Category: Video

Friday Joke: Nuclear Winter Wonderland

December 8th, 2017 by

Winter wonderland

Click on the links below for a Nuclear Winter Wonderland (either a Quicktime movie or a PowerPoint)

Nuclear Winter Wonderland Movie.mov

Nuclear_Winter_Wonderland.pptx

The PPTX is the best quality.

Or try this YouTube video…

 

Technically Speaking – Custom Banner and Report Images

November 30th, 2017 by

Here is a look at how to add custom images to your TapRooT® VI banner and reports.

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!

Can Your Company Afford a Second Rate Improvement Program?

November 28th, 2017 by

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Sometimes it seems like management’s only objective is to cut costs. Can you produce excellence and record profits by cost cutting alone? Your company needs a world-class improvement program!

How do you get a world-class improvement program? As George Washington Carver said:

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Start where you are with what you have.
Make something of it and never be satisfied.

Have you become satisfied? Is it time to improve?

If you have never attended TapRooT® Training, start your improvement journey with a 2-Day TapRooT® Root Cause Analysis Course.

But most readers here have already learned the basics. They are ready for more. Perhaps a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. It’s a great place to learn to improve your skills to learn to investigate difficult, high-risk incidents.

If you are looking to go beyond just improving your own knowledge and you want to improve your company’s performance improvement initiatives, try reading our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to get your copy.

That’s a great start but there is even more…

Would you like to benchmark with industry leaders and learn from improvement experts from around the world? Attend the 2018 Global TapRooT® Summit. Many Summit attendees have explained that attending the Summit is a great way to learn from others and make your improvement program world-class.

People share their success and learn from others…

Many attend the pre-Summit advanced courses to get even more learning packed into their trip…

NewImage(Barb teaching the Effective Interviewing and Evidence Collection Course)

Improvement is a never ending cycle of discovery. What are you doing to move the process forward?

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Is it time to make your improvement program world-class or are you settling for second rate performance?

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Navy Releases Reports on Recent Collisions and Provides Inadequate Information and Corrective Actions

November 2nd, 2017 by

Punish

At the end of the cold war, politicians talked of a “peace dividend.” We could cut back our military funding and staffing.

Similar action was taken by the USSR Government for the Soviet fleet. I watched the Soviet Fleet deteriorate. Ships weren’t maintained. Training was curtailed. What was the second best navy in the world deteriorated. I thought it was good news.

What I didn’t know was that our fleet was deteriorating too.

Fast forward to the most recent pair of collisions involving ships in the 7th Fleet (The USS Fitzgerald and the USS John S McCain). If you read the official report (see the link below) you will see that the Navy Brass blames the collisions on bad people. It’s the ship’s CO’s and sailors that are to blame.

Screen Shot 2017 11 01 at 4 40 39 PMUSNAVYCOLLISIONS.pdf

The blame for the ship’s leadership and crews includes (list shortened and paraphrased from the report above by me):

USS Fizgerald

  • The Officer of the Deck (OOD) and bridge team didn’t follow the Rules of the Road (laws for operating ships at sea).
  • The ship was going too fast.
  • The ship didn’t avoid the collision.
  • Radars weren’t used appropriately.
  • The lookout (singular) and the bridge team was only watching the port side and didn’t see the contacts on the starboard side.
  • The Navigation Department personnel didn’t consider the traffic separation lanes when laying out the proposed track for navigating the ship (and this should have been well known since this ship was leaving their home port).
  • The navigation team did not use the Automated Identification System that provides real time updates on commercial shipping positions.
  • The Bridge team and the Combat Information Center team did not communicate effectively.
  • The OOD did not call the CO when required.
  • Members of the Bridge team did not forcefully notify and correct others (including their seniors) when mistakes were suspected or noted.
  • Radar systems were not operating to full capability and this had become accepted.
  • A previous near-collision had not be adequately investigated and root causes identified by the ship’s crew and leadership.
  • The command leadership did not realize how bad the ship’s performance was.
  • The command leadership allowed a schedule of events which led to fatigue for the crew.
  • The command leadership didn’t assess the risk of fatigue and take mitigating actions.

