Category: Performance Improvement

Can Your Management Learn?

August 15th, 2018 by

Challenger

Long ago, my boss was tasked with reviewing the Challenger space shuttle accident for lessons learned for a major chemical company. I assisted him and his conclusion was that all the same management system causes were present at our company.

He had a dilemma. How should he present this to senior management? He would be presenting to the company President and all the Senior Vice Presidents. He knew they were NOT expecting to here that they had problems. This might severely hurt his career.

He decided to just present the “facts” and that they would reach the same conclusions that he did.

He made the presentation. I was there. At the end, the President of the company thanked him for his hard work and said to everyone else that it was good that there was no similarities between NASA’s management and our company’s management. In other words, no lessons for us.

So much for just presenting the facts.

Why didn’t senior management reach the same conclusions that my boss did when presented with the same facts? The problem was that our management couldn’t critically review their own management systems. They thought that they were doing great and any other feedback was outside their paradigm. They were not being self-critical. They could not face the facts. And no one else was willing to tell them that they needed to improve (lot’s of “yes men” around them).

Of course, NASA’s management didn’t learn their lesson. They went on to have the Colombia shuttle accident because they didn’t learn from their experience and could not face the facts.

Another example of management not being able to learn was the BP’s management after the BP Texas City Refinery explosion.

First, they had a hard time getting past blaming the operators and supervisors (five were fired). There was an internal BP group (the Bonse report – see Bonse Main Report.pdf) that recommended management discipline (blaming the lower levels of senior management). However, no immediate disciplinary action was taken. Within two years, all the senior line management from the Refinery General Manager to the CEO were gone (none were fired immediately as part of the incident response). So the ability of that management to learn didn’t make any difference – they were gone!

However, managers on the upstream (exploration and production) side of the organization, didn’t seem to learn from the the accident on the downstream side of the organization. The result? The BP Deepwater Horizon accident happened because of failure to apply process safety lessons learned to the management of exploration operations.

These examples of failures to learn are the reasons why I ask the question in the title of this article:

Can your management learn?

That brings up the question:

What should managers do to learn?

Here are some ideas…

First, management has to be self-critical. Instead of blaming people at the pointy end of the stick (operators, maintenance people, and supervisors), they should say…

What did we do to cause this incident?
What should we do differently to prevent future incidents?

Being self-critical also means understanding Rickover’s “Facing the Facts” concept. See more about that concept at:

http://www.taproot.com/archives/53656

Second, senior management needs to understand root cause analysis. This may be more common today than it was thirty plus years ago because more senior managers have had some experience with advanced root cause systems (TapRooT®). They need to understand their (management’s) impact on management systems and their impact on investigations and implementation of corrective actions.

Management may also need to understand advanced trending concepts (we are publishing a book later this year about this) to be able to learn from their company’s statistics (or at least be critical of presentations about statistics).

What ideas do you have? Leave them as comments to share with others.

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

August 15th, 2018 by

Join our Facebook Live session today as TapRooT® professionals Ken Reed and Benna Dortch discuss human factors. As you listen and glean takeaways from this discussion, start making plans to learn even more from the Human Factor Track at the 2019 Global TapRooT® Summit, designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s only part of what you’ll get through attending the Human Factor Track at the 2019 Summit.

Plan ahead to tune in for next week’s Wednesday with FB Live. Put a reminder on your calendar, in your phone, or a post-it on your forehead to tune in for TapRooT®’s FB Live. Dig in with us as we explore a workplace-relevant topic with takeaways. And, as always, feel free to join the discussion via comments on our Facebook page.

Here’s the scoop for tuning in:

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

When? Today, Wednesday, August 15, 2018

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

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.

Intelex and TapRooT® Partner to Offer In-Depth Root Cause Analysis

August 14th, 2018 by

In this video, hear about TapRooT®’s recent partnership with Intelex Technologies, a leading global provider of cloud-based Environmental, Health, Safety and Quality (EHSQ) management software. The integration of Intelex Technologies with TapRooT® allows customers to enter an injury in Intelex, perform a detailed root cause analysis using TapRooT®, and capture the result of the root cause analysis within Intelex. Customers are able to leverage Intelex’s powerful reporting and analytics foresight on injury and root cause data, ultimately producing better decisions and reducing the risk of repeat incidents, injuries and illnesses. The integration will also remove the administrative and record keeping hassle of managing two disparate incident and root cause analysis tools.

