Archive for the ‘TapRooT’ Category

Root Cause Analysis Day One at Golden Pass LNG, Sabine Pass Texas

Wednesday, September 1st, 2010

Golden Pass LNG Terminal LLC, the owner of the Golden Pass LNG Terminal, is 70 percent owned by an affiliate of Qatar Petroleum, 17.6 percent owned by an affiliate ExxonMobil, and 12.4 percent owned by an affiliate of Conoco Phillips.

Taking the lead before their first shipment of LNG, Golden Pass LNG started the Root Cause Analysis process and training early on. Below are just of few pictures from the first hands-on exercise.

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Root Cause Analysis Tip: “Death by Data” also known as “Data Paralysis”

Wednesday, September 1st, 2010

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Understanding your process data, filtering the good from the bad and detecting when there are true problems coming to light should not be like hand-sorting grains of rice.

Yet I hear this question frequently, “We have a large database and we would like to ……..?”

When I ask what processes are being measured and what data are tied to the process’ outcome, the answers are often very vague if not delayed with a, “I will get back with you, good question.”

Now most of us our good at tracking outcomes (often because we are required by Regulations) like:

… number of defects

… costumer complaints

… OSHA recordables

… Sentinel Events

With tracking outcomes however, comes the data merging error that hides the fact that all rice does not come from the same fields and cannot always be included in the same analysis. For example:

… we had a wonderful month with lower injuries in July per assigned employees.

Problem: Cannot compare the number of employees assigned in July with the other months because we had a 2 week plant shutdown.

… we count all defect opportunities and perform frequent audits but the leading indicators do not seem to predict the change.

Problem: Not all audits are created equal. Often leading indicator metrics are too global and general. In other words, “just plain rice”. When you see indicators change but there is no correlation to your lagging output metrics, stop and Go Out And Look (GOAL) at the tasks being performed to identify the correct leading metrics.

This is just the tip of the iceberg when looking at wrong data collection thoughts. Just remember just because you collect lots of data does not mean this a good thing…. you just get more grains of salt to sift through.

Below are two presentations to dig a little deeper in this thought process.

http://www.taproot.com/wordpress/2009/10/30/trending-with-the-taproot%C2%AE-v5-software/

http://www.taproot.com/wordpress/2009/10/30/proactively-using-leansix-sigma-with-taproot%C2%AE/

Also, check out our metrics course being offered during our October Pre-Summit. It is the only this year it is offered as a public course: http://www.taproot.com/summit.php?t=pre-summit#advancedtrending

Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course held for Boart Longyear in Santiago, Chile

Sunday, August 29th, 2010

Marco Flores sent these pictures from the class…

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Pictures from the Johannesburg Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Friday, August 27th, 2010

This was a full course and people had a great time learning advanced root cause analysis.

Pictures from the Cognitive Interviewing Exercise:

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Pictures of the final exercise …

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Class photo …

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Caribbean Nitrogen Company (CNC) Limited holds TapRooT@ Root Cause Courses in Trinidad

Friday, August 27th, 2010

CNC invited System Improvements, Inc. back to Trinidad to teach a 1-Day Refresher and 2-Day Root Cause Analysis Courses this week. It was pleasure for Mark Olson and I to work with their energetic and passionate team.

Here are a few picture from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis:

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A few pictures of life in Trinidad:

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Talk About TapRooT® and Get a Free Spin-A-Cause™ at the VPPPA Meeting in Orlando

Tuesday, August 24th, 2010

Here are Linda, Ken, and Dave talking about TapRooT® and giving away Spin-A-Cause™s at the VPPPA Conference reception in Orlando.

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If you are at the VPPPA Meeting, stop by booth 503 and say hello. (And get your own Spin-A-Cause™.

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Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Training held at Subsea 7 in the UK

Wednesday, August 18th, 2010

Here’s Roland Reid teaching his first TapRooT® Class at Subsea 7 in the UK with Mhorvan Sherret. Subsea 7 is a licensed TapRooT® User and they do their own 2-Day classes with Certified TapRooT® Instructors that work for Subsea 7.

