Category: Summit

Where Do You Get Ideas To Improve Root Cause Analysis?

January 31st, 2018 by

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

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 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

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Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

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Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

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People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

New Name Gives Nod to 1982 Knoxville World’s Fair

January 31st, 2018 by

Visitors and Knoxvillians will enter an updated building and a new phase in the life of the formerly named Knoxville Convention and Exhibition Center, now known as the World’s Fair Exhibition Hall. The area underneath the downtown Holiday Inn is undergoing a 2.1 million renovation, to include a new roof and remodeled restrooms. The rename and remodel of the hall will be celebrated with a new logo displaying the 1982 World’s Fair flame and international flags in Rubik’s Cube fashion.

The 2018 Global TapRooT® Summit will be hosted in Knoxville Convention Center, February 26 – March 2. Register now to change the way you do business and solve problems.

Road Trip: Find Yourself in Knoxville

January 30th, 2018 by

You’re never quite the same after a memorable road trip. Curiosity can seize you on a trip, yes, even on a business trip. The 2018 Global TapRooT® Summit is in Knoxville, Tennessee. You have some free time to wander. Time to check out the life and lifestyles. Make new contacts or new friends. Put on a foodie hat and eat like a boss. Pick up souvenirs.

Here, in Knoxville, we invite you to open yourself up to a city that brims with 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. Save time to sample our downtown winery and distilleries, and hop on a Knox Brew Tour.

Here’s a smattering of suggestions for exploring and good times.

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.
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
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
14. First Friday Knoxville

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
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.

4 Signs You Need to Improve Your Investigations

January 29th, 2018 by

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.

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FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.

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SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

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You can download the matrix that Jack uses here: http://www.taproot.com/content/wp-content/uploads/2015/04/RateRootCauseAnalysis11414.xlsx.

Don’t be satisfied. Continually improve your root cause analysis!

Introducing the 2018 Global TapRooT® Summit Software Track

January 25th, 2018 by

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

Join Us for the Quality Track for the 2018 Summit

January 25th, 2018 by

Chris Vallee put an awesome track together for professionals who are involved in quality processes. If that’s you, you don’t want to miss this informative video!

REGISTER NOW or

Learn more!

Have FUN at the 2018 Global TapRooT® Summit!

January 25th, 2018 by

We don’t want the 2018 Global TapRooT® Summit to be boring. We want you to meet smart industry leaders, learn amazing best practices, and have fun!

Learning while having fun is much more effective that trying to stay awake during boring presentations. That’s why we organize the Global TapRooT® Summit to have activities, Keynote Speakers, and sessions that are active and entertaining.

Plus we start with the Name Game and have an excellent Reception on Wednesday.

This year we will again have rock star Carl Dixon as our entertainment at the reception where you can network with the new friends and important contacts that you have established.

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Here’s Carl back in the day playing with April Wine …

And more classic rock from Carl and April Wine …

And just one more …

I think he is even better today. Don’t miss the 2018 Global TapRooT® Summit reception!

What Pre-Summit Course Should I Attend?

January 23rd, 2018 by

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That’s a tough question…

Here is more course info: http://www.taproot.com/taproot-summit/pre-summit-courses

Attending the 2018 Global TapRooT® Summit and a Pre-Summit course is a great way to learn more AND get a discount of $200 off the course.

And if you bring a team to the Summit, you can get discounts up to $600 off per person!

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CLICK HERE to REGISTER!

Ready for a road trip? Then wrap up your travel planning for the 2018 Global TapRooT® Summit in Knoxville, Tennessee!

January 18th, 2018 by

 


When some people think of Knoxville, Tennessee they often think of the regional attractions such as the Smoky Mountains and the area’s large, picturesque lakes. However, this city has plenty to offer without ever leaving town. Knoxville’s Urban Wilderness is just three miles from the Knoxville Convention Center where the 2018 Global TapRooT® Summit will be held. It includes 50 miles of natural surface for hikers, mountain bikers and trail runners. The city also has a rich musical heritage, which includes stars like Dolly Parton, the Everly Brothers and Roy Acuff. Popular music venues today include the historic Tennessee Theatre, Bijou Theatre, the Square Room and a host of clubs that present live music every night of the week. Dining options are numerous . . . you’ll find a heavy focus on farm-to-table fare during your visit downtown. In addition to hiking, biking, music, history and arts, the city has an exciting craft beer scene and the opportunity to relax with some of the country’s finest beers and people.

