Category: Investigations

What’s Wrong with Pharmaceutical Root Cause Analysis?

August 8th, 2018 by

Pharma

I was forwarded a copy of an interesting letter about American and Canadian Standards Boards with certifying bodies rejecting pharmaceutical quality incident reports because of poor root cause analysis. It stated that 90% of the rejections of reports were due to three types of root causes that were unacceptable (and I quote):

  1. Employee Error / Human Error / Operator Error OR anyone else who made an error is not an acceptable root cause – Was the training ineffective?  Was the procedure too vague?
  2. Misunderstood the requirement / Did not know it was a requirement / Our consultant told us this was ok OR any other misunderstandings is not an acceptable root cause.  Was the training effective?
  3. We had a layoff / Mona was on maternity leave / we moved locations / we scaled back production / we are still closing out Wayne’s 40 deviations from the last audit OR most other employee or business conditions are not acceptable root causes  They are DIRECT CAUSES.

The letter proposed four rules to follow with all future submissions:

  1. RULE #1:  The root cause can not be a re-statement of the deviation.  Example:  Deviation – Company XYZ did not document Preventive Actions as required by procedure.  Root Cause – We did not document Preventive Actions as required by the procedure.
  2. RULE #2:  There can not be an obvious “Why” that can be easily answered to the provided root cause – in this case they have not gone deep enough.  Example: Root Cause – The purchasing coordinator made a mistake and did not check to see if the supplier was approved.  Obvious “WHY” Was the training effective?  Did the procedure provide enough detail in this area?
  3. RULE #3:  The root cause can not be a direct cause.  Example:  Deviation – There were a number of internal audits scheduled for 2008 that were not completed.  Root Cause – We had a layoff and we did not have enough Internal Auditors to conduct the audits.
  4. RULE #4:  The root cause is a brief description of the cause of the problem.  We do not want any long stories regarding direct causes or what they are doing well even though this happened or who said what.  This is un-necessary detail and only adds confusion.

Wow! I would have thought this guidance would not be necessary. Are responses to quality incidents really this poor? Or is this letter a fake?

No wonder TapRooT® Users have no problem getting approvals for their root cause analysis. None of these problems would happen with any investigation using TapRooT®.

Why would TapRooT® Users never stop at the three causes listed above? Because they would understand that some are Causal Factors (the start of the root cause analysis) and they would have guidance provided by the Root Cause Tree® Diagram to help them find the real, fixable root causes of human performance and equipment failure related problems. This includes analyzing things like “internal audits not completed”; “human error”; and “misunderstood requirements.”

In addition, the TapRooT® Software helps investigators develop concise custom reports that only includes the details needed to understand what happened, how it happened, the root causes, and the effective corrective actions needed to prevent recurrence.

If you are in the pharmaceutical industry and you want to stop having problems with root cause analysis and want to start having effective investigations, root cause analysis, and fixes for problems, attend our TapRooT® Training and learn how simple advanced root cause analysis is.

TapRooT® Around the World: Onsite, Topaz Marine, Baku, Azerbaijan

August 7th, 2018 by

Enjoy a glimpse into a recent 2-Day TapRooT® Root Cause Analysis Training, held onsite at Topaz Marine, in Baku, Azerbaijan, taught by TapRooT® instructor Per Ohstrom. We appreciate Per passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Adealaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Remembering An Accident: Sayano-Shushenskaya Hydroelectric Dam

August 2nd, 2018 by

One of the world’s largest hydroelectric plants, Sayano-Shushenskaya Hydroelectric Dam, suffered a catastrophic failure On August 17, 2009, that lead to the death of 75 people, and the pollution of the Yenisei River with 40 tons of oil spilling into it. So how did a major incident like this happen?

On the day of the accident the dam was undergoing major repairs and upgrades. Nine of the ten turbines were operating at full capacity, even the troublesome  #2 turbine. This turbine had previously been offline because of persistent vibrations and maintenance issues, but it was brought back online the previous night. A fire at the Bratsk Power Station caused a drop in electricity production and the decision was made to run Turbine #2 to help with the electrical shortage.