NewImageFired (reassigned) CO of USS Fitzgerald

USS John S McCain

  • Then training of the helm and lee helm operators was substandard in at least part because some sailors were assigned temporarily too the ship and didn’t have adequate training on the differences in the ships rudder control systems.
  • The aft steering helmsman failed to verify the position of the rudder position on his console and made a bad situation worse.
  • Senior personnel and bridge watch standers on the USS John S McCain seemed to have inadequate knowledge of the steering control system.
  • The ship’s watch standers were not the most qualified team and Sea Detail should have been set sooner by the Commanding Officer.
  • The OOD and Conning Officer had not attended the navigation brief held the previous day that covered the risk of the evolution.
  • Five short blasts were not sounded when a collision was immanent giving the other ship a chance to avoid the collision.
  • The CO ordered an unplanned shift of the propulsion control from one station to another without clear notification of the bridge watch team. This order occurred in a shipping channel with heavy traffic.
  • Senior officers and bridge watch standers did not question the report of loss of steering by the Helmsman or pursue the issue to resolution.

NewImageCO & XO of USS John S McCain that were fired (reassigned).

That’s a significant blame list. Can you spot what is missing?

First, the factors that are listed aren’t root causes or even near-root causes. Rather they are Causal Factors and maybe a few causal categories.

Second, the report doesn’t provide enough information to judge if the list is a complete list of the Causal Factors.

Third, with no real root cause analysis, analysis of Generic Causes is impossible. Perhaps that’s why the is no senior leadership (i.e., the Brass – Admirals) responsibility for the lack of training, lack of readiness, poor material condition, poor root cause analysis, and poor crew coordination. For an idea about Generic Cause Analysis of these collisions and potential corrective actions, see: http://www.taproot.com/archives/59924.

Here is a short recreation of the USS Fitzgerald collision to refresh you memory…

The US Navy did not release the actual accident investigation report (the Command and the Admiralty investigations) because the Chief of Naval Operations, “… determined to retain the legal privilege that exists with the command Admiralty investigations in order to protect the legal interests of the United States of America and the families of those Sailors who perished.” I believe the release of the actual investigation reports has more to do with protecting Navy Admirals and an inadequate training and manning of US Navy ships than protecting the US Government legally.

It seems to me that the US Navy has sunk (no pun intended) to the same low standards that the Soviet Navy let their fleet deteriorate to after the cold war ended. Bad material condition, low readiness, and, perhaps, poor morale. And the US Navy seems to have the same “transparency” that the USSR had during the communist hay day.

But I was even more shocked when I found that these problems (Training, manning, material condition, …) had been noted in a report to senior US Navy leadership back in 2010. That’s right, military commanders had known of these problems across the fleet for seven years and DID NOT take actions to correct them. Instead, they blame the Commanding Officers and ship’s crews for problems that were caused by Navy and political policy. Here is a link to that report:

https://www.scribd.com/document/43245136/Balisle-Report-on-FRP-of-Surface-Force-Readiness

Why didn’t senior leadership fix the problems noted in the report? One can only guess that it didn’t fit their plans for reduced manning, reduced maintenance, and more automated systems. These programs went forward despite evidence of decreased readiness by ships in the fleet. A decreased state of readiness that led two ships to fatal collisions. This cutting of costs was a direct response to budget cuts imposed by politicians. Thus “supporting our troops” is too expensive.

It seems from the reports that the Navy would rather punish Commanding Officers and the ship’s crews rather than fix the fleet’s problems. No accountability is shared by the senior naval leadership that has gone along with budget cuts without a decrease in the operating tempo and commitments.

NewImageChief of Naval Operations who says these types of accidents should “never happen again.”

More blame is NOT what is needed. What is needed is advanced root cause analysis that leads to effective corrective actions. The report released by the Navy (at the start of this article) doesn’t have either effective root cause analysis or effective corrective actions. I fear the unreleased reports are no better.