About the partnership, TapRooT®’s Vice President and Chief Technology Officer Dan Verlinde said, “We’re excited to establish a partnership with Intelex. TapRooT® and Intelex both create safer work places and help companies achieve operational excellence—that’s why this was an obvious opportunity to collaborate. This partnership will allow our joint customers to realize an integrated Environmental Health and Safety and Root Cause Analysis solution, while reducing duplicate effort.” And, Kristen Duda, Vice President, Strategic Alliances and Partnerships at Intelex, observed of the new integration, “This partnership provides customers with an industry-leading, integrated solution for taking their injury and root cause analysis data to the next level. By leveraging Intelex and TapRooT®, customers can drive impactful proactive safety decisions.”

Connect with us on Wednesdays for TapRooT®’s Facebook Live:

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

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

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.

Career Opportunities for Candidates with TapRooT® Skills

August 13th, 2018 by

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Specialist HES Operations

Senior Process Engineer

HSE Technical & Administrative Assistant 

Patient Safety Analyst

HES Drilling Specialist

Safety Specialist/Safety Officer 

Service Specialist

HSE Associate Coordinator

Service Operator 

Associate- Senior Engineer Nuclear

Site Safety Coordinator

Safety Coordinator

Nurse

Senior Safety Advisor

Specialist HSE

SHE Coordinator

Project Operations Manager 

If you are not TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skills and training. Pursue your goals through these TapRooT® courses to advance your professional development and your career.

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

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

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

Bogota, Colombia, August 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Bogota, Colombia, August 31, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 3, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 4, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

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

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

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

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Houston, Texas, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 2018: 2-Day TapRooT® Root Cause Analysis Training

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.

Tune in Today: TapRooT® Has News You Can Use, Noon EST

August 8th, 2018 by

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

We ‘re excited to be with you on Wednesdays! Feel free to add comments on TapRoot®’s Facebook page during the discussion. Here’s how to connect with us for today’s Facebook Live:

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

When? Wednesday, August 8

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

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.

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.

Tune in Tomorrow for TapRooT®’s Facebook Live, Noon EST

August 7th, 2018 by

It’s TapRooT® time! Join us tomorrow at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

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

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

When? Wednesday, August 8

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

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.

Monday Accidents & Lessons Learned: Dumping the Electronic Flight Bag En Route

August 6th, 2018 by

The electronic flight bag (EFB) has demonstrated improved capability to display aviation information such as airport charts, weather, NOTAMs, performance data, flight releases, and weight and balance. This portable electronic hardware has proven facilitative for flight crews in efficiently performing management tasks. While the EFB provides many advantages and extensive improvements for the aviation community in general and for pilots specifically, some unexpected operational threats have surfaced.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. Today’s particular instance relates to EFB operation in a particular phase of flight:

An ERJ175 pilot attempted to expand the EFB display during light turbulence. Difficulties stemming from the turbulence and marginal EFB location rendered the EFB unusable, so the pilot chose to disregard the EFB entirely.

“We were on short final, perhaps 2,000 feet above field elevation. [It had been a] short and busy flight. I attempted to zoom in to the Jepp Chart, currently displayed on my EFB, to reference some information. The EFB would not respond to my zooming gestures. After multiple attempts, the device swapped pages to a different chart. I was able to get back to the approach page but could not read it without zooming. I attempted to zoom again but, with the light turbulence, I could not hold my arm steady enough to zoom. [There is] no place to rest your arm to steady your hand because of the poor mounting location on the ERJ175.

“After several seconds of getting distracted by…this EFB device, I realized that I was … heads-down for way too long and not paying enough attention to the more important things (e.g., acting as PM). I did not have the information I needed from the EFB. I had inadvertently gotten the EFB onto a company information page, which is bright white rather than the dark nighttime pages, so I turned off my EFB and continued the landing in VMC without the use of my EFB. I asked the PF to go extra slowly clearing the runway to allow me some time to get the taxi chart up after landing.

“… I understand that the EFB is new and there are bugs. This goes way beyond the growing pains. The basic usability is unreliable and distracting. In the cockpit, the device is nearly three feet away from the pilot’s face, mounted almost vertically, at a height level with your knees. All [EFB] gestures in the airplane must be made from the shoulder, not the wrist. Add some turbulence to that, and you have a significant heads-down distraction in the cockpit.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes of some common problems that pilots have experienced. In this issue, we learned about precursor events that have occurred during the EFB’s adolescence.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend situations and find and fix problems. Attend one of our courses. Among our offerings are a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

TapRooT® Around the World: Onsite, Oman, Sohar Aluminium

August 2nd, 2018 by

The Sohar Aluminium project team in Oman learned a lot and had a great class. Many thanks to Randy Creek for sharing these pictures!

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.

The Reality of High-Reliability Organizations

August 1st, 2018 by

For the past decade, I’ve seen people write about their ground breaking high-reliability organization research. It often makes me chuckle because I’ve worked in a high-reliability organization and what the researchers “learn” isn’t always what is really going on.

