Root Cause Analysis Blog

Once a year we offer a special class that teaches the TapRooT® Software called “Getting the Most from Your TapRooT® Software.”
This year the course is in Las Vegas on June 23-24.

This course is an intensive review of the TapRooT® Version 5 Enterprise (web) Software including:

- installation,

- configuration,

- data migration (from Version 4),

- administration,

- best practices,

- custom reports, and

- future release information.

Learn all the capabilities built into the amazing TapRooT® Software.

If you are a TapRooT® Power User or Software Administrator, don’t miss this course. Sign up at:

http://www.taproot.com/courses.php?d=15

In February I had the opportunity to teach a portion of the science behind The TapRooT® System to the ASQ Automotive chapter in Detroit. The presentation went well and the research that supported my presentation was recently published in the ASQ Automotive Excellence Magazine. For more information about the article and ASQ, click on this link: ASQ Automotive Excellence Spring Magazine. There are also over 40 references listed in the article that helped me give a robust representation of root cause analysis research that you can look up.

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

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

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

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

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

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

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

Portland, Oregon opened its doors to 30 employees from various industries attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis course. If you have never attended a TapRooT® public course and want to, who might you be be sitting next to? Here are the companies that attended our Portland course:

U.S. Mint
Intel Corporation
Alaska Airlines
Tidewater
Sause Bros.
Virgin America
Duke Energy Corporation
Southern California Edison
Lawrence Berkeley National Laboratory
Tyco Thermal Controls
Intrepid Potash

…. Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) teaches the difference between facts and events.

…. good investigation teams communicate and stay focused.

…. no blame… just the facts during the what phase of investigation.

…. facts…. facts… facts; you get it right here and your root causes and corrective actions stay connected to the true problems.

…. we teach…. you learn…. you practice …. we guide.

The 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course is the world’s premier root cause analysis training. On top of that, it’s an amazing value. Why do I say that?

1. TapRooT® is the root cause system chosen by industry leaders worldwide. This course teaches all the TapRooT® root cause analysis tools. For a few success stories from users, see:

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

2. There’s more. Learn:

- advanced cognitive interviewing techniques,

- advanced human performance improvement methods,

- procedure improvement ideas,

- innovative, yet proven methods to change behavior,

- how to present investigation results to management,

- how to avoid common mistakes when trending addcident/incident data,

- advanced corrective action development techniques, and

- proactive performance improvement.

3. Attendees receive the patented TapRooT® Software. The course fee is only $2395. The software alone costs $1495. That makes the 5-Day TapRooT® Course an exceptional value.

Our special offers make the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training an even more outstanding value. The special offers include:

1. Prior Course Attendee Discount: Prior 2-Day TapRooT® or 3-Day Equifactor® Course attendees get a $500 discount off the course fee.

2. Licensed Site Discount: Attendees from a licensed TapRooT® Site/Com¬pany qualify for the $500 discount.

3. Multiple Course Attendee Discount: If you sign up 3 or more people at one time for a 5-Day Course, you get a $100 discount for each person.

The maximum discount is the $500 discount plus the $100 discount.

If your folks qualify, they could attend the 5-Day TapRooT® Course for just $1795 each. These special offers make the 5-Day Course an even greater value! For course info, locations, and dates, see:

http://www.taproot.com/courses.php?d=2

Lessons from recent travels . . . Differences between Europe and the US.

Regulators in Europe are convinced that pre-job hazard assessments (safety cases in the UK) are the key to improved safety. Workers wouldn’t be at risk and there would be no accidents if people would just review the job, spot all the hazards, implement effective techniques to remove or ameliorate the hazard, and then conduct the work.

The US regulatory view seems to be to regulate the highest hazard industries with rules to make people safe in the highest hazard jobs. Keeping people safe is the responsibility of the employer. If the employer fails, they are fined to encourage them to do better in the future (and as a warning to other employers). Some companies use pre-job hazard assessments, but a safety case isn’t required across every industry and job.

In the UK, many companies employ consultants to write the safety case. These people are trained and are an external set of eyes. Many (but not all) are experienced in the industries and jobs they are reviewing. They generally don’t use advanced root cause analysis as part of their assessment. They are not part of the workforce and it seems to me that they are viewed as outsiders. Their work isn’t appreciated much by the workers (who often see the restrictions they generate as unnecessary and a waste of time).

