“HILTON HEAD ISLAND, S.C. – The kit-built single-engine plane was gliding quietly as it came down for an emergency landing on a beach. Pharmaceutical salesman Robert Gary Jones, listening to his iPod while jogging, likely never saw or heard it before the aircraft hit him from behind Monday evening and killed him.”
Should we ban headphones from public beaches or post a warning jog with headphones at your own risk?
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 Buck Griffith for his group. Watch and learn …
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 Steve Cavanaugh for his group. Watch and learn …
While performing your PROACTIVE TapRooT® Root Cause Analysis, you observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. He lifts 30 pipes an hour 3 times a day from a rack waist high to a pallet placed on timbers floor level. This task used to be performed by two loaders before recent lay offs, so you go to the Root Cause category of Excessive Lifting and see these two questions in the Root Cause Tree Dictionary:
* Was the issue related to excessive lifting or force to move an object?
* Did the task require repetitive motion (lifting, twisting, bending, etc.) that lead to a musculoskeletal problem?
Since this is a Proactive Assessment there are no issues yet, so your are asking what is the worse issue that could occur by the lifting movements above? Now what does excessive mean? What would excessive lifting, twisting and bending be? We could bring in an external Ergonomic Expert… or we can use a simple calculation ourselves first?
NIOSH 1991 Lifting Calculator. Centers for Disease Control and Prevention (CDC), National Institute of Occupational Safety and Health (NIOSH), 208 KB ZIP*.
As you start doing these calculations, you should also see another Root Cause under Human Engineering start becoming very apparent: Arrangement / placement.
A question that comes to mind from the Root Cause Dictionary is:
* Did poor arrangement, placement, or situation of equipment, displays, or controls contribute to an issue?
So with these new found calculators and a better understanding of just a little bit of the Root Cause Tree Dictionary is this task a risk or not:
” You observe a person loading a pallet with 10′ L x 6″ dia. 30 pound metal pipes by himself. This task used to be performed by two loaders before recent lay offs.”
The Associated Press reported that Chief Electrician’s Mate John G. Conyers suffered a severe electrical shock and was later pronounced dead at Sharp Coronado Hospital.
The AP reported that the Chief was conducting “routine work” when he was killed.
Normally, Chiefs are supervising, not performing, work. And there is nothing “routine” about working with electricity aboard a ship. Complacency (routine) with electricity on a ship is a deadly combination.
One of my early shipboard jobs in the Navy was being the Electrical Division Officer aboard USS Arkansas (a nuclear powered cruiser). One of the first “performance improvement” programs I ever attempted was to re-instill respect for electricity and get 100% compliance with our lock-out/tag-out program to isolate and check dead all sources of voltage during electrical maintenance work.
People who work with any hazard (for example, electricity), tend to become complacent over time. I’m not sure if this happened on the USS Ronald Reagan, but it certainly is a problem that every manager/supervisor who supervises people who work with a hazard has to confront head-on.
Also, supervisors can frequently be tempted to do work and even take shortcuts to get a job done. This takes them out of their roll to supervise a job and make sure it is done safely and puts them into a dangerous situation where no one is looking over their shoulder to make sure the job is done safely. Once again, I have no evidence that this happened aboard the USS Ronald Reagan, but I’ll be interested in what the eventual accident report has to say.
What can we learn from this fatality BEFORE the investigation is even completed?
First, TapRooT® Users would be getting a complete picture of WHAT happened before they started analyzing WHY it happened. As you can see from my background, there are several problems that I would automatically look for. But, TapRooT® requires the investigator to look at the evidence first before starting the root cause analysis. They have to have a good, complete, accurate, detailed SnapCharT® before they identify the accident’s Causal Factors and find each Causal Factor’s root causes.
Second, TapRooT® Users have a systematic root cause analysis technique, called the Root Cause Tree®, that helps them be sure to check for the many different potential root causes of a problem (Causal Factor). The tree helps guide them to areas they may not have thought of to investigate before. It helps the investigator get beyond blame to find real, fixable root causes that, when fixed, can prevent future accidents.
