Category: TapRooT

Lunch & Learn: Meet TapRooT® at noon EST on Facebook Live!

April 18th, 2018 by

Tune into TapRooT®’s Facebook Live today. You’ll join TapRooT® professionals as we explore a contemporary, workplace-relevant topic. We look forward to being with you on Wednesdays!

Here’s how to connect with us for today’s Facebook Live:

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

When? Today, Wednesday, April 18

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

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

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

Gear up with TapRooT® in Gatlinburg

April 18th, 2018 by

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

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

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

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

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

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

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

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

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

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

April 17th, 2018 by

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

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

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

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

How many investigations are enough?

April 16th, 2018 by

 

I’d like you to think about this scenario at work.  You’ve just sent your team to Defensive Driving School, and made sure they were trained and practiced on good driving skills.  They were trained on how to respond when the vehicle is sliding, safe following distances, how to respond to inclement weather conditions, etc.

Now that they’re back at work, how many managers would tell their recently-trained employees, “I’m glad we’ve provided you with additional skills to keep yourself safe on those dangerous roads.  Now, I only want you to apply that training when you’re in bad weather conditions.  On sunny days, please don’t worry about it.”  Would you expect them to ONLY use those skills when the roads are snow-covered?  Or ONLY at rush hour?  I think we would all agree that this would be a pretty odd thing to tell your team!

Yet, that’s what I often hear!

I teach TapRooT® courses all over the world. We normally start off the class by asking the students why they’re at the course and what they are expecting to get from the class. I often hear something that goes like this:

“I’m here to get a more structured and accurate root cause analysis process that is easy for my staff to use and gets repeatable results.  I don’t expect to use TapRooT® very often because we don’t have that many incidents,  but when we do, we want to be using a great process.”

Now, don’t get me wrong, I appreciate the sentiment (we don’t expect to have many serious incidents at our company), and we can definitely meet all of the other criteria.  However, it does get a little frustrating to hear that some companies are going to reserve using this fantastic product to only a few incidents each year.  Doesn’t that seem to be a waste of terrific training?  Why would we only want our employees to use their training on the big stuff, but not worry about using that same great training on the smaller stuff?

There are a couple of reasons that I can think of that we have this misconception on when to use TapRooT®:

  • Some managers honestly believe that they don’t have many incidents.  Trust me, they are not looking very hard! Our people (including ourselves) are making mistakes every day.  Wouldn’t it be nice if we went out there, found those small mistakes, and applied TapRooT® to find solid root causes and corrective actions to fix those small issues before they became large incidents?
  • Some people think that it takes too long to do a good RCA.  Instead, they spend time using an inferior investigation technique on smaller problems that doesn’t fix anything anyway.  If you’re going to take time to perform some type of RCA, why waste any time at all on a system that gives you poor results?
  • Some people don’t realize that all training is perishable.  Remember those defensive driving skills?  If you never practice them, do you ever get good at them?

I recognize that you can’t do an RCA on every paper cut that occurs at your facility.  Nobody has the resources for that.  So there must be some level of “incident” at which makes sense to perform a good analysis.  So, how do we figure out this trip point?

Here are some guidelines and tips you can follow to help you figure out what level of problem should be investigated using TapRooT®:

  • First of all, we highly recommend that your investigators perform one TapRooT® investigation at least every month.  Any longer than that, and your investigation skills start becoming dull.  Think about any skill you’ve learned.  “Use it, or lose it.”
    • Keep in mind that this guideline is for each investigator.  If you have 10 investigators, each one should be involved in using TapRooT® at least monthly.  This doesn’t have to be a full investigation, but they should use some of the tools or be involved in an investigation at least every month.
  • Once you figure out how many investigations you should perform each year to keep your team proficient, you can then figure out what level of problem requires a TapRooT® investigation.  Here is an example.
    • Let’s say you have 3 investigators at your company.  You would want them to perform at least one investigation each month.  That would be about 36 investigations each year.  If you have about 20 first aid cases each year, that sounds like a good level to initiate a TapRooT® investigation.  You would update your company policy to say that any first aid case (or more serious) would require a TapRooT® investigation.
    • You should
      also do the same with other issues at the company.  You might find that your trigger points would be:

