Author Archives: Mark Paradies
4 Steps to Playing like a Champion in 2018
Posted: January 8th, 2018 in Career Development, Summit
Ever wonder what your life would feel like if you had the knowledge to live life at the top of your game? Champions know how to compete, but they are not born that way. Every champion has to first learn how to qualify for the game before they even get a chance to compete for the win.
So, how do you qualify to play?
First
Begin today by forming a mental picture of where you want to be. If you can form a strong mental picture and rehearse it, your brain will find a way to get you there. Write it down. Read it daily.
Second
Expect setbacks and move past them. Let them be lessons learned that propel you forward not anchors that weigh you down. A champion is an ordinary individual who persists through obstacles. Are expectations causing you stress? Don’t put the high expectations of others in a negative light. Expectations are really support… a belief that you can accomplish a goal.
Third
Stay focused on your mental picture of success and support yourself with positive affirmations. If you are not telling yourself that you are capable of success every single day, there is no way you are going to experience it. If you are waiting for someone else to believe in you, they are probably waiting for you to believe in yourself. Stay positive.
Fourth
Strive for improvement. You will experience wins practicing these steps but regardless of your achievements, operate under the goal of self-improvement. So, practice these steps to qualify to play, and then join us at the 2018 Global TapRooT® Summit to continue improving! Boaz Rauchwerger is our special keynote speaker on Wednesday, February 28 at 12:30 p.m., presenting “Play Like a Champion Every Day.” After his keynote, he will be presenting “Improve People Skills and Become More Productive” in a best practice session from 1:30 pm to 2:30 pm on the Alternative Sessions Track.
Boaz Rauchwerger is Speaker of the Year for Vistage International, the world’s largest organization of CEO’s. He is the founder and president of Boaz Power Corp., a Los Angeles-based high performance consulting firm. He is also an internationally-known professional business speaker for major corporations such as American Airlines, Xerox, and Toyota.
Previously, Boaz was a newspaper publisher, owned his own advertising agency and has produced corporate films as well as a network television show. He is the author of “How to Create Exceptional Outcomes – Become the CEO of a Very Successful Life.” Boaz holds a degree in journalism, public relations and advertising from the University of Tulsa.
Join us for his game-changing presentations and live your life like a champion in 2018!
Resolve to Improve!
Posted: January 2nd, 2018 in Current Events, Performance Improvement, Pictures, Summit, TapRooTOn New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:
- Get healthy.
- Get organized.
- Live life to the fullest.
- Learn new hobbies.
- Spend less/save more.
- Travel.
- Read more.
Are you surprised by any of the above? Nothing earth shattering there. Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.
Here are some work-related resolutions to consider…
- Eliminate the blame environment when someone makes a mistake.
- Stop problems from happening over and over again.
- Save time and get better results when you perform an incident investigation.
- Learn best practices to make your workplace safer and more productive.
- Become better at your job by applying state-of-the-art root cause analysis.
How do you do these things?
TapRooT®
Start by attending TapRooT® Training. See our upcoming courses here:
http://www.taproot.com/store/Courses/
Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:
http://www.taproot.com/taproot-summit/summit-schedule
And register here:
http://www.taproot.com/taproot-summit/register-for-summit
The knowledge you will gain will help you make 2018 the best year ever.
Take some time off!
Posted: December 26th, 2017 in PicturesEach week I try to write something engaging about root cause analysis, incident investigation, or performance improvement.
This week I’m taking some time off to be with the family.
I suggest you do the same.
- Stop responding to electronics.
- Stop reading e-mails.
- Put your cell phone on do not disturb.
Live in the minute and enjoy those around you for one week.
Then you can get back to the grind of making your company excellent.
Best Regards!
The Georgia State Public Services Commission Demands Root Cause Analysis of Atlanta Airport Blackout
Posted: December 21st, 2017 in Accidents, Current Events, Equipment/Equifactor®, Investigations, PicturesRead about the story in The Atlanta Journal-Constitution: http://www.ajc.com/news/georgia-regulators-demand-answers-about-atlanta-airport-blackout/nDwICT5QFrUyXOvFnZbroM/
It’s hard to believe there wasn’t a redundant transmission line and transformers to such a vital resource.
