Category: investigation

2018 Global TapRooT® Summit Best Practices – Implement a Dedicated Investigation Team

May 17th, 2018 by

After you’ve attended a TapRooT® course and learned how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? And what do team members require to optimally focus on the actual investigation process?

At the 2018 Global TapRooT® Summit, attendees listened and learned about implementing best practices for a dedicated investigation team. Shelley Hassen, HSE Assurance & Compliance Manager, Willbros, a leading contractor in specialty energy infrastructure, was an informative part of this discussion, as you will learn from this Vimeo.

 

 

For another look at Shelley’s insights into best practices, see the blog, Success Story Contest: Saving Time, Resources & Effort with Single User Software.

NOTE: Remember to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Root Cause Tip: Repeat-Back Strengthens Positive Communication

May 17th, 2018 by

Misunderstood verbal communication can lead to a serious incident.

Risk Engineer and HSE expert, Jim Whiting, shared this report with us recently highlighting four incidents where breakdowns in positive communications were factors. In each circumstance, an operator proceeded into shared areas without making positive communication with another operator.

Read: Positive communication failures result in collisions.

Repeat-back (sometimes referred to as 3-way communication) can reinforce positive communication. This technique may be required by policy or procedure and reinforced during training on a task for better compliance.

Repeat-back is used to ensure the information shared during a work process is clear and complete. In the repeat back process, the sender initiates the communication using the receiver’s name, the receiver repeats the information back, and the sender acknowledges the accuracy of the repeat back or repeats the communication if it is not accurate.

There are many reasons why communications are misunderstood. Workers make assumptions about an unclear message based on their experiences or expectations. A sender may choose poor words for communication or deliver messages that are too long to remember. The message may not be delivered by the sender in the receiver’s primary language. A message delivered in the same language but by a worker from a different geographical region may be confusing because the words do not sound the same across regions.

Can you think of other reasons a repeat-back technique can be helpful? Please comment below.

Cyber Attack Root Cause Analysis

May 4th, 2018 by

(if you can’t see the video, here’s a link)

Yes .. It happened right here in Knoxville! A cyber attack on the county computer system on election night!

What is the root cause? The county is having an outside contractor look into it.

Can you use the TapRooT® Root Cause Analysis System to do a root cause analysis of a cyber security attack. Yes! People have been doing it for decades.

Monday Accidents & Lessons Learned: When There Is No Right Side of the Tracks

April 30th, 2018 by

On Tuesday, February 28, 2017, a wall section began to collapse at the top of a cutting above a four-track railway line between the Liverpool Lime Street and Edge Hill stations in Liverpool, England. From approximately 5:30 pm until 6:02 pm, more than 188 tons of debris rained down from the embankment wall collapsing across all four tracks. The Liverpool Lime Street is the city’s main station, one of the busiest in the north of England.

With the rubble downing overhead power lines and damage to infrastructure, all mainline services to and from the station were suspended. The collapse brought trains to a standstill for three hours, with a necessary evacuation of three trains. Police, fire, and ambulance crews helped evacuate passengers down the tracks. Two of the trains were halted in tunnels. Passengers were stranded on trains at Lime Street station due to power outage resulting from the collapse. A passenger en route to Liverpool from Manchester Oxford Road reported chaos at Warrington station as passengers tried to find their way home.

A representative from Network Rail spoke about the incident, “No trains are running in or out of Liverpool Lime station after a section of trackside wall, loaded with concrete and cabins by a third party, collapsed sending rubble across all four lines and taking overhead wires with it. Early indications suggest train service will not resume for several days while extensive clear-up and repairs take place to make the location safe. More precise forecasts on how long the repairs will take will be made after daybreak tomorrow.”

Read more about the incident here.

We invite you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Press Release: CSB to Investigate Husky Refinery Fire

April 26th, 2018 by

CSB

Washington, DC, April 26, 2018 –  A four-person investigative team from the U.S. Chemical Safety Board (CSB) is deploying to the scene of an incident that reportedly injured multiple workers this morning at the Husky Energy oil refinery in Superior, Wisconsin. The refinery was shutting down in preparation for a five-week turnaround when an explosion was reported around 10 am CDT.

According to initial reports, several people were transported to area hospitals with injuries. There have been no reports of fatalities. Residents and area schools near the refinery were asked to evacuate due to heavy smoke.