First, let me say that my high-reliability organization experience was in Admiral Rickover’s Nuclear Navy. Seven years and two ships – the USS Arkansas and the USS Long Beach – both nuclear powered cruisers. I had close friends on submarines and nuclear-powered carriers. To learn more about the Nuke Navy record and Rickover’s philosophy, read the series of article at:

http://www.taproot.com/archives/54027

So what is the difference between the research and reality? Here are some of the ideas to consider…

1. Real high-reliability organizations vs fake high-reliability organizations.

Rickover’s Nuclear Navy was the original high-performance organization. In my experience, there isn’t anything that comes close. I’ve seen research that described carrier flight deck operations as a high-reliability organization. But from the accidents and injuries I’ve seen or heard about, I just don’t think they meet the standard.

That brings up a question. What is the standard?

I think the answer is ZERO. Rickover’s Nuclear Navy was (and still is even after he is gone for almost forty years) an organization that achieves the amazing record of ZERO reactor safety related accidents. There were no fatalities, no major releases of radioactive material, and no core-melt accidents. And this record was set during Rickover’s leadership when the Navy was running hundreds of reactor at sea every year. Today that’s a record of sixty years of continuous operation of many nuclear reactors without a major reactor related accident.

If you are in the process industry, think of this as all the US refineries having no fires or explosions or significant environmental releases for 60 years.

For carrier aviation to qualify as a high reliability organization, they would have to have zero flight deck related fatalities, explosions, or aviation related crashes on all the US carriers for years. As far as I know, they don’t achieve this record for a single year (usually not a single deployment).

Therefore, if you are going to learn from a high-reliability organization, make sure it is a real high-reliability organization.

2. High-Reliability Organizations aren’t good at everything.

Rickover’s Nuclear Navy record for reactor safety was amazing. However, submarine or nuclear surface ship industrial safety was pretty average. Thus, the same excellence emphasis was not applied to everything.

Let’s use a sports example. If you are a great athlete, you have the chance to excel at a sport. But you probably can’t be good at every sport. The world’s greatest basketball player may not be able to switch over and become the worlds greatest baseball player … or golfer. They might be better than average but they probably won’t be great.

Why? Because being great requires focus. If your focus becomes too broad, you lose your focus and performance slips. Thus, you can talk about high-reliability organizations like they are great at everything, but they probably aren’t. They probably focus their attention to become great.

3. The high COST for exceptional excellence.

You can ask the Nuke Navy sailors about the cost of excellence:

  • 12 to 18 hour days
  • failed marriages
  • burnout

Recruiting the exceptional sailors required to meet the highest standards wasn’t easy (and still isn’t easy). There is a financial bonus to keep Nuke Navy sailors in the Nuke Navy. This is a significant chunk of change to keep the best from being recruited away because the average sailor just didn’t cut it in the Nuclear Navy.

4. Weak Signals

Research about high-reliability organizations describes detecting “weak signals” that indicated problems. Let me put this straight. If you are in a high-reliability organization, those signal aren’t weak. They scream out at you.

The problem is that non-high-reliability organizations have on a double set of hearing protection. Many don’t hear or see the signals until dead bodies pile up at their feet.

There is no secret to hearing the signals. If you know what makes your systems highly reliable, then you make sure that these important factors are looked after, maintained, and nurtured. The Rickover article linked to above lays out these factors for the Nuclear Navy (and they are the same factors that apply in process safety).

Here’s an example…

If the budget is cut so that you start getting a maintenance backlog, that isn’t a weak signal. Management high and low should be hearing the signal (there is a maintenance backlog).

If the budget is cut so much that safety significant maintenance isn’t getting done, the system is screaming at you. (This should be monitored and discussed in weekly management meetings.)

If you are having precursor incidents because of deferred maintenance, the top management (the COO) should know about it and should be demanding changes.

Thus weak signals aren’t weak if you are a high-reliability organization.

And if you think they are weak signals – you aren’t in a high-reliability organization.

That’s a start. I’ll stop here and not belabor the point.

Living high-reliability and
researching high-reliability
are two quite different experiences.

If I was going to get advice about becoming a high-reliability organization (quite a challenge if you aren’t one), I would talk to someone who lived in a high-reliability organization and who also has worked at a non-high-reliability organization. Or, better yet, I would hire that person to help lead the effort. I would not become part of someone’s university research detached from the experience of living in the organization.

But be ready for difficulties and major change. Talking about high-reliability is much easier than living high-reliability.

Just my advice … take it or leave it.