Are you interested in improving human performance? Try this four step plan!
Posted: December 19th, 2017 in Courses, Great Human Factors, Human Performance, Performance Improvement, Pictures, SummitIs discipline the main way you “fix” human error problems?
Are you frustrated because people make the same kind of mistakes over and over again?
Have you tried “standard” techniques for improving human performance and found that they just don’t get the job done long term (they have an impact short term but not long term)?
Is management grasping for solutions to human error issues?
Would you like to learn best practices from industry human performance experts?
Try this four step plan:
1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Course.
The TapRoot® System is made to reactively and proactively help you solve human performance issues. It has built in human factors expert systems that guide you to the root causes of human errors and help you develop effective fixes. The 5-Day TapRooT® Course is the best way to learn the system and get started fixing human performance issues.
See the upcoming course schedule here: http://www.taproot.com/store/5-Day-Courses/
2. Attend the Understanding and Stopping Human Error Course
At this two day class, Dr. Joel Haight, a human factors and safety improvement expert and industrial engineering professor at the University of Pittsburg (where he is the Director of the Safety Engineering Program) shares the reasons why people make mistakes and what you can do to understand the problems and fix them.
Joel is an expert TapRooT® User having extensive experience apply TapRooT® to fix human factors problems at a Chevron refinery and in the oil field in Kazakhstan. He is also an expert in applying other human performance analysis and improvement techniques. He brings this knowledge to the 2-Day Understanding and Stopping Human Error Course.
It is best if you have already attended at least a 2-Day TapRooT® Course prior to attending this course. See the course description here: http://www.taproot.com/taproot-summit/pre-summit-courses#HumanError
3. Attend the Human Factors Track at the 2018 Global TapRooT® Summit
Once a year we put together a track at the Global TapRooT® Summit that is designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s what you get at the Human Factor Track at the Summit. What are the sessions at the 2018 Global TapRooT® Summit?
- TapRooT® Users Share Best Practices – This is a workshop designed to promote the sharing of investigation, root cause analysis, and human performance best practices from TapRooT® Users from around the world. Every year I attend this session and get new ideas that I share with others to help improve performance. Many say this is the best session at the Summit because they get such great ideas and develop new, helpful contacts from many different industries.
- Top 5 Reasons for Human Error and How to Stop Them – Mark Paradies, President of System Improvements and a human factors expert, shares his deep knowledge of the top five reasons that he see’s for people making “human errors.” For each of these he shares his best ideas to stop the problems in their tracks.
- Stop Daily Goofs for Good – Kevin McManus, a TapRooT® Instructor and performance improvement expert, shares systematic improvement ideas s to prevent human error and improve cognitive ergonomics on the job.
- Using Wearables to Minimize Daily Human Errors – Using “wearables” is a technological approach to error prevention. Find out more about how it is being used and may be applied even more effectively in the future.
- Alarm Management, Signal Detection Theory, and Decision Making – Are people at your facility overwhelmed by alarms? Do the become complacent because of nuisance alarms? Dr. Joel Haight, Director of the University of Pittsburg Safety Engineering Program will discuss control system decisions, decision execution, alarm management, signal detection theory, and decision making theory and how it could be critical in an emergency situation.
- The Psychology of Failing Fixes – Why do your fixes fail to prevent human error? That’s what this session is all about!
- What is a Trend and How Can You Find Trends in the TapRooT® Data? – looking for trends in human error data is an important activity to identify generic human factors problems and take the first step to major human performance improvements. Now for the bad news. Most people really don’t understand trending. Find out what you need to know and how to put trending to work in your improvement program.
- Performance Improvement Gap Analysis – This is the session where you put everything together. Where does your program have holes? How can you apply what you have learned to fill those holes? What are others doing to solve similar problems? Put your plan together so you are ready to hit the ground running and make improvements happen when you get back to work.