Have you taken the steps to a memorable road trip? It’s simple!

Step 1: REGISTER for the 2018 Global TapRooT® Summit.

Step 2: Do your travel planning and get a hotel booked.

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And don’t miss the activities the week of the Summit.

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Miranda Lambert is performing at Thompson-Boling Arena on Thursday, March 1, 2018.

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Tape Face, the Comedian, is performing at the Bijou Theatre on Sunday, February 25, 2018.

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Jonny Lang with Tony Lucca Solo is performing at the Bijou Theatre on Tuesday, February 27, 2018.

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Beth Hart is performing at the Bijou Theatre on Thursday, March 1, 2018.

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The Wizard of Oz national tour will be starring at The Tennessee Theatre on Friday, Saturday and Sunday, March 1, 2 and 3, 2018.

Why are the SMARTEST people going to the 2018 Global TapRooT® Summit?

January 17th, 2018 by

SummitHands

About three Summits ago, I had a Summit attendee come up to me and say:

Mark, it is amazing the quality of speakers and topics you put together for the Summit.
But even more amazing is the networking. The people at this Summit are some of
the smartest people working on real life performance improvement in industry!
I just wanted to tell you thanks for making this happen.

 How do we get such high quality attendees? That’s the kind of people who use TapRooT® Root Cause Analysis to stop accidents, improve quality, reduce risk, and improve equipment reliability.

If you haven’t registered for the 2018 Global TapRooT® Summit yet, GET HOT! Visit the Summit web site and get registered TODAY!

Don’t Miss the TapRooT® Family Reunion

January 17th, 2018 by

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The Global TapRooT® Summit was almost named the TapRooT® Family Reunion. Why? Because that’s the way it feels.

Friendly folks getting together to say hello and get reacquainted.

Unless you belong to a dysfunctional family, you know what I mean.

This family has a common goal. They to share best practices and learn how to achieve outstanding performance. TapRooT® Root Cause Analysis is a part of that effort. But there is so much more to learn and share at the reunion (Summit). And that’s why we sponsor the Summit and spend lavishly on speakers.

We want to provide the opportunity for our best clients to meet face to face, develop relationships, and get new ideas to make safety, quality, equipment reliability, patient and process safety, and productivity even better. And leave the Summit inspired to go back home and make performance great.

The learning that takes place is one of the reasons that we require Certified TapRooT® instructors to attend the Summit at least once every two years. We think that keeping up to date on the latest improvement ideas is that important.

So don’t miss the reunion (the Summit) and your chances to make your performance improvement efforts that much better. Register for the 2018 Global TapRooT® Summit (February 26 – March 2, Knoxville, TN) TODAY by CLICKING HERE.

Which Summit Track Should You Attend?

January 15th, 2018 by

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There is so much to new information to learn and so many best practices being shared that the hardest question you have to answer is:

“What Best Practice Track should I attend at the 2018 Global TapRooT® Summit?”

 That’s a tough question to answer. Maybe you should bring enough folks so that some attends each track?

If you have to pick just one, watch these videos and read the information at the links below to help you select the right track that will help you improve performance at your company.

Quality

http://www.taproot.com/archives/61257

Patient Safety

http://www.taproot.com/archives/61721

Human Performance

http://www.taproot.com/archives/60950

Investigator

http://www.taproot.com/archives/61241

Asset Optimization

http://www.taproot.com/archives/61327

Safety

http://www.taproot.com/archives/60790

Software

http://www.taproot.com/archives/61000

Some info about the new software …

 

TapRooT® Certified Instructor

http://www.taproot.com/archives/61023

General Discussion and Keynote Speakers

Now REGISTER! 

What Will You Learn in the Patient Safety Best Practice Track at the Summit?

January 12th, 2018 by

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Since 1994, System Improvements has included information about improving Patient Safety in the Summit. This year we have a whole best Practices Track dedicated to improving patient safety and a Keynote Speaker talking about a fatal sentinel event.