Just before 8:13 am large vibrations were felt by a technician worker on the roof, and according to his recount of the the incident the vibrations gradually grew into a load raw. Shortly after two massive explosion occurred and turbine #2 shoot through the floor 50 feet into the air, and then it came crashing back down. The water that was spinning the turbine was now gushing out at a rate of 67,600 gallons a second. The gushing water produced massive amounts of pressure that ripped the room apart leading to the roofs collapse.

Eventually the gushing water flooded the lower levels and submerged the other turbines. Unfortunately, the plant’s automatic safety system failed to turn off turbines #7 and #9, which were operating at full capacity. This triggered short circuits that left the plant in total darkness adding to the confusion and mayhem.

Several employees struggled to manually close the pen-stock intake gates, and finally succeed at 9:30 am putting an end to the disastrous incident. Because of communication failures and system failures 75 people lost their lives, many were injured, and 40 tons of oil polluted the Yenisei River. Restoring the damage caused by the explosion took years and it cost US$89.3 million to complete.

(Before & After Photo)

To learn more about the Sayano-Shushenskaya Hydroelectric Dam incident click here.

 

Major disasters are often wake-up calls for how important it is to ensure that they never happen again.

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

Investigating Even the Smallest Problems using TapRooT®

July 31st, 2018 by

 

Many companies think about using TapRooT® only when something really significant occurs. Things like major environmental releases, or serious injuries, or expensive quality control issues. These are considered Major Investigations in TapRooT®.

Some companies are also using TapRooT® on less complex, lower risk problems. Problems such as a dropped object, a small spill from a container, or a minor first aid case might be investigated using the Simple Investigation process in TapRooT®.

However, what about REALLY simple problems? Does it make sense to perform entire TapRooT® investigations for just a simple problem that you spot on the job site? Actually, TapRooT® is EXCELLENT at helping you quickly find root causes for even small issues, before they become incidents or near misses. Think about the benefits of finding, analyzing, and fixing these tiny problems:

  • They are pretty easy to find
  • They are pretty easy to fix
  • They are pretty inexpensive to fix
  • They have the opportunity to prevent major issues in the future

Chris Vallee and I talked a bit about this on our last TapRooT® Live session.  Take a look here and let us know what you think.

Why Does Blame “Make Sense”?

July 25th, 2018 by

Think about a recent accident …

  • a ship runs aground
  • a refinery has a major fire
  • an oil well has a blowout and explosion
  • a pharmaceutical plant makes a bad batch of drugs and it gets by the QA process and customers are harmed

One thing that you can be sure of in ALL of the accidents above is that:

someone screwed up!

You never have a major accident if all the Safeguards function as designed. And guess what … we depend on human actions, in many cases, as a significant or sometimes as the ONLY Safeguard.

Therefore, when an accident happens, there is usually at least one human action Safeguard that failed.

If you are in a blame oriented organization, the obvious answer is to BLAME the individual (or team) that failed to prevent the accident. If you can find who is to blame and punish them, you can get back to work.

It MAKES SENSE because “if only they had done their job …” the accident would not have happened. Punishing the individual will set an example for everyone else and they will try harder not to make mistakes.

Sure enough, when the same accident doesn’t happen again right away, management believes they fixed the problem with blame and punishment.

I was thinking of this the other day when someone was talking to me about an investigation they had done using TapRooT®. They had recently adopted TapRooT® and, in the past, had frequently blamed people for accidents.

In this case, a worker had made a mistake when starting up a process. The mistake cost the facility over $200,000. The operator thought that she probably was going to be fired. Her apprehension wasn’t reduced when someone told her she was going to be “taprooted.”

She participated in the investigation and was pleasantly surprised. The investigation identified a number of Causal Factors including her “screw up.” But, to her surprise, they didn’t just stop there and blame her. They looked at the reasons for her mistake. They found there were three “root causes” that could be fixed (improvements that could be made) that would stop the mistake from being made in the future.

She came away realizing that anybody doing the same job could have made the same mistake. She saw how the investigation had improved the process to prevent future similar mistakes. She became a true believer in the TapRooT® System.

When you discover the real fixable root causes of human performance related Causal Factors, BLAME DOES NOT MAKE SENSE. In fact, blame is counter productive.

If people see that the outcome of an investigation is usually blame and discipline, it won’t take long until most incidents, if at all possible, become mystery incidents.

What is a mystery incident?