And the Best Practice Sessions outlined above are only a start. You will also see five great Keynote Speakers:
Mike Williams will share his experience surviving the Deepwater Horizon explosion.
Dr. Carol Gunn will share the story of the her sisters unnecessary death in a hospital and patient safety improvement.
Inky Johnson will share his experience with a debilitating football injury and how it changed his life and helps him inspire excellence in others.
Mark Paradies will help you get the most out of your application of TapRooT®.
Vincent Ivan Phipps will teach yo to amplify your leadership skills and communication ability.
We know that the Summit will provide you with new ideas and the inspiration to implement them.
4. Get started! Analyze your human performance issues and make improvements happen!
Just Do It! get back to work and implement what you have learned. Need more help? We can provide training at your site to get more people trained in using TapRooT® so that you have help making change happen.
Don’t wait! Get your four step plan started! Register for the courses and Summit today!
Hack of safety system causes plant shutdown …
Posted: December 18th, 2017 in Accidents, Current Events, Investigations, UncategorizedJim Whiting (TapRooT® Instructor) sent me this link to a plant shutdown caused by a hack of a safety system computer code.
There isn’t a lot of specifics in the article but it does make one wonder about the applicable corrective actions and how they should be applied across the whole industry.
Old incident (2014) but is the sub fleet still overworked?
Posted: December 15th, 2017 in Current Events, PicturesCan it be true that a Nuclear Navy submarine has sat in port in Guam for six months awaiting repairs while it was suppose to be deployed? Read: “Bizarre Deployment” in Navy Times.
Secretary of the Navy Strategic Readiness Review – Management System Problems Broke the US Navy
Posted: December 14th, 2017 in Accidents, Current Events, Human Performance, Investigations, Performance Improvement, PicturesYes, “Management System Problems Broke the US Navy” is my headline.

The report to the Secretary of the Navy is much worse than I thought. The report outlines how budget restrictions and congressional leadership made the Navy conform to the structures of the Army and the Air Force and de-emphasized the role of providing seapower. That’s how the US Navy was broken. And it will be difficult to fix. (“All the King’s horses and all the King’s men couldn’t put Humpty Dumpty together again!” was a lesson learned in 1648 during the English civil war.)
Many of the problems are Management System problems as outlined in a Navy Times article about the Strategic Review report to the Secretary of the Navy. The good news is … the authors of the Strategic Review get the Management System root causes pretty much right! The bad news is that it is less clear that the Navy has the ability to fix the issues because they are a result of Congressional action (funding, ship procurement, the Defense Officer Personnel Management Act, the Goldwater-Nichols Act of 1986, and National Defense Authorization Act provisions) and the Navy’s response to congressional cutbacks (Optimum Manning, the SWOS-in-a-box, modifications to the surface warfare officer sea-shore rotations and assignments, and the 2001 Revolution in Training for enlisted personnel).
The review says that the Navy must cut back their commitments to operational requirements in “peacetime.” But that is unlikely in the near wartime footing that they Navy faces in their forward deployments.
One of the recommendations made by the Strategic Review is for the Type Commanders to implement the “Rickover Letters” that are part of the Nuclear Navy Commanding Officer reporting structure. This will only work if the Type Commanders maintain strict requirements that Admiral Rickover established in the Nuclear Navy. This has not been the culture in the conventional surface Navy – EVER. Thus this would be a dramatic cultural shift.
Navy brass in the 1980’s and 1990’s wished that sailors at sea could do more with less and that “technology” would make that possible. Unfortunately the cuts were made (Optimal Manning and Continuous Maintenance Plan) without proof of concept testing. Now, over two decades later, the chickens have come home to roost.
The USA is an island nation. We can’t exist in our modern economy without sea trade. Thus, the USA must be the premier sea power. This requirement is independent of the “War on Terror,” the “War on Drugs,” or other missions to support land forces. Somehow past Presidents and Congressional leaders have not funded the seapower mission. Thus, we find ourselves in a bind that will be hard to fix.