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Let’s start by telling you about Dr,. Carol Gunn, one of our Keynote Speakers. She is a medical doctor who was trained to use the TapRooT® Root Cause Analysis System before she became a doctor. While she was a doctor, her sister died in a hospital from “complications.” It turns out that those complications were a result of a medical error. She will tell the story of her sisters death and what can be learned when root cause analysis is used properly and what happens when sentinel events are covered up.

Now let’s look at what’s covered in the Patient Safety Best Practices Track:

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Improving Patient Safety – Gaining a Win from a Loss (Michel Lindsay): Michele will share the evolution and success of their system for managing patient safety incidents and the expanded role of the Quality of Care Committee (QCC) on its journey to a high reliability organization at Southlake Regional Health Centre. A serious incident can have devastating outcomes to patients, their families, and to the caregivers involved. Even errors that result in no or mild harm to the patient can be devastating and career changing for staff and physicians. We have created structures and supports for immediate and long term organizational learning and improvements from incidents while maintaining a culture of care. Learn how the process QCC role has assisted in removing the shame and blame from an incident and turned it into a powerful lever for caring, sharing and repairing. Michele will describe the investigation processes using illustrations and case studies to describe how patient safety, learning, performance and culture has been positively impacted by their approach. The presentation includes the input from the COO & SVP Operations, Director of Surgery, the Director of Risk, the Manager of Risk, the Manager of a Cardiac Clinical Program, a Physician and the Quality Specialist.

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Improving Sentinel Event Investigations (Ken Turnbull): Ken is one of the authors of the new book, Improving Patient safety with TapRooT® Root Cause Analysis (to be released somewhere around the time of the Summit) and will share some of the new ideas presented in the book.

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Using Wearables to Minimize Daily Human Errors (Kevin McManus): Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

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Deep Dive Into the Procedures Basic Cause Category (Ralph Brickey): Procedures (checlists) are almost a new concept being used to improve patient safety. Learn from the TapRooT® procedures best practices including: Learn: the philosophy and practice of using procedures; different types of procedures and how they are addressed in the TapRooT® Root Cause Dictionary and the Root Cause Tree®; and two human performance tools to aid in proper procedure use

Influencing Change (Jonathon Kennedy): Change is what improving performance is all about. What is the best way to influence change? Hear what Jonathan Kennedy has to say.

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Top 7 Secrets of a Great Investigation Interview (Barb Carr): Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.
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TapRooT® Users Share Best Practices (Linda Unger): Share best practices about root cause analysis, investigations, and performance improvement with industry leaders from around the world.

Performance Improvement Gap Analysis (Linda Unger): Evaluate where you are and where you want to go and how you will apply what you have learned at the Summit to improve performance at your facility. The goal of this session is to go back to work with a plan to improve patient safety.

That an impressive list of breakout sessions.

So are you really interested in improving patient safety? Then you should attend the 2018 Global TapRoot® Summit. Register HERE!

Why does your site need someone (or a team) at the 2018 Global TapRooT® Summit?

January 10th, 2018 by

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Since there are so many high-quality conferences and events put on each year, you really need to think about which ones you should go to. If you haven’t signed up for the 2018 Global TapRooT® Summit yet, here are four top reasons to attend.

REASONS TO ATTEND THE SUMMIT

1. SAVE MONEY

You can’t afford a major accident, a fatality, a serious quality defect, a sentinel event or an unexpected equipment failure.

The TapRooT® Summit is a unique gathering of people intent on improving performance. They share ideas across companies, disciplines, and continents. The sharing of new ideas and best practices will help you develop ideas to stop accidents, fatalities, quality issues, sentinel events, and equipment failures.

What you may not have thought of is how much money this could save your company. Do you know the costs of human errors that occurred at your site? What were your workman’s comp costs? How much does unexpected downtime and lost production cost your site? What were the costs of legal issues due to mistakes and the resulting lawsuits? You will be far ahead financially if you stop just ONE major issue.

2. GET A PROMOTION

What will happen to your career is you are seen as an essential problem solver that leads the sites improvement efforts?

But where will you get the skills and ideas to lead improvement at your site? That’s easy. Attend the 2018 Global TapRooT® Summit.