A refinery plant manager told me this story:

Back early in his career, he had been an engineer involved in the construction and startup of a major facility. One day when they were doing testing, the electrical power to some vital equipment was lost and then came back on “by itself.” This caused damage to some of the equipment and a delay in the startup of the plant. An investigation was performed and no reason for the power failure or the reason for the power coming back on could be found. No one admitted to being in the vicinity of the breaker and the breaker was closed when it was checked after the incident.

Thirty years later they held an unofficial reunion of people who had worked on the project. At dinner, people shared funny stories about others and events that had happened. An electrician shared his story about accidentally opening the wrong breaker (they weren’t labeled) and then, when he heard alarms going off, re-shutting the breaker and leaving the area. He said “Well, I’m retired and they can’t punish me for it now.”

That electrician’s actions had been the cause of the incident. The refinery manager telling the story added that the electrician probably would have been fired if he had admitted what he had done at the time. The refinery manager then added that, “It is a good thing that we use TapRooT® and know better than to react to incidents that way. Now we look for and find root causes that improve our processes.”

Are you looking for the root causes of incidents and improving processes?

Or are you still back in the “bad old days” blaming people when a mistake happens?

If you haven’t been to a TapRooT® Course, maybe you should go now and see how to go beyond blame to find the real, fixable root causes of human error.

See our upcoming TapRooT® Courses by clicking on THIS LINK.

Or contact us to get a quote for a course at your site by CLICKING HERE.

And if your management still thinks that blame and punish is a good idea, maybe you should find a way to pass this article along (without being identified and blamed).

What Are SnapCharT®s and Why Are They Important?

July 23rd, 2018 by

TapRooT®’s systematic process for finding the root causes of problems is used around the world to investigate and fix all categories of mission-critical issues, problems, and potential incidents. The first steps of the TapRooT® process are planning the investigation, collecting information, and understanding what happened. The investigator draws a SnapCharT® to understand what happened and to organize the information about what happened. In this Facebook Live session, you will learn more about the value and vital importance of SnapCharT®s from TapRooT® professionals Benna Dortch and Dave Janney.

Watch the session here in Vimeo.

TapRooT® has special tools—such as the Root Cause Tree® and TapRooT® Root Cause Tree Dictionary—to help investigators find root causes of Causal Factors. Our books and training through our custom courses, software and webinars, and TapRooT® professionals will educate, facilitate, and guide you through investigations into the root causes of human performance problems. Let us know how we may help you. Contact or call us: 865.539.2139.

 

The Best Incident Investigation Performance Indicator

July 18th, 2018 by

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If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:

  • Was the root cause analysis inadequate?
  • Were the corrective actions ineffective?
  • Why didn’t management or peer review catch the problem with the previous investigation?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).

Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.

Here are two examples:

  • Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
  • Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?

Cancel your lunch plans! Join TapRooT® today at noon EST!

July 11th, 2018 by

Join TapRooT® professionals Benna Dortch and Ken Reed today at noon EST for TapRooT®’s Facebook Live discussion.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, July 11

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Recently, on TapRooT®’s Facebook Live, we learned that only through effective listening will you learn to pick up on the “right” questions to ask in your investigations. TapRooT® Instructor Barb Carr gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below, featuring TapRooT® professionals Benna Dortch and Barb Carr, to review your skills:


Do your own investigation into our courses and discover what TapRooT® can do for you.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Winners and Losers in Healthcare’s Shift to Value-Based Payments

July 9th, 2018 by

 

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The 2010 Affordable Care Act (ACA) was established to shift payment away from the volume of services provided toward the quality of those services. The ACA directed the Department of Health and Human Services to create a budget neutral payment model. CMS (Centers for Medicare & Medicaid Services) published an ACA fact sheet in 2015 that can be found here.

What does budget neutral mean in this case? A very smart healthcare executive explained it to me.  She said that budget neutral means you will have losers and you will have winners. The Department of Heath and Human Services had to put a payment model in place that takes money away from the losers and gives it to the winners so Medicare doesn’t see an increase in costs but still incentivizes providers to focus on quality. If you don’t have positive outcomes, money will be taken away and given to the providers that do show positive outcomes (the winners). So the difference between winners and losers is the quality of their outcomes. TapRooT® should be the quality improvement process healthcare organizations use to ensure they are on the winning side by improving quality and safety which also protects their revenue and margins. To find out more how your organization can improve your outcomes and protect your reimbursement, please contact me at marcus.miller@taproot.com.

