Author Archives: Mark Paradies

Root Cause Analysis Audit Idea

Posted: March 22nd, 2018 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips

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In the past couple of years has your company had a major accident?

If they did, did you check to see if there were previous smaller incidents that should have been learned from and if the corrective actions should have prevented the major accident?

I don’t think I have ever seen a major accident that didn’t have precursors that could have been learned from to improve performance. The failure to learn and improve is a problem that needs a solution.

In the TapRooT® root cause analysis of a major accident, the failure to fix pervious precursor incidents should get you to the root cause of “corrective action NI” if you failed to implement effective corrective actions from the previous investigations.

If this idea seems like a new idea at your facility, here is something that you might try. Go back to your last major accident. Review your database to look for similar precursor incidents. If there aren’t any, you have identified a problem. You aren’t getting good reporting of minor incidents with potential serious consequences.

If you find previous incidents, it’s time for an audit. Review the investigations to determine why the previous corrective actions weren’t effective. This should produce improvements to your root cause analysis processes, training, reviews, …

Don’t wait for the next big accident to improve your processes. You have all the data that you need to start improvements today!

What does bad root cause analysis cost?

Posted: March 7th, 2018 in Accidents, Performance Improvement, Pictures, Root Cause Analysis Tips, Training

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Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

Is Having the Highest Number of Serious Incidents Good or Bad?

Posted: March 6th, 2018 in Accidents, Current Events, Medical/Healthcare, Pictures

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I read an interesting article about two hospitals in the UK with the highest number of serious incidents.

On the good side, you want people to report serious incidents. Healthcare has a long history of under-reporting serious incidents (sentinel events).

On the good side, administrators say they do a root cause analysis on these incidents.

On the bad side, the hospitals continue to have these incidents. Shouldn’t the root cause analysis FIX the problems and the number of serious incidents be constantly decreasing and becoming less severe?

Maybe they should be applying advanced root cause analysis?

Highlights from the 2018 Global TapRooT® Summit

Posted: March 5th, 2018 in Performance Improvement, Pictures, Summit, Video

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Coming up with a highlight reel from the 2018 Global TapRooT® Summit is almost impossible. I always think that the Summit just can’t get any better and then we outdo ourselves planning the next one. Here are some highlights followed by the top six items attendees shared that they needed to do better at their facilities.

First, a video to share the experience…

By the way, the next Global TapRooT® Summit is scheduled for March 11-15, 2019, in Houston (Montgomery, TX) at the La Torretta Lake Resort & Spa (picture below).

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Now for my impressions of the highlights …

First, the Keynote Speakers were outstanding.

We started with Dr. Carol Gunn who gave an inspiring talk about medical errors and how to encourage error reporting and effective investigations. Carol is a TapRooT® User and medical doctor … she knows what she is talking about.

Next, we had an UNBELIEVABLE talk by Boaz Rauchwerger who told us all to take a positive approach to improvement.

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The final keynote on Wednesday was Inky Johnson. How can I explain how he inspired us? There was a long line of people who just came up to thank Inky and get their picture taken with him. If you don’t know Inky’s story. watch it below for motivation to accomplish more in life.

 

After Inky’s keynote, Carl Dixon entertained us at the Summit Reception. Here I am singing Proud Mary with him…

 

On Thursday, I was the opening keynote and concluded with a TapRooT® Implementation Gap Analysis. People shared where they needed to improve their TapRooT® implementation. What were the top 6 items they needed to do better?

  1. Use advanced root cause analysis (TapRooT®) for both reactive and proactive investigations.
  2. Use an investigation rewards program more effectively.
  3. Guide their improvement programs through management’s use of performance measures and advanced trending techniques.
  4. Proactive improvement that drives improvement success (tie with 5).
  5. Develop a leadership succession plan.
  6. Communicate improvement accomplishments successfully.

These items will help us plan sessions for next year’s Summit.

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Vincent Phipps closed out the day with his discussion of the four personality types and how to use them to communicate more effectively.

On Friday we started with the session that helped attendees develop plans to fill their program gaps (started with the gap analysis performed on Thursday).

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Then, I (Mark Paradies) interviewed Mike Williams about his experiences when the Deepwater Horizon experienced a blowout, explosion(s), and fire. Wow! What an experience. People were sitting on the edge of their seats as Mike answered my questions and all the questions from the Summit participants. We actually ran over the finish time by 15 minutes as people asked interesting questions. The lessons learned from this one session about emergency response, investigations, and safety were … UNBELIEVABLE! I learned several things about the accident that I didn’t know from the various reports (CSB, Presidential Commission, BP, or Coast Guard) that added to my understanding of the Causal Factors and root causes. There was also an important lesson for investigators about empathy and PTSD after a major accident.