The people in senior Navy leadership positions have grown up in a broken system. We must now ask them to fix (restore) the system when they have never seen it work properly. The CNO in a Navy Nuke from the submarine fleet that has faced budget reductions but has not faced the same personnel and training issues. He grew up in a different culture.
By making the US Navy the “same” as the Air Force and the Army, the unique requirements of the Navy were overlooked and the Navy was broken. Can it be fixed? The recommendations of the Strategic Review could start the repair process. But it is only a start. Many uniquely “Navy” cultural and readiness issues are not addressed in the report. Plus, this report probably will not get the attention it deserves until a failure of our war-fighting ability at sea produces a major foreign policy fiasco or, even worse, economic collapse at home because our island nation is cut off from overseas supplies.
One last comment.
The Strategic Review calls for the establishment of a “learning culture.” The authors of the Strategic Review call for proactive learning instead of the current culture of punishment based reactive learning. They frequently mention the “normalization-of-deviation” as if it a relatively recent US Navy cultural problem rather than being the state of the conventional surface navy for decades (or centuries?). They should read the article about Admiral Rickover and the normalization-of-excellence to better understand the changes that are needed. Also, establishing a proactive, learning culture isn’t possible until the US Navy understands advanced root cause analysis (which current investigations and corrective actions prove that the Navy does not understand).
The recommendations of section 6.3 of the Strategic Review are putting the “cart in front of the horse.” The FIRST step in correcting the Navy’s culture is for all naval officers (senior commanders through junior officers) to understand advanced root cause analysis. Without this understanding, learning – either proactive or reactive – is impossible. We have worked with industry leaders and we know of what we speak.
I certainly hope the US Navy makes significant progress in correcting the glaring shortcomings outlined in the Strategic Review. The lives of sailors at sea depend on it. But even worse, a failure to fix the root causes of the Management System problems and the poor understanding of advanced root cause analysis will certainly lead to failures of our seapower and serious foreign policy issues that may cause tremendous economic troubles for the US. I’m old and may not see the day when we discover that under-investment in seapower was a gigantic mistake. But if this problem isn’t fixed rapidly and effectively, certainly my children and grandchildren will face an uncertain, dark future.
I would be happy to discuss the improvements in root cause analysis that are needed with any Navy leader concerned that a more effective approach is needed.
What are the favorite blog posts from this year and from all time?
Posted: December 12th, 2017 in Current Events, Pictures, TapRooTThe end of the year is coming and sometimes it is good to look back and see whats been trending for people who read this blog. Let’s look at the articles posted in 2017 and see what’s been trending …
5. How Far Away is Death? (October – above)
4. Friday Joke: An Old Nuke Navy Joke… (October)
3. US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald (August)
2. What happens when root cause analysis becomes too simple? Six problems I’ve observed. (July)
1. What is the Root Cause of the USS Fitzgerald Collision? (July)
And then let’s look back to the past to see the top five most popular articles of all time:
5. Root Cause Tip: What’s a Causal Factor? (2012)
4. 7 Secretos / secretos del análisis de Causa raíz (2011)
3. Live Your Core Values: 10 Minute Exercise to Increase Your Success (2013)
2. 7 Secrets of Root Cause Analysis (2011)
1. An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts… (2007)
Dennis Osmer – RIP
Posted: December 8th, 2017 in Current Events, Meet Our Staff, PicturesDennis Osmer, 70, TapRooT® User/Instructor and safety and ergonomics expert died on December 1, 2017 from bladder cancer.
Dennis started using TapRooT® at Novartis and became the worldwide head of occupational health, safety, environment, and emergency management at CIBA Vision.
After he retired from CIBA Vision in 2008, he became a TapRooT® Instructor and for five years helped students learn to apply TapRooT® to improve safety and quality. In addition, he helped clients by facilitating difficult investigations to stop future safety issues.
