There is MORE:
You’ll meet in the morning and afternoon with attendees from all tracks to hear the keynote speakers:
• Dr. Joel Fish, Brian Tink, and Jim Thompson will talk about how just one root cause analysis changed an industry practice.
• E.D. Hill from Fox News will talk about “Lessons Learned from Success.”
• Mike Kelley will deliver an empowering talk called “Establishing a Culture that Promotes Super-Performance” where he will discuss his view that personal and professional growth are tied together and how they ultimately add to the success of the organization.
• Mark Paradies, our President, and Dave Prewitt will present thoughts on systematic ways to manage performance.
• Best selling author John Miller will open the day on Friday with a powerful talk on personal accountability.
These keynote talks provide a good balance of usable techniques, personal improvement, and motivation, and alone are easily worth the cost of the summit! How much would it cost to hire just one of these amazing speakers?
And by the way, there is one more thing – the last session you attend will be “Planning Your Improvements” where TapRooT® Instructors will facilitate attendees in developing action plans for when you return. The difference in success and failure can come down to one simple process; setting goals and following through to achieve them.
Keep Current! Tell your management that you want to attend the Certified TapRooT® Instructor Track and a pre-summit course at the 2009 Summit. Write down the value to you of each of these sessions, and decide how much the summit is worth to you? I think you’ll agree, much more than the cost.
Linda Unger is Vice President of System Improvements, Inc. She first became involved in incident investigation and root cause analysis in 1986 as a field engineer working for DuPont where she performed investigations into operating and maintenance problems. Since that time she has become an expert in root cause analysis, incident investigation, and development of performance improvement programs. Currently, Linda helps clients use TapRooT® as part of their performance improvement program by developing implementation strategies. In addition, Linda is responsible for the development of the 2-Day TapRooT® Training program and licensing of TapRooT® Training and Software to clients. She also teaches TapRooT® Courses and is the co-author of the TapRooT® Changing the Way the World Solves Problems Book released in 2008.
Among the many responsibilities that Linda covers to make the Summit spectacular, she will be facilitating a popular TapRooT® Summit forum, “TapRooT® User Best Practice Sharing.” How is TapRooT® being utilized to promote best practices at your facility? Come prepared to discuss these and other issues as we seek to promote operational excellence!
Mark you calendar for the 2009 TapRooT® Summit, October 7-9 in Nashville, Tennessee!
Shane Deichman has 17 years of experience as a government civilian employee, working as the Operations Manager for Joint Futures Lab, Science Advisor for Marine Corps Forces-Pacific, and Assistant Lecturer on Homeland Security and Counter-Terrorism Joint Forces Staff College. He created a “Joint Red Team” to provide risk and vulnerability analysis for U.S. Joint Forces Command.
Shane graduated from the U.S. Naval War College with a B.S. in Nuclear Physics, and an M.S. in Management. He is a Certified TapRooT® Instructor, and Board Certified in Emergency Management.
Shane will be presenting “Analyzing the Attack on the USS Stark” at the 2009 TapRooT® Summit. In May 1987, the U.S. Navy frigate STARK was struck by two missiles while on a routine patrol in the Persian Gulf. In this session, Shane Deichman (a former U.S. Navy scientist) will demonstrate the versatility of the TapRooT® problem solving tool in providing a deeper understanding of *any* event.
Learn more about the Summit, October 7-9 in Nashville, Tennessee by visiting our website.
Practical Solutions Group has offices in Perth, Australia and Singapore.
Malcolm Gresham
Malcolm Gresham is the Managing Director of Practical Solutions Group. He has over 17 years of experience including risk management consulting, systems analysis, systems development and training. He has worked throughout Australia, New Zealand, Singapore, Malaysia, Indonesia, PNG, US and Canada. He has facilitated investigations for clients in the mining, Maritime, Rail and Petrochemical industries. Malcolm has a BCom in Information Systems and has been a Certified TapRooT® instructor since 2006.