And that’s just a summary of the Keynote Speakers impact. There were also some great Best Practice Sharing sessions and speakers. My favorite was the TapRooT® Users Share Best Practices Session (soon, you will be seeing videos from this session to share some of the best practices).

Here are what some TapRooT® Users had to say about their 2018 Global TapRooT® Summit experience…

 

What a Summit! Hope to see you in Houston in 2019!

Big Fines for Safety Incidents in the UK

Posted: February 27th, 2018 in Accidents, Current Events, Pictures

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$1.1m £ fine for ejection seat manufacturer after Red Arrow pilot killed. Click here.

$120k £ fine for employee injured by circular saw. Click here.

$1.4m £ fine for Tata Steel after crane crushes worker. Click here.

If you have facilities in the UK, are you doing all you can to avoid HSE issues? You should consider improving your root cause analysis to improve your efforts to stop accidents. Learn about advanced root cause analysis by CLICKING HERE. Then attend one of these public courses in the UK and Europe.

 

 

 

Great Courses! Getting Ready for the 2018 Global TapRooT® Summit…

Posted: February 26th, 2018 in Pictures, Summit, Training

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There are over a hundred people attending various TapRooT® Courses in Knoxville on Monday and Tuesday before the 2018 Global TapRooT® Summit that starts on Wednesday.

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There people taking the 2-Day TapRooT® Root Cause Analysis Training …

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and several advanced courses teaching trending, software, interviewing, human factors, safety culture, Equifactor®, and risk management.

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And the set-up is progressing for Wednesday’s 2018 Global TapRooT® Summit General Session kick-off. Looking forward to seeing you there!
 
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Comments from a TapRooT® Course Participant

Posted: February 23rd, 2018 in Courses, TapRooT

Malcolm Gresham, one of our instructors from Australia, sent me this video of a long time TapRooT® User who was attending a course for refresher training. Click the link below to watch a .mov (QuickTime) video.

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Thanks Michael for having the course and you have a great memory! Keep reading the definition! Hope to see you at the Global tapRooT® Summit one of these years!

Nuclear Plant Fined $145,000 for “Gun-Decked Logs”

Posted: February 21st, 2018 in Current Events, Human Performance, Performance Improvement, Pictures

When I was in the Navy, people called it “gun-decking the logs.”

In the Navy this means that you falsify your record keeping … usually by just copying the numbers from the previous hour (maybe with slight changes) without making the rounds and taking the actual measurements. And if you were caught, you were probably going to Captain’s Mast (disciplinary hearing).

The term “gun-decking” has something to do with the “false” gun deck that was built into British sailing ships of war to make them look like they had more guns. Sometimes midshipmen would falsify their navigation training calculations by using dead reckoning to calculate their position rather than using the Sun and the stars. This might have been called “gun-decking” because the gun deck is where they turned their homework over to the ships navigator to be reviewed.

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What happened at the Nuke Plant? A Nuclear Regulatory Commission inspector found that 13 operators had gun-decked their logs. Here’s a quote from the article describing the incident:

“An NRC investigation, completed August 2017, found that on multiple occasions during the three-month period, at least 13 system operators failed to complete their rounds as required by plant procedures, but entered data into an electronic log indicating they had completed equipment status checks and area inspections,” the NRC said in a statement.”

What was the corrective action? The article says:

“The plant operator has already undertaken several corrective actions, the NRC said, including training for employees, changes in the inspection procedures and disciplinary measures for some staff.”

Hmmm … training, procedures, and discipline. That’s the standard three corrective actions. (“Round up the usual suspects!”) Even problems that seem to be HR issues can benefit from advanced root cause analysis. Is this a Standards, Policy, and Administrative Controls Not Used issue? Is there a root cause under that Near Root Cause that needs to be fixed (for example, Enforcement Needs Improvement)? Or is discipline the right answer? It would be interesting to know all the facts.

Want to learn to apply advanced root cause analysis to solve these kinds of problems? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the upcoming public courses by CLICKING HERE. Or CLICK HERE to contact us about having a course at your site.

Summit Details for Attendees

Posted: February 20th, 2018 in Pictures, Summit

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Are you attending the 2018 Global TapRooT® Summit? Here is some important information…

Link to Summit Presentation Slides … CLICK HERE

Knoxville Convention Center layout…

The address is: 701 Henley Street, Knoxville, TN 37902.

The security/lost and found number there is: 865-251-6040.

Emergency muster site during the Summit …

Summit Schedule

Bring Business Cards … You need these for networking.

Dress for Summit … Business Casual. Definitely bring a coat or sweater because it can be cold in February and March in East Tennessee. Here is a picture of “Business Casual” from the internet …

I thought it was too dressy. I found this “do and don’t” photo and had a laugh …

Then I thought … Why not show a photo of people from a past Summit!