Third, once the root causes are identified, TapRooT® has a module called the Corrective Action Helper® that helps the investigator develop effective corrective actions. This helps the investigator and management develop corrective actions that might be “outside the box” as far as their experience with corrective actions is concerned.
If you are a TapRooT® User, you have already learned these lessons (but it is good to have them reinforced).
If you are NOT a TapRooT® User, get to a TapRooT® Course NOW! Investigating smaller accidents, incidents, and near misses, as well as using the TapRooT® techniques proactively, can help you avoid major accidents and keep your employees safe.
For more TapRooT® information, including success stories from TapRooT® users, see:
What would your answers be for the Homework Questions below?
What is the answer when a TapRooT® instructor asks the class, “what are the three most frequent types of Corrective Actions?” Training shows up on every list! We then encourage students to look outside the box and even give industry accepted best practices in our Corrective Action Helper®.
STOP! Does this mean Training should not be a Corrective Action or a Root Cause? NO! It just means that you should understand the problem and behavior before you select Training as a “catch-all” or a “magic bullet”.
Understanding Training?
First off understand that Training has one initial goal: IMPROVE or SUSTAIN PERFORMANCE on a particular BEHAVIOR.
Second, Training is directed to the person doing a particular task. Regardless of the higher level regulatory requirements and internal company policy of how the training program should look or run… Training must be effective for the user.
Third, Training is not an independent function that can stand up on its own…..
A. Employee Hiring must be tied to core skills and task required of the employee.
B. Finance, Engineering, Quality Departments, and Safety must be tied to the Training and Hiring Group to ensure new processes and needs are incorporated and tie in the business case.
Finally, understand that there are four other Basic Cause Categories that will have an impact on what and who is trained:
A. Human Engineering (Level of Usability and Complexity of equipment and task)
B. Work Direction (Level of Qualifications and Supervision for and during the task)
C. Procedures (Quantity of steps performed during a task and risk of missing a step or performing the step incorrectly)
D. Communication (Focusing on person’s ability to understand AND apply the terminology)
Lastly, I asked about Training Effectiveness as it relates to metrics in the Homework Questions above. What might the Chart below depict as it relates to Training?
Often, I have seen this chart track two types of measures: Training Expenditures and Defect or Incident Expenditures…. usually there is a strong correlation between both charts once mapped out after the fact. What do your metrics show?
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 William Missal for his group. Watch and learn …
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 Ryan Cezair for his group. Watch and learn …
I thought that I would provide the guidance by breaking up the suggestions by the 7-Step TapRooT® Reactive Investigation Process that is detailed in Chapter 3 of the TapRooT® Book (Copyright 2009, used here by permission).
NOTE: If you don’t understand the terminology or reasons for the management actions below, it could be that you need more TapRooT® Training!
TapRooT® 7-Step Reactive Investigation Process
STEP 1
So let’s start with Step 1: Planning the Investigation - Getting Started.
Since we are just getting started, there is nothing for management to review. However, management does have several responsibilities.
a. Management needs to set criteria for what gets investigated. This should be documented in the site’s incident investigation procedure. Management should then make sure that all incidents are reported and investigated. Occasionally, management will identify an incident that doesn’t meet the criteria, but still, in their opinion, deserves a complete investigation and root cause analysis.
b. Management should make sure that their site is prepared for investigations. This includes having an investigation procedure, trained investigators, and investigation review process, and trained management. See the TapRooT® Book (Chapters 3 and 6 and Appendix A and C) for more information.
c. Management should ensure that evidence is preserved for the team.
d. Management should make sure they they have assigned an adequate investigative team to perform the investigation and that the team has all the resources and support that they need. Depending upon the seriousness of the investigation, the team may include independent facilitators or coaches to help the team and outside experts for technical guidance. Management should assign an independent (not from the organization involved in the incident) Team Leader for all but the most minor investigations. The Team Leader should be thoroughly trained (probably in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course).
e. Management should agree to an initial investigation scope (although the team should have the freedom to enlarge the scope based on the facts discovered during the investigation).
