Root Cause Analysis Blog

I’ve heard of cutting off the branch you are sitting on, but this is a little bit different.

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(link to pictures with major findings highlighted)

If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.

It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?

A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.

My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.

Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.

For details, see:

http://www.nukeworker.com/job/view.php?job_id=6700

Why do articles about medical errors have an erie similarity?

The latest article comes from the Irish Medical Times. It tells the stories of two deaths from medical errors, the aftermath of litigation, and a failure to learn.

I’ve seen this article dozens of times. It could be written in the US, Canada, the UK, Australia, and many other countries. Which brings me to the question:

Is the Healthcare Industry Ready to Change?

I hope the time has come. Harry Wetz of Integris Health and I have worked hard to develop a useful, diverse, insightful Medical Error Reduction Best Practices Track for the TapRooT® Summit. The knowledge from this track plus the knowledge available about root cause analysis (either in the 2-Day TapRooT® Course or the 2-Day TapRooT®/FMEA Course before the Summit) could help a hospital that is willing to change make major strides to stop medical errors.

What’s in the Medical Error Reduction Best Practices Track? Here’s a list:

• Morbidity & Mortality Reviews (Hot Case Rounds) - Dr. Johnny Griggs, MD, Tommy Garnett & David Davies, PS2C2

• The Human Design Spec: Minimizing Human Error While Working in a 24/7 Medical Environment - Bill Sirois, VP & COO, Circadian Technologies

• MEDCAS - Richard Cook, Anesthesiologist, University of Chicago Medical Center

• Improving Patient Safety & Reducing Risk Go Hand-in-Hand - Leilani Kicklighter, The Kicklighter Group

• Measuring Performance - Dr. Joel Haight, Professor, Penn State

• Process for Running a Healthcare Root Cause Analysis - Tommy Garnett & David Davies, PS2C2

• TapRooT® User Success Stories from Industry & Healthcare - Linda Unger

• “Outside the Box” Creative Solutions - Michele Lindsay, P2, Canada

Also, participants will hear from five very interesting and motivating Keynote Speakers:

• Nikki Stone - Olympic Champion

• Lt. Col. Ralph Hayles - Gulf War I Veteran

• Carolyn Griffiths - Chief Inspector of the UK Rail Accident Investigation Board

• Ed Frederick - Operator during the Accident at Three Mile Island

• Marcia Wieder - America’s Dream Coach

In addition to these great sessions and speakers, there will be outstanding networking and best practice sharing that goes beyond the typical “medical industryt only” sessions. The Summit will have international performance improvement experts from a wide variety of industries who medical industry personnel can share ideas and learn from.

The good news is that there is still time for healthcare professionals to sign up for the Summit that is being held on June 25-27 in Las Vegas. For registratio, see:

http://taproot.com/summit-single.php

Now is the time to learn practical, proven methods to improve performance and stop the next “medical error” article by eliminating bad practices and implementing good practices.

See:

http://skorcareer.com.my/jobs/engineer-mmc-utilities/engineering/2008/05/

The Air Force Link reports that Col. Richard Haddan will chair an investigation board looking into a recent crash of a T-38 training jet. The crash killed Maj. Brad Funk and his student, 2nd Lt. Alec Littler.

No other information will be released prior to the completion of the board’s investigation.

(Investigators gone wild!)

SPARE TIME INVESTIGATIONS

I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!

(Spare time maintenance.)

SOMETHING FOR NOTHING

Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

- Poor investigations & corrective actions

- Repeat incidents

- Increased risk of big accidents

- Risk of regulatory action after a big accident or because of repeat incidents

- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

- Overworked, disheartened investigators

- Investigators trying to dodge investigation assignments

- Disenchanted employees who look at investigations as a waste of time

- Inaccurate investigation statistics

- Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.

(Climb the ladder to work on the roof. A reasonable assignment?)

REASONABLE ASSIGNMENTS

If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

HOW MUCH WORK?

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”

(Benchmarking at the Summit.)

BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES

Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!

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

Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.

Here’s a video of the crash that caused the investigation we previously reported on.

I’ve seen the pictures of landings over this beach, but this is the first video…

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

A subway accident is scary. On Sunday, the derailment of one wheel on two cars of a subway train required 449 passengers to be evacuated on a “rescue train.”