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

The Board does not issue citations or fines but does make safety recommendations to plants, industry organizations, labor groups, and regulatory agencies such as OSHA and EPA. Visit the CSB website, www.csb.gov

Here is additional coverage of the fire …

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http://www.kbjr6.com/story/38049655/explosion-injuries-reported-at-husky-energy-superior-refinery?autostart=true

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

Monday Accidents & Lessons Learned: Putting Yourself on the Right Side of Survival

April 23rd, 2018 by

While building an embankment to circumvent any material from a water supply, a front end loader operator experienced a close call. On March 13, 2018, the operator backed his front end loader over the top of a roadway berm; the loader and operator slipped down the embankment; and the loader landed turning over onto its roof. Fortunately, the operator was wearing his seat belt. He unfastened the seat belt and escaped the upside-down machine through the broken right-side window of the loader door.

Front end loaders are often involved in accidents due to a shift in the machine’s center of gravity. The U.S. Department of Labor Mine Safety and Health Administration (MSHA) documented this incident and issued the statement and best practices below for operating front end loaders.

The size and weight of front end loaders, combined with the limited visibility from the cab, makes the job of backing a front end loader potentially hazardous. To prevent a mishap when operating a front end loader:
• Load the bucket evenly and avoid overloading (refer to the load limits in the operating manual). Keep the bucket low when operating on hills.
• Construct berms or other restraints of adequate height and strength to prevent overtravel and warn operators of hazardous areas.
• Ensure that objects inside of the cab are secured so they don’t become airborne during an accident.
• ALWAYS wear your seatbelt.
• Maintain control of mobile equipment by traveling safe speeds and not
overloading equipment.

We would add the following best practices for loaders:
• Check the manufacturer’s recommendations and supplement appropriate wheel ballast or counterweight.
• Employ maximum stabilizing factors, such as moving the wheels to the widest setting.
• Ensure everyone within range of the loader location is a safe distance away.
• Operate the loader with its load as close to the ground as possible. Should the rear of the tractor tip, its bucket will hit the ground before the tractor tips.

Use the TapRooT® System to put safety first and to solve problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Gear up with TapRooT® in Gatlinburg

April 18th, 2018 by

Learn TapRooT® in the beautiful Smoky Mountains!

In less than a week, learn everything you need to know to conduct an investigation and develop effective Corrective Actions. A TapRooT® course can be a career booster or a professional game changer.

From beginners to experts, TapRooT® Techniques are designed for everyone. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other types of problems. Techniques learned include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. Upon course completion, attendees will receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. Most importantly, you will have the advantage of professional training in your wheelhouse and on your resume!

Attendees should bring safety incidents or quality issues from their workplace for a team exercise. These may be either written reports or, alternately, you may have knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a different problem.

For the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, we’ll gather at Hilton Garden Inn Gatlinburg on June 4. The inn offers out-the-door convenience to local highlights or for a stroll through downtown Gatlinburg.

Experience Gatlinburg
Wrapped by the hazy blue Smoky Mountains, Gatlinburg is beautiful by day and by night. Take a break from your coursework and soak up live music (and maybe some moonshine!) at one of these venues: Smoky Mountain Brewery, Crystelle Creek Restaurant and Grill, Ole Smoky Moonshine Distillery, Sugarlands Distilling Company. If you want to go farther afield, Townsend, Pigeon Forge, and Sevierville have much to offer.

Catch a show at the Space Needle or Sweet Fanny Adams Theatre. Soar up Crockett Mountain on the Gatlinburg Sky Lift by night for one of the best panoramic overlooks of the mountain town. Ascend to Ober Gatlinburg for indoor ice skating, a wildlife encounter, the alpine slide, and a scenic chairlift.

Hiking and biking are great ways to get next to nature in the Smokies. The sky’s the limit here: Cades Cove, Greenbriar, Mount LeConte, Ramsey Cascades, Laurel Falls, and so many more. Drive through Roaring Fork Motor Trail for a true taste of the grandeur of these ancient mountains. Insider’s tip: Roll your car windows down on this motor trail and listen to the force of the water.

Discover gems to explore on our Gatlinburg Pinterest page and plan your TapRooT® trip to Gatlinburg today.