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Want to find out what it takes to be a Certified TapRooT® Instructor at your company? See:

http://www.taproot.com/wordpress/2005/12/06/process-for-becoming-a-certified-taprootr-instructor/

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Pictures from the on-site 5-Day TapRooT® Advance Root Cause Analysis Team Leader Course held for BoartLongyear in Perth, Australia

Monday, August 16th, 2010

Our instructors at PSG in Perth sent these pictures of the students practicing what they learned …. drawing a SnapCharT® – during the recent 5-Day TapRooT® Course held for BoartLongyear.

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Need an advanced root cause analysis course at your site? Call us at 001-865-539-2139 or contact us by clicking here.

USA Today Reports: Aviation safety in Alaska improves, but still hazardous

Wednesday, August 11th, 2010

USA Today published an article about the recent crash that killed ex-Senator Ted Stevens and the hazards of flying to remote locations in Alaska.

The story mentioned several reasons for improving safety in Alaska but missed one. What is the one they missed? TapRooT®.

Back in 2002 we licensed The Medallion Foundation to teachTapRooT® and use it to investigate aviation accident in Alaska.

Then in 2003, we licensed the FAA in Alaska to use TapRooT® for accident investigations.

Now they cooperate in their investigative efforts to improve aviation safety in Alaska.

How has TapRooT® Helped improve Alaska aviation safety? Attend the TapRooT® Summit and find out. Dennis Ward, Executive Director of the Medallion Foundation and a certified TapRooT® Instructor, will present “Improving Performance by Analyzing Multiple Aviation Accidents for Common Causes” in the Investigation, Troubleshooting, and Root Cause Analysis Track. His talk explains the use of TapRooT® to find deeper meaning from the analysis of multiple accidents.

This is part of The Medallion Foundation’s efforts to improve the safety culture of the aviation industry in Alaska. Their web site has the following information:

“The Medallion Foundation is a non-profit organization promoting aviation safety through systems enhancements by providing management resources, training, and support to the aviation community. Our mission of reducing aviation accidents is fostered by research, analysis, education, auditing, and advocacy of Safety Management Systems and higher flight-training standards.”

It also says:

“The Medallion Foundation provides specific training classes, one-on-one company mentoring, and auditing in conjunction with and supplemental to the Five-Star / Shield programs. Courses such as System Safety, Safety Officer, Flight Risk Management, and TapRooT® Root Cause Analysis are offered as prerequisites for the Star Programs.”

OK … I added the emphasis on TapRooT®. But hearing how Dennis used TapRooT® to find significant Generic Causes of accidents from their root cause analysis, will help you understand why I put emphasis on using TapRooT® as a fundamental part of any improvement program.

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Pictures from the 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in Sao Paulo, Brazil

Tuesday, August 10th, 2010

Boris Resnic, out TapRooT® Instructor in Brazil, sent these pictures from the recent 2-Day Course in Sao Paulo.

Where is our next public course in Brazil? MACAÉ

When is it? November 8-12

See our complete public course schedule at:

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

To schedule an on-site course for your facility, contact us by clicking here.

PICTURES

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Pictures from the First TapRooT® Root Cause Analysis Course Held in Libya

Monday, August 9th, 2010

Mhorvan Sherret, on of our UK instructors, sent these pictures from Libya where we held a 5-Day TapRooT® Advanced Root Cause Analysis Course for Suncor.

Lifting of restrictions on Libya now allow us to provide on-site training so people can use TapRooT® to improve performance and save lives in Libya.

Here are the class photos …

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If you need a course at your facility anywhere in the world, click here for a quote.

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Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Angola for ExxonMobil

Monday, August 9th, 2010

Companies hold TapRooT® Courses around the world. here are pictures from a special 5-Day TapRooT® Course with a day of Equifactor® Training (equipment troubleshooting) built in.

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If you need some TapRooT® Root Cause Analysis Training for your site, call us at 865-539-2139 or e-mail us by clicking here.