In Europe, when an accident happens, it is viewed as:

1) A failure of the pre-job hazard assessment/safety case process,

2) A failure of the hazard removal/amelioration techniques, or

3) A violation of the rules ordered by the pre-job hazard assessment/safety case.

Many in Europe don’t see root cause analysis as a particularly complex task. Their view is that all they need to do is discover which of the the three problems above is to blame, and then do a better job of hazard assessment/safety case, hazard removal/amelioration, and/or enforcing the rules next time . . . then the problems will go away.

In the US, since companies are blamed if something goes wrong and pre-job hazard assessment/safety case is not seen as a universal fix, companies are much more open to process improvement as a solution to problems and accidents. Because process improvement has a wide range of options to improve human and equipment performance, root cause analysis is seen as a more difficult and valuable process. US companies are more open to investing in advanced root cause analysis tools that can be applied across the enterprise to improve not only industrial, process, and public safety, but equipment reliability, product and service quality, process reliability, and environmental stewardship.

How could both cultures improve?

I know you won’t find it surprising that “Mr. TapRooT®” sees the application of advanced root cause analysis both BEFORE and AFTER work as a necessary part of effective improvement.

I think there is value in proactive pre-job assessments; they would be even more effective if advanced root cause analysis (TapRooT®) was applied proactively as part of the pre-job assessment/safety case by the employees (workers and supervisors) who would be trained to conduct the hazard assessment, develop the hazard reduction strategies, and even write the safety case (or at least help the consultant write it). This would create more effective pre-job assessment and better compliance with the resulting hazard mitigation rules and strategies and become a great way to improve safety both in the US and Europe.

Second, employers need to see accidents as more than failures of hazard assessment/safety case. They need to use advanced root cause analysis (TapRooT®) to understand the true causes of the accident and take effective steps to reduce the hazard by improving the process. This failure analysis technique - applying TapRooT®’s advanced root cause analysis tools - can then be applied across the enterprise to improve processes, safety, productivity, environmental stewardship, and profitability.

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

After being introduced to TapRooT® through a public course, GPIC decided that they were ready to train key employees in TapRooT® Root Cause Analysis onsite. Pictured above and below after teaching the course in the Kingdom of Bahrain is Steve Swarthout (TapRooT® Root Cause Analysis Instructor & President of Performance Improvement of Virginia) with the key GPIC employees who made this course happen and GPIC course attendees.

This week we have a full 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Knoxville. I was teaching with Linda Unger, VP at SI, on Monday and too these “action” photos of the class listening, learning, and participating.

Why are so many people from industry leading companies attending TapRooT® Training? Because TapRooT® is so effective finding and helping people fix the root causes of problems. Also, our courses are interesting, fun, and effective.

For more course info, see:

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

Linda teaching…

Welcome to the course exercise…

Drawing their first SnapCharT®…

Another topic being discussed…

Checking the Root Cause Tree® Dictionary while looking for Root Causes…

Using the TapRooT® Software Corrective Action Helper® Module to develop SMARTER Corrective Actions…

That’s just the first day of the 5-Day TapRooT® Course.

This of this as a class photo taken one table at a time…

And here are some shots of the instructors …

Day 1 of the 2-Day TapRooT® Course. Lot’s of team exercises and learning.

Here’s some pictures of some teams in the first team exercise.

This update is for all users of the TapRooT® System Software, regardless of version.

This file will update your local TapRooT® Dictionary Help File, the file that is referenced whenever you look up the definition of root causes and/or corrective actions.

Download the update here. The update is 7.5MB in size.

And remember, if you have any issues or questions regarding the TapRooT System Software, be sure to check out the Support Knowledgebase to help you in resolving them, or to contact Technical Support.

An article in the Daily Express described the trouble at Heathrow as a “Baggage Meltdown.”

The results of thousands of “lost” bags are called a “Luggage Mountain.”

They have had to fly jumbo jets loaded with just bags across the ocean to try to unite travelers with their luggage.

And news outlets say the problem could get WORSE!

The cost of this “incident” is more than just the immediate costs to the airlines and travelers. Some say it has caused damage to the whole British reputation.

What is the “cause?” Everyone has an opinion. Most are looking for someone to blame.

But instead of looking for someone to blame, they should try advanced root cause analysis.

TapRooT® has been applied by many major airlines. Alaska Airlines even used it to analyze delayed flights and improve on-time departure statistics.

Perhaps British Air should try TapRooT® to stop the baggage meltdown and improve customer service?