Register here to advance your professional development in beautiful Gatlinburg, Tennessee.

Are you ready for quality root cause analysis of a precursor incident?

April 17th, 2018 by

Many companies use TapRooT® to investigate major accidents. But investigating a major accident is like closing the barn door after the horse has bolted.

What should you be doing? Quality investigations of incidents that could have been major accidents. We call these precursor incidents. They could have been major accidents if something else had gone wrong, another safeguard had failed, or you were “unlucky” that day.

How do you do a quality investigation of a precursor incident? TapRooT® of course! See the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book.

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Or attend one of our TapRooT® Root Cause Analysis Courses.

Evidence Collection: Two things every investigator should know about scene management

April 17th, 2018 by

You may not be part of scene management when an incident occurs at your facility but there are two things every investigator should know:

  1. Hazards that are present in the work area and how to handle them. It’s impossible to anticipate every accident that could happen but we can evaluate hazards that are present at our facilities that could affect employees and the community at large to structure a scene management plan.
  2. Priorities for evidence collection. The opportunity to collect evidence decreases over time. Here are a few things to keep in mind during, and immediately following, scene management.
    • Fragile evidence goes away.
    • Witnesses forget what they saw.
    • Environmental conditions change making it hard to understand why an incident occurred.
    • Clean-up and restart begins; thus, changing the scene from its original state.

Learn more by holding our 1-Day Effective Interviewing & Evidence Collection Training at your facility. It is a standalone course but also fits well with our 2-Day TapRooT® Root Cause Analysis Training. Contact me for details: carr@taproot.com.

 

Monday Accidents & Lessons Learned: We’re Not Off the Runway Yet

April 16th, 2018 by

NASA’s Aviation Safety Reporting System (ASRS) from time to time shares contemporary experiences to add value to the growth of aviation wisdom, lessons learned, and to spur a freer flow of reported incidents. ASRS receives, processes, and analyzes these voluntarily submitted reports from pilots, air traffic controllers, flight attendants, maintenance personnel, dispatchers, ground personnel, and others regarding actual or potential hazards to safe aviation operations.

We acknowledge that the element of surprise, or the unexpected, can upend even the best flight plan. But, sometimes, what is perceived as an anomaly pales in comparison to a subsequent occurrence. This was the case when an Air Taxi Captain went the second mile to clear his wingtips while taxiing for takeoff. Just as he thought any threat was mitigated, boom! Let’s listen in to his account:

“Taxiing out for the first flight out of ZZZ, weed whacking was taking place on the south side of the taxiway. Watching to make sure my wing cleared two men mowing [around] a taxi light, I looked forward to continue the taxi. An instant later I heard a ‘thump.’ I then pulled off the taxiway onto the inner ramp area and shut down, assuming I’d hit one of the dogs that run around the airport grounds on a regular basis. I was shocked to find a man, face down, on the side of the taxiway. His coworkers surrounded him and helped him to his feet. He was standing erect and steady. He knew his name and the date. Apparently [he was] not injured badly. I attended to my two revenue passengers and returned the aircraft to the main ramp. I secured the aircraft and called [the Operations Center]. An ambulance was summoned for the injured worker. Our ramp agent was a non-revenue passenger on the flight and took pictures of the scene. He stated that none of the workers was wearing a high visibility vest, which I also observed. They seldom have in the past.

“This has been a recurring problem at ZZZ since I first came here. The operation is never [published in the] NOTAMs [for] an uncontrolled airfield. The pilots just have to see and avoid people and animals at all times. I don’t think the person that collided with my wingtip was one of the men I was watching. I think he must have been stooped down in the grass. The only option to [improve the] safety of the situation would be to stop completely until, hopefully, the workers moved well clear of the taxiway. This is one of…many operational deficiencies that we, the pilots, have to deal with at ZZZ on a daily basis.”

We invite you to use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Where to Start When Finding Root Causes

April 11th, 2018 by

I had someone ask me the other day …

”Where do I start when finding root causes?”

To me, the answer was obvious. You need to understand what happened BEFORE you can understand why it happened.

That’s why the TapRooT® System starts by developing a SnapCharT® of what happened.

Here is a simple example.

Someone sprains their ankle while walking to their car in the parking lot.

What is the root cause.