STEPS 2 & 3
Next, come Steps 2 & 3. I include these together because the main aspect that management will be reviewing is the team’s SnapCharT® with the incident’s Causal Factors. Management should make sure that:
a. The team has a detailed, logical SnapCharT® that is based on the evidence (facts) about the incident. Each Event and Condition should have a factual bases and not be an assumption (unless the reason for not verifying the assumption is adequately explained).
b. The evidence cannot support alternative scenarios.
c. All facts (not just those that supported this sequence of events) were considered.
d. Each Event includes the “Who did what” or “What did what” to clearly indicate the action that occurred.
e. ALL Causal factors have been identified (including those that were a “catch” for an error). May want to consider the using Safeguard Analysis to check the completeness of the Causal Factors.
f. The Causal Factors are the big picture causes of the incident and are not root causes. (They meet the definition of a Causal Factor and are at the “most general” end of the “So What?” chain.)
g. All Causal Factors have the associated information about them grouped together under the Causal Factor.
h. Only job positions (not people’s names) are used on the SnapCharT®.
i. Emphasis adjective are not used on the SnapCharT® (just state the facts - quantified when possible).
j. The Causal factors are repeatable and sufficient to cause the Incident.
STEPS 4 & 5
Next come Steps 4 & 5 - finding the incident root and generic causes. For these two steps, management should ensure that:
a. The team took each Causal Factor though the Root Cause Tree®.
b. Each root cause has evidence to support the finding and that the evidence provides a “Yes” answer to one of the questions in the Root Cause Tree® Dictionary.
c. The evidence is on the team’s SnapCharT®.
c. Management System root causes were considered.
d. The team checked for previous similar incidents and previous ineffective corrective actions.
e. Generic causes were considered for each root cause that was discovered.
f. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) was considered in analyzing the root causes’ generic causes.
g. There is evidence to support the finding of generic causes.
STEPS 6 & 7
The final management jobs in Steps 6 & 7 are to ensure that sufficient corrective actions are adopted and implemented to prevent recurrence of this incident and, if applicable, similar incidents. Therefore, management should ensure that:
a. Each root cause/generic cause has a corrective action.
b. The corrective action is SMARTER.
c. The investigation team considered the recommendations in the Corrective Action Helper® (check their recommendations against the Corrective Action Helper®).
d. For a significant incident’s root causes, Type 1-4 corrective actions are used (see below). Preference should be given to removing the hazard if possible, next removing the target, and then guarding the target.
(From the TapRooT® Book. Copyright 2008. Used by Permission.)
e. Any corrective action that includes a “re” should be questioned. (For example: retrain, remind, and re-emphasize.) “Re” corrective actions are just repeating actions that didn’t work in the past. Why do we expect them to work now? Also, note that if the corrective action is counseling an employee to remind them about rules or procedures, this is “re” corrective action and should not be used alone, but must be combined with other behavior change techniques.
f. Reject any corrective action that includes these words - Ensure, Assure, Insure, Make Sure - unless the team can explain how they will make sure that the change occurs (and this additional information should be included in the corrective action to make it specific).
g. Corrective actions that are studies be carefully evaluated to see why the study has to be delayed and can’t be completed before the investigation is concluded. (Examples of studies are: Investigate, Evaluate, Consider, Analyze.)
h. Any corrective actions that require behavior to change have considered what factors are causing current behavior and how these will be removed and what rewards/incentives and punishment will be clearly linked to the desired behavior to make it occur.
i. Training is not used as punishment or to embarrass an employee.
j. The scope of the problem (Extent of Condition) and the scope of the cause (Extent of Cause) were considered in developing corrective actions and are documented on the SnapCharT®.
k. The people responsible for implementing the corrective actions and the people impacted by the corrective actions agree that the corrective action will be effective.
l. Corrective action will be sufficient to eliminate significant risk or if additional Safeguards or process redesign need to be considered because the risk is so significant.
m. Corrective actions are assigned to the appropriate individual/organization for implementation.
n. The organization responsible for corrective actions has adequate resources to implement the corrective action by the assigned due date.
o. The corrective actions are tracked, and if significant enough, verified, and validated. Management should periodically be updated on corrective action status, especially overdue corrective actions.
p. Significant corrective actions are periodically checked (audited) to ensure their continued effectiveness.
q. Significant corrective actions that may impact other facilities are shared within a corporation.
r. Names of employees are not used in the report.
s. Emphasis adjective are not used in the report (just state the facts).
t. Pictures are used effectively to help explain what happened in the report and presentation.
u. Rewards are given for good investigations.
v. Evidence and reports are retained to meet any legal requirements.