Ever have trouble with root cause analysis during batch production with impurities?

July 6th, 2018 by

We received the question below in our TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn, please join the discussion with your experiences and best practices.

How would one do a SnapCharT® for intermittent product quality issues that span weeks/months?

The only way to detect the product impurity is to use the product. Even so, the impurity seems random in the same batch or lot, at different weeks or months, with different upstream raw material suppliers, with different personnel. Past root cause analysis was not systematic enough to find the rc. Fixes did not solve.

Investigative Interviewing Series, (Part 3 of 3): Extension Techniques

June 28th, 2018 by

Ever wondered how to get more than one word or one sentence answers from the witnesses you interview? Here’s your answer!

What are extension techniques and why are they so important from TapRooT® Root Cause Analysis on Vimeo.

Join TapRooT® tomorrow at noon EST for Facebook Live

June 26th, 2018 by

Join us tomorrow when TapRooT® professionals Barb Carr and Benna Dortch discuss the topic, “What are extension techniques and why are they so important?” This is the third part of the investigative interviewing series. In the first installment, Barb discussed a powerful but underutilized technique: building rapport. Last week’s tip presented another powerful interviewing technique: effective listening.

Take a read through Barb’s recent articles for more context: Evidence Collection: Top 3 Tips for Improving your Investigative Interviewing Skills Series and Investigative Interviewing Series, (Part 2 of 3): Effective Listening. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to join in for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, June 27

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Last week on TapRooT®’s Facebook Live in the Effective Listening session, we learned that only through effective listening will you learn to pick up on the “right” questions to ask. Barb gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below to review your skills:

Investigative Interviewing Series, (Part 2 of 3): Effective Listening

June 21st, 2018 by

Last week, we started our 3-part investigative interviewing series. In the first installment, I discussed a powerful but underutilized technique: building rapport. This week’s tip presents another powerful interviewing technique: effective listening.

Most interviewers approach interviews with the idea that they need to know the right questions to ask. We challenge you to examine how you can possibly know the right questions to ask going into the interview when you haven’t even heard what the interviewee saw or knows.

Only through effective listening will you be able to know the “right” questions to ask. The first question is the only one you need to know going in: “Tell me, from start to finish, what you observed the day of the incident.”

Then, sit back, listen and identify which follow-up questions need to be asked.

How are your effective listening skills? No one is born with them, but you can develop them with practice. Take our listening inventory quiz below and become a better investigative interviewer.

Watch here via video.

So, how do you encourage interviewees to keep talking and give you the whole story? Join us next Wednesday as we discuss extension techniques.

Monday Accident & Lessons Learned: Why is Right of Way Maintenance Important?

June 18th, 2018 by

Here is another example of why right of way maintenance is important for utility transmission and distribution departments …

Wildfires

An article on hazardex reported that the California Department of Forestry and Fire Protection (Cal Fire) said in a press release that 12 of the wildfires that raged across California’s wine country were due to tree branches touching PG&E power lines.

Eight of the 12 fires have been referred to county District Attorney’s offices for potential criminal prosecution for alleged violations of California laws.

The fires last October killed 44 people, burned more than 245,000 acres, and cost at least $9.4 billion dollars of insured losses. PG&E has informed it’s shareholders that it could be liable costs in excess of the $800 million in insurance coverage that it has for wildfires.

PG&E is lobbying state legislators for relief because they are attributing the fires to climate change and say they should not be held liable for the damage.

What lessons can you learn from this?

Sometimes the cost of delayed maintenance is much higher than the cost of performing the maintenance.

Can you tell which maintenance is safety critical?

Do you know the risks associated with your deferred maintenance?

Things to think about.

Investigative Interviewing Series (Part 1 of 3): The Power of Rapport

June 14th, 2018 by

Gather more quantity and quality of information from interviews conducted during incident investigations. In this 3-week series, we will examine 3 top tips to improve your interviewing skills. Today’s segment highlights the power of rapport.

The Power Of Rapport For Investigative Interviewing from TapRooT® Root Cause Analysis on Vimeo.

View the session on video here:

We are global to meet your needs. Please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139 or 865.357.0080.