TapRooT® Training in Calgary

August 1st, 2018 by

Register here for TapRooT® Training on September 24, 2018, in Calgary, Canada: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Register here for TapRooT® Training on November 29, 2018, in Calgary, Canada: 2-Day TapRooT® Root Cause Analysis Training

Exposure to the 2-Day TapRooT® Root Cause Analysis Training in Calgary will equip you to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. In the Calgary 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course, you’ll learn the Essential Techniques—including SnapCharT®, Root Cause Tree® & Corrective Action Helper®—plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement.

A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Calgary, you will want to get out and about. Below, to route you on the road to Calgary, we’ve included highlights of this Canadian city. Be sure to discover even more gems to explore on our Calgary Pinterest board.

Experience Calgary

Magnificent Canadian Rockies & Alaskan Cruise 2018 (13 destinations) - Scenic Luxury Cruises & Tours

Located in the Canadian province of Alberta, Calgary is the gateway to the Canadian Rockies and Banff National Park. It’s also jam-packed with adventures, nightlife, foodie experiences, spectacular natural beauty, and urban mojo.

Related image

Prince’s Island Park stretches along the Bow River, encompassing walking paths and bike lanes that line the riverbanks. You’ll catch sight of gardens and horse-drawn carriages along the pathway known as “River Walk,” which runs into the East Village and links with other bike paths. The bright red pedestrian Peace Bridge on the park’s west end is noted as a top architectural achievement.

In summer, it’s a playground; during the winter, it’s for downhilling, snowboarding, or cross country—the Canada Olympic Park, or WinSport. Built for the 1988 Calgary Winter Olympics and a year-round training ground for Olympians, the park offers mountain biking, a bobsled track, a ski-jump zip-line, and a luge.

Venture to 17 Avenue S.W., often called “the Red Mile,” to find bistros, coffee shops, boutiques, and terrific patios for al fresco dining.

Check out an amazing sculpture, “Wonderland,” on Centre Street and 6 Avenue.

Taste Calgary

Related image

Take advantage of extraordinary dining experience to add to your taste of Calgary. Whether you’re after a well-crafted brew or a palate-pleasing, chef-prepared experience, Calgary has your order.

River Cafe: Resting on the riverbanks, the cafe is popular for brunch, lunch, or dinner.

Eau Claire Market: At the entrance to Prince’s Island Park, the market hosts many restaurants as well as a food court, movie theater, and shops.

National Beer Hall: Stop in for an impressive selection of brews, good service and fare, and a fun atmosphere. Multiple locations.

Earls: Relish brunch, cocktails and happy hour, or the ever-expanding menu at the different locations around town.

The Metropolitan Grill: Bright, contemporary, and casual dining on Stephen Avenue—the grill serves up everything from steak to lobster mac and cheese.

Charcut Roast House: Known for its Alberta beef and prime rib, the Charcut Roast House prides itself on pleasing every palate.

Teatro: Expect to leave satisfied in this eatery featuring seasonal Mediterranean fare and international wines in a circa-1911 bank building. Reservations suggested.

Register here for TapRooT® Training on September 24, 2018, in Calgary, Canada: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Register here for TapRooT® Training on November 29, 2018, in Calgary, Canada: 2-Day TapRooT® Root Cause Analysis Training

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

It’s TapRooT® Time! Join Us Today at Noon EST

August 1st, 2018 by

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

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, August 1

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

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.

Explore Knoxville & Learn TapRooT® Root Cause Analysis

July 31st, 2018 by

Register here for TapRooT® Training on October 15, 2018, in Knoxville, Tennessee: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Exposure to the 5-Day TapRooT® Root Cause Analysis Training course in Knoxville will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Knoxville, you will want to get out and about. Below, to route you on the road to Knoxville, we’ve included highlights of this southeastern city. Be sure to discover even more local gems to explore on our Knoxville Pinterest board, and look for regional highlights on our East Tennessee Pinterest board

Image result for knoxville tn

Experience Knoxville

Ah, Knoxville in the fall. So much for you to see and savor, including nature’s paintbox of brilliant fall colors. Knoxville is a friendly city—its hospitality inviting you to open up to sporting events and nightlife, artists and art, live music and concerts, Broadway performances. Take advantage of our region’s breathtaking scenic drives and take a hike to immerse yourself in spectacular natural beauty. Experience an embarrassment of foodie havens, some mighty fine shopping, and the warmest Southern hospitality around. Sample our downtown winery and distilleries or hop on a Knox Brew Tour.

Here’s a smattering of suggestions for exploring, having good times, and making memories in the Marble City.

Image result for downtown knoxville tn

Downtown Knoxville

1. Knoxville Visitors Center, 301 S. Gay St., Knoxville, TN 37902: This building dates to 1925 and besides information about our fair city, you’ll find award-winning WDVX and its famous Blue Plate Special.