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Class Photos from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course Held for Vestas in Portland

Friday, August 6th, 2010

Dennis Osmer (one of our TapRooT® Instructors) sent these cell phone pictures from the course…

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Do you need at TapRooT® Root Cause Analysis Course at your site?

Call us at 865-539-2139 or click here to e-mail a request.

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What a 5-Day TapRooT® Class in Gatlinburg, TN! Is your Industry really that different?

Saturday, July 31st, 2010

This 5-Day Root Cause Course was definitely an adventure. When you start with a class of combined industries such as Mining, Military Health, Manufacturing, Nuclear, Power Generation, Drilling, Oil, Gas, and Chemical, day one starts off like this…..

“Our Industry is different than ________ (fill in the blank).”

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Can you point out who is from what Industry? At the end of the 5-day, all industries were having the same conversations and sharing best practices…. I love TapRooT® Public Courses!

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An evening with the Military Health Group above…. great discussions with members’ assignments spreading from Texas all the way to Korea.

Some more pictures from the course below.
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Pictures from Day 3&4 of the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Seattle

Friday, July 30th, 2010

Here’s more pictures from the Seattle public TapRooT® Course …

Pictures from “After the Class”

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We had a post class meeting at Kells Irish Pub for class attendees and my Seattle LinkedIn contacts. Guinness was very popular!

More shots from the class…
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Fatigue a Potential Issue in an Investigation? Try FACTS!

Thursday, July 29th, 2010

An announcement from
CIRCADIAN Technologies

EXPERT SYSTEM TO ASSESS FATIGUE IN ACCIDENT INVESTIGATIONS

WEDNESDAY 28 JULY 2010

TRY FACTS FOR FREE

Have an accident you want to investigate? Try FACTS

WHAT IS FACTS?

FACTS is an online diagnostic expert system to help investigators and companies readily determine if human fatigue may have been a causal factor in an accident/incident.

ABOUT CIRCADIAN®

CIRCADIAN® provides Fatigue Risk Management Systems, Shift Schedules, Software, and Training & Publications to solve the challenges of the 24/7 workforce.

Learn More about CIRCADIAN®

FACTS is a web-based investigatory tool that helps users determine if human fatigue may have been a causal factor in an accident/incident. Developed by the world’s leading experts in sleep, fatigue, and circadian rhythms, FACTS generates results that correlate well (r = .91) with conclusions reached by experts who investigated NTSB and other industrial accidents.

FACTS helps you do the following:

- Determine whether or not fatigue affected the individual involved in an accident/incident.

- Calculate what percentage of your operations incidents/accidents/deviations are due to fatigue.

- Estimate the cost of employee fatigue impairment at your operation.

Have an accident you want to investigate?

FATIGUE ACCIDENT/INCIDENT CAUSATION TESTING SYSTEM (FACTS)

Fatigue is one of the most pervasive yet under-reported causes of human error-related accidents, incidents, and injuries in both the industrial and transportation sectors.

Because fatigue is difficult to detect (i.e., no blood, urine or breathalyzer test exists to identify it) companies have a difficult time quantifying the true impact and cost of fatigue in their operations.

To bridge this gap, CIRCADIAN® created an online diagnostic expert system to help investigators and companies readily determine (by standardizing criteria and with high probability) if human fatigue may have been a causal factor in an accident/incident.

- – - END OF ANNOUNCEMENT

One additional note …

One of the developers of FACT will be at the TapRooT® Summit to share information about the technique and how to use it.

This presentation is in the Changing Behavior and Stopping Human Error track from 10:40-12 on Thursday, October 28.

For more information on the TapRooT® Summit, see:

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

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“Hands-only CPR, pushy dispatchers are lifesavers”

Wednesday, July 28th, 2010

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Read more here: http://news.yahoo.com/s/ap/20100728/ap_on_he_me/us_med_hands_only_cpr

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Pictures from Day 2 of the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Seattle

Wednesday, July 28th, 2010

Another great day at the Seattle 5-Day TapRooT® Course. Here are pictures of people learning and practicing their root cause analysis, interviewing, and corrective action development skills.