Jim Whiting
Jim Whiting the Principal Risk Engineer and MD of Practical Solutions Group. He is an internationally known risk engineer and HSE expert. He has over 25 years of experience in risk management, safety and performance improvement. Jim was a former Chief Executive Officer of the National Safety Council of Australia and has 18 years of experience as a Senior Lecturer in Medical Physics and Bioengineering.
You will have the opportunity to meet both Malcolm and Jim at the 2009 TapRooT® Summit in Nashville, Tennessee (October 7-9). To view upcoming courses in Perth, Bangkok, Sydney, Karratha and Kuala Lumpur, visit the Practical Solutions Group website.
Ed Skompski has been with System Improvements since 1996, and has taught and specialized in performance improvement through teaching the TapRooT® System for root cause analysis, performing and facilitating investigation, and helping companies implement performance improvement programs. He has taught hundreds of training courses around the world at both client sites and through public seminars.
Ed has been a Partner since 2000, and a VP since 2006. Prior to joining System Improvements, Ed provided environmental evaluation, remediation consulting and project supervision for Radian Corporation and Law Engineering.
He is currently manager of software development, technical support, e-commerce, and network support. Additional responsibilities include client management, training, and product development. Ed has also spearheaded the projects focused on reducing medical errors in the healthcare industry through the implementation of root cause analysis techniques. Ed will be a co-facilitator of the “Healthcare Performance Improvement Best Practice Sharing” session at the 2009 TapRooT® Summit.
Greg Allan established Capability Resources in 2000 (Quality Endorsed to ISO 9001). Capability Resources employs a staff of 50, and specializes in safety, training, labor supply, compliance and welding safety.
Greg has 26 years of mining and associated industry experience with Rio Tinto, BHP and CSR in technical operations and quality control management roles. He has investigated numerous serious mining industry incidents. Greg’s qualifications include: BSc, Cert IV Assessment & Workplace Training, and his memberships include: MemberAusIMM, Coal Preparation Society, FellowQSA.
Michael Smith
Michael Smith is a Manager at Capability Resources. He has 25 years of mining industry experience with Rio Tinto in both operations and process superintendent roles (specializing in coal preparation and dispatch). Michael has investigated numerous mining industry incidents, and has 11 years of experience in quality control and operational roles in the steel manufacturing industry with BHP Australia.
Both Greg and Michael will be presenting Best Practice Sessions at the 2009 TapRooT® Summit in Nashville, Tennessee (October 7-9). Make plans to attend and see for yourself how our worldwide instructors pool their expertise to provide the latest improvement best practices!
Capability Resources is located in Singleton, Australia. View Capability Resources upcoming TapRooT® courses in Sale Vic, Adelaide, Brisbane, Newcastle and Darwin by visiting their course calendar.
Ralph’s experience in facilitating individuals and teams through transformational change has given him an appreciation for the potential for sustainable high performance within every organization. His work with exceptional leaders at all levels has confirmed the importance of developing the spirit of leaders to enable them to inspire organizations to achieve results. Ralph works with organizations to prepare and empower facilitators and culture change leaders to effectively impact the attainment of a thriving high performance culture.
Ralph has ten years experience facilitating insight-based learning experiences and working with teams to enhance effectiveness and performance. He has facilitated numerous root cause analysis learning experiences with many corporate clients throughout the United States and Canada. He has a special interest in improving cultures to impact safety in organizations. As program manager for Tennessee Valley Authority’s STAR 7 culture-shaping program, Ralph coached both internal facilitators and executives on their leadership skills. His successful experience with executives, first line leaders, and union members has given him unique insights into thriving cultures and the ability to move comfortably from sector to sector when working with organizations.
Ralph holds a Doctor of Education in Collaborative Learning from the University of Tennessee. His research interests are dialogue and reflective practice. Ralph is curious about almost everything and interested in the rest. He is beginning to research the impact of culture on safety within high risk organizations. He has represented the University of Tennessee in facilitating two seminars on Action Research in Thailand.