2018 Global TapRooT® Summit Best Practices: Engineers Have Freedom To Investigate Low Level Incidents

June 13th, 2018 by

2018 Global TapRooT® Summit Best Practices – Engineers Have Freedom To Investigate Low Level Incidents from TapRooT® Root Cause Analysis on Vimeo.

Here’s another way to watch the Best Practices session via video:

Learn more about investigating low-level incidents in the TapRooT® book Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents and through our courses. Discover what TapRooT® can do for you; Contact or call us: 865.539.2139.

Our Best Practices speaker for this session is Will Canda, representing Nutrien Ltd. The Saskatchewan agriculture industry leader, Nutrien, has more than 1,500 farm retail centers and employs more than 20,000 people across operations in 14 Canadian countries. Nutrien is the biggest global fertilizer producer by capacity, and has the largest U.S. network of farm retail stores.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

 

 

We have a sneak peek for you on today’s Facebook Live!

June 13th, 2018 by

TapRooT® professional Barb Carr will be featured on today’s Facebook Live session. To get a sense of the subject, look at Barb’s recent article.

As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

We look forward to being with you on Wednesdays! Here’s how to join us today:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, June 13

What time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

If you missed last week’s Facebook Live discussion with Mark Paradies and Benna Dortch, catch it below on Vimeo or here on video.

Why do we still have major process safety accidents from TapRooT® Root Cause Analysis on Vimeo.

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Get a sneak peek tomorrow on TapRooT®’s Facebook Live!

June 12th, 2018 by

Not to give too much away here but you have the unique opportunity to gather very useful information tomorrow during TapRooT’s Facebook Live session.

We can announce that TapRooT® professionals Barb Carr and Benna Dortch will be the facilitators for the session. To get a glimmer of the subject, take a look at Barb’s recent article. As always, please feel free to chime in on the discussion in real time. Or leave a comment and we’ll get back to you.

Here’s how to get your sneak peek for tomorrow’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, June 13

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

 

2018 Global TapRooT® Summit Best Practices: Instilling Competencies Around Employees

June 12th, 2018 by

2018 Global TapRooT® Summit Best Practices – Instilling Competencies Around Employees from TapRooT® Root Cause Analysis on Vimeo.

You can view the Best Practices discussion on video here.

In this session, Steven Sandlin, Oceaneering International Inc., discusses investigations in his company’s incident management process, and the vetting and roles of the individuals responsible for the investigations.

Is your team trained to handle a catastrophic event?

Major accidents happen when precursors are missed. Precursors are indicators that a potential crisis is brewing; however, they can be proactively analyzed to stop that crisis from occurring as well as reactively analyzed so they never happen again.

Our 5-day TapRooT® Advanced Root Cause Analysis Team Leader Training equips your team to recognize critical precursors. Find and fix the root causes of a major accident using all of the essential TapRooT® techniques plus advanced tools to analyze problems, and find root causes that you previously would have overlooked before they become a major crisis. Onsite training is available for 10 or more.

View course outline.

Inquire about hosting an onsite course for 10 or more at your company.

Register one or more for a public course near you.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

New Study Suggests Poor Officer Seamanship Training Across the Navy – Is This a Generic Cause of 2017 Fatal Navy Ship Collisions?

June 7th, 2018 by

BLAME IS NOT A ROOT CAUSE

It is hard to do a root cause analysis from afar with only newspaper stories as your source of facts … but a recent The Washington Times article shed some light on a potential generic cause for the fatal collisions last year.

The Navy conducted an assessment of seamanship skills of 164 first-tour junior officers. The results were as follows

  • 16% (27 of 164) – no concerns
  • 66% (108 of 164) – some concerns
  • 18% (29 of 164) – significant concerns

With almost 1 out of 5 having significant concerns, and two thirds having some concerns, it made me wonder about the blame being placed on the ship’s Commanding Officers and crew. Were they set up for failure by a training program that sent officers to sea who didn’t have the skills needed to perform their jobs as Officer of the Deck and Junior Offiicer of the Deck?

The blame heavy initial investigations certainly didn’t highlight this generic training problem that now seems to be being addressed by the Navy.

Navy officers who cooperated with the Navy’s investigations faced court martials after cooperating.