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For more about the course, see:

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

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Pictures from the Seattle Public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course

Monday, July 26th, 2010

People worked had in exercises at Day 1 of a 5-Day TapRooT® Root Cause Analysis Course in Seattle.

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If you are interested in our upcoming public TapRooT® Courses around the world, see:

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

To get a quote for a course at your site, contact us at:

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

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Medical device problems hurt 70,000+ kids annually

Monday, July 26th, 2010

..”About one-fourth of the problems were things like infections and eye abrasions in contact lens wearers. These are sometimes preventable and can result from wearing contact lenses too long without cleaning them.”

..”Other common problems found by researchers at the U.S. Food and Drug Administration include puncture wounds from hypodermic needles breaking off in the skin while injecting medicine or illegal drugs; infections in young children with ear tubes; and skin tears from pelvic devices used during gynecological exams in teen girls.”

..”The most serious problems involved implanted devices such as brain shunts for kids with hydrocephalus (water on the brain); chest catheters for cancer patients receiving chemotherapy at home; and insulin pumps for diabetics. Infections and overdoses are among problems associated with these devices. Only 6 percent of patients overall had to be hospitalized.”

…”Malfunction and misuse are among possible reasons”

I read the article and then asked “AND”? There is so much more information that needs to be collected and compared.

… “is there damage with this equipment for children and adults?”

… “is there a difference between different manufacturers for the same types of equipment?”

…”what allowed 70,000 incidents to occur without having the root causes listed already?” …. yes I know there are patient and company privacy issues but that is not a good excuse!

So what would your next steps be? (more…)

Do you have $200K for Safety Violations?

Thursday, July 22nd, 2010

South Carolina manufacturing plant fined by OSHA for fall and electrical hazards…. I believe the term of the day was “willful” violations.

Read more here:

http://heraldbanner.com/local/x315773731/Local-plant-fined-197k-for-safety-violations

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Equipment Failure Event: Cracks that could cause the engines to fall off on the Boeing 767

Wednesday, July 21st, 2010

“The FAA safety order affects 138 planes registered in the United States out of a global fleet of 314 planes. Aviation officials in other countries usually follow the FAA’s lead on safety of U.S.-manufactured planes.”

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“The order only applies to 767s that have the original pylon design. Boeing changed the design after the problem first became known…. FAA issued a safety order for these planes in 2005 requiring inspections for cracks every 1,500 flights. The new order accelerates that schedule to every 400 flights or every 90 days, whichever is later.”

read more here:http://news.yahoo.com/s/ap/20100721/ap_on_bi_ge/us_boeing_safety_order

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Root Cause Analysis Tip: The Myth of the Cost of Poor Quality

Wednesday, July 21st, 2010

One of the biggest trends in quality improvement was the term “The Cost of Poor Quality” tied with “Zero Defects”, with many COPQ financial models popping up in many Fortune 500 companies. In the safety world there was a similar drive with the term Cost of Compensation tied with “Zero Injuries” and OSHA driven recordables to be tracked.

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The Safety Iceberg

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Yet the focus for both safety and quality were lead by lagging visible indicators. In other words good or bad, the findings are just too late. You march your troops with the “Zero Defects” and “Zero Injuries” flags raised and once you reach your destination you turn around and see who and what equipment you have left.

Now don’t get me wrong, identifying and being able to comprehend the end damage is a vital part of the process and unfortunately not realized by some. It is just NOT where you should focus your drive and effort.

So what now you may ask? “Build quality in… do not inspect quality in!”

The phrase above often goes to deaf ears because it is misunderstand. “If you do not assess the quality of your work, then how do you know if it is to standards,” people would ask. “I have to trust everybody’s work?” In the safety world the phrase “Safety must be part of every action we do,” is often trumpeted. But how?!

Start with these 3 steps first:

1. First things first, Quality and Safety are NOT silo’s and they should work together. Setting up a task that can be worked efficiently, correctly and safely by employees is a combined goal and SHOULD NOT be competing goals.