The accident caused Monday commuter service to be disrupted.

For more info, see the AP article at:

http://www.nj.com/news/index.ssf/2008/05/nycs_r_and_n_subway_lines_are.html

72 people have died after an accident in east China. The corrective action that has made headlines is the firing of officials. So far, eight have been fired. For a story with more information, see:

http://afp.google.com/article/ALeqM5gVmWAIUCA2mL6PlOR8ySRM3eHJmw

Is this effective corrective action?

For details, see:

http://www.myedinburghjobs.co.uk/Jobsite/Jobs/783596/Health-Safety-Manager

For more details, see:

http://www.expatengineer.net/jobs.nsf/z/129516

For details, see:

http://www.eluta.ca/search?ptitle=Production+Supervisor&position=af1b3528232630ee26e5204c3e81a3b2&imo=1

http://www.hospitalcompare.hhs.gov

What hospital in your area has the best and worst record for a type of treatment that you need? See the link above, review the performance measures, and find out before you decide where to have treatment.

Fatalities at sporting events are difficult to imagine. It seems we are past the point of gladiatorial combat where the spectacle of death was part of the show. But not every sport has heard about safety. For some interesting reading, see the following articles about a fatality during a practice run for a street luge race and an actual accident at a Formula 1 race.

Street Luge Article:

http://www.kansascity.com/115/story/596177.html

Formula 1 Accident Article:

http://www.telegraph.co.uk/sport/main.jhtml?xml=/sport/2008/04/28/umkova228.xml

The difference? Engineered Safeguards!

Your body is no match for a tree at 60 miles per hour.

But your body can survive a 150 miles an hour crash into a wall if it is properly protected.

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

For details, see:

http://afp.google.com/article/ALeqM5hMTIeesS8CXfofZqKjKYIk9hOWHA

For more info see the AP story on the CNN web site.

Answer: It depends on how the child is sitting in the chair!

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

Use Safeguards Analysis to analyze this “event.”

(Click on the picture above to ply the .wmv format video)

If the truck tumbled down the hill, killing the driver and perhaps spectators, what would the Causal Factors and Root Causes be?

A press release from the CSB:

Washington, DC, April 30, 2008 - The U.S. Chemical Safety Board (CSB) announced that it will convene a public meeting on Tuesday, May 13, 2008, in Danvers, Massachusetts, to review  the final CSB investigation report on the causes of the November 2006 explosion at the CAI/Arnel ink and paint manufacturing plant.

The report examines company work practices, state and local licensing and permitting procedures, and state and national fire codes for the safe handling and processing of flammable liquids.

The meeting will begin at 6:30 p.m. at the Sheraton Ferncroft Hotel, North Shore Ballroom, located at 50 Ferncroft Road in Danvers.  The meeting is free and open to the public.  Members of the public are encouraged to attend and comment on the draft report prior to the Board’s consideration.  The meeting is expected to conclude at approximately 9 p.m.

On the night of November 22, 2006, a CAI mixing tank containing flammable heptane and alcohol solvents overheated, releasing vapor that filled the building and then ignited at about 2:45 a.m.  The resulting explosion and fire destroyed the facility and created a blast wave that damaged or destroyed dozens of nearby homes and businesses in the Danversport neighborhood.  As CSB investigators noted at a May 2007 public meeting in Danvers, the building’s ventilation system was routinely turned off at night, contributing to the accumulation of the flammable vapor.

The meeting will include a detailed presentation by the CSB investigative team of the findings and conclusions from the agency’s investigation.  In preparing the final report, investigators examined the accident site; interviewed numerous company personnel, neighbors, and officials; conducted blast modeling and laboratory testing; and examined relevant federal, state, and local regulations and standards.

The investigation team will present new safety recommendations to prevent future accidents for consideration by the Board.

Following the presentation of the CSB report and recommendations, a panel of outside witnesses will describe changes in state and local oversight of chemical facilities that have been proposed or implemented since the explosion.  Officials from the state government and the Massachusetts fire services have been invited to testify, along with a community representative.

For more information, please contact Public Affairs Specialist Hillary J. Cohen at (202) 261-3601.