You might think the obvious answer is …

“They didn’t have their eyes on path!”

But you are jumping to conclusions! You don’t know what happened. So start here…

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You are starting to develop the story of what happened. You keep working on the story until you have clearly defined Causal Factors …

SprainSnapwCF

That’s a lot more information! It isn’t as simple as “eyes on path.”

Now you are ready to start identifying the root causes of each of the four Causal Factors.

So, that’s where you need to start to find root causes!

Scientific Method and Root Cause Analysis

April 4th, 2018 by

Screen Shot 2018 03 26 at 2 15 18 PM

I had someone tell me that the ONLY way to do root cause analysis was to use the scientific method. After all, this is the way that all real science is performed.

Being an engineer (rather than a scientist), I had a problem with this statement. After all, I had done or reviewed hundreds (maybe thousands?) of root cause analyses and I had never used the scientific method. Was I wrong? Is the scientific method really the only or best answer?

First, to answer this question, you have to define the scientific method. And that’s the first problem. Some say the scientific method was invented in the 17th century and was the reason that we progressed beyond the dark ages. Others claim that the terminology “scientific method” is a 20th-century invention. But, no matter when you think the scientific method was invented, there are a great variety of methods that call themselves “the scientific method.” (Google “scientific method” and see how many different models you can find. The one presented above is an example.)

So let’s just say the scientific method that the person was insisting was the ONLY way to perform a root cause analysis required the investigator to develop a hypothesis and then gather evidence to either prove or disprove the hypothesis. That’s commonly part of most methods that call themselves the scientific method.

What’s the problem with this hypothesis testing model? People don’t do it very well. There’s even a scientific term the problem that people have disproving their hypothesis. It’s called CONFIRMATION BIAS. You can Google the term and read for hours. But the short description of the problem is that when people develop a hypothesis that they believe in, they tend to gather evidence to prove what they believe and disregard evidence that is contrary to their hypothesis. This is a natural human tendency – think of it like breathing. You can tell someone not to breath, but they will breath anyway.

What did my friend say about this problem with the scientific method? That it could be overcome by teaching people that they had to disprove all other theories and also look for evidence to disproves their theory.

The second part of this answer is like telling people not to breath. But what about the first part of the solution? Could people develop competing theories and then disprove them to prove that there was only one way the accident could have occurred? Probably not.

The problem with developing all possible theories is that your knowledge is limited. And, of course, how long would it take if you did have unlimited knowledge to develop all possible theories and prove or disprove them?

The biggest problem that accident investigators face is limited knowledge.

We used to take a poll at the start of each root cause analysis class that we taught. We asked:

“How many of you have had any type of formal training
in human factors or why people make human errors?”

The answer was always less than 5%.

Then we asked:

“How many of you have been asked to investigate
incidents that included human errors?”

The answer was always close to 100%.

So how many of these investigators could hypothesize all the potential causes for a human error and how would they prove or disprove them?

That’s one simple reason why the scientific method is not the only way, or even a good way, to investigate incidents and accidents.

Need more persuading? Read these articles on the problems with the scientific method:

The End of Theory: The Data Deluge Makes The Scientific Method Obsolete

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

That’s just a small handful of the articles out there.

Let me assume that you didn’t read any of the articles. Therefore, I will provide one convincing example of what’s wrong with the scientific method.

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Supposedly he did this using the scientific method. And it worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Einstein was wrong!

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were wrong but that most everyone believed … what chance do you and I have to develop the right answer during our next incident investigation?

Now for the good news.

Being an engineer, I didn’t start with the scientific method when developing the TapRooT® Root Cause Analysis System. Instead, I took an engineering approach. But you don’t have to be an engineer (or a human factors expert) to use it to understand what caused an accident and what you can do to stop a future similar accident from happening.

Being an engineer, I had my fair share of classes in science. Physics, math, and chemistry are all part of an engineer’s basic training. But engineers learn to go beyond science to solve problems (and design things) using models that have limitations. A useful model can be properly applied by an engineer to design a building, an electrical transmission network, a smartphone, or a 747 without understanding the limitations of quantum mechanics.

Also, being an engineer I found that the best college course I ever had that helped me understand accidents wasn’t an engineering course. It was a course on basic human factors. A course that very few engineers take.