To save money, many companies do not cross-train employee’s from different departments. Why not if it makes sense? For example, while many of our clients started using TapRooT® Root Cause Analysis in their safety departments first, the more people saw the process used, the more operations and facilities come onboard for the same training.

Now this cross-training concept also works in the opposite direction. As the quality department leaders started working with the safety, quality tools from Stakeholder Analysis to Force Field Analysis were also shared with the safety department. After all, inside all world class companies are different departments that are all part of the same company with one goal.

2. Building Quality and Safety into a process starts in the beginning stages of planning but can be recovered after the employees try to use an existing process (it just costs more time and money!).

When our clients use our Root Cause Analysis process to investigate defects and incidents it soon becomes apparent that the opposite of each one of our root causes are best practices that can be implemented proactively.

While most Quality Experts are excellent at mapping out front end value streams, process maps and spaghetti maps, there is often a gap in knowledge of research and industry best practices in human engineering, communication, procedures, training and work direction. So if you were a Quality Professional and had access to multiple experts in front of you everyday, would you utilize them? Here is small list of courses that can give you best practice access: Best Practice Courses

3. No process, no matter how well designed is perpetually stable and it must be audited/assessed periodically based on risk for unknown and known changes…. note: this is not the same thing as “inspecting in quality”!

This is one of the most misunderstood ingredients relating to Inspections.

If you have a hold point inspection that must be completed by an Independent Inspector BEFORE a task can be completed or a part received or shipped, you are admitting that you have a high risk potential that is not capable of being completely mistake proofed.

– OR-

You have a process or task where you have not truly identified the human and equipment behaviors with their associated Root Causes, and have decided that it is worth spending the extra money and time to inspect instead of fixing the problem. You refuse to build in quality.

Now this is not saying that you should not target high risk tasks proactively and continually audit or assess these areas to ensure nothing has changed or is different. This type of inspection must still occur.

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Pictures from the Public 2-Day TapRooT® Incident Investigation & Root Cause Analysis Course in San Francisco (Tiburon)

Tuesday, July 20th, 2010

Dana Barclay, one of our TapRooT® Instructors, sent these pictures from the Public San Francisco 2-Day TapRooT® Course …

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Oil Spill in China

Tuesday, July 20th, 2010

“China rushed to keep an oil spill from reaching international waters Tuesday, while an environmental group tried to assess if the country’s largest reported spill was worse than has been disclosed.

Crude oil started pouring into the Yellow Sea off a busy northeastern port after a pipeline exploded late last week, sparking a massive 15-hour fire. The government says the slick has spread across a 70-square-mile (180-square-kilometer) stretch of ocean.”

Read more here:http://news.yahoo.com/s/ap/20100720/ap_on_bi_ge/as_china_pipeline_explosion

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Pictures from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Fenner Dunlop

Monday, July 19th, 2010

Dennis Osmer, one of our TapRooT® Instructors, sent these pictures from the 5-Day Course for Fenner Dunlop. Students hard at work learning by doing (an exercise).

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Need training at your site? Please call us at 865-539-2139 or click here to e-mail your request.

The Building Blocks of a Good Quality Program… is it in the Name?

Thursday, July 8th, 2010

TQM, TQC, TOC, PDCA, Six Sigma, Lean, Lean Sigma, MBO, 8D… just to mention a few Quality Programs many in the world of Quality have been exposed to…. but is it the name of or the effectiveness of the process that make a good Quality Improvement Program? Seems like a silly question until you have lived in the world of change.

…..”Six Sigma is not the same as TQM”

…. “Lean Six Sigma is definitely better than Six Sigma”

…. “Is it a Lean Project or a Six Sigma Project?”

Each new buzz was normally preceded by a period of frustration, low morale and a loss money followed by blame or a feeling of hopelessness. Often employee’s were also taught the term of “empowerment” which led to suggestions with no follow up by management. Each time a new process with a new name was introduced, we would “throw the baby out with the bath water.” So a new name was also perceived by many as reinventing the wheel in the name of rebuilding an Effective Quality Program.