Food: Breakfast and lunch are supplied at the Summit and at the pre-Summit courses. There will also be food and drink at the Wednesday night reception. We will try as best as possible to accommodate special meal requests but … you don’t get your own private chef!

Reception on Wednesday: Plan to attend the Wednesday night TapRooT® Summit Reception. There will be live music, food, and drinks. It is a great place to meet and make friends. Your spouse is invited, too. Carl Dixon and band will provide musical entertainment.

Be On Time: Don’t miss the OPENING WELCOME at 8 AM on Wednesday. You will have three people looking to meet you during THE NAME GAME and a reward for completing the game. Also, you will get a ticket for a prize drawing whenever you are on time for a session.

Breakfast Activities: Breakfast on Thursday and Friday is from 8 to 9. On Thursday, the breakfast activity will be a Version 6 TapRooT® Software trial. If you want to learn more about the TapRooT® Software, come to breakfast at 8 AM. On Friday, we will prepare for the keynote presenter, Mike Williams, with a review of the Deepwater Horizon accident.

DON’T LEAVE EARLY! Friday is an important day at the Summit. The Gap Analysis Session will help you design the improvements your company needs. You will go back to work with a planned mission to improve. PLUS the final speaker is Mike Williams – the real life hero from the movie Deepwater Horizon. We are doing a question-and-answer format; so if you have questions about the accident, get answers from someone who was there. Don’t schedule your flight until the afternoon. Or stay until Saturday and have time to meet and talk with Mike after his presentation.

Follow us on Twitter and use the hashtag #taprootsummit (Learn more.)

If you have any questions about anything regarding the Summit, call our office at: 865-539-2139.

Deepwater Horizon … The Movie

Posted: February 20th, 2018 in Accidents, Current Events, Documents, Pictures, Summit, Video

Last night, to prepare for the 2018 Global TapRooT® Summit, I watched the movie Deepwater Horizon.

I’m interviewing Mike Williams (who was played by Mark Wahlberg in the movie … see the trailer above).

I have a hard time watching the movie. The needless death of those men and the needless pain and suffering of the rest of the crew was totally avoidable.

What we do at System Improvements is to teach people to use TapRooT® Root Cause Analysis to find and fix the root causes of problems BEFORE major accidents happen. This could have been done BEFORE the Deepwater Horizon accident. I sometimes think that I didn’t do enough to get people who don’t use TapRooT® to fix problems and improve performance. If only I could have convinced BP and Transocean to use TapRooT®, maybe the accident would have been prevented.

That’s why we hold the TapRooT® Summit each year. It is one more way to get people fired up about performance improvement and stopping major accidents.

Hope to see you next week at the Summit and spend an hour talking to a survivor of the Deepwater Horizon accident.

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If you want to watch the movie before the Summit, you can download it at Amazon by CLICKING HERE.

Or you can read the Presidential Commission report, by clicking on this link: DEEPWATERPresidentCommission.

Ot read the Chemical Safety Board Executive Summary report: CSB BP Deepwater Horizon Exec Summary.

Frequently Asked Questions Page of the 2018 Global TapRooT® Summit Web Site

Posted: February 14th, 2018 in Summit

What are some of the most frequently asked questions about the Global TapRooT® Summit? See the FAQ page by clicking below.

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Stop Assumptions in Their Tracks!

Posted: February 13th, 2018 in investigation, Investigations, Root Cause Analysis Tips

Assumptions can cause investigators to reach unproven conclusions.

But investigators often make assumptions without even knowing that they were assuming.

So how do you stop assumptions in their tracks?

When you are drawing your SnapCharT®, you need to ask yourself …

How do I know that?

If you have two ways to verify an Event or a Condition, you probably have a FACT.

But if you have no ways to prove something … you have an assumption.

What if you only have one source of information? You have to evaluate the quality of the source.

What if one eye witness told you the information? Probably you should still consider it an assumption. Can you find physical evidence that provides a second source?

What if you just have one piece of physical evidence? You need to ask how certain you are that this piece of physical evidence can only have one meaning or one cause.

Dashed Boxes

Everything that can’t be proven to be a fact should be in a dashed box or dashed oval on your SnapCharT®. And on the boxes or ovals that you are certain about? List your evidence that proves they are facts.

Now you have stopped assumptions in their tracks!

New TapRooT® Family Member

Posted: February 12th, 2018 in Current Events, Pictures

Sat hello to Lucy Belle … an 8 lb 8 oz girl.

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Pass along congratulations to the proud mom, Amanda Biesbroeck (our Corporate Counsel) by leaving a comment below!

Carl Dixon returns to the 2018 Global TapRooT® Summit!

Posted: February 9th, 2018 in Current Events, Summit, TapRooT, Video

Carl Dixon, who sang and played with Coney Hatch, April Wine, and The Guess Who, is back at the 2018 Global TapRooT® Summit as the entertainment for our reception. Don’t miss the great music and good times!

