Category: Pictures

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.

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.

TapRooT® Around the World: Sao Paulo, Brazil

August 3rd, 2018 by

Here’s a peek into a recent 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Sao Paulo, Brazil, taught by TapRooT® instructors Boris Risnic and Marcelo Marquez. Many thanks to Marcelo for passing along these insightful images!

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.

TapRooT® Around The World: Bogota, Colombia

August 3rd, 2018 by

Many thanks to, Diana Munevar, for sending in these great course photos from last weeks TapRooT® Training class in Bogota, Colombia.

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. Click here to view some of our upcoming courses.

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.

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

Caption Contest!

August 1st, 2018 by

Alright, who’s ready for the August caption contest? I know I am!

So, here is your chance to win some free TapRooT® swag! All you have to do is follow the easy instructions below.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest instructions:
1. Create your caption to the photo above in six words or lessAll captions with more than six words will be disqualified.
2. Type your caption in the comments section of this post by August 20, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Good luck and, most importantly, have fun!

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.

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.

Caption Contest Winner!

July 30th, 2018 by

And this months caption contest winner is…. Drrrrrrrrrrrrrrrrrum-roll……

Congratulations Steve. K. !!

Won with the comment, “Drop goes the diesel.”

 

This month’s contest was an extremely close race. In no particular order, here are some of our honorable mentions.

  • “Yup. It’s definitely a boy!” – Tom. S.
  • “I am Optimus… erm, maybe not.” – Andy Hampson
  • “Hi-potential near miss incident.” – Suman Sarker
  • “Cleanliness is next to godliness!” – Daniel
  • “Yes it’s safe, I’m wearing PPE.” – Dennis Egginton
  • “We always do it like this.” – Goran Mihalic

Thank you to everyone who participated in this months Caption Contest. I truly enjoy managing the Caption Contest and reading all your funny comments. It’s a great way to start my day, so again thank you!

 

Keep an eye out for next months new August Caption Contest! Remember, just because you’ve won in the past doesn’t mean you can’t win again.

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).

TapRooT® Around the World: Brazil

July 24th, 2018 by

Marcelo Marquez and Boris Risnic sent this class photo in from Arlanxeo in Triunfo, Brazil. Looks like an excellent class. Thanks for the great photo!

 

Register for a TapRooT® course in Latin America – Click here for upcoming course list.

TapRooT® Around The World – Portland, OR

July 23rd, 2018 by

Here’s a look at a recent TapRooT® training course held in Portland, OR, taught by Ken Reed, Kevin McManus, and Marcus Miller. In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Marcus Miller for sharing these wonderful pictures of the course location and giving us insight to the interactive learning during the course.

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

 

TapRooT® Training Around the World: New Zealand

July 12th, 2018 by

Here is a glimpse into a recent in-house 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group in New Zealand. In just 5 days through TapRooT® Training, 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.

TapRooT® Techniques within the 5-Day course included SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement. Upon completion of the course, the students received a certificate of completion and a 90-Day Subscription to TapRooT® VI online.

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. We thank Narelle Wright at Practical Solutions Group for sharing these pictures of the interaction and learning during the course!

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 is a listing of our upcoming 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

TapRooT® Around the World: Singapore

July 11th, 2018 by

TapRooT® Instructor Malcolm Gresham, certified in TapRooT® instruction since 2006, was recently in Singapore teaching students the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course at Practical Solutions Group. In a course taught by one of our expert TapRooT® instructors, you will understand how to troubleshoot and identify the root cause of any issue and/or incident. We thank Narelle Wright for sharing these pictures of the interaction and learning during the course!

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 5-Day courses:

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dallas, Texas, August 06, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Newcastle, Australia, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

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

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

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Dubai, United Arab Emirates, October 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Brisbane, Australia, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

New Orleans, Louisiana, November 12, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Monterrey, Mexico, November 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Perth, Australia, November 26, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Houston, Texas, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, December 3, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Edmonton, Canada, December 10, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

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

TapRooT® Around the World: Onsite Course, Ensign Energy, Neuquén, Argentina

July 10th, 2018 by

TapRooT® Instructor Piedad Colmenares sent us some “course captures” of the recent 2-Day TapRooT® Root Cause Analysis Training class she taught in Neuquén, in chilly Argentine Patagonia, onsite at Ensign Energy.