So why reinvent the wheel? Why not forgot the name, identify the strengths and weaknesses of your current quality program processes and improve what really needs to be improved. This is the proper way to spend your money and time for the best return on investment and acceptance of your employees.

So the burning platform, pain and frustration felt by many in charge of ensuring quality processes sustain, is still a current issue addressed by many professionals that I met at ASQ World Conference this year. They were not arguing on whether it was 8D or Lean Six Sigma. The good thing is that many are realizing that numerous tools and processes previously divided into opposing teams can be combined without a large new program investment.

With that said one area of common interest by many at the ASQ Conference was Root Cause Analysis. The interest was not in how to calculate significance or sigma level because most there could calculate these with their eyes closed. The interest was in how to reduce bias, widen root cause perspectives and to add more qualitative substance behind the numbers. There were two Root Cause Booths at the conference….. guess whose booth had the most traffic, the TapRooT® Booth where we were able to share a portion of our process that could easily be combined with all the current processes listed above to gain more value and quality sustainability.

Every other week on this blog, I will dig a little deeper into current Quality Program frustrations. To help guide these posts to your quality needs, please chime in and post your issue of the week.

Here is the previous article in case you missed it: http://www.taproot.com/wordpress/category/quality/

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What’s in the TapRooT® Book?

Wednesday, July 7th, 2010

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When we first released the new TapRooT® Book, I published a copy of the Table of Contents. After my article last week, some people have been asking, “What’s in the new TapRooT® Book?” To find out, go to this link:

http://www.taproot.com/wordpress/2008/05/12/whats-in-the-new-taproot®-book/

Where Would You Like a TapRooT® Course in 2011?

Tuesday, July 6th, 2010

I’m preparing our course public TapRooT® Course schedule for 2011 and I’d like your help.

If you would like to attend a course OR if you have some people to send to a public TapRooT® Course, I’d like to get your ideas about WHERE to hold the training.

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So let me know the following by leaving a comment to this article:

1. WHERE would you like the course?

2. WHAT KIND of course? (2-Day, 5-Day, Equifactor®)

3. How many people would you plan to send?

So please let me know ASAP and I’ll get the plans set for 2011.

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When is the last time you have Experienced Riyadh, Saudi Arabia?

Tuesday, June 29th, 2010

While this was my third tour to Saudi Arabia, this was my first true Saudi Culture experience while in Riyadh. My first two trips were with the United States Air Force for two tours of duty. These pictures are posted with great appreciation to the employees (my friends) from the Saudi Food and Drug Authority.

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Until recently, skyscrapers were not allowed to be built (a night time picture from the skybridge)…..

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Experiencing Authentic Arabic Cuisine

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History of and formation of a Unified Saudi Arabia
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The first Medical Devices in Saudi Arabia
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What Color is Your TapRooT® Book?

Tuesday, June 29th, 2010

I had a TapRooT® User call me and ask a question about finding root causes using TapRooT® in an investigation. I said, “That’s covered in  Chapter 3 of the TapRooT® Book.

He said, “I tried looking in the book and didn’t see anything.

I looked up the page number and gave it to him. He replied, more puzzled, “I still don’t see it.

That’s when I realized we weren’t talking about the same book. I asked, “What color is your book?” He answered, “Sort of a cream color.

It was the old 1996 three ring binder version!

He was two versions behind the times!

More than 12 years out of date.

He promised to upgrade.

How about you?

If your TapRooT® Book has a green cover, you are using the 2000 version. You’re eight years behind the 2008 TapRooT® Book.

Next, check your Dictionary and Tree. Make sure they are the 2007 version.

Also, do you have the spiral bound Corrective Action Helper® Guide?

It’s always amazing to me that people would get so out of date with a technology that is so important to performance improvement.

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Get the latest knowledge. Upgrade to the BLACK 2008 TapRooT® Book. We are busy producing the second printing (almost 20,000 sold). It will be around for a long time.

Call 865-539-2139 to order yours or go to the TapRooT® Store.