Not every one of these “management must” items must be performed by a manager for each investigation. Management can set up systems , review teams, or review boards to help ensure the quality of investigations.
- - - -
Now for your comments … What do you think? Additions? Deletions? Modifications?
And how is your site doing to make sure the TapRooT® Process is being used correctly, efficiently, and effectively?
By the way, many of the points above originally were shared as best practices at the TapRooT® Summit. If you would like to keep up with the latest TapRooT® best practices, attend the 2010 TapRooT® Summit in San Antonio on October 27-29.
The Workers’ Compensation Board of British Columbia do a great job of sharing lessons learned after an investigation. Watch the video in this link to learn where Controls NI, Plant/Unit Differences, Arrangement/Placement, and Fatigue Root Causes come into the picture during a fatality investigation. Do you think this was the first time the wrong switch has been selected?
We introduce these root causes in our TapRooT® Root Cause Analysis Courses, however seeing the impact of muscle memory and an almost reflex like movement in this fatality really adds strength to why these Root Causes are part of our analysis process. To help people get a better understanding of a person’s ability to feel, see, hear, smell, and move in his/her environment, I added hands on exercises in our Stopping Human Error course last year, which will be taught again in San Antonio this October at the Pre-Summit. For those students who took the course last year and asked for additional behavior changing techniques, this request was heard and will be added in this year.
So looking at the fatality above and after reviewing the video what could have been done when the two trucks were introduced to the workforce:
1. Inexpensive fix: Turn the toggle switches to match the movement of the container (↑ Up, ↓ Down, ← Out, → In); even with muscle memory from driving one truck or another, the person would get feedback when the switch did not move and the label would not need to be the only indicator.
2. Little more expensive fix: Put more space in between the switches which according to Fitt’s Law will improve speed and accuracy trade off.
Remember to use SMARTER, Corrective Action Helper®, and Root Cause Dictionary to help develop achievable and sustainable corrective actions.
If you happen to be in Aberdeen, Scotland, at the 2010 Subsea Conference, stop by the TapRooT® exhibit and talk to Mhorvan Sherret or Alan Smith. They would be happy to discuss how you can use TapRoot® reactively or proactively to improve performance.
Plus, you can get your very own Spin-A-Cause™ for FREE!
That’s Mhorvan (first picture) and Alan (second picture) below talking to future TapRooT® clients…
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 Renauld Washington for his group. Watch and learn …
Because TapRooT® produces consistent results (it is structured and repeatable).
Because TapRooT® helps investigators find causes beyond their current knowledge.
Because TapRooT® helps investigators find all the root causes, rather than just the most obvious or their favorite ones.
Because TapRooT® has been tested and proven at leading companies around the world. (See Success Stories at: http://www.taproot.com/about.php.)
Because TapRooT® has patented software to make an investigator more productive.
Because TapRooT® has the Corrective Action Helper® Module to assist investigators in developing effective corrective actions.
Because management can understand the results and can approve the recommendations to improve performance.
Because TapRooT® is constantly being improved by a dedicated staff of experts that receive feedback from thousands - actually, tens of thousands - of users around the world.
Because the TapRooT® books, training, and investigation aids are so helpful.
Because TapRooT® Users are supported by newsletters and a Summit to help them continually improve their investigation skills.
That’s just a start of the reasons that TapRooT® Users are so successful and that you should be thinking about using TapRooT® if you don’t already use it.
Perhaps the NHS will look for improved root cause analysis tools (their current training, that I found outlined on-line, mentions 5-Whys and Brainstorming) and get better results that will help them improve outcomes in the UK. At least that what I thought when I read the article.
Here’s some pictures taken during an exercise during a recent class we held for Rio Tinto in Brazil (Ken Turnbull and Boris Resnic were the instructors) …
Part 2, as promised, is a discussion on our TapRooT® Users and Friends LinkedIn Group. This begins with a question asked by Jason Laws, a plant manager and client. Join us if you want to get into this conversation or even just to contact Jason directly.