Runaway barges were rounded up after a collision with a bridge on the Mississippi River. For details, see:

http://www.natchezdemocrat.com/news/2008/apr/30/all-barges-recovered-cause-accident-investigated/

A company providing aerospace and industrial products seeks a Quality Engineer with 4+ years of experience in quality engineering or quality administration positions. Knowledge and successful application of tools and techniques relating to Process Certification, Root cause analysis, Mistake proofing, standard work, cab and reduction of quality escapes is needed.

For more information, see:

http://jobs.50statejobs.com/jobdetails.cfm?jid=262919

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.

I’m not sure how a voluntary federal medical error reporting system will help. (How can voluntary data be seen as accurate?) But the system set up by law in the 2005 Patient Safety and Quality Act is starting to be implemented. See:

http://www.ama-assn.org/amednews/2008/05/05/gvsd0505.htm

See:

http://www.myedinburghjobs.co.uk/Jobsite/Jobs/762929/Health-Safety-Manager

See:
http://www.aaib.dft.gov.uk/publications/formal_reports/5_2008_oo_tnd.cfm

Be careful! If your class doors are too clear, bad things can happen…

Interesting article at:

http://www.woodtv.com/Global/story.asp?S=8230122&nav=menu44_2

See:

http://www.nukeworker.com/job/view.php?job_id=6609

See:

http://jobs.guardian.co.uk/job/509124/quality-manager?RSSSearch=100728139&gusrc=gu_jobs_box_Science&link=Science_jbx_vac

For more information see:

http://www.examiner.com/a-1363995~2_killed_in_explosion_at_coal_gasification_plant.html

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).

For details, see:

http://www.chron.com/disp/story.mpl/world/5734833.html

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.

CNN posted an Associate Press article on their web site that explains FAA efforts to get accurate reports of controller errors that lead to violations of minimum separation requirements.

These efforts follow earlier disclosures (2005) of under-reporting by the same FAA region (Dallas).

What do you do to encourage reporting of near-misses at your facility? Are people afraid to report near-misses? Do they cover up mistakes? Do you need to improve your near-miss program to get even more near-misses reported?

Perhaps you should attend the TapRooT® Summit?

The Summit is a great place to network and benchmark with industry leaders.

Attend the TapRooT® User Best Practices session and hear about industry leading programs to use root cause analysis to improve performance.

Attend the TapRooT® User Success Stories session and hear three TapRooT® Users describe the results of successful improvement programs.

Attend The Good, The Bad, and The Ugly: Rating Improvement Programs and & Incident Investigations session and participate in a evaluation/benchmarking session to evaluate your efforts and programs.

And that’s just the start. There are five outstanding Keynote Speakers and a host of other sessions.

The Summit is being held on June 25-27 in Las Vegas, Nevada. Sign up now at:

http://taproot.com/summit-single.php

Just a slight miscommunication …

The UK Rail Accident Investigation Branch (UK RAIB) has released a report on a collision between a train and a tractor near Limavady Junction, Northern Ireland, on August 2, 2007. The RAIB has made six recommendations. For the complete report see:

http://www.raib.gov.uk/cms_resources/070424_R102008_XL202.pdf

The UK Rail Accident Investigation Board has released two new reports.

The first is an investigation into the derailment of a tram at Pomona, Manchester on 17 January 2007. See:

http://www.raib.gov.uk/cms_resources/080424_R092008_Pomona.pdf

The second is an investigation into a runaway engineering wagon and its subsequent collision with a road-rail vehicle at Armathwaite, Cumbria, on 28 January 2007. See:

http://www.raib.gov.uk/cms_resources/070424_R082007_Armathwaite.pdf

Job Posting from Sysmex:

Sysmex currently has a great opportunity available for a Failure Analysis Manager in our Technical Services group based in Mundelein, IL. This position will be responsible for the failure analysis and root cause processes within Technical Services. By applying good engineering and quality process disciplines, this individual will own selection of failure analysis tools and techniques and their application to medical device technical service activities. Position calls for associate to develop and conduct training in the use and application of troubleshooting tools and will participate in field escalations to assure appropriate tools and techniques are applied to specific situations. Position will also participate in quality review activities and become a member of the QRM team. This position also requires close cooperation with the Technical Support Managers and Technical Consultant teams. This associate’s main objectives will be to realize productivity business benefits through troubleshooting process improvements in the service business.