Dennis was one of our first clients to show how TapRooT® could be used to investigate and prevent ergonomics issues while working for CIBA Vision. Here is a link to the success story that he presented at the Global TapRooT® Summit: http://www.taproot.com/archives/18992. This work saved many workers the pain and suffering from ergonomic injuries in the facilities customer support and distribution departments and saved the company over $6 million dollars in workers compensation costs in the six years after the program was implemented.
Some people just have an ability to make positive change happen and Dennis was one of those people. Everyone here at System Improvements and all of his students and co-workers, as well as his family, will miss him.
See this link: http://www.legacy.com/obituaries/atlanta/obituary.aspx?pid=187407009, for his obituary and memorial.
Friday Joke: Nuclear Winter Wonderland
Posted: December 8th, 2017 in Documents, Jokes, VideoClick on the links below for a Nuclear Winter Wonderland (either a Quicktime movie or a PowerPoint)
Nuclear Winter Wonderland Movie.mov
Nuclear_Winter_Wonderland.pptx
The PPTX is the best quality.
Or try this YouTube video…
Fake News or Real?
Posted: December 6th, 2017 in Accidents, Current Events, How Far Away Is Death?, Human Performance, Investigations, Pictures, TapRooTThat’s the headline. Here is the link:
http://www.abcnews-us.com/2017/12/05/morgue-employee-cremated-by-mistake-while-taking-a-nap/
Could it really be true? I guess the funeral home industry needs TapRooT®!
(Editor’s update: After this post was published, Snopes reported this as fake news and the news story was removed. Thank goodness!)
This is “National Hand Washing Awareness Week”
Posted: December 6th, 2017 in Current Events, Medical/Healthcare, PicturesWant to prevent infections? Wash your hands!
A press release from the Henry the Hand Foundation …
National Handwashing Awareness Week Dec 3-9, 2017
In a recent article in New England Journal of Medicine “Chasing Seasonal Influenza” it was reported …according to the Australian Government Department of Health. Influenza A (H3N2) viruses predominated, and the preliminary estimate of vaccine effectiveness against influenza A (H3N2) was only 10%. The implications for the Northern Hemisphere are not clear, but it is of note that the vaccine for this upcoming season has the same composition as that used in the Southern Hemisphere.
BUT, No need to worry because in 1999 during first Flu vaccine shortage a community wide coalition created events promoting handwashing with coloring contests throughout schools and community centers and ended during the first National Handwashing Awareness Week! Result was one of the healthiest year for our community!
Share the National Handwashing Awareness Week poster with everyone you believe could benefit!! And an additional bonus is True Flu Prevention poster for those who do NOT want the flu or flu-like illness!!
Our latest innovation is the first portable self teaching Hand Hygiene Learning Center that helps students train themselves. Sized for Early Childhood age group and one for larger students, as well! Put it outside the Classroom, in the cafeteria, playground or wherever there may a norovirus/shigella outbreak!
There is a Classroom Tool Kit included to help your students sustain the habit! The addition of the Tool Kit can help train your staff, students and their families with the tools to keep them healthy year round by practicing Henry the Hand’s 4 Principles of Hand Awareness.
The BEST science-based, multi sensory curriculum in a Tool Kit that is so easy to understand it teaches itself! Your gift for Global Handwashing Day!!
In the Science of Habit, Dr Jelena Vujcic discusses the two critical components around habit : first, creating a good habit and second, is sustaining the habit. However, sustaining the habit is the more difficult component to achieve!
Visit the Henry the Hand Website.
Not Near-Misses … They Are Precursors
Posted: December 5th, 2017 in Investigations, Performance Improvement, Root Cause Analysis TipsI had an epiphany today.
Have you ever noticed how management doesn’t take near-miss incidents seriously? They don’t see them as just one step away from a fatality?
I think part of the problem may be the terminology.
Near-miss just doesn’t sound very serious. After all … it was a miss.
But what if we called these incidents PRECURSORS.