Piedad says, “Despite the intense cold of winter, it was a very special course. We shared experiences, and it was also very pleasant to experience the excitement of the World Cup. It was very exciting to receive the gift they gave me: a shirt of the Argentine soccer team, autographed by all the students.” Piedad gives a shout-out of thanks to all the participants of the Ensign Energy onsite course.

In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Piedad for sharing these pictures of action and insights into the interactive learning during the course!

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 a few of our upcoming courses:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

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

Manchester, United Kingdom, October 1, 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.

Monday Accident & Lessons Learned: Fatal Accident While Unloading a Truck

July 9th, 2018 by

WKBW TV reported that two employees were killed when a stack of Corian counter tops that weighed 800 pounds per slab (11 slabs total) fell on them. The accident occurred at 1:30 a.m. and the employees were pronounced dead at the scene.

The company issued a statement that said:

“We’re saddened to report that a tragic accident occurred this morning at our facility in Lockport, NY that resulted in the death of two of our colleagues. We’re working with our safety team and local law enforcement to understand the circumstances under which this tragedy occurred. Our deepest sympathies are with their families and our Lockport team members.”

OSHA will be conducting an investigation of the deaths. OSHA has investigated two other serious injuries at XPO facilities elsewhere in New York state.

What was the Hazard in this accident?

The heavy, high-piled load.

Who were the targets?

The two employees.

What were the Safeguards?

From the newspaper articles, we don’t know.

We also don’t know any of the reasons for the Safeguard’s failure.

The root cause analysis will have to determine the Safeguards, why they failed, and if they were sufficient. (Do we need additional Safeguards?)

In the TapRooT® System, a SnapCharT® would be used to collect and organize the information about what happened.

Then the failed Safeguards would be identified.

Next, the failed Safeguards (Causal Factors) would be analyzed to find their root causes using the Root Cause Tree® Diagram.

Once the root causes for all the Safeguards were found, the team would start developing corrective actions.

The Safeguards would be reviewed to see if after they were strengthened, if they would be adequate. If they would not be adequate, either additional Safeguards would be developed or the process could be modified to reduce or remove the hazard. For example, stack the counter tops no more that 16 inches high.

To improve the Safeguards that failed, you would address each of the root causes by developing SMARTER corrective actions using the Corrective Action Helper® Module of TapRooT® Software.

What is a SMARTER corrective action?

Specific

Measurable

Accountable

Reasonable

Timely

Effective

Reviewed

To learn more about the TapRooT® System, SnapCharT®, Safeguard Analysis, Causal Factors, the Root Cause Tree® Diagram, the Corrective Action Helper® Module, the TapRooT® Software, and SMARTER, attend one of our 2-Day or 5-Day TapRooT® Courses. Here is a list of the dates and locations of the courses being held around the world:

http://www.taproot.com/store/Courses

Happy 4th of July

July 4th, 2018 by

4th

In the US we celebrate declaring our independence from The British crown on the 4th of July. It was a great risk for a minor colony to stand up to the world’s mightiest power. Perhaps were were foolish or you might say reckless … but the outcome was a system without a king and with a constitution that affirmed and guaranteed our God given rights.

So today when you are celebrating somewhere in the US, remember those who risked all for the freedoms we enjoy today and those who stand ready to do that today.

Happy Independence Day!

Testimonial Tuesday

July 3rd, 2018 by

Are you interested in learning TapRooT®, but you’re not sure where to start? Below I’ve provided some 2-Day and 5-Day TapRooT® Training Testimonials to help you decide which course is right for you.

TapRooT® is a world-class software system designed to help investigators solve every day hurdles. TapRooT® take the investigator beyond his or her knowledge to choose root causes that are “outside the box” of common root causes such as writing poor procedures or inadequate training.

2-Day Client Testimonials:

  • “Great interactive exercises to better understand the basics of SnapCharT®.” – Aspinall
  • “Very informative section on how to correctly identify causal factors.” – Neil
  • “Excellent software that quickened the process.” – Tony
  • “Great group exercises working in small teams using the Root Cause Tree®.” – Fox

5-Day Client Testimonials:

  • “I enjoyed the “Putting It All Togehter” unit, because it helped me remember all the things we have learned and how to implement these strategies.” – Einini
  • “Great approach to actually solving issues and behaviors.” – Anonymous
  • “Enjoyed working through a real incident. Very beneficial.” – Evan
  • “It wasn’t all lecture, the practical hands-on training was great.” – Robby

 

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location and reserve your seat today by clicking on the links below.