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What is an “Accident”

Thursday, June 24th, 2010

After I started writing about the BP/Transocean Deepwater Horizon accident, I’ve had several people write me that I should stop using the term accident because it implies there is noting that can (or could have) been done to stop “an accident” from occurring.

So I thought I would look up an official definition of the word and see if I was misusing the term.

Here’s the definition from Merriam-Webster’s On-Line Dictionary:

1 a : an unforeseen and unplanned event or circumstance b : lack of intention or necessity : chance <met by accident rather than by design>

2 a : an unfortunate event resulting especially from carelessness or ignorance b : an unexpected and medically important bodily event especially when injurious <a cerebrovascular accident> c : an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought d —used euphemistically to refer to an involuntary act or instance of urination or defecation

3 : a nonessential property or quality of an entity or circumstance <the accident of nationality>

I think the definition covers events like the BP/Transocean Deepwater Horizon explosion, the BP Texas City refinery explosion, Three Mile Island, … . Especially when you consider 2 a.

2 a :  an unfortunate event resulting especially from carelessness or ignorance.

Also, you might think about definition 2 c.

2 c : an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought 

In both of these cases you can do something (or could have done something) to prevent the accident.

Accidents are not “unpreventable.” They are un-prevented.

Therefore, I will continue to use the word accident knowing that we can do something about accidents. Either proactively (before they happen to prevent them) or reactively (after they happen to prevent them from happening again).

After all, that’s what TapRooT® is all about – proactively or reactively preventing accidents.

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Hot Topics in this Week’s Edition of the TapRooT® Friends & Experts e-Newsletter!

Tuesday, June 22nd, 2010

Hot Topics:

President Names “Independent” Blue Ribbon Commission to Investigate Gulf Oil Spill – Are They Qualified? (Join Discussion!)

MSNBC Investigates Scandal of BP Deepwater Horizon Incident – Corporate Homicide? (Join Discussion!)

Are We Blaming BP Rather Than Learning From What Went Wrong? (Join Discussion!)

How Long Must We Wait to Learn? (Join Discussion!)

and Timely Articles:

Are Fatigued Doctors the Only Answer?

Management Systems: Do You Have One?

The Safety Pyramid and Its Impact on Safety Performance Improvement

An ASQ Discussion on Quality, Root Cause Tree, and the Ishikawa Diagram

Career Development: Take a Vacation!

Which TapRooT® Summit Track is Right for You?

VIEW MORE in the North American edition and (to view course listings outside of North America, view the International edition) of the Friends & Experts e-Newsletter: Latest News Updates.

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Pictures from the Final Exercise at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course for Dolphin Energy in Abu Dhabi

Saturday, June 19th, 2010

The end of another successful course …

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Root Cause Analysis Tip: An ASQ discussion on Quality, Root Cause Tree, and the Ishikawa diagram (also called fishbone diagrams or cause-and-effect diagrams)

Wednesday, June 16th, 2010

Dave Janney and I recently had a great opportunity personally talking one to one to over 450 plus ASQ (American Society for Quality) Members in St. Louis at the ASQ World Conference. There were 1,000 plus members present but I want to focus on the one on one discussions in this tip of the week.

Discussion Tip 1: “The TapRooT® Root Cause Tree is definitely more than a Fish-Bone and 5-Why tool!”

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A Director of Quality walked up to our booth and looked at the back of our Root Cause Tree. Seeing some of the Basic Cause Categories such as: Human Engineering, Management System, Training, Work Direction……. He stated, “that looks a little like the Categories on the Ishikawa Diagram, what is the difference? Why would I as an expert need to use it?”

So I put him through the test and covered up the multiple research and industry based Root Causes under our Basic Cause Category of Human Engineering. Then calling this the “Man/Person” section of the Diagram I asked, ” with your expert knowledge with man/person in quality, what human engineering questions would you ask?”

He stopped and realized that this was not his area of expertise. We have 7 areas of expertise to help you analyze your problems… In simpler form, you as the quality director have 7 more experts sitting next to you that are usually not present when developing your Ishikawa diagram.