      • Any first aid report or above
      • Any reportable environmental release
      • Any equipment damage worth more than $100,000
    • When you add them all up, they might be about 36 investigations each year.  You would adjust these levels to match your minimum number to maintain proficiency.
  • At the end of each year, you should do an evaluation of your investigations.  Did we meet our goals?  Did each investigator only do 4 investigations this year?  Then we wasted some opportunities.  Maybe we need to lower our trip points a bit.  Or maybe we need to do more audits and observations, with a quick root cause analysis of those audit results.  Remember, your goal is to have each investigator use TapRooT® in some capacity at least once each month.
  • Note that all of this should be specified in your company’s investigation policy.  Write it down so that it doesn’t get lost.

Performing TapRooT® investigations only on large problems will give you great results.  However, you are missing the opportunity to fix smaller problems early, before they become major issues.

TapRooT®: It’s not just for major issues anymore!

Where to Start When Finding Root Causes

April 11th, 2018 by

I had someone ask me the other day …

”Where do I start when finding root causes?”

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

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

Here is a simple example.

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

What is the root cause.

You might think the obvious answer is …

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

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

NewImage

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

SprainSnapwCF

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

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

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

Pick up TapRooT® in Auckland

April 10th, 2018 by

Take two days to become TapRooT® Trained in Auckland. Within these two days, you’ll gain experience and perspective in myriad workplace situations. You will learn to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events, and many other categories of problems.

At the completion of your course, you’ll receive a certificate and a 90-day subscription to TapRooT® VI, the online software service. The true benefit is that you will have added the advantage of professional training to your expertise and on your resume!

While you’re in Auckland, you may want to take a day or two and explore the area. Cornwall Park is a haven in Auckland’s center, featuring gardens, panoramic views, grazing sheep and cattle, free seasonal events, and recreational paths. See views atop Sky Tower, the tallest structure in the Southern Hemisphere. Tiritiri Matangi Island, in the sparkling blue waters of the Hauraki Gulf of New Zealand, 19 miles northeast of Auckland, is rich in Māori and European history and a stunning wildlife sanctuary for New Zealand’s native birds. Ferry to Waiheke Island, with pristine forests and vineyards, for a wine or culinary experience. When you’re making plans or while you are there, be sure to use our Auckland Pinterest board to discover adventures, dining suggestions, and city sights.

In the course, we’ll participate in an exercise, using safety incidents or quality issues from your work environment. Be sure to bring one or more for us to dive into. These may be written reports, or you may share knowledge of an incident without a written report. We’ll divide into teams of 2-4 people, with each team analyzing a unique problem. You’ll be amazed at how much you learn in two days that you can immediately apply!

Advance your professional development through TapRooT® Training: Register for a two-day, game-changing experience in Auckland.

Technically Speaking – March Customer Satisfaction Survey Winner

April 5th, 2018 by

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner. This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous, and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a Survey, all respondents are entered into a monthly drawing to win a TapRooT® polo shirt.
Everyone, let’s congratulate the user, who prefers to stay anonymous, from National Grid as the winner for the month of March!

Scientific Method and Root Cause Analysis

April 4th, 2018 by

Screen Shot 2018 03 26 at 2 15 18 PM

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

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

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

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

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

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

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

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

The biggest problem that accident investigators face is limited knowledge.

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

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

The answer was always less than 5%.

Then we asked:

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

The answer was always close to 100%.

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

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

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

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

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

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

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

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

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

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

Now for the good news.

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

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

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

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

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

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

Technically Speaking – SnapCharT® Tips

March 29th, 2018 by

Does that picture ever represent you after completing an exhaustive SnapCharT®? If not, we listed a few resources to help you master the SnapCharT® tool in TapRooT® VI.

Tips For Building a SnapCharT®

SnapCharT® Versions

SnapCaps

Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, it doesn’t mean it has to be complicated!

Are you a Proficient TapRooT® Investigator?