And next time they should use root cause analysis as a PROACTIVE tool to improve performance BEFORE they open a new terminal and thus avoid a major quality of service incident.

Coming to System Improvements, Inc. as a Six Sigma Black Belt with ” the good, the bad, and the ugly” of Six Sigma company implementations, I often get asked how does the TapRooT® root cause analysis system tie in with the above pictured improvement systems and tools? During recent WebEx’s and conference calls, System Improvements, Inc. clients are often concerned about the cost of replacing their current highly invested Six Sigma Programs with TapRooT®. Peculiar thing is that companies questioned the same thing about Kaizen, Lean, and Six Sigma implementations as discussed in an article by Terence T. Burton. For those with existing Six Sigma Programs you can rest; TapRooT® does not replace the above mentioned processes but instead compliments the gaps in root cause analysis (Define and Analyze) and corrective actions (Implementation) to ensure robust proactive and reactive solutions to multiple system problems. For more about six sigma and lean practices integration with TapRooT® sign up for the TapRooT® Summit.

Below are some hard learned lessons, I picked up along the way that should be useful to current process improvement practitioners.

1. There should be no improvement “system” distinction between lean, six sigma, or any other improvement tool or process. People argue needlessly for days. Think about the old schools of psychology, you were either for nurture or nature, or crazy like Freud. Now schools teach that people are effected in the womb by the environment (nurture) and the cells develop (nature) like good soup. Needs to be the right temp and right conditions at the right time and don’t shake the pot. When we are born we are predispositioned to behave certain ways… all the music lessons in the world will not give you a good ear for music. Then it is up to the environment to guide the person. Point is that you must integrate the tools in a process that suppliment or compliment weakness and strengths. See an example of combining a six sigma tool and TapRooT®.

2. “Experts” who implement lean without truly understanding the integrated supply chain, the business needs, and the market will work improvement projects that sub-optimize other projects. A bad thing.

3. Perceived easiness of certain root cause tools in company experts’ hands… i.e. engineers, mechanics, operators, QA…, are actually limiting the analysis. As experts we developed rules-of-thumb and already “know” what the problem is. Funny thing, our children must be ignorant because all they want to do is ask a lot of why and what questions. It is not until we become adults that we know everything. Link to root cause research

4. YOU (the project black belt) must personally convince the boss to change to make the boss commit to a project; if you can’t too bad….Wrong! Influencing without authority means find the person the boss listens to and convince that person the project is the right thing to do…. there are a number of ways to “plant the seeds” of change.

5. Toyota experts developed excellent tools to improve their company… wrong. They went out and looked, understood their process, and then developed tools to represent their improvement needs. The problem with this is that we go out and buy fancy tools, put garbage data in from a company process that we do not not fully understand and then blame six sigma for its failure. You must understand the process used to improve, understand the process you are trying to change, and use tools to complement these processes.

6. Another major problem of six sigma is keeping safety, hr, and training as the outsiders who don’t see the “hidden factory”. Why… because of the initial low Return of Investment. When has your six sigma program observed the core competencies (skills and tasks) needed to perform their job and do it successfully? Does annual training still cover key skill needs?

Hope this helps and I see you in Las Vegas at the TapRooT® Summit.
Link to root cause research

The China Association for Quality Promotion (CAQP) has recognized Otis Elevator Company as a leading service provider in China for its consistent national service model, standardized processes and best-in-class response time. Otis is a unit of United Technologies Corp and a Licensed TapRooT® User.

Otis was the only elevator company to receive the distinction and one of only 15 companies selected out of the 2,339 evaluated.

Otis Elevator Company is the world’s largest manufacturer and maintainer of people-moving products including elevators, escalators and moving walkways. With headquarters in Farmington, Connecticut, Otis employs 63,000 people, offers products and services in more than 200 countries and territories and maintains 1.6 million elevators and escalators worldwide. United Technologies Corp., based in Hartford, Connecticut, is a diversified company providing high technology products and services to the building and aerospace industries. United Technologies is a Licensed TapRooT® User worldwide.

For more info, see:

http://www.forbes.com/prnewswire/feeds/prnewswire/2008/03/26/prnewswire200803260700PR_NEWS_USPR_____NEW009.html

Malcolm Gresham of Practical Solutions Group in Australia sent these photos from the course in Singapore.

Class hears theory and concepts, learns practical methods and root cause tools.