A precursor tells you that something IS going to happen unless you change.
If management saw these incidents as an indicator that something was GOING TO HAPPEN, then, maybe, they would take action.
You may have already thought of this and changed the language that you use around incidents … but I haven’t seen the words PRECURSOR INCIDENTS used very often. Now may be the time to start.
One more thing … Precursor Incidents mean that incidents that could not cause an accident ARE NOT precursors. Thus, paper cuts are not precursors of amputations.
Therefore, we can stop wasting our time investigating incidents that will never cause a serious injury.
Just a thought…
Can Your Company Afford a Second Rate Improvement Program?
Posted: November 28th, 2017 in Performance Improvement, Summit, TapRooT, VideoSometimes it seems like management’s only objective is to cut costs. Can you produce excellence and record profits by cost cutting alone? Your company needs a world-class improvement program!
How do you get a world-class improvement program? As George Washington Carver said:
Start where you are with what you have.
Make something of it and never be satisfied.
Have you become satisfied? Is it time to improve?
If you have never attended TapRooT® Training, start your improvement journey with a 2-Day TapRooT® Root Cause Analysis Course.
But most readers here have already learned the basics. They are ready for more. Perhaps a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It’s a great place to learn to improve your skills to learn to investigate difficult, high-risk incidents.
If you are looking to go beyond just improving your own knowledge and you want to improve your company’s performance improvement initiatives, try reading our new book:
TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems
CLICK HERE to get your copy.
That’s a great start but there is even more…
Would you like to benchmark with industry leaders and learn from improvement experts from around the world? Attend the 2018 Global TapRooT® Summit. Many Summit attendees have explained that attending the Summit is a great way to learn from others and make your improvement program world-class.
(Barb teaching the Effective Interviewing and Evidence Collection Course)
Improvement is a never ending cycle of discovery. What are you doing to move the process forward?
Is it time to make your improvement program world-class or are you settling for second rate performance?
A Thanksgiving Story from a Mayflower Decendant
Posted: November 23rd, 2017 in Current Events, PicturesHere is my Thanksgiving posting. I post it every year, lest we forget…
In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!
One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.
During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.
The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.
With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.
Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.
The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.
Is this the root cause of Thanksgiving?
This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:
“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”
William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.
How Do You Get Started Using TapRooT® to Improve Your Root Cause Analysis?
Posted: November 21st, 2017 in Performance Improvement, Pictures, Root Cause Analysis TipsStart where you are, with what you have.
Make something of it and never be satisfied.
George Washington Carver
When someone asks me where they should start when implementing TapRooT® to improve root cause analysis, my answer is ALWAYS:
It depends on where you are.
Your company vision makes all the difference in deciding what you need to do first to implement TapRooT® as you problem solving tool of choice.
What is your corporate vision? It is one of these three:
- Blame Vision
- Crisis Vision
- Opportunity to Improve Vision
If you don’t know about these three types of “Vision,” read about them in the TapRooT® Root Cause Analysis Leadership Lessons book.
If your company looks for problems as an opportunity to improve, you are in luck! Your company has the Opportunity to Improve Vision and you have a high probability of success! You can begin with any of the “getting started” sections of the book, TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems.
There are three main places to start that are described in the book…
Chapter 1 describes the most frequently used way to start using the TapRooT® Root Cause Analysis System: “Just Do It.” This is a fast way to see the benefits that TapRooT® Root Cause Analysis provides.
Chapter 2 describes incorporating the TapRooT® Root Cause Analysis Tools into an already existing improvement system. If you have implemented Lean, Six Sigma, TQM, RCM, TPM, ISO, Operational Excellence, Process Safety Management, Patient Safety, Behavior Based Safety, or HU, this might be the place that you choose to start implementing TapRooT®.
Chapter 3 describes a complete implementation of TapRooT® based on the best practices we have observed from TapRooT® Users from around the world. This guide to audit a “complete” implementation may seem complex. Perhaps that is why so many TapRooT® Users start with the simpler methods described in Chapters 1 and 2 and use Chapter 3 as their ultimate goal.