March 19th, 2018 by

 

 

 

 

 

 

 

I teach a lot of TapRooT® courses all over the world, to many different industries and departments.  I often get the same questions from students during these courses.  One of the common questions is, “How do I maintain my proficiency as a TapRooT® investigator?”

This is a terrific question, and one that you should think carefully on.  To get a good answer, let’s look at a different example.:

Let’s say you’ve been tasked with putting together an Excel spreadsheet for your boss.  It doesn’t have to be anything too fancy, but she did ask that you include pivot tables in order to easily sort the data in multiple ways.  You decide to do a quick on-line course on Excel to brush up on the newest techniques, and you put together a great spreadsheet.

Now, if your boss asked you to produce another spreadsheet 8 months from now, what would happen?  You’d probably remember that you can use pivot tables, but you’ve probably forgotten exactly how it works.  You’ll most likely have to relearn the technique again, looking back over your last one, or maybe hitting YouTube as a refresher.  It would have been nice if you had worked on a few spreadsheets in the meantime to maintain the skills you learned from your first Excel course.  And what happens if Microsoft comes out with a new version of Excel?

Performing TapRooT® investigations are very similar.  The techniques are not difficult; they can be used by pretty much anyone, once they’ve been trained.  However, you have to practice these skills to get good at them and maintain your proficiency.  When you leave your TapRooT® course, you are ready to conduct your first investigation, and those techniques are still fresh.  If you wait 8 months before you actually use TapRooT®, you’ll probably need to refresh your skills.

In order to remain proficient, we recommend the following:

  • Obviously, you need to attend an initial TapRooT® training session.  We would not recommend trying to learn a technique by reading a book.  You need practice and guidance to properly use any advanced technique.
  • After your class, we recommend you IMMEDIATELY go perform an investigation, probably within the next 2 weeks or so.  You need to quickly use TapRooT® in your own work environment.  You need to practice it in your own conference room, know where your materials will be kept, know who you’re going to contact, etc.  Get the techniques ingrained into your normal office routine right away.
  • We then recommend that you use TapRooT® at least every month.  That doesn’t necessarily mean that you must perform a full incident investigation monthly, but maybe just use a few of the techniques.  For example, you could perform an audit and run those results though the Root Cause Tree®.  Anything to keep proficient using the techniques.
  • Refresher training is also a wonderful idea.  We would recommend attending a refresher course every 2 years to make sure you are up to speed on the latest software and techniques.  If you’ve attended a 2-Day TapRooT® course, maybe a 5-Day Advanced Team Leader Course would be a good choice.
  • Finally, attending the Annual Global TapRooT® Summit is a great way to keep up to speed on your TapRooT® techniques.  You can attend a specialized Pre-Summit course (Advanced Trending Techniques, or Equifactor® Equipment Troubleshooting, or maybe an Evidence Collection course), and then attend a Summit track of your choosing.

There is no magic here.  The saying, “Use it, or Lose it” definitely applies!

TapRooT® Around the World

March 16th, 2018 by

TapRooT® instructor, Marco Flores-Verdugo, sent us these photos from a course in Monterrey, Mexico that Marco and Jesus Reynoso taught. Looks like a fun group, and they had a good time learning how to use TapRooT®.

Want to attend a TapRooT® training course?

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

2-Day TapRooT® Root Cause Analysis Training

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

March 14th, 2018 by

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

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

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

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

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

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

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

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

Watch Facebook Live on Wednesdays: Next up is Body Language

March 13th, 2018 by

Be sure to catch TapRooT®’s Facebook Live session on Wednesday, March 14, 2018. TapRooT® Instructor and Nonverbal Communication Expert Barb Phillips and Implementation Strategist Benna Dortch will discuss, among other topics, how to interpret common body language cues.

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

When? Wednesday, March 14

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

Another recent FB Live sessions features Benna Boring and Ken Reed discussing the top six takeaways attendees said they wanted to incorporate into their companies after attending the 2018 Global TapRooT® Summit. We can’t wait for March 11-15, 2019, for our next Summit near Houston, Texas! Mark your calendars and begin making plans now!