(Practice using the tools is a part of every TapRooT® Course.)

(Ready for graduation and applying what they have learned to improve the company.)

If you are a TapRooT® Software Administrator or a Power User who wants to get the most from their TapRooT® Software, you should attend the TapRooT® Summit and the Pre-Summit Course (Getting the Most from Your TapRooT® Software).

The Pre-Summit Course in on June 23-24. Tha TapRooT® Summit is on June 25-27. Both are being held in Las Vegas.

WHY SHOULD YOU BE THERE?

1. This is the only time during the year that we hold specialized TapRooT® Software Training: Getting the Most from Your TapRooT® Software.

Ed Skompski, VP of TapRooT® Software Development, and Dan Verlinde, Software Project Manager, will teach an intensive review of the TapRooT® Version 5 Web Software system administration. Topics include software installation, configuration, data migration (from Version 4), software support and maintenance best practices, custom reports, and discuss future software development. The goal of the course is to help you get the most from the amazing version 5 software.

2. This is the only time during the year that we have a meeting that allows software users to discuss their best practices with other users and the developers. This happens at the TapRooT® Summit in the TapRooT® Software Techniques and Administrator Best Practices Track.

What’s included in the track? Here’s an outline of the sessions:

1. What’s New in the TapRooT® V5 Software - a User’s Forum

2. TapRooT® V5 Enterprise Software Implementation

3. Extracting Data from Your TapRooT® Database

4. TapRooT® User Best Practices

5. TapRooT® V5 Software Administration - From Installation to Configuration

6. TapRooT® User Success Stories

7. TapRooT® V5 Software - User to SUPER User!

8. Trending & Analysis Tools in TapRooT® V5 Software

9. Planning Your Improvements

Getting the most from your TapRooT® Software installation can save your company thousands or even hundreds of thousands of dollars. How? By using the full capacity of the software to maintain and analyze your accident data. You may be able to replace old accident databases (thus saving hundreds of thousands of dollars in support/upgrade/maintenance fees by using the full capacity of the TapRooT® Database. Also, you may be able to more effective analyze incident trends to provide management with better information to more effectively improve performance - and save even more! 

Between the pre-Summit Course and the sessions at the Summit, TapRooT® Software Administrators will go back to work with plans to get much more from their TapRooT® Software installation.

Also, Summit participants will here the 5 Keynote Speakers -

Lt Col Ralph Hayles

Gold Medal Winner Nikki Stone

UK RAIB Chief Inspector Carolyn Griffiths

TMI Operator during the accident, Ed Frederick

America’s Dream Coach, Marcia Wieder

But there is more! (At least more fun!)

Participants will also attend the Summit Reception (with Elvis and Nikki Stone), and can join the TapRooT® Cup Golf Tournament on Friday afternoon.

And besides these activities, there is always something to do in Vegas! Click here for some ideas.

So start planning to attend the Summit and training NOW!

Another happy class ready to find root causes.

Just one final exercise left and these students will be ready to tackle tough incident investigations, quality issues, equipment failures, and plant upsets.

Attending the TapRooT® Summit and a pre-Summit Course at least once every two years is part of the continuing education requirements to maintain Certification as a Certified TapRooT® Instructor. Attending EVERY year is an even better idea (going beyond the minimum requirement.)

Each year, Linda Unger (VP at SI and the Certified TapRooT® Instructor Best Practices Track Chair) and I plan the sessions that will help Certified TapRooT® Instructors return from the Summit to be even better instructors, better investigators, and better at leading their company’s performance improvement program.

The 2008 Summit has a blockbuster track for returning (or new) Certified TapRooT® Instructors. This posting will give you a quick overview of sessions and the speakers.

Here is an overview of the 9 Best Practice Tracks:

Best Practice Session 1: What’s New in Investigations & Corrective Actions

Brian Locker - Latest Methods to Define Causal Factors
Kay Gallogly - IEEE Root Cause Analysis Standard
Bryce Donaldson - Advanced Multimedia Techniques for Sharing Lessons Learned

This session has three short presentations.

In the first, Brian Locker, a TapRooT® Instructor, will show the new methods for defining Causal Factors from the new TapRooT® Book. This is a significant improvement over past Causal Factor definition teaching, so all Certified Instructors will want to see these new methods.

Second, Kay Gallogly (a TapRooT® User, nuclear industry consultant and member of the IEEE Committee that is writing the standard) will discuss the progress that the committee has made in agreeing to ways to standardize and improve root cause analysis in the nuclear industry.