What can we do? Demand better from our representatives. Our sailors (and other branches as well) deserve the budget and manning needed to accomplish their mission. We can’t change the past but we need to go forward with effective root cause analysis and corrective actions to fix the problems that have caused the decline in mission capabilities.

Using Audio Forensics to Develop a Timeline

October 25th, 2017 by

This is a New York Times investigation into the Las Vegas shooting. They use audio forensics to develop a shooting timeline. Very interesting and a good example of using whats available to start an investigation.

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

TapRooT® provides world-class root cause analysis. But did you know that your results can vary depending upon the goodness of your implementation of the TapRooT® System?

What causes the implementation to vary? Try these factors …

  • Need to improve clearly defined.
  • Senior management support achieved.
  • Written program plan approved by senior management.
  • Proactive improvements drive improvement success.
  • Use advanced root cause analysis for both reactive and proactive investigations.
  • Improvement accomplishments being communicated successfully.
  • Adequate budget/staffing for the improvement organization.
  • Training plan implemented.
  • Employees, supervisors, managers, and contractors/suppliers willingly participate in the program.
  • Software selected, customized, and implemented.
  • Performance measures and advanced trending techniques used by management to guide the program.
  • Organizational learning occurring by effective sharing of lessons learned.
  • Plan for continuous improvement of the program is followed.
  • Leadership succession plan established.
  • Rewards program being used effectively.

This list is provided as a checklist and explained in more detail in Chapter 3 of our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to order your copy.

One more idea you might want to pursue to improve your performance improvement program. Attend the 2018 TapRooT® Global Summit in Knoxville, TN, on February 26 – March 2! It’s a great place to keep up with the state of the art in performance improvement and network with industry leaders.

Start by attending one of our advanced courses on Monday & Tuesday:

  • TapRooT® Root Cause Analysis Training
  • Equifactor® Equipment Troubleshooting and Root Cause Analysis
  • Advanced Causal Factor Development Course
  • Advanced Trending Techniques
  • TapRooT® Analyzing and Fixing Safety Culture Issues
  • Risk Assessment and Management Best Practices
  • Getting the Most from Your TapRooT® VI Software
  • TapRooT® for AuditsTapRooT®
  • Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
  • Understanding and Stopping Human Error

Then attend the Summit on Wednesday – Friday.

What’s on the agenda for the 2018 Global TapRooT® Summit? First, there are five keynote speakers:

  • Inquois “Inky” Johnson – Honor and Legacy
  • Vincent Ivan Phillips – How to Communicate Successfully
  • Dr. Carol Gunn – When Failure Becomes Personal
  • Mark Paradies – How Good is Your TapRooT® Implementation?
  • Mike Williams – Deepwater Horizon

Then there are nine different tracks that include 8 breakout sessions each. These tracks include:

  • Safety
  • Quality
  • Human Factors
  • Asset Optimization
  • Investigator
  • Patient Safety
  • TapRooT® Software
  • TapRooT® Instructor Recertification
  • Alternatives

See the Summit schedule at: http://www.taproot.com/taproot-summit/summit-schedule.

Remembering an Accident: 23 killed in Phillips Pasadena Explosion

October 23rd, 2017 by

On October 23, 1989, the Phillips Chemical Plant exploded killing 23 people. Here’s a video about the accident that was one of the accidents that lead to the development of the OSHA Process Safety Management Standard.

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

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes reactively and significant issues that may lead to major problems proactively.

Register today: TapRooT® Advanced Root Cause Analysis Team Leader Training

Using TapRooT® Proactively – Mapping Out the Process

October 5th, 2017 by

Watch Dave Janney discuss how TapRooT® can be used to map out the process.

TapRooT® featured on Worldwide Business with kathy ireland®

September 5th, 2017 by

Mark & Kathy discussing root cause analysis and human performance.

Watch the recorded television broadcast below.

Technically Speaking – Revisiting the New Attachments Tab

August 31st, 2017 by

In an effort to make our new TapRooT® users aware of the great features introduced in TapRooT® VI, we want to highlight some of our previous posts about TapRooT® VI features. Here is a quick video highlighting the Attachments Tab and how to upload files in TapRooT® VI.