1. Achieve business benefits by developing and applying failure analysis processes for medical instrument service and support functions.

2. Select and apply quality tools and techniques to product service processes for in-house and field based service and support such as decision tree, fault tree, cause and effect, and other six-sigma and lean quality tools.

3. Perform trend analysis on service processes to identify improvement opportunities and take actions to realize targeted improvements.

4. Support and audit the field escalation process to assure field staff applies good troubleshooting practices to quickly and accurately determine root causes of failures.

5. Trains technical service staff on effective troubleshooting and analysis processes.

6. Participate in the product quality reviews representing complaint trends and recommendations for corrective action and product improvement to manufacturing and design functions.

7. Work in a team environment with members of the Technical Consultant field escalation team and Technical Support Managers to realize serviceability and product quality improvements.

Education/Experience: Bachelors in science or engineering, 7+ years engineering/process improvement experience, ASQ certification, Lean certification and Six-Sigma experience a plus.

…to build a promising future.

If you’re ready to work in a dynamic, real-world setting and have a positive impact, then apply today!

We offer competitive benefit choices that support both physical and emotional well-being, including medical/vision/dental plans, life insurance, and company-matched 401K.

(NO THIRD PARTY.)

To apply, see:

http://www.sysmex.com/usa/career/career_ops.cfm

and type in “Failure Analysis Manager” in the search field.

An article in Advance for Nurses includes some interesting items:

Cost of a needle stick injury could = $1 million.

Fatigue, long hours, and shiftwork are a big cause of accidental needle sticks.

Best Safeguard … Go needleless.

The article is at:

http://nursing.advanceweb.com/Editorial/Search/AViewer.aspx?AN=NW_08apr14_n8p19.html&AD=04-14-2008

Needle Stick References:

http://nursingworld.org/MainMenuCategories/OccupationalandEnvironmental/occupationalhealth/SafeNeedles.aspx

Company travel policies are strange.

For example, some companies don’t allow travel to Las Vegas for conventions or meetings.

Why? The only answers that I’ve heard is that these companies believe that employees won’t work (or learn) in the “What Happens in vegas Stays in Vegas” environment that is portrayed on TV.

We’ve had courses in Las Vegas for years and can report that students who attend there learn just as well as students in other venues. But that still doesn’t satisfy some corporate policy makers.

So here is a new idea…

If your corporate travel approval team says no travel to Vegas … suggest that you attend with a chaperone. Ask your boss to attend with you to make sure that you both spend your work time productively learning all the best practices available at the Summit.

The two of you can make plans for developing your improvement program at the “Planning Your Improvements” session on Friday of the Summit.

Policies shouldn’t stand in the way of improvement. Don’t let an arbitrary rule stop the progress of your improvement program. get signed up for the Summit NOW!

Register at:

http://taproot.com/summit-single.php

The Alberta Centre for Injury Control & Research (ACICR) is recruiting an individual to work with Métis communities throughout Alberta to coordinate and integrate regional and local community support for the Alberta Traffic Safety Plan. In this role, you will partner with local Métis communities to identify traffic safety issues, develop strategies; and provide traffic safety resources which link local, regional and provincial safety initiatives. Critical to your success will be facilitating the development of traffic safety committees and networks and providing support to existing partnerships and initiatives.
The ideal candidate will have a related degree or an equivalent combination of training and experience. Knowledge and experience in the areas of traffic safety and/or community development strategies is essential along with a working knowledge of the Métis culture and Métis governance. The incumbent will work out of Edmonton in the Métis Nation of Alberta Offices and will travel extensively to Métis communities located throughout Alberta. 
Salary range for the position is $4,707.73 – $6,006.00 per month and includes an excellent benefits plan (note: the salary is currently under review and dependent on the successful candidate’s experience and education). The position is a joint initiative of Alberta Health and Wellness, Alberta Infrastructure and Transportation and ACICR for an initial term of 30 months with the possibility for extension. The final candidate must have access to a reliable vehicle and be willing to undergo a security screening.  To view full position details and to apply online, go to: http://www.careers.ualberta.ca/. 
Please forward applications before May 15, 2008 to:
Patti Stark, ACICR
School of Public Health
4075 RTF, 8308 – 114 Street
Edmonton, Alberta T6G 2E1

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…