Third, Bryce Donaldson, a TapRooT® Instructor, will demonstrate how some advanced multimedia techniques can be used to share lessons learned and be used to provide records of employee reviews.

Best Practice Session 2: FACTS - Computerized Analysis of Fatigue as a Cause of an Accident

Bill Sirois

Bill Sirois, VP and COO of Circadian Technologies, will demonstrate the use of FACTS. FACTS is a fatigue evaluation tool for accident investigations that was started as a result of collaboration between System Improvements and Circadian Technologies three years ago. The testing phase of the development is nearing it’s end and Bill will show how the tool can be used in the near-future by investigators in the field when they need to evaluate if fatigue played a roll in an accident.

Best Practice Session 3: Root Cause Analysis of Major Accidents

Ken Turnbull - Lexington Airport Runway Mixup
Mark Wittrup - Cameco Cigar Lake Mine Flood
Mario Chacon - Cal OSHA Fatality Investigations

Certified TapRooT® Instructors will be interested in investigations and the analysis of root causes. Two of the investigations in this session will demonstrate the use of TapRooT®. The first presentation, by Ken Turnbull - a TapRooT® Instructor, will demonstrate how to use TapRooT® with data from someone else’s investigation. The second, by Mark Wittrup, a TapRooT® User at Cameco, will show the results of an investigation by TapRooT® Users of a major investigation - a mine flooding accident.

Best Practice Session 4: TapRooT® User Best Practices

Facilitated by Linda Unger and Michele Lindsay

Michele and Linda will facilitate a user best practice session where TapRooT® Users will network and share their best practices for applying TapRooT® to a wide variety of improvement initiatives.

Best Practice Session 5: Certified TapRooT® Instructor Best Practices

Linda Unger, Benna Dortch, Michelle Young

THIS SESSION IS ONLY FOR PEOPLE FROM LICENSED TapRooT® SITES.

The new TapRooT® Book, new Corrective Action Helper® Book, and the new TapRooT® 2-Day Course revisions will be the highlight of this session. TapRooT® Instructors from Licensed TapRooT® sites will receive a CD with the revised 2-Day Course PowerPoint when they attend this session.

Best Practices Session 6: TapRooT® User Success Stories from Healthcare and Industry

Facilitators: Linda Unger and Barbara Phillips

Here the stories of three TapRooT® Users. They will present the challenges they faced and how TapRooT® helped them achieve success.

Best Practice Session 7: From TapRooT® V5 Software User to SUPER User

Susan Nelms and Dan Verlinde

Susan, a TapRooT® User from Mirant, and Dan, Manager of the TapRooT® version 5 Software, will help you go beyond just using the TapRooT® Software and understand how you can get much more from your company’s software investment.

Best Practice Session 8: Root Cause Analysis of the Accident at Three Mile Island

Ed Frederick

Participants will draw a SnapCharT® of the accident at Three Mile Island using information they “know” and information obtained by asking questions of Ed Frederick, one of the operators on-duty during the accident.

Best Practice Session 9: Planning Your Improvements

Take everything you have learned and develop an improvement paln for when you return to work. TapRooT® Instructors will facilitate these sessions and can evaluate the plans you develop.

       
Ralph Hayles/Nikki Stone/Carolyn Griffiths/Ed Frederick/Marcia Wieder

Of course, Certified TapRooT® Instructors will be interested in the five Keynote Speakers at this year’s Summit. For details about their backgrounds see:

http://www.taproot.com/keynote_speakers.html

One more thing that certified TapRooT® Instructors need to do to maintain their certification is to attend one of the pre-Summit courses. This year there are 11 to choose from. They are:

1. 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course
2. Advanced Trending Techniques
3. 2-Day Equifactor® Equipment Troubleshooting & Root Cause Analysis Course
4. Risk Management Best Practices
5. Stopping Human Error
6. Interviewing and Evidence Collection
7. Innovation & Creative Solutions
8. Getting the Most from Your TapRooT® Software
9. Hazard Recognition Best Practices
10. Engineering Equipment Reliability Techniques
11. TapRooT® and FMEA for Healthcare Root Cause Analysis

For more information about these courses, see:

http://www.taproot.com/pre-summit_courses.html

Don’t forget to make your hotel reservations early. The Summit is being held at the Westin Causuarina Hotel at 160 East Flamingo Road (just off the strip in Las Vegas). Visit the Travel & Accommodations page at the Summit web site for more info.