TapRooT® Around the World

March 9th, 2018 by

TapRooT® instructor, Heidi Reed, sent us these photos from a course that she and Barry Baumgardner are teaching at Energy XXI in Grand Isle, LA. Looks like a great group!

 

Want to learn about your onsite course options?

Contact us!

Comments from a TapRooT® Course Participant

February 23rd, 2018 by

Malcolm Gresham, one of our instructors from Australia, sent me this video of a long time TapRooT® User who was attending a course for refresher training. Click the link below to watch a .mov (QuickTime) video.

CourseCritique.mov

Thanks Michael for having the course and you have a great memory! Keep reading the definition! Hope to see you at the Global tapRooT® Summit one of these years!

Technically Speaking – The 2018 TapRooT® Global Summit is Right Around the Corner

February 16th, 2018 by

The TapRooT® Support team is excited to remind you that the 2018 Global TapRooT® Summit is right around the corner with the Pre-Summit classes starting 2/26 and the Summit starting a couple days later on the 2/28. The Summit is a great way to improve your Root Cause Analysis skills, network with fellow TapRooT® users, and see how others use TapRooT® to help reduce the number of incidents at their company. We will have a table out in the Cumberland Concourse and we’d love for you to stop by and say hi!

You can register for the 2018 Global TapRooT® Summit and Pre-Summit here

Gain Team Leader knowledge and experience in our 5-day training

February 13th, 2018 by


The 5-day training course is our “Team Leader” training course. This provides an expert level of knowledge on all of the TapRooT® techniques and on the TapRooT® Software. This course targets those investigators that will be system experts and team leaders and provides the knowledge to manage and utilize the TapRooT® process for any kind of investigation. TapRooT® Software is used throughout the 5 days. When leaving this training course, the investigator will have experience analyzing issues, performing interviews, leading an investigative team, and using the TapRooT® software as an aid and tool.

A great course that will expand your abilities to investigate.
The course not only looks at human performance but equipment failures as well.
~ R. Klahs

Register for an upcoming course:

Monterrey, Mexico – March 5

Charlotte, North Carolina – March 19

New Orleans, Lousiana – April 16

Edmonton, AB Canada – April 23

Las Vegas, Nevada – April 23

 

Carl Dixon returns to the 2018 Global TapRooT® Summit!

February 9th, 2018 by

Carl Dixon, who sang and played with Coney Hatch, April Wine, and The Guess Who, is back at the 2018 Global TapRooT® Summit as the entertainment for our reception. Don’t miss the great music and good times!

Here’s a video from back in the day – Carl and Coney Hatch …

and April Wine …

And here is Carl in 2010 with the Guess Who …

And finally CARL SINGING “No Sugar” with The Guess Who in 2016 …

You’re Invited to Our 30th Anniversary Party!

February 9th, 2018 by

2018 marks an extremely special year for System Improvements Inc., it’s the year we turn 30. So come join us at the Knoxville Summit and help us celebrate three decades of saving lives!

The celebration will start Wednesday March 1 after the 4:00 pm session, and it will be located right outside the main session hall in the Cumberland Concourse. There will be appetizers, drinks, and Carl Dixon will be there for live entertainment.

Don’t forget to bring your tickets! Blue tickets will be distributed for a prize drawing, and you will receive orange tickets for two free drinks. So get ready to eat, drink, and be merry!

To learn more about the Summit click here or email me at roberts@taproot.com. Looking forward to seeing everyone soon.

Audit Prep: A Deeper Look at the Definition of a Significant Issue.

February 1st, 2018 by

Here is Dave Janney taking a deeper look into the definition of a significant issue when preparing for an audit.

Carl Dixon at the 2018 Global TapRooT® Summit Reception

February 1st, 2018 by

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

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

January 31st, 2018 by

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

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


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

Knowing this…..

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

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

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

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.

Mark Ed 2

 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.”

L M Astronaut

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.

Linda1988

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.

Bestpractice

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…

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.

Screen Shot 2018 01 25 at 10 01 23 AM

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!

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!

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