Read TapRooT® Root Cause Analysis Implemention – Changing the Way Your Company Solves Problems and learn more about implementing TapRooT® at your site. Or give us a call at 865-539-2139 or contact us through our web site by CLICKING HERE to discuss your options.
But whatever you do … DON”T WAIT. Problems aren’t going to get any smaller while you wait to improve your root cause analysis.
Monday Accident & Lessons Learned: NTSB Reports that “Ignored Safety Procedures, Fractured Safety Program Led to Fatal Amtrak Derailment”
Posted: November 20th, 2017 in Accidents, Current Events, Human Performance, Investigations, PicturesThis accident may seem like a simple case of a supervisor failing to make a call. However, the NTSB investigation shows there were many more issues that caused the fatalities.
Here is the press release from the NTSB:
Ignored Safety Procedures, Fractured Safety Program Led to Fatal Amtrak Derailment
11/14/2017
WASHINGTON (Nov. 14, 2017) — The National Transportation Safety Board determined Tuesday the April 3, 2016, derailment of Amtrak train 89 near Chester, Pennsylvania was caused by deficient safety management across many levels of Amtrak and the resultant lack of a clear, consistent and accepted vision for safety.
A backhoe operator and a track supervisor were killed, and 39 people were injured when Amtrak train 89, traveling on the Northeast Corridor from Philadelphia to Washington on track 3, struck a backhoe at about 7:50 a.m. The train engineer saw equipment and people working on and near track 3 and initiated emergency braking that slowed the train from 106 mph to approximately 99 mph at the time of impact.
The NTSB also determined allowing a passenger train to travel at maximum authorized speed on unprotected track where workers were present, the absence of shunting devices, the foreman’s failure to conduct a job briefing at the start of the shift, all coupled with the numerous inconsistent views of safety and safety management throughout Amtrak, led to the accident.
“Amtrak’s safety culture is failing, and is primed to fail again, until and unless Amtrak changes the way it practices safety management,” said NTSB Chairman Robert L. Sumwalt. “Investigators found a labor-management relationship so adversarial that safety programs became contentious at the bargaining table, with the unions ultimately refusing to participate.”
The NTSB also noted the Federal Railroad Administration’s failure to require redundant signal protection, such as shunting, for maintenance-of-way work crews contributed to this accident.
Post-accident toxicology determined that the backhoe operator tested positive for cocaine, and the track supervisor and tested positive for codeine and morphine. The locomotive engineer tested positive for marijuana. The NTSB determined that while drug use was not a factor in this accident, it was symptomatic of a weak safety culture at Amtrak.
As a result of this investigation, the NTSB issued 14 safety recommendations including nine to Amtrak.
The NTSB also made two safety recommendations to the Federal Railroad Administration, and three safety recommendations were issued to the Brotherhood of Maintenance of Way Employees Division, American Railway and Airway Supervisors Association, Brotherhood of Locomotive Engineers and Trainmen, and Brotherhood of Railroad Signalmen.
The abstract of the NTSB’s final report, that includes the findings, probable cause and safety recommendations is available online at https://go.usa.gov/xnWpg. The final report will be publicly released in the next several days.
The webcast of the board meeting for this investigation is available for 90 days at http://ntsb.capitolconnection.org/.
Contact: NTSB Media Relations
490 L’Enfant Plaza, SW
Washington, DC 20594
Terry Williams
(202) 314-6100
Terry.williams@ntsb.gov
Is TapRooT® Root Cause Analysis a Tool or the Whole Toolbox?
Posted: November 14th, 2017 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooTI had a self-proclaimed root cause analysis expert tell me that investigators needed lots of “tools” in their root cause analysis toolbox. For most people that leads to the question:
How many tools do I need to learn?