“Common Sense, the Root Cause Tree and a perceived recent lack in the up and coming work force that I have noticed”
My Production Supervisor asked me the other day if there was a place in the root cause tree for Common Sense. I actually said, I didn’t think so. That when we come across “a common sense” causal factor the root causes are usually identified in a Management Systems, Training, and Procedures…. I may really be wrong there….I hate to think it would be in work direction and I am running into more and more unqualified candidates.
Where I have struggled recently is with this very idea. Some things, it would never have occurred to me that we would need to drill training down to that level.
(It was common to police up your work site at the end of a job. When cutting you always cut away, use the right tool for the right job, there is very little in the world that is fit to bang on other than nails, use a chalk line and plumb bob to put up a line of pipe supports, place the labels on the totes level and neatly, check the breaker when the pump won’t start, ….These are just the ones that have come to mind but the list continues.) [ I don't put in don't dead head or run a pump dry. I've been doing this too long to expect that.]
That does bring me to one point I have tried. That is the Poke Yoke or “Error Proof” things. All pumps go in with a Power Monitor shut off now. You can’t run it dry or dead head it.
Still, I am with my Production Supervisor…and have had the same conversation with my Maintenance Director. Is there a place for Common Sense in the root cause tree? Am I the only one? Is the work force changing? Has Nintendo killed the opportunity to get the basic knowledge I and others did with chores, play, hobbies and jobs when were young? If so, what can be done? If the answer is drill spac, training and procedures deeper down into the core knowledge, how do you know how far and how to you identify knowledge that you take for granted that really isn’t.
Sorry, if that was a bit of a ramble, but the Production Supervisor really got me curious.
ah…back to the when I was young, I walked up hill to and from work and pushed double the product you youngin’s push out and with no mistakes!
First off Jason you are right, many of the new employees of today have different skills sets than us old folks…. of course they would tell us it was “common sense” not to upgrade your software with out….etc… AFTER we locked up our computer. After all, didn’t we know this was not compatible for this computer.. duh!
At the same time the craftsman-apprentice relationship from years back no longer exists in many industries. Often it is the junior employee training the junior employee. The senior experienced employee is too busy fixing things to train anyone and often retires without documenting what s/he knows from experience.
The thought that any worker selection process, training process, and mistake-proofing remain stable and does not need to be flexible is a myth. Look at job descriptions, many are outdated, impacting the hiring process and training process.
First attack at the problem:
1. Identify the core skills needed by the employee to perform the core critical tasks for her/his job. Look up AMOD/ DACUM
2. Identify where the employees actually get the needed training. Often training programs get stuck looking at just missed appointments and regulatory required training, thus losing contact with the how the training impacts operations. (Where did the senior workers get their knowledge?)
3. Review the employee’s supervisor’s skill’s and training as well. Often new managers are hired based on needing to have a degree but never get the technical training listed above. The employee then asks the supervisor is this good enough…. how would s/he know?
4. If the training program is outdated (or just broke), then temporarily bring in a knowledgeable mechanic that has a retired and let them help revamp the new program with hands on training.
So if the employee needs a mechanical aptitude to perform certain jobs, then why was s/he not tested prior to hiring? After all, what happened to the unskilled in years past if s/he could not meet the aptitude need? S/he was either trained or kicked out the door.
After all, if common sense where the answer, you would not need the root cause tree either. So GOAL (go out and look) to find what the core skills and tasks are and then ensure that these requirements are met. Also see what you can learn from the new employees as well.
Posted 1 month ago | Delete comment
Response from: Kenneth Reed, Senior Associate and TapRooT® Instructor
You’re right, Jason. There is no Root Cause labeled “common sense NI” anywhere on the Root Cause Tree®. Just like there is no “attention to detail NI” or “operator error.” Although they initially seem like root causes, in reality they are just a convenient way to shift blame.
For example, if I told you the Root Cause was “common sense NI,” what would be your Corrective Action? How do you fix “common sense?” You can’t! Just like you can’t fix “inattention to detail” or ” operator error.” Therefore, we would default to poor Corrective Actions like, “Counsel the employee on using common sense when using a knife.” Completely useless Corrective Action, with almost no hope for better performance.