By combining the knowledge of high reliability systems that I gained in the Nuclear Navy with my knowledge of engineering and human factors, I developed a model that could be used by people without engineering and human factors training to understand what happened during an incident, how it happened, why it happened, and how it could be prevented from happening again. We have been refining this model (the TapRooT® System) for about thirty years – making it better and more usable – using the feedback from tens of thousands of users around the world. We have seen it applied in a wide variety of industries to effectively solve equipment and human performance issues to improve safety, quality, production, and equipment reliability. These are real world tests with real world success (see the Success Stories at this link).

So, the next time someone tells you that the ONLY way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there is a better way to do it today.

If you don’t know how to use the TapRooT® System to solve problems, perhaps you should attend one of our courses. There is a basic 2-Day Course and an advanced 5-Day Course. See the schedule for public courses HERE. Or CONTACT US about having a course at your site.

Monday Accidents & Lessons Learned: When a snake leads you down a rabbit hole

April 2nd, 2018 by

While Lewis Carroll did not create the rabbit hole, he did turn those holes into a literal abyss down which people could fall. Today, “rabbit hole” has become a metaphor for extreme diversion, redirection, or distraction. Industries spiral down them all the time, resulting in a talespin that, sometimes, cannot be rerouted.

A Captain experienced a unique problem during the pre-departure phase of a flight. Within earshot of passengers, the Gate Agent briefed the Captain, “I am required to inform you that while cleaning the cockpit, the cleaning crew saw a snake under the Captain’s pedals. The snake got away, and they have not been able to find it.”

The incident report from NASA’s Aviation Safety Reporting System (ASRS) details the Captain’s response and reaction: “At this time, the [international pre-departure] inspection was complete, and I was allowed on the aircraft. I found two mechanics in the flight deck. I was informed that they had not been able to find the snake, and they were not able to say with certainty what species of snake it was. The logbook had not been annotated with a write-up, so I placed a write-up in the logbook. I was also getting a line check on this flight. The Check Airman told me that his father was deathly afraid of snakes and suggested that some passengers on the flight may suffer with the same condition.

“I contacted Dispatch and discussed with them that I was uncomfortable taking the aircraft with an unknown reptile condition. . . . The possibility [existed] that a snake could expose itself in flight or, worse on the approach, come out from under the rudder pedals. Dispatch agreed with my position. The Gate Agent then asked to board the aircraft. I said, “No,” as we might be changing aircraft. I then contacted the Chief Pilot. I explained the situation and told him I was uncomfortable flying the aircraft without determining what the condition of the snake was. I had specifically asked if the cleaning crew had really seen a snake. I was informed, yes, that they had tried to vacuum it up and it had slithered away. The Chief Pilot agreed with me and told me he would have a new aircraft for us in five minutes. We were assigned the aircraft at the gate next door.

“. . . When I returned [to the airport], I asked a Gate Agent what had happened to the “snake airplane.” I was told that the aircraft was left in service, and the next Captain had been asked to sign some type of form stating he was informed that the snake had not been found.”

Don’t wait for a snake-in-the-cockpit experience to improve your processes. Reach out to TapRooT® to curtail rabbit holes and leave nothing to chance.

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

March 14th, 2018 by

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Stop Assumptions in Their Tracks!

February 13th, 2018 by

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!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

4 Signs You Need to Improve Your Investigations

January 29th, 2018 by

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!

Introducing the 2018 Global TapRooT® Summit Software Track

January 25th, 2018 by

Ken Reed has some exciting news about the TapRooT® Software Track. If you use TapRooT® software or if you investigate accidents and incidents and are interested in what TapRooT® software can do for you, register today!

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Angie ComerAngie Comer

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Anne RobertsAnne Roberts

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Barb CarrBarb Carr

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Chris ValleeChris Vallee

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Dan VerlindeDan Verlinde

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Dave JanneyDave Janney

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Garrett BoydGarrett Boyd

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Ken ReedKen Reed

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Linda UngerLinda Unger

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Mark ParadiesMark Paradies

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Success Stories

Many of us investigate accidents that the cause seems intuitively obvious: the person involved…

ARCO (now ConocoPhillips)

We started using TapRooT® in the mid 1990s after one of our supervisors wanted to instill a more formal process to our investigations…

CONOCO PHILLIPS
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