Image result for market square knoxville

2. Market Square
3. Krutch Park (adjacent to Market Square)
4. East Tennessee Historical Society
5. Old City
6. Blue Slip Winery
7. Knox Whiskey Works

Image result for postmodern spirits knoxville

8. PostModern Distilling
9. Boyd’s Jig & Reel
10. Knoxville Museum of Art
11. World’s Fair Park
12. Volunteer Landing Park
13. Women’s Basketball Hall of Fame

Image result for the university of tennessee in the fall

The University of Tennessee

15. The University of Tennessee, 2704 Kingston Pike, Knoxville, TN 37919,
and Neyland Stadium
16. The McClung Museum of Natural History & Culture

Other fun attractions 

17. Zoo Knoxville
18. Knoxville Botanical Garden

Related image

19. Great Smoky Mountains National Park
20. Cades Cove
21. Maple Hall Bowling
22. World’s Fair Park Sunsphere
23. Ijams Nature Center

24. Navitat Canopy Experience
25. The Muse

26. Cruze Farm Ice Cream
27. Pete’s Coffee Shop
28. Mast General Store

Here’s where to park, sorted by location.

Register here for our Knoxville 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

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.

Join TapRooT® Tomorrow for Facebook Live at Noon EST

July 31st, 2018 by

Make plans now to join our knowledgeable TapRooT® professionals tomorrow for the weekly Facebook Live discussion that brings you insights and improvements for your workplace life.

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

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

When? Wednesday, August 1

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

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.

Monday Accidents & Lessons Learned: Zooming to “Too Low Terrain”

July 30th, 2018 by

When the Electronic Flight Bag (EFB) platform—frequently a tablet device—was introduced as a human-machine interface into the aviation industry and the cockpit, the platform proved to  facilitate improvements for both pilots and the aviation community, but the human-machine interface has encountered operational threats in the early years of EFB utilization.

NASA’s Aviation Safety Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One routine problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, and unknowingly “slides” important information off the screen, making it no longer visible. A second type of problem manifests itself in difficulty operating the EFB in specific flight or lighting conditions. Yet a third wrinkle relates to EFB operation in a particular flight phase.

Let’s look at what happened in an A319 when “zoom” went awry:

Prior to departure, an A319 crew had to manage multiple distractions. An oversight, a technique, and a subtle EFB characteristic all subsequently combined to produce a unrecognized controlled flight toward terrain.

“We received clearance from Billings Ground, ‘Cleared … via the Billings 4 Departure, climb via the SID.’ During takeoff on Runway 10L from Billings, we entered IMC. The Pilot Flying (PF) leveled off at approximately 4,600 feet MSL, heading 098 [degrees]. We received clearance for a turn to the southeast … to join J136. We initiated the turn and then requested a climb from ATC. ATC cleared us up to 15,000 feet. As I was inputting the altitude, we received the GPWS alert, ‘TOO LOW TERRAIN.’ Immediately, the PF went to Take Off/Go Around (TO/GA) Thrust and pitched the nose up. The Pilot Monitoring (PM) confirmed TO/GA Thrust and hit the Speed Brake handle … to ensure the Speed Brakes were stowed. Passing 7,000 feet MSL, the PM announced that the Minimum Sector Altitude (MSA) was 6,500 feet within 10 nautical miles of the Billings VOR. The PF reduced the pitch, then the power, and we began an open climb up to 15,000 feet MSL. The rest of the flight was uneventful.

“On the inbound leg [to Billings], the aircraft had experienced three APU auto shutdowns. This drove the Captain to start working with Maintenance Control. During the turn, after completion of the walkaround, I started referencing multiple checklists … to prepare for the non-normal, first deicing of the year. I then started looking at the standard items. It was during this time that I looked at the BILLINGS 4 Departure, [pages] 10-3 and 10-3-1. There are no altitudes on … page [10-3], so I referenced [page] 10-3-1. On [page] 10-3-1 for the BILLINGS 4 Departure at the bottom, I saw RWY 10L, so I zoomed in to read this line. When I did the zoom, it cut off the bottom of the page, which is the ROUTING. Here it clearly states, ‘Maintain 15,000 or assigned lower.’ I never saw this line. When we briefed prior to push, the departure was briefed as, ‘Heading 098, climb to 4,600 feet MSL’; so neither the PF nor the PM saw the number 15,000 feet MSL. The 45-minute turn was busy with multiple nonstandard events. The weather was not great. However, that is no excuse for missing the 15,000-foot altitude on the SID.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend, 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.