Here’s a video from back in the day – Carl and Coney Hatch …

and April Wine …

And here is Carl in 2010 with the Guess Who …

And finally CARL SINGING “No Sugar” with The Guess Who in 2016 …

How far away is death?

Posted: February 8th, 2018 in How Far Away Is Death?, Pictures

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Just one more ladder and …

What is the Fastest Way to Get Fired After an Accident?

Posted: February 7th, 2018 in Accidents, Performance Improvement, Pictures, Training

If you work at a blame-oriented company, the answer to the question above is easy. Just admit that you were the last person to touch whatever went wrong that caused the accident.

Or, if you are in the Navy, all you have to do is to be the CO of a ship that has a collision at sea.

A slower way to get fired is to be the Plant Manager or Division Manager who doesn’t have good answers when he or she is asked by the corporate VP, “What are you going to do to prevent a repeat accident in the future?” Actually, they probably don’t fire someone this high in the organization. Rather, they transfer them to a staff job where they are never heard from again.

What is the best way to avoid being fired? Don’t have the accident in the first place! Instead, have a proactive improvement program that identifies problems, finds their root causes, and effectively fixes them before an accident happens.

Want to learn more about using TapRooT® in a proactive improvement program? Attend Dave Janney’s pre-Summit course: TapRooT® for Audits.

What’s covered in the course?

DAY ONE

  • TapRooT® Process Introduction and Initial Audit
  • SnapCharT® and Exercise
  • Significant Issues and Exercise
  • Root Cause Tree® and Exercise
  • Generic Causes
  • Corrective Actions and Exercise

DAY TWO

  • The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
  • Audit Programs, Trend and Process Root Cause Analysis
  • TapRooT® Software Introduction
  • Frequently Asked Questions about TapRooT®
  • Final Audit Observation Exercise

Don’t miss this course coming up quickly on February 27-27 in Knoxville, TN. Register by CLICKING HERE.

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Friday Joke: Safety Pizza Party

Posted: February 2nd, 2018 in Accidents, Jokes, Video

This reminds me of a cookout safety lunch celebration. Something in the food went bad and many got sick.

Emmett – Newest Addition to the TapRooT® Family

Posted: February 1st, 2018 in Uncategorized

Proud father Garrett Boyd sent us this photo of his newborn son, Emmett…

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Send Garrett congratulations by leaving comments here…

 

Carl Dixon at the 2018 Global TapRooT® Summit Reception

Posted: February 1st, 2018 in Accidents, Current Events, Summit, TapRooT, Video

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

Where Do You Get Ideas To Improve Root Cause Analysis?

Posted: January 31st, 2018 in Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, Summit, TapRooT, Training, Video

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

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 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

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Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

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Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

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People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

4 Signs You Need to Improve Your Investigations

Posted: January 29th, 2018 in investigation, Investigations, Performance Improvement, Summit, TapRooT

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.

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FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.

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SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

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You can download the matrix that Jack uses here: http://www.taproot.com/content/wp-content/uploads/2015/04/RateRootCauseAnalysis11414.xlsx.

Don’t be satisfied. Continually improve your root cause analysis!

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

Posted: January 29th, 2018 in Accidents, Current Events, Investigations, Pictures

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On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

CSB to Investigate Fatal Well Explosion in Oklahoma

Posted: January 27th, 2018 in Accidents, Current Events, Investigations

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

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CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

Have FUN at the 2018 Global TapRooT® Summit!

Posted: January 25th, 2018 in Current Events, Pictures, Summit, TapRooT, Video

We don’t want the 2018 Global TapRooT® Summit to be boring. We want you to meet smart industry leaders, learn amazing best practices, and have fun!

Learning while having fun is much more effective that trying to stay awake during boring presentations. That’s why we organize the Global TapRooT® Summit to have activities, Keynote Speakers, and sessions that are active and entertaining.

Plus we start with the Name Game and have an excellent Reception on Wednesday.

This year we will again have rock star Carl Dixon as our entertainment at the reception where you can network with the new friends and important contacts that you have established.

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Here’s Carl back in the day playing with April Wine …

And more classic rock from Carl and April Wine …

And just one more …

I think he is even better today. Don’t miss the 2018 Global TapRooT® Summit reception!

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Our ongoing, sustained effort is to make jobs safer and to reduce (and eventually…

Otis Elevator, Russia

Saving Time, Resources & Effort using TapRooT® Sofware Submitted by: Shelley Hassen, HSE Assurance & Compliance Manager Company: WILLBROS Canada Challenge Our company was utilizing the Web Based version of the TapRooT® Software globally to perform and record all RCAs but our work is very project-based and often in remote locations with internet connectivity issues. …

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