When we plan the Summit we take the lessons we learn from teaching root cause analysis around the world and build sessions that we know will help solve frequently occurring issues that we have observed at courses. You will be surprised how many people face issues similar to the ones that you face and how there are people who have figured out how to improve performance and stop those problems. Don’t reinvent the wheel. Attend the Summit and learn from the success of others.

3. GET FIRED UP!

Improving performance requires constant attention. Working hard to constantly improve performance can wear you down. Where do you get the motivation to continually challenge the status quo? Attend the TapRooT® Summit!

Most people we talk to before the Summit say that they are attending to learn new skills and get new ideas and best practices to help their site improve performance. And after the Summit they agree that they learned valuable information well worth the time and expense of attended. But they are surprised that they got an unexpected benefit that was even more valuable. They left the Summit FIRED UP to go back to work and make things happen.

Why is motivation so valuable? Because an unmotivated person is unlikely to have the stamina to see an improvement effort through to completion. They get started but they don’t get things done.

We understand motivation and making improvements happen and that’s why we know that motivation is important. That’s why we build in events to motivate you throughout the Summit. Attend the 2018 Global TapRooT® Summit and go back to work CHARGED UP to make improvement happen.

4. HAVE FUN

What? How can fun be an important reason to attend the TapRooT® Summit? We have learned that people learn more, retain more, and bring more and better ideas back to work from the Summit if they have fun learning and sharing.

After all, who says that work and learning have to be dull and boring? We have discovered how to make the Summit an activity that you will find valuable and ENJOYABLE every time you attend.

ONE MORE IDEA…

Have you ever noticed how an effective team accomplishes much more than a single motivated individual?

That’s why we recommend that a site truly interested in achieving excellence send an improvement team to the TapRooT® Summit.

A team can spread out across the various sessions (there are tracks with various topics to pick from). Someone might attend the Safety Track while someone else attends the Quality Track, while someone else attends the Human Factors Track, while someone else attends the Asset Optimization Track. See the schedules for the various tracks by CLICKING HERE.

GUARANTEE

We know that you will find the 2018 Global TapRooT® Summit a valuable experience. We know that you will have a great return on your investment of time and money. And we provide you with this guarantee:

Attend the Summit and go back to work and use what you’ve learned. If you don’t get at least 10 times the return on your investment, simply return the Summit materials and we’ll refund the entire Summit fee.

So don’t wait. REGISTER TODAY!

Want to see what people who attend the Summit have to say after they attend? Here’s a video I made a few years ago and it sure is a blast from the past that still applies today…

Sorry, we won’t be having golf at this Summit (the first week in March in Tennessee just doesn’t work) but we will have a great reception and a lot of sharing.

4 Steps to Playing like a Champion in 2018

January 8th, 2018 by


Ever wonder what your life would feel like if you had the knowledge to live life at the top of your game? Champions know how to compete, but they are not born that way. Every champion has to first learn how to qualify for the game before they even get a chance to compete for the win.

So, how do you qualify to play?

First

Begin today by forming a mental picture of where you want to be. If you can form a strong mental picture and rehearse it, your brain will find a way to get you there. Write it down.  Read it daily.

Second

Expect setbacks and move past them. Let them be lessons learned that propel you forward not anchors that weigh you down. A champion is an ordinary individual who persists through obstacles. Are expectations causing you stress? Don’t put the high expectations of others in a negative light.  Expectations are really support… a belief that you can accomplish a goal.

Third

Stay focused on your mental picture of success and support yourself with positive affirmations. If you are not telling yourself that you are capable of success every single day, there is no way you are going to experience it. If you are waiting for someone else to believe in you, they are probably waiting for you to believe in yourself. Stay positive.

Fourth

Strive for improvement. You will experience wins practicing these steps but regardless of your achievements, operate under the goal of self-improvement. So, practice these steps to qualify to play, and then join us at the 2018 Global TapRooT® Summit to continue improving! Boaz Rauchwerger is our special keynote speaker on Wednesday, February 28 at 12:30 p.m., presenting “Play Like a Champion Every Day.” After his keynote, he will be presenting “Improve People Skills and Become More Productive” in a best practice session from 1:30 pm to 2:30 pm on the Alternative Sessions Track.