Get TapRooT® Trained in San Antonio

July 29th, 2018 by

Register here for TapRooT® Training on October 3, 2018, in San Antonio, Texas: 2-Day TapRooT® Root Cause Analysis Training

The 2-Day TapRooT® Root Cause Analysis Training in San Antonio will exponentially expand your professional knowledge. In two days, you will learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include SnapCharT®, Root Cause Tree®, & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply.

While in San Antonio, you will want to check out the city. To route you on the road to San Antonio, we’ve included highlights below of this enchanting city in Texas. Be sure to discover even more gems to explore on our San Antonio Pinterest board.

Experience San Antonio

Related image

Boat down the San Antonio River for the best way to delve into the heart of this city. Meander along the 2.5-mile-long San Antonio River Walk. Pick what you want to explore among the mix of shops, bars, and more.

The Alamo: This must-see piece of American history was originally known as Mision San Antonio de Valero and represents a pivotal event in the Texas Revolution.

Related image

The San Antonio Zoo: In Brackenridge Park, this 35-acre zoo has a collection of over 3,500 animals representing 750 species.

1. The King William Historic District dates back to the 1790s, when the land that once belonged to the Mission San Antonio de Valero (now known as The Alamo) was made available for native settlers in the area or sold at auction, according to the Office of Historical Preservation. Photo: 871519, Courtesy / Lonely Planet Images

Destination: Southtown. Head to South Alamo Street to discover where the locals go for cool arts experiences, robust bars and restaurants, quirky shops, and great coffee. Get a glimpse of the King William district’s historic homes and terrific views of the River Walk and its residential neighborhoods. Southtown shops and galleries are a unique scene. Keep going until you’ve arrived at the Blue Star Arts Complex and mix with the arts and crafts, the museum, and the brewpub. There are also bikes for rent here.

Taste San Antonio

Southtown is long on food, too. Here, you can find European cuisine at La Frite, Latin fare at Azuca, and fancier eateries, like Monterey or farm-to-fork Feast. If it’s simply Tex-Mex you’re craving,  head to Tito’s!

Bella on the River: On the River Walk, this locally owned restaurant features Southern European fare with a Mediterranean flare. Try the pan-seared scallops or the antipasto. Live jazz is played most nights here.

Nightlife: Try neighborhood favorites The Friendly Spot and La Tuna, fun for relaxing with brews and tunes. Check out the Alamo Eats Food Truck Bar for more of a food focus. If you’re after margaritas, go to Rosario’s. Tuck into appetizers, a mojito, and the hip bar vibe at Restaurant Bliss

Register here for our San Antonio 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

TapRooT® Around the World: Onsite Course, NGC, in Trinidad & Tobago

July 25th, 2018 by

Here’s a peek into a recent in-house 2-Day TapRooT® Root Cause Analysis Training course at NGC, the National Gas Company of Trinidad and Tobago. Through TapRooT® Training with instructors Ralph Blessing and Heidi Reed, 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.

Many thanks to TapRooT® instructor Heidi Reed for sharing these pictures of a great classroom experience!

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.

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).

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

July 25th, 2018 by

Join our Facebook Live session today as TapRooT® professional Ken Reed discusses, How to Use TapRooT® to Analyze a Single, Small Problem. As Ken observes, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

There is a full spectrum of possible uses of TapRooT® in your improvement programs. Use TapRooT® for:

  • Really large, complex, high-risk incidents (Major Investigations)
  • Smaller, less complex problems (Low-to-Medium Risk Incidents)
  • A very simple problem found, for example, during an audit (single Causal Factor)

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 25

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

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.

Learn with TapRooT® Tomorrow at Noon EST on Facebook Live: How to Use TapRooT® to Analyze a Single, Small-Sized Problem

July 24th, 2018 by

Make plans now to join TapRooT® professional Ken Reed tomorrow for our Facebook Live discussion: How to Use TapRooT® to Analyze a Single, Small Problem. Ken observes that, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

To put this into the big-picture TapRooT® perspective, Ken explains, “You can use TapRooT® for:

  1. Really large, complex, high-risk incidents (Major Investigation)
  2. Smaller, less complex problems (Low-to-Medium Risk Incidents)
  3. A very simple problem found, for example, during an audit (single Causal Factor)

So, this gives you a full spectrum of possible uses of TapRooT® in your improvement programs.”

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

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

When? Wednesday, July 25

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

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.

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.

 

Meet TapRooT® in Manchester

July 23rd, 2018 by

Register here for TapRooT® Training on October 1, 2018, in Manchester, England: 2-Day TapRooT® Root Cause Analysis Training

Exposure to the 2-Day TapRooT® Root Cause Analysis Training course in Manchester will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Manchester, you will want to get out and about. Below, to route you on the road to Manchester, we’ve included highlights of this British city. Be sure to discover even more gems to explore on our Manchester Pinterest board.