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

Caption Contest!

July 2nd, 2018 by

A new month means a new caption contest! This month’s caption contest photo comes from my husband, Jared.

So, here is your chance to win some free TapRooT® swag! All you have to do is follow the easy instructions below.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest instructions:
1. Create your caption to the photo above in six words or lessAll captions with more than six words will be disqualified.
2. Type your caption in the comments section of this post by July 23, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Good luck and, most importantly, have fun!

Remembering An Accident: Ixtoc I Oil Spill

June 27th, 2018 by

On June 3, 1979 the Ixtoc I ,located in the Bay of Campeche in the Gulf of Mexico, exploded and caught fire at 3:30 AM. The Ixtoc oil spill became one of the largest oil spills in history.

So what happened?..

On June 2nd, the day before the blowout, the drill hit a spot with soft sedimentary soil that caused a bit weight reduction, also known as a break. This break unfortunately, caused a fracture in the wells’ piping that resulted in a complete loss in mud circulation drilling. As PeMex and Sedco argued over the best course of action oil began to build up in the west well column. Once the decision was made to remove the drill it was a little to late. Pressure had built to up extremely high, dangerous, and unstable levels. This caused a surge of mud to race up the drill pipe and spill onto the drilling platform. After the surge of mud multiple safety failures occurred creating a chain of events that resulted in the disastrous blow out.

 

After the blow out the now escaping oil ignited, and once it came into contact with gas fumes from a motor that powered the derrick aboard the platform the Ixtoc exploded at 3:30 am. The fire burned until about 10:00 am the next day. The fire caused the Sedco 135 drilling tower to collapse leading to the total loss of the drilling rig. Oil continued spilling out of the destroyed well for a total of 290 days, until the well was finally capped on March 23, 1980.

 

To learn more about the Ixtoc I Oil Spill 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

 

Practice, Feedback, & Improve (Develop Skills)

June 27th, 2018 by

With any new skill that you learn, you need practice to implant the skill into long term memory. To get better at the skill, you need more practice and feedback (coaching).

The same is true of the skills you learn in a TapRooT® Course. You need to practice your new investigation and root cause analysis skills and get feedback (coaching) on ways to improve what you are doing.

Who will provide you with that feedback? Here are some ideas:

  1. Set up a peer review group. The members of this group should attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and have experience doing investigations.
  2. Have a senior manager become an expert in root cause analysis and provide feedback on investigations when performing senior manager reviews.
  3. Have experts from System Improvements review your incident investigations as they progress, CONTACT US to find out how to get these reviews scheduled.

If you have only attended the 2-Day TapRooT® Root Cause Analysis Course, consider attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. You will get more practice with the essential TapRooT® Techniques and learn the advanced techniques including:

  • Cognitive interviewing techniques
  • Critical Human Action Profile (CHAP)
  • Change Analysis
  • Proactive use of Safeguard Analysis
  • Equifactor® Equipment Troubleshooting

Plus you will discuss human error and ways to improve human performance.

Here is a link to the upcoming public 5-Day TapRooT® Training schedule for courses held around the world:

http://www.taproot.com/store/5-Day-Courses/

For anyone interested in advanced root cause analysis training, CLICK HERE for more information.

TapRooT Around the World: Perth, Australia

June 26th, 2018 by

Here’s a peek into the recent 2-Day TapRooT® Root Cause Analysis Training Course in Perth, Australia, taught by Malcolm Gresham at the Practical Solutions Group. In a TapRooT® course, you will grasp how to troubleshoot and identify the root cause of any issue and/or incident, learning from one of our expert instructors. Many thanks to Narelle Wright for sharing these pictures of action and insights into the interactive learning during the course!

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:

Brisbane, Australia, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Portland, Oregon, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Nairobi, Kenya, July 16, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Perth, Australia, July 19, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 2-Day Root Cause Analysis Training

Reno, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Bogota, Colombia, July 25, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Bogota, Colombia, July 27, 2018: 1-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, August 13, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

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

Manchester, United Kingdom, October 1, 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.

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