Also remember, it is not how many questions you ask! What you ask and how you ask it is what will give you an effective Root Cause Analysis.

Discussion Tip 2: “I already have a list of common Root Causes developed by ABC Inc., why get a new process?”

This question came from a Tier 1 Supply Quality Leader. So my first question was, “which category do you see selected most often during a Root Cause Analysis?” His response, “depends on which department lead the investigation.”

Caution of the day, if the investigator is steering the analysis then you have a Root Cause Tool that allows bias instead of facts to run the investigation. The analogy is like telling your inspectors to measure the dimensions of a cube. Each person selects their favorite measuring device and goes at it. Just do not expect them to come up with identical end measurements.

Our TapRooT® process takes you through a standard/robust question process that needs facts to say yes to or no to and not opinions. It is this true and tried process (20 years in use) that allows the Quality Inspectors to remain consistent.

Now don’t get me wrong, TapRooT® Root Cause does not replace the quantitative tools used by certified quality leaders. It does however improve the qualitative portions of your analysis.

Look for more Quality Tips and Articles to come…. there is just so much more to continuous improvement. Question? Comments?

Final Exercise Picture from the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Norway

Monday, June 14th, 2010

Mhorvan Sherret sent this photo of folks working on their final exercise at the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course held by Talisman in Norway.

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Call us at 865-539-2139 or CLICK HERE to contact us to schedule a course at your site.

Pictures from the São Paulo, Brazil, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course that was held in Portuguese

Friday, June 11th, 2010

Here’s pictures from São Paulo, Brazil. Boris Risnic, our instructtor from São Paulo, said it was a great class. You can see from the pictures that people were involved with discussion and interviews.

Boris is an experienced TapRooT® User who first learned TapRooT® while he worked at Otis Elevator, a division of United Technology. After he retired from Otis, he came to work as a Contract Instructor for SI and provides training throughout Brazil.

Interested in a TapRooT® Course in Brazil (or anywhere around the world)? Drop us a note (click here) and we will give you a quote.

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Quality Manufacturing Article of the Week: The balance between production, product safety, and speed

Thursday, June 10th, 2010

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I read this article today in ASQ Quality News Today: “Toyota’s Safety Blitz May Delay Product Plan”.

Read this excerpt and then think about it for a minute: “Some analysts warn that product development will slow as Toyota takes more time to review its quality and safety processes, and diverts resources to those areas.”

Is “warn” the right word of the day. In TapRooT® Root Cause Analysis Training we teach problem facilitators not to be judgmental when writing down facts…. it is best to keep a root cause analysis objective and nonemotional. Of course most of us are all human so what did you feel or infer when you heard the word “warn”?

My thoughts? Isn’t the rapid pace of new products tied to the current massive recalls? “Warn” sounds like there is worry that new products in the pipeline may now have to be delayed which $$$ people feel may be bad for future return on investment based on expected delivery dates?

Now the good news is the great response to the quote above from project general manager for vehicle safety Seigo Kuzumaki. He stated that shifting resources to safety was the right compromise at the right time. “Toyota needs to move faster to respond to customer needs,” he said.

..any comments?

Picture from the 5-Day TapRooT® Advanced Root Cause Analysis Course for Talisman in Norway

Wednesday, June 9th, 2010

Mhorvan Sherret (one of our instructors from Scotland) sent this picture of Kevin Palardy (one of our instructors from Canada) teaching at a 5-Day TapRooT® Course for Talisman in Norway.

Yes, our courses do have an international flavor.

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If you want training anywhere around the world, contact us by clicking here.

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Pictures from the Niagara Falls Public 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course

Monday, June 7th, 2010

Brian Tink, one of our TapRooT® Instructors from Canada, sent these pictures from the recent 2-Day TapRooT® Root Cause Analysis Course in Niagara Falls, Ontario.

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If you are ready to attend some highly interactive, highly rated training to learn tools that will help you perform effective, repeatable root cause analysis that has been proven to stop problems and change performance for the better … see our upcoming courses at:

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