Image result for manchester england

Experience Manchester

At Long Millgate, Manchester, Greater Manchester, M3 1SB, you will find Chetham’s Library, founded 1653, the oldest library in the English-speaking world. Explore medieval college buildings containing furniture, furnishings, and a library harkening to the seventeenth century. Drop in Monday – Friday, 9:00 – 12:30 and 1:30 – 4:30, or make an appointment at 0161 834 9644 for a tour or to hear a concert at the adjacent School of Music on Wednesdays.

Product Image

Manchester is rooted in innovation as home to the first steam-powered mill and microcomputer, as well as fresh initiatives borne out in its universities. With its massive collection of vintage vehicles and halls full of steam-powered machines in action, you’re sure to be fascinated at the Museum of Science and Industry. See how the Industrial Revolution influenced Britain’s cities and people; take a train ride; and participate in hands-on workshops.

Product Image

Be awestruck at a Victorian Gothic masterpiece, the John Rylands Library is dedicated to  one of the most successful industrialists and encompasses the most ancient artifact of the New Testament, the St. John Fragment. The Rylands houses other treasures such as medieval manuscripts and Chaucer’s Canterbury Tales, the 1476 William Caxton edition.

On a 90-minute bus tour, venture highlights of Manchester’s heritage, its progressive growth, and its role in science, politics, music, arts and sport. Among key sites on the Sightseeing Manchester 15-stop, hop-on hop-off tour, you will visit Town Hall Manchester, National Football Museum, Museum of Science and Industry, and Manchester United Football Club.

Wigan Pier to Arley Hall

Manchester offers a unique collection of 20 premier walking trails. Among them: a circular walk around picturesque Worsley Village; along Leeds-Liverpool Canal and up Wigan’s renowned 23-locks flight to Top Lock along the canal-side trail of Wigan Pier to Arley Hall; and take in regal views from woodland to riverside along Peel Tower, Holcombe Moor and Ramsbottom.

Go for a fascinating Manchester walking experience with a themed tour. Avail yourself  of a well-developed theme; among the offerings are architectural, foodie, political, history and heritage, and Victoria baths.

Taste Manchester

Have a classic espresso or a handcrafted cocktail in the glamorous, sophisticated Dirty Martini, 1 Peter Street, Manchester, Greater Manchester, M2 5QR.

Partake in drinks, English afternoon tea, fish and chips, steak and ale, or more at Radisson Edwardian, Free Trade Hall, Peter Street, Manchester, Greater Manchester, M2 5GP.

Corn Exchange Manchester

The Corn Exchange: A fusion of flavors from around the globe, the Corn Exchange has something for everyone, from among these offerings and more: Wahaca, Pho, Cosy Club, Cabana, Alston Bar & Beef, Mowgli, Banyan Bar and Grill, Zizzi, Pizza Express, Salvi’s, Vapiano, and Tampopo.

North Star Piccadilly: You’ll find award-winning coffee and specialty teas here, at 77 Dale Street, Manchester, M1 2HG. Choose among paninis and salads, platters and hot specials, or delicious daily soups. Finish with sweet or savory snacks or fresh-baked cakes. 

Fazenda Rodizio Bar & Grill: At Avenue, Spinningfields, Manchester, Lancs, M3 3AP, Fazenda’s Brazilian influence offers wonderful wines, gourmet salads, and freshly grilled meats, set in a modern ambience.

Register here for our Manchester 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

 

Monday Accidents & Lessons Learned: A Taxiway by Any Other Name

July 23rd, 2018 by

An EFB, or electronic flight bag, is portable electronic hardware, increasingly utilized for flight deck or cabin use to facilitate flight crews perform flight management tasks easier and more efficiently. At a basic level, EFBs can perform flight-planning calculations and offer a variety of digital documentation, such as navigational charts, operations manuals, and aircraft checklists.

NASA’s Aviation Safety and Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. This report illustrates how complications between EFBs and human operators develop into precursor events:

“A B737 Captain encountered frustration while using his moving map. Although the specific incident is not cited, the Captain clearly identifies an EFB operational problem and offers a practical solution for the threat.

‘In [our] new version of [our EFB chart manager App], … a setting under Airport Moving Map (AMM) … says, “Set as default on landing,” [and I cannot] … turn it off. If [I] turn it off, it turns itself back on. This is bad.… It should be the pilot’s choice whether or not to display it at certain times—particularly after landing. Here’s the problem with the AMM: When you zoom out, the taxiway names disappear.