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According to and article in The Maritime Executive Lt j.g. Sarah Coppock, Officer of the Deck during the USS Fitzgerald collision, pled guilt to charges to avoid facing a court martial. Was she properly trained or would have the Navy’s evaluators had “concerns” with her abilities if she was evaluated BEFORE the collision? Was this accident due to the abbreviated training that the Navy instituted to save money?

Note that in the press release, information came out that hadn’t previously been released that the Fitzgerald’s main navigation radar was known to be malfunctioning and that Lt. j.g. Coppock thought she had done calculations that showed that the merchant ship would pass safely astern.

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In other blame related news, the Chief Boatswains Mate on the USS McCain plead guilty to dereliction of duty for the training of personnel to use the Integrated Bridge Navigation System, newly installed on the McCain four months before he arrived. His total training on the system was 30 minutes of instruction by a “master helmsman.” He had never used the system on a previous ships and requested additional training and documentation on the system, but had not received any help prior to the collision.

He thought that the three sailors on duty from the USS Antietam, a similar cruiser, were familiar with the steering system. However, after the crash he discovered that the USS McCain was the only cruiser in the 7th fleet with this system and that the transferred sailors were not familiar with the system.

On his previous ship Chief Butler took action to avoid a collision at sea when a steering system failed during an underway replenishment and won the 2014 Sailor of the Year award. Yet the Navy would have us believe that he was a “bad sailor” (derelict in his duties) aboard the USS McCain.

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Also blamed was the CO of the USS McCain, Commander Alfredo J. Sanchez. He pleaded guilty to dereliction of duty in a pretrial agreement. Commander Sanchez was originally charged with negligent homicide and hazarding a vessel  but both other charges were dropped as part of the pretrial agreement.

Maybe I’m seeing a pattern here. Pretrial agreements and guilty pleas to reduced charges to avoid putting the Navy on trial for systemic deficiencies (perhaps the real root causes of the collisions).

Would your root cause analysis system tend to place blame or would it find the true root and generic causes of your most significant safety, quality, and equipment reliability problems?

The TapRooT® Root Cause Analysis System is designed to look for the real root and generic causes of issues without placing unnecessary blame. Find out more at one of our courses:

http://www.taproot.com/courses

Decisions that get people killed

May 30th, 2018 by

When you read “decisions that get people killed” do you think about decisions that workers make? These are not the decisions we are referring to!

What are we referring to? Come and learn at the 2019 Global TapRooT® Summit. We are pleased to announce our first confirmed keynote speaker, Mark Paradies, President of System Improvements, Inc.

He will be discussing decisions that set up major accidents. These types of decisions are usually made by senior management, and they can have very serious consequences. Management needs to know about them, and what they need to do to prevent major accidents.

 

Mark your calendar to join us for the 2019 Global TapRooT® Summit, March 11 – 15, 2019 at La Toretta Lake Resort & Spa, Montgomery, Texas.

Avoid Big Problems By Paying Attention To The Small Stuff

May 24th, 2018 by

If you didn’t catch the Facebook Live discussion yesterday, join in now to hear TapRooT® professionals Mark Paradies and Benna Dortch discuss this week’s topic: Avoid Big Problems by Paying Attention to the Small Stuff. After you’ve listened to the discussion via the Vimeo below, go to Mark’s article here for further exploration of the precursor mindset.

Avoid Big Problems By Paying Attention To The Small Stuff from TapRooT® Root Cause Analysis on Vimeo

The 2-Day TapRooT® Root Cause Analysis Course is a good choice to send folks to for learning how to investigate precursor incidents. Your best problem-solvers need to learn more to gain the necessary skills for coaching others, and to investigate significant incidents and major accidents; they would attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. And, we can always come to your workplace to teach your team, just let us know or call us: 865.539.2139.

We look forward to being with you on Wednesdays! Here’s how to connect with us for our weekly Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Every Wednesday

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

May 22nd, 2018 by

Screen Shot 2018 05 22 at 4 37 39 PM

Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

May 21st, 2018 by

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years. 

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing. 

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB.  The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

  • Captain’s actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Company’s safety management system
  • Inadequate company oversight
  • Need for damage control plan
  • Flooding in cargo holds
  • Loss of propulsion
  • Downflooding through ventilation closures
  • Need for damage control plan
  • Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

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.

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