Instead, we need to look a little deeper at the problem. This is what Chris was alluding to above. Why did the operator slice his hand open? Was it really just a common sense problem? Or is there something we as management can do to prevent this issue?
That’s where the 15 questions, the Dictionary®, and the Root Cause Tree® come in. We need to ask ourselves the questions on the tree to dig deep enough into the problem. Instead of asking, “why didn’t this guy use common sense when cutting that wire, and cut away from himself?”, maybe we should ask:
- Was the worker fatigued, impaired, upset, bored, distracted, or overwhelmed?
- Was he using the right tool? Did we provide him with the right tool?
- Was the right person performing this job?
- Was this job really required in the first place?
- Do supervisors ever watch their people do this particular job? Why not?
- Would a supervisor have stopped this evolution before an injury occurred? If so, why didn’t he? If not, why not?
- Was the worker properly trained for this task?
- since I’m sure the worker did not intend to cut himself, what lead him to think doing the job in this manner was OK?
I could go on, but you get the point. When you find yourself saying, “This was just a dumb person, not using common sense, just a simple human error that I have no control over,” it’s time to step back and let the system work for you. Let the Root Cause Tree® and Dictionary® help you ask the right questions.
I also know that sometimes we think that people should already know these things. There are 2 possibilities:
1. The person really didn’t know (to cut away from himself)
- Therefore, this is a training issue
2. The person DID know, but chose to do it anyway.
- This is when my discussion above comes into play.
Hope this helps a little.
Posted 1 month ago | Reply Privately | Delete comment
Response from Jason:
Thanks Chris and Ken. One thing I have been trying to do, and encouraging my people to do (though finding the resources is always the challenge) is to use TapRooT® in audit mode.
I have worked the tree through these issues and developed corrective actions to account….mainly training, human engineering and Management systems.
My frustration can come from I just haven’t seen or anticipated the lack of knowledge in the first place to head it off at the pass. I am not even sure some of these issues would have occurred to me if I was putting together an audit SnapChart®.
Thinking on this thread, maybe the broader use of CHAPs might catch some of this. In a resource starved environment, I am trying to bring the tools I have to the best and most efficient use.
So, with GOAL. Maybe an Audit SnapChart®, the 15 questions, a CHAP and the Dictionary® I prevent some of these.
The struggle that remains is to overcome the blind spot of assumptive experience and figure out what needs to be trained for in the first place. What are the things we take for granted that really aren’t.
Once again. Thanks guys. I appreciate the feedback.
Posted 1 month ago | Reply Privately | Delete comment
Music to my ears Jason…. “proactive CHAP”. When people are first introduced to Critical Human Action Profile, they look for critical steps in a task that if skipped, done wrong, or in the wrong sequence, could have caused the incident or made it worse. A proactive audit can look for steps that are critical to safety and process.
As far as the “blind spot for assumptive experience”, this is a generic issue as you have described it. So what system should be controlling the hazard of having unskilled employees on the shop floor (or in the field)?
Steps of the process:
1. Company or Contractor Human Resources hire employees that have the skills and capabilities to perform their assigned core tasks.
Problem: Metrics that HR are usually measured by for the hiring process are retention and number of new employees. No tie made to direct labor and rework.
2. Training department has a structured training program that uses classroom and hand’s on training for the cores tasks (process and regulatory).
Problem: Training is often measured by Number of missed appointments and upkeep of regulatory training. No tie made to direct labor and rework costs.
3. Shops have floating experts identified for employees who need a little help.
Problem: The new are training the new. The senior employees are too busy to.
So ask your HR department and your training department, how do they know that they have been successful when hiring and training a person? Most likely it will not be tied to operations ROI. .
Have senior employees attend training with new employees to help all do right.
Look at your critical job’s and tasks to determine what skills and capabilities should be covered for each person and then use GOAL to identify what is missing.
We have scheduled a public root cause analysis training course for Spanish speaking professionals in Monterrey, Mexico.