‘Consider this scenario: As you turn off the runway at a large airport, you look down at the map (which is the AMM, not the standard taxi chart, because the AMM comes on automatically, and [I] cannot turn that feature off). You get some complicated taxi instructions and then zoom out the AMM [to] get a general, big-picture idea of where you’re supposed to go. But when [I] zoom out the AMM, taxiway names disappear.… [I] have to switch back to the standard taxi chart and zoom and position that chart to get the needed information. That’s a lot of heads-down [tablet] manipulation immediately after exiting the runway, and it’s not safe.

‘[Pilots should have] control over whether or not to automatically display the AMM after landing. The AMM may work fine at a small airport, but at a large airport when given taxi instructions that are multiple miles long, the AMM is useless for big-picture situational awareness.'”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend situations and find and fix problems. Attend one of our courses. Among our offerings are a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Learn TapRooT® in Edmonton

July 23rd, 2018 by

Register here for TapRooT® Training on August 2, 2018, in Edmonton, Alberta, Canada: 2-Day TapRooT® Root Cause Analysis Training

Exposure to the 2-Day TapRooT® Root Cause Analysis Training course in Edmonton will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Edmonton, you will want to get out and about. Below, to route you on the road to Edmonton, we’ve included highlights of this Canadian city. Be sure to discover even more gems to explore on our Edmonton Pinterest board.

5 Fun Things To Do in Edmonton, Alberta, Canada

Experience Edmonton

Edmonton, capital of Alberta, is home to the largest expanse of urban parkland in Canada, the North Saskatchewan River Valley Parks System. Back-to-back parks along both sides of the river make urban Edmonton a delightfully green space for all kinds of outdoor recreation. In Edmonton, you’ll also have access to North America’s largest shopping mall, art museums and galleries and street art, hockey games, farmers markets, world-class skiing and biking, and a burgeoning foodie scene. You can easily get around the city via buses and light rail trains, and also Uber and taxis. Among your “discovering,” try to explore 124th and 104 streets. In that area, you will find Sir Winston Churchill Square and the Art Gallery of Alberta. Jasper Avenue hosts several cool coffee spots, such as Lock Stock Coffee.

edmonton-2

Four shimmering glass pyramids pinpoint iconic Muttart Conservatory on Edmonton’s skyline. The biomes house more than 800 species of plants from all over the world. Photo ops are rich from the roof.

You may hear it referred to as “The Leg” in Western Canada. The Alberta Legislature Building is the place for watching the sun set, with its gardens, pools and fountains.

Walk, stroll, bike, hike, paddle–get out and take advantage of the urban stretch that encompasses 20 major parks, the North Saskatchewan River Valley, that runs through downtown Edmonton.

Taste Edmonton

Duchess Bake Shop, Edmonton, Canada

At an incredible bakery, Duchess, you can’t go wrong with any selection from its classic French pastries: macarons, croissants, eclairs, butter tarts, and more. Made from scratch daily. The desserts on display are bewitchingly tempting!

Ampersand 27: An interesting, palate-pleasing mix of traditional and international flavors have earned this restaurant its cool factor.

Fumaca Brazilian Steakhouse: Come hungry and dine gaucho-style! During dinner, you will offered about 15 cuts of meat, grilled pineapple, the salad bar, and more. All that and a fabulous view of Edmonton overlooking Waterdale Bridge and the skyline.

Central Social Hall: The menu beckons you to try more than you can eat, and it’s all delicious. Try Belgian waffles at brunch; Texas rub wings with drinks; and the salad with grilled herb chicken is good anytime.

Blue Plate Diner: In the trendy Warehouse district, the diner is retro, with a artsy ambience. Open for breakfast, lunch, dinner, and also for brunch on weekends. Great salads, soups, breakfasts.

Register here for our Edmonton 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is 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 to discuss what we can do for you, or call us at 865.539.2139.

Connect with Us

Filter News

Search News

Authors

Angie ComerAngie Comer

Software

Anne RobertsAnne Roberts

Marketing

Barb CarrBarb Carr

Editorial Director

Chris ValleeChris Vallee

Human Factors

Dan VerlindeDan Verlinde

VP, Software

Dave JanneyDave Janney

Safety & Quality

Garrett BoydGarrett Boyd

Technical Support

Ken ReedKen Reed

VP, Equifactor®

Linda UngerLinda Unger

Co-Founder

Mark ParadiesMark Paradies

Creator of TapRooT®

Michelle WishounMichelle Wishoun

Licensing Paralegal

Per OhstromPer Ohstrom

VP, Sales

Shaun BakerShaun Baker

Technical Support

Steve RaycraftSteve Raycraft

Technical Support

Wayne BrownWayne Brown

Technical Support

Success Stories

Four years ago I was an incident investigator, an incident reviewer, and an investigation techniques…

Hydro One

Fortunately, I had just been introduced to a system for incident investigation and root cause analysis…

Enmax Corporation
Contact Us