Boaz Rauchwerger is Speaker of the Year for Vistage International, the world’s largest organization of CEO’s. He is the founder and president of Boaz Power Corp., a Los Angeles-based high performance consulting firm. He is also an internationally-known professional business speaker for major corporations such as American Airlines, Xerox, and Toyota.

Previously, Boaz was a newspaper publisher, owned his own advertising agency and has produced corporate films as well as a network television show. He is the author of “How to Create Exceptional Outcomes – Become the CEO of a Very Successful Life.” Boaz holds a degree in journalism, public relations and advertising from the University of Tulsa.

Join us for his game-changing presentations and live your life like a champion in 2018!

Register today!

Learn more.

Root Cause Tip: Causal Factor Development

January 4th, 2018 by

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Human Error?

 

Hi, everyone.

I thought I’d do a quick discussion on some ideas to help you when developing Causal Factors on your SnapCharT®.

Let me start out by stressing the importance of using the definition of a Causal Factor (CF) when you are looking at your SnapCharT®. Remember, a Causal Factor is a mistake, error, or failure that, if corrected would have prevented the incident, or mitigated it’s consequences.  The most important part of the definition are the first few words:  mistake, error, or (equipment) failure.  As you are looking for CFs, you should be looking for human error or mistakes that led directly to the incident.  Remember, we aren’t blaming anyone.  However, it is important to realize that almost all incidents are “caused” by someone not doing what they were supposed to do, or doing something they shouldn’t.  This isn’t blame; this is just a recognition that humans make mistakes, and our root cause analysis must identify these mistakes in order to find the root causes of those mistakes.

With this definition in mind, let’s talk about what is NOT a CF.  Here are some examples:

  • “The operator did not follow the procedure.”  While this may seem like a CF, this did not lead directly to the incident.  We should ask ourselves, “What mistake was made because someone did not follow the procedure?”  Maybe, the operator did not open the correct valve.  Ah, that sounds like a mistake that, if it had not occurred, I probably would not have had the incident.  Therefore, “Operator did not open valve VO-1” is probably the CF.  Not following the procedure is just a problem that will go under this CF and describe the actual error.
  • “Pre-job brief did not cover pinch points.”  Again, we should ask ourselves, “What mistake was made because we did not cover pinch points in our pre-job brief?”  Maybe the answer is, “The iron worker put his hand on the end of the moving I-beam.”  Again, this is the mistake that led directly to the incident.  The pre-job brief will be a piece of information that describes why the iron worker put his hand in the pinch point.
  • “It was snowing outside.”  I see this type of problem mis-identified as a CF quite often.  Remember, a CF is a mistake, error, or equipment failure.  “Snowing” is not a mistake; it is just a fact.  The mistake that was made because it was snowing (“The employee slipped on the sidewalk”) might be the CF in this case, again with the snowy conditions listed under that CF as a relevant piece of data.

Hopefully, this makes it a little easier to identify what is and is not a CF.  Ask yourself, “Is my Causal Factor a mistake, and did that mistake lead directly to the incident?”  If not, you can then identify what actually lead to the incident.  This is your CF.

Want to learn more? Attend our 2-day Advanced Causal Factor Development course February 26 and 27, 2018 in Knoxville, Tennessee and plan to stay for the 2018 Global TapRooT® Summit, February 28 to March 2, 2018.

Asset Optimization Track at the Summit – Are you in?

January 2nd, 2018 by

If you are a typical procrastinator, you probably haven’t signed up for the Global TapRooT® Summit yet. Well, it’s now 2018, and procrastination is over! Don’t miss the chance to get in on one of the best opportunities to improve your company.