Ralph lives in Kingston, Tennessee with his wife Janice. Ralph enjoys traveling and exploring out of the way places. He is very interested in amateur archaeology and has visited the Angkor Wat complex in Cambodia, Authyia in Thailand, the Khyber Pass in Pakistan/Afghanistan, and most of the major pyramids and sites in Mexico and Central America. He enjoys playing with his three young grandsons and introducing them to bicycles, motorcycles, jeeps, caves, cliffs and kayaks, just a few of his many and varied interests. He frequently rides long distance bicycle tours both solo and with groups. His longest ride was a 3,000 mile Pacific to the Atlantic coast ride in 27 days.
“As an explorer, I am excited about partnering with organizations to explore and appreciate together what I believe is the unlimited potential for growth and excellence of performance in both individuals and teams to create healthy high performance safety cultures.”
Ralph will be co-presenting “Tools to Help Management Evaluate Corrective Actions” with TapRooT® Instructor, Dana Barclay at the 2009 TapRooT® Summit. Learn how to “walk away” with a permanent, effective problem solution by scheduling this excellent session! Visit this blog posting for more session info!
Michele Lindsay will be teaching “Get ‘Outside the Box’ Corrective Actions” at the 2010 TapRooT® Summit (October 27-29 in San Antonio, Texas).
Dennis Osmer, former Worldwide Head of HSE, will be teaching “Communicating with Management About Risk” at the 2010 TapRooT® Summit (
Kevin McManus will be teaching How to Set-Up and Sustain a Continuous Improvement System
Kevin McManus is the President of 
Ken Turnbull is a Consultant and TapRooT® Instructor with an impressive resume of worldwide experience. Ken specializes in developing proactive measurements for safety programs, coaching executives in demonstrating management commitment to safety, and doing root cause investigations.
Michele Lindsay is always developing new ideas that inspire and empower others, like the popular 2-day course, 
Steve Swarthout is President and Senior Partner of Performance Improvement of Virginia, Inc. He has 40 years of engineering/equipment troubleshooting experience and has taught TapRooT® to thousands of people. He has held a Senior Reactor Operator license at a commercial nuclear utility and facilitated over 100 incident investigations.
From his youth, Marco Flores has dedicated himself to exploring the limits. During his school days in 1965, he was a member of the International Society of Interplanetary Studies, and the University Society for Experimental Rocketry. While at M.I.T. pursuing a Master’s Degree in Aeronautics and Astronautics, he was part of the Innovation Center and the Commission for Hispanic Rights, dedicated to defending the human rights of the Spanish-speaking prisoners in Massachusetts. While at the Innovation Center he produced the famous “Phantom Potential Racer” and the “Automatic Banana Peeler” that took center place in the news in Boston, and was interviewed by Eye Witness News for the banana peeler, and by Boston Public Television on the impact of automation on rural unemployment in Latin America and migration to the United States.
Certified TapRooT® instructor, Arturo de la Garza Guajardo has a B.S in Chemical Engineering from Nuevo Leon State University and an advanced degree in Industrial Engineering. He has received designation as a Certified Safety Professional from the Mexican Council of Risk Prevention, Num 029.
In June 2007, Piedad Colmenares started a consulting firm, HSEQ Soluciones Integrales, providing services to national companies with emphasis in Occupational Health in Bogotá, Colombia. In 2006, she worked as a Consultant for Occupational Health Division of the General HQ – Military Forces Health System. From 1990 – 2006, Piedad served in the Colombian Navy, was promoted up to Lieutenant Commander, and held the following positions: Director Occupational Health Department, Director of Statistics Division of the Navy Health System, Director of Occupational Health of Naval Medicine Center in Bogota, Director of Bacteriological Laboratory at the Naval Medicine Center in Bogota, and Director of Bacteriological Laboratory at the Naval Hospital in Cartagena.
Brian Locker is the president of 