It’s morning in Amsterdam and the class is hard at work on their first SnapCharT®. By the end of the week they will be ready to investigate difficult accidents, incidents, quality problems, and equipment failures.

Rama teaches

Teams working on their SnapCharT®s

As a TapRooT® and Equifactor® instructor for System Improvements, I get the opportunity to meet quality, engineering, safety, manufacturing, operations and medical company experts from around the world. In two or five days these experts learn the basics of the TapRooT® System for finding the root causes of problems PLUS some attend one day of Equifactor® Equipment Troubleshooting Technique for root cause failure analysis of equipment problems. These are grueling days of lecture and hands on application that does not allow much time to teach people the science behind good root cause analysis. Just as important, I do not get to show people why being an expert in your field of work can actually impede your investigation due to “tunnel vision” of the mind.

Experts who are now using TapRooT®, have learned how to investigate with an open mind based on tons of research in human and workplace system interactions. But with all the knowledge our experts bring to the table why was this a limiting factor before TapRooT® use? After presenting at the ASQ Automotive Conference in Michigan this February, audience members wanted to know more about root cause tool limitation and expert use of rules-of-thumb. So if you want to understand more of our thinking processes in problem solving and why we have a tendency to assume we know why an incident occurred before we really know what occurred, link to the paper below.

“Why ask why when you should be asking what?”

For those that aren’t aware, I am the Summit Chair and with the help of the TapRooT® Advisory Board, the Track Chairs, the staff at System Improvement, and previous year Summit participants (that a lot of help!), I plan the TapRooT® Summit.

I also hand pick the courses that are offered prior to the Summit - this year on June 23-24. I pick these courses based on the experience I have with performance improvement programs around the world. My goal is to put together a world-class selection of courses that will help people solve their toughest problems.

Each year I bring back some old favorites and some brand new courses.

The old favorites are based on previous attendance and feedback.

The new courses are based on requests from participants and problems that I observe in my extensive travels.

This year there are three new courses:

1. Hazard Recognition Best Practices

2. Engineering Equipment Reliability Techniques

3. TapRooT® and FMEA for Healthcare Root Cause Analysis

There are also, eight returning veterans:

1. Advanced Trending Techniques (10th year)

2. Innovation & Creative Solutions (2nd year)

3. Stopping Human Error (5th year)

4. Risk Management Best Practices (5th year)

5. Interviewing and Evidence Collection (3rd year)

6. Getting the Most from Your TapRooT® Software (2nd year)

7. 2-Day Equifactor® Equipment Troubleshooting & Root Cause Analysis Course (8th year)

8. 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course (13th year)

That makes 11 courses with a wide variety of topics to choose from. Where can you find out more information? See:

http://www.taproot.com/pre-summit_courses.html

And here are a couple of videos where previous course attendees share their experience…

(more…)

Here’s some photos from the course…

Ken Reed (center front) sent me this photo from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course that was held in London last month.

This week Ken is in Charleston, SC teaching a larger public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course.

Interested in our public TapRooT® Course schedule around the world? See:

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

When you are intimately involved with TapRooT® and Equifactor® the way I am, you sometimes take for granted that people understand exactly what Equifactor® is and how it relates to the rest of the TapRooT® system. At one of my recent Equifactor® classes, a long-time TapRooT® user attended, and he was surprised to learn what Equifactor® actually does. I thought I’d put out a quick description of the overall philosophy of equipment troubleshooting using the Equifactor® module of the TapRooT® system.

When you start an investigation into an equipment failure, you may find yourself heading in a couple of specific directions:

1. Your troubleshooting team has found the “root cause” of the failure. For example, they have discovered that the bearing failed due to inadequate lubrication.

2. Your troubleshooting team is stumped, and has run out of ideas.

For the first option, take a look at this particular “root cause.” This sounds an awful lot like a causal factor. In fact, with a little change in the wording (Mechanic does not lubricate the bearing at the required periodicity), it now becomes a “who did what incorrectly”, and is actually a Casual Factor. What do you do with a Causal Factor? That’s right. Add it to your SnapCharT® gather any additional information to complete building your Summer SnapCharT® (mechanic training and experience? supervision? procedure correct? etc), and then analyze the CF using the Root Cause Tree®.

For the second opt