I wanted to give you a little more information about one of the most exciting tracks at the Summit: the Asset Optimization Track (doesn’t that sound so much better than “Equipment Fixing Track”?) We’ll be providing some great sessions to get your reliability and maintenance processes moving in the right direction in 2018. Besides the Summit Keynote addresses common to all tracks, here are a few of the sessions that make the Asset Optimization track right for you:

  • Multiple Failures Without Learning:  Tired of repeat failures?  Chris Vallee will give you some examples of why the “break it – Fix it” mentality is no longer the way to go.
  • Improved maintenance Troubleshooting using Equifactor®:  I’ll be leading a session on how Equifactor® Equipment Troubleshooting module of the TapRooT® VI software service works, including some of the new features available in the software.  For some reason, I think this is the best session of all!
  • The Business End of Equipment Reliability:  OK, maybe my session is NOT the best!  Heinz Bloch will be with us again this year, giving us his unique insight into the business case behind reliably operating your equipment.
  • The Psychology of Failing Fixes:  Kevin McManus will be sharing his unique view on how root cause analysis is the key to a truly reliable operation.  Don’t miss the opportunity to soak up some of Kevin’s enthusiasm!

We’re going to have a great Summit this year, in our hometown for the first time ever.  Please plan on signing up for the Summit.  Don’t tell yourself, “Oh, yeah, I need to do that sometime.”  The time is now; the Summit is next month! REGISTER NOW for the Asset Optimization Track!

Resolve to Improve!

January 2nd, 2018 by

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On New Year’s Eve, did you make a resolution? According to the data company, iQuanti, here were the top seven resolutions made:

  1. Get healthy.
  2. Get organized.
  3. Live life to the fullest.
  4. Learn new hobbies.
  5. Spend less/save more.
  6. Travel.
  7. Read more.

Are you surprised by any of the above? Nothing earth shattering there.  Outside personal improvements, there is a way to truly make a difference in your own life as well as the lives of others. The one resolution not on the top seven list that you shouldn’t overlook is a work-related resolution.

Here are some work-related resolutions to consider…

  • Eliminate the blame environment when someone makes a mistake.
  • Stop problems from happening over and over again.
  • Save time and get better results when you perform an incident investigation.
  • Learn best practices to make your workplace safer and more productive.
  • Become better at your job by applying state-of-the-art root cause analysis.

How do you do these things?

TapRooT®

Start by attending TapRooT® Training. See our upcoming courses here:

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

Then make sure that you are at the 2018 Global TapRooT® Summit to learn best practices from around the world. That’s the best place to learn best practices from industry leaders from around the world. The Summit is in Knoxville, TN, on February 26 – March 2. See the Summit schedule here:

http://www.taproot.com/taproot-summit/summit-schedule

And register here:

http://www.taproot.com/taproot-summit/register-for-summit

The knowledge you will gain will help you make 2018 the best year ever.

2018 Global TapRooT® Summit Updates!

December 19th, 2017 by

There’s been LOTS of exciting news posted lately about the upcoming 2018 Global TapRooT® Summit, so I thought I’d organize it all into one post and help you catch up.

There are NINE Best Practice Tracks you can choose from for your Summit experience (February 28 – March 2):

  1. Human Factors
  2. Investigator
  3. Quality
  4. Safety
  5. Software
  6. TapRooT® Instructor Recertification
  7. Alternative Sessions (More info to come in January)
  8. Asset Optimization
  9. Patient Safety (More info to come in January)

There are TEN 2-day Pre-Summit Courses for you to choose from (February 26 – 27)

  1. TapRooT® Root Cause Analysis Training (Course description)
  2. Equifactor® Equipment Troubleshooting and Root Cause Analysis (Course description)
  3. Advanced Causal Factor Development Course (Course description)
  4. Advanced Trending Techniques (Recent update! | Course description)
  5. TapRooT® Analyzing and Fixing Safety Culture Issues (Recent update! | Course description)
  6. Risk Management – Best Practices & Risk-Based Thinking (Recent update! | Course description)
  7. Getting the Most from Your TapRooT® VI Software (Recent update!Course description)
  8. TapRooT® for Audits (Recent update! | Course description)
  9. TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills (Recent update! | Course description)
  10. Understanding and Stopping Human Error (Recent update! | Course description)

Make plans to attend the Reception with Carl Dixon.

And don’t forget to check out the recently updated Hotel & Travel page for ideas about:

  • where to stay.
  • how to get around Knoxville once you arrive (“Transportation Tips”).
  • what’s happening around town that you may be interested in during your free time.

And CLICK HERE to view our informative short Summit videos.

REGISTER NOW.