When we started to develop TapRooT® back in the 1980’s, we thought we just needed a tool. We soon learned that we needed a toolbox. So we went to work finding, developing, and refining the best root cause analysis tools and adding them to our root cause analysis toolbox called the TapRooT® Root Cause System.
You might ask:
What’s in the toolbox?
The TapRooT® 7-Step Major Investigation Process from the book, Using TapRooT® Root Cause Analysis for Major Investigations, shows all the major tools in the right column.
How can you learn these techniques and “fill your toolbox” with tools proven to be successful by TapRooT® Users from around the world? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See the locations and dates for our public courses around the world at:
http://www.taproot.com/store/5-Day-Courses/
But why should you learn these tools?
First, we spent decades of research and developing choosing, developing, and refining these techniques to make them the most successful root cause analysis toolbox in the world. See our user success stories at:
http://www.taproot.com/archives/category/success-stories?s=
The research and testing we performed showed us the limitations of some common root cause analysis tools that some experts try to teach and have trouble getting their students to achieve consistent results. We based our selection of techniques on human factors principles. This makes our system robust yet easy to use.
We also decided to limit the techniques we chose to those that you would really need. Most people don’t get tremendous amounts of experience performing root cause analyses. Thus, we wanted to minimize the training and practice required to use TapRooT®. We made it so that TapRooT® can be applied to low-risk incidents (simple incidents) or medium to high-risk incidents. In that way people get experience applying TapRooT® to simple incidents so that they are practiced using the techniques when something big happens (God forbid).
Also, we built human factors experts systems (AI) into the TapRooT® System to help investigators find the root causes of human errors and equipment problems.
Finally, do other root cause analysis systems provide this course guarantee:
Attend this 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.
That’s a powerful guarantee. And we can offer it because of the hundreds of thousands of people we have trained who apply TapRooT® sucessfully. We know you, too, will be successful.
Why not create your own toolbox?
You could duplicate our efforts, spend decades researching and perfecting your own toolbox of root cause analysis tools. Then you could develop training courses to teach what you learned. But guess what … your system still wouldn’t be as good as TapRooT®. Why? Because while you were doing your research, we would be improving. We constantly make the TapRooT® Books, Training, and Software better.
Besides the feedback we get from thousands of users and from classes we hold around the world, we have a TapRooT® Advisory Board that makes suggestions and reviews improvement ideas. This helps us keep making the best even better.
And one last advantage that we have … very talented instructors. We have 50 instructors at various locations around the world that have extensive experience teaching and using the TapRooT® System. And these instructors are constantly sharpening their skills. We have a link on our blog with a few profiles of our instructors but we are way behind on keeping it updated. This gives us something to improve!
If you want to learn more about TapRooT®, attend a class. Or at least see the About TapRooT® page on our web site.
What Does a Patient Want After a Medical Error?
Posted: November 8th, 2017 in Medical/HealthcareOf course, a patient would prefer that a medical error NEVER happens. Thus most people want the hospital they attend to have a great performance improvement program that proactively PREVENTS errors from occurring. However, even with the best programs, an error is still possible (even if it is highly unlikely).
A study in the JAMA Internal Medicine says that patient’s and their families want physicians and hospitals to communicate with them to explain what the facility is doing to prevent similar future incidents. We are going to try harder is not enough. They want real root cause analysis with effective corrective actions.
The study said that “Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.”
So what do patient’s want?
- Adequate compensation
- Friendly communication
- To be heard by the physician and the hospital.
- How the hospital/physician would prevent future errors
If you don’t have advanced root cause analysis you can’t meet the patient’s expectation.
Maybe it is time to learn about TapRooT® and start your facilities journey to world-class root cause analysis and performance improvement?
Where is the nearest TapRooT® Training?
Posted: November 7th, 2017 in Courses, Current Events, Pictures, TapRooTWe hold public TapRooT® Courses all over the world. See our upcoming courses at:
http://www.taproot.com/store/Courses/
If you have 10 or more people to train, you could probably save money by having an on-site course for your folks. Get a quote by CLICKING HERE.