Monterrey is the third largest city in Mexico. Monterrey visitors can enjoy a rich nightlife, cultural activities, and exciting sporting events. Many of the local people enjoy locally brewed beer while watching fútbol on a weekly basis. Visitors can also enjoy machaca con huevo, a traditional Monterrey dish. We are taking registration for:
3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis - March 1 - 3
Some popular tourist destinations in Monterrey are:
The Museum of Mexican History is an informative and interesting collection of Mexican history. The museum offers free guided tours during regular hours as well as self-guided tours of the many exhibits. Tuesday and Fridays are free admission to the museum and there are frequently concerts for museum guests. El Museo de Mexicana Historia is an enjoyable place for people of all different interests to visit.
Futbol is an important part of the culture in Monterrey. There are two teams that call Monterrey home and much of Monterrey entertainment revolves around the schedules of the games. The Rayados and the Tigres both play in Monterrey.
“El Templo de la Purísima, es el símbolo de la piedad cristiana de Monterrey. La Basílica y Parroquia La Purísima Concepción de Monterrey, es parte de la Arquidiócesis de Monterrey y en su organización Diocesana corresponde al Decanato I de Catedral y a la primera Zona de Pastoral” (http://lapurisimamonterrey.org/index.php).
The church of the Immaculate was built in the 1940s and was the first religious building with modern architecture in Mexico. The design was very controversial at the time it was being built, but is not a well-known landmark in Monterrey. Visitors can attend Roman Catholic masses twice a day each day of the week.
The Outdoors
“Are you the outdoors type? The mountains surrounding Monterrey offer recreation options available nowhere else in Mexico! Go rock climbing or hiking. Explore caves few humans have ever visited. Take a mountain bike down some of the most extreme slopes anywhere!” (Source: http://www.allaboutmonterrey.com/)
Are you looking for a Spanish speaking root cause analysis course, or do you have an associate who would be interested in performance improvement, problem-solving and corrective action programs taught in Spanish?
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 …
The Associated Press reports that an Air Force official reported that a missile intercept test failed because “the system’s sea-based X-band radar did not perform as expected.”
The story also said:
“The statement says officials from the Missile Defense Agency that conducted the test will conduct an extensive investigation to determine the cause of the failure.“
Let’s hope they use an advanced root cause analysis tool to find the real root causes of the failure and develop effective corrective actions. They need TapRooT®!
What happens when an Aviation Evaluator, OIMS Advisor, SHE Pipeline Coordinator, Drilling Superintendent, Field Safety Coordinator, EHS Consultant, Laboratory Project Coordinator, Laboratory Senior Administrator, General Engineer, Safety Engineer,,, just mention to few, sit in the same room? It must be a TapRooT® course! Heidi Reed and I have enjoyed teaching root cause analysis to this lively group.
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 Jeffery Hubbartt for his group. Watch and learn …
“A new round of construction problems on U.S. Navy vessels built by Northrop Grumman Corp. have spawned yet another investigation into the nation’s largest Navy shipbuilder.
Northrop, already under fire for widespread yet unrelated welding problems that surfaced two years ago at its Newport News shipyard, now faces quality issues at its Gulf Coast yards in Avondale, La., and Pascagoula, Miss., the Navy said Thursday.
All Gulf Coast vessels built by the company over the last several years are under investigation for a host of problems, including improper welds and defective engines and lube-oil systems, the Navy said.“
Other bad press for Northrop Grumman Shipyards include:
Sounds like they need better root cause analysis and better corrective actions! Maybe it’s time they took a TapRooT® Course?
Poor quality over an extended period of time is an indicator that your problem reporting and corrective action programs aren’t working. Applying the same old corrective actions of blame, counseling employees, more training, and making procedures longer doesn’t solve quality issues. People stuck in the blame game need a systematic investigation process that finds the true root causes of problems and the solutions.
TapRooT® does that with proprietary, copyrighted systems and training, and patented software that comes with a money back guarantee. Nobody else stands behind their system like we do. And that’s just one of the reasons that industry leaders choose TapRooT®.
If you are interested in thorough investigation of quality problems with effective corrective actions, consider sending some of your quality professionals to a 5-Day TapRooT® Advanced Team Leader Training public course. See:
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 Dan Evans for his group. Watch and learn …
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