Sign up now for the February 2018 Global TapRooT® Summit Quality Track

December 19th, 2017 by

 

Need a jumpstart on your Quality Management System’s improvements to better utilize your company’s product realization? Sign up for the Quality Track during the Global TapRooT® Summit, Knoxville, Tennessee, February 26 – March 2, 2018

Improve Your Resource Usage Management by attending:

Mark Paradies (the creator of TapRooT®)

How to Replace 5 Whys with TapRooT® for Better Results

People argue that 5-Whys is a “good enough” root cause analysis tool. They say it’s simple to ask “why” five times and that people in the field can “understand it.” Well, the time has come to put that argument to bed… 5-Whys is inadequate. It has fundamental flaws that make it inadequate. This session will demonstrate how replacing 5-Whys with TapRooT® provides better results.

 

Kevin McManus– Great Systems!

Stop Daily Goofs for Good

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job.

Using Wearables to Minimize Daily Human Errors

Look at how wearables are being used both now and in the future to help prevent errors and identify problems more effectively.

 

Barb Carr – System Improvements, Inc.

Top 7 Secrets of a Great Investigation Interview

Take your interviewing skills to the next level and collect better quality and quantity of information from your investigative interviews by harnessing the power of the seven secrets.

 

Improve Your Management Responsibility by attending:

 John Boyle

Making Audits an Integral Part of a Proactive Improvement Program –

This session has a proactive, process-based focus, and promotes the use of systematic improvements to prevent human error and improve cognitive ergonomics on the job. Kevin McManus

 Jonathan Kennedy

Influencing Change

Nothing happens without change. Nothing happens without support of change. Learn techniques to increase the ability to change with full management support.

 

Improve Your Analysis and Improvements by attending:

Christopher Vallee – System Improvements, Inc.

What is a Trend and How Can You Find Trends in the TapRooT® Data?

You have invested in TapRooT® and have root cause data, but do you know what the data tells you? Do you know if what you are measuring has changed for the good or the bad? Do you know how to access your trend-able data in your VI Software? Learn what to look for, what needs to be acted on and how to access the data on VI Software.

Performance Improvement Gap Analysis

Put together everything that you learned this week in your Summit Tracks and from your peers, then develop your action plan to hit the ground running.

REGISTER NOW or

Learn more!

Are you interested in improving human performance? Try this four step plan!

December 19th, 2017 by

Plan4

Is discipline the main way you “fix” human error problems?

Are you frustrated because people make the same kind of mistakes over and over again?

Have you tried “standard” techniques for improving human performance and found that they just don’t get the job done long term (they have an impact short term but not long term)?

Is management grasping for solutions to human error issues?

Would you like to learn best practices from industry human performance experts?

Try this four step plan:

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1. Attend a 5-Day TapRooT® Advanced Root Cause Analysis Course.

The TapRoot® System is made to reactively and proactively help you solve human performance issues. It has built in human factors expert systems that guide you to the root causes of human errors and help you develop effective fixes. The 5-Day TapRooT® Course is the best way to learn the system and get started fixing human performance issues.

See the upcoming course schedule here: http://www.taproot.com/store/5-Day-Courses/

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2. Attend the Understanding and Stopping Human Error Course

At this two day class, Dr. Joel Haight, a human factors and safety improvement expert and industrial engineering professor at the University of Pittsburg (where he is the Director of the Safety Engineering Program) shares the reasons why people make mistakes and what you can do to understand the problems and fix them.

Joel is an expert TapRooT® User having extensive experience apply TapRooT® to fix human factors problems at a Chevron refinery and in the oil field in Kazakhstan. He is also an expert in applying other human performance analysis and improvement techniques. He brings this knowledge to the 2-Day Understanding and Stopping Human Error Course.

It is best if you have already attended at least a 2-Day TapRooT® Course prior to attending this course. See the course description here: http://www.taproot.com/taproot-summit/pre-summit-courses#HumanError

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3. Attend the Human Factors Track at the 2018 Global TapRooT® Summit

Once a year we put together a track at the Global TapRooT® Summit that is designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s what you get at the Human Factor Track at the Summit. What are the sessions at the 2018 Global TapRooT® Summit?

  • TapRooT® Users Share Best Practices – This is a workshop designed to promote the sharing of investigation, root cause analysis, and human performance best practices from TapRooT® Users from around the world. Every year I attend this session and get new ideas that I share with others to help improve performance. Many say this is the best session at the Summit because they get such great ideas and develop new, helpful contacts from many different industries.
  • Top 5 Reasons for Human Error and How to Stop Them – Mark Paradies, President of System Improvements and a human factors expert, shares his deep knowledge of the top five reasons that he see’s for people making “human errors.” For each of these he shares his best ideas to stop the problems in their tracks.
  • Stop Daily Goofs for Good – Kevin McManus, a TapRooT® Instructor and performance improvement expert, shares systematic improvement ideas s to prevent human error and improve cognitive ergonomics on the job.
  • Using Wearables to Minimize Daily Human Errors – Using “wearables” is a technological approach to error prevention. Find out more about how it is being used and may be applied even more effectively in the future.
  • Alarm Management, Signal Detection Theory, and Decision Making – Are people at your facility overwhelmed by alarms? Do the become complacent because of nuisance alarms? Dr. Joel Haight, Director of the University of Pittsburg Safety Engineering Program will discuss control system decisions, decision execution, alarm management, signal detection theory, and decision making theory and how it could be critical in an emergency situation.
  • The Psychology of Failing Fixes – Why do your fixes fail to prevent human error? That’s what this session is all about!
  • What is a Trend and How Can You Find Trends in the TapRooT® Data? – looking for trends in human error data is an important activity to identify generic human factors problems and take the first step to major human performance improvements. Now for the bad news. Most people really don’t understand trending. Find out what you need to know and how to put trending to work in your improvement program.
  • Performance Improvement Gap Analysis – This is the session where you put everything together. Where does your program have holes? How can you apply what you have learned to fill those holes? What are others doing to solve similar problems? Put your plan together so you are ready to hit the ground running and make improvements happen when you get back to work.

And the Best Practice Sessions outlined above are only a start. You will also see five great Keynote Speakers:

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Mike Williams will share his experience surviving the Deepwater Horizon explosion.

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Dr. Carol Gunn will share the story of the her sisters unnecessary death in a hospital and patient safety improvement.

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Inky Johnson will share his experience with a debilitating football injury and how it changed his life and helps him inspire excellence in others.

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Mark Paradies will help you get the most out of your application of TapRooT®.

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Vincent Ivan Phipps will teach yo to amplify your leadership skills and communication ability.

We know that the Summit will provide you with new ideas and the inspiration to implement them.

Start

4. Get started! Analyze your human performance issues and make improvements happen!

Just Do It! get back to work and implement what you have learned. Need more help? We can provide training at your site to get more people trained in using TapRooT® so that you have help making change happen.

Don’t wait! Get your four step plan started! Register for the courses and Summit today!

5 Reasons Why You Should Attend the Pre-Summit Course: Getting the Most from Your TapRooT® VI Software

December 19th, 2017 by

 

  1. Learn to create your own Custom Tab and Custom Fields. Creating custom tabs and fields is a very powerful feature in the software and this course will go into great detail on how to customize these for your business needs.
  2. Learn to create your own Custom Reports and Report Templates. The TapRooT® VI software does not assume to know exactly what reports you want to see and share with your team members. This course will teach you how to build reports that contain specifically what you want and how to create and share the same templates with other users.
  3. Learn to use the redesigned Optional Techniques. Do you know that the software contains tools and techniques that can help you build better SnapCharT®s and more thoroughly investigate your incidents? This course will show you how to use Safeguard Analysis, Change Analysis, Equifactor® and CHAP.
  4. Learn the Administrative functions available to give your users more options. This course will go into great detail on the new administrative features including Notifications, Maintenance Mode and Custom Equifactor®.
  5. Learn how to use the Trending features to understand where opportunities exist in your business. The new dashboard is customizable and offers hundreds of options to look at root cause, location and classification trends. You will also learn to export custom data to create additional custom reports.

Come join us February 26th and 27th before the Global TapRooT® Summit to get the most from your TapRooT® VI Software!

CLICK HERE to register today.

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