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!

How to Be a Great Root Cause Facilitator (Part 3)

August 24th, 2017 by

In the third and final part of this series, Benna Dortch, Ken Reed and Mark Paradies, Creator of TapRooT®, discuss the last few important and valuable traits of a great root cause facilitator. If you want some best practice tips to help you improve your investigations and just be better at your job, watch this series.

 

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

Second Navy Ship Collides – What is going on?

August 23rd, 2017 by

First, god bless the missing and dead sailors and their families and shipmates who experienced this, the second crash in the past two months.

I’ve waited a couple of days to comment on this second Navy collision with fatalities because I was hoping more information would be released about what happened to cause this collision at sea. Unfortunately, it seems the Navy has clamped down on the flow of information and, therefore, no intelligent comments can be made to compare the collision of the USS John S. McCain with the earlier collision of the USS Fitzgerald.

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What do we know?

  • They are both similar Navy DDG’s with the same staffing levels (only 23 officers).
  • They were both in a shipping channel.
  • They both hit (or were hit by) a merchant ship.
  • The crew was trained to the same Navy standards.

That’s about it.

Of course, we know what they did to those involved in the previous accident (see my previous article HERE).

Was the timing of this second collision just bad luck?

We could use the Navy’s collision statistics to answer that question. Of course, you would have to agree about what is a collision. Would a grounding count? Would there have to be injuries or a fatality?

We would then use the advanced trending techniques that we teach in our pre-Summit trending course to see if the second collision was so close in time to the first that it indicated a significant increase in the collision frequency. To learn about these techniques, see:

http://www.taproot.com/taproot-summit/pre-summit-courses#AdvancedTrendingTrending

Since we don’t have facts (and will probably never get them), what is my guess? The things I would consider for this accident are the same as for the last. Look into what happened including:

  1. Fatigue
  2. Where was the CO?
  3. What did the CIC watch team do?
  4. Experience/training of the bridge and CIC team.

What should the Navy do? A complete, detailed TapRooT® Investigation.

Admiral Richardson (formerly the head of the Navsea 07 – the Nuclear Navy) has the right words about the analysis the Navy is performing. What is missing? A systematic guide for the investigators and prevent them from jumping to conclusions.

In a TapRooT® Investigation, we would start collecting facts and developing a SnapCharT® to truly understand what happened. Next we would identify all the causal Factors before we started analyzing their root causes using the Root Cause Tree® Diagram. Next, we would consider the generic causes and then develop effective (SMARTER) corrective actions. Unfortunately, this will be hard to do because of the Navy’s tradition of blame.

Some of my friends have been asking if I thought that some type of sabotage was involved. Some sort of hacking of the combat systems. In my experience, unless it was extremely foggy, you should be able to use your eyes and the simple bridge radar to navigate. You don’t need fancy technology to keep you from colliding. Simple “constant bearing decreasing range” tells you a collision is coming. To prevent it you turn or slow down (or perhaps speed up) to get a bearing rate of change to bring the other ship down whichever side is appropriate (use the rules of the road).

The trick comes when there are multiple contacts and restricted channels. That’s when it is nice to have someone senior (the Commanding Officer) on hand to second check your judgment and give you some coaching if needed.

Most of the time you spend of the bridge is boring. But when you are steaming in formation or in a shipping channel with lots of traffic, it quickly goes from boring to nerve-racking. And if you are fatigued when it happens … watch out! Add to that an inexperience navigation team (even the Commanding Officer may be inexperienced) and you have an accident waiting to happen.

Is that what happened to the USS John S. McCain? We don’t know.

What we do know is that the Navy’s typical blame and shame response with a safety stand down thrown in won’t address the root causes – whatever they may be – of these accidents.

The Navy seldom releases the results of their investigations without heavily redacting them. What we do know is that previous  investigations of previous collisions were heavy on blame and included little in the way of changes to prevent fatigue or or inexperienced watch standers. The fact is that the corrective actions from previous collisions didn’t prevent this string of collisions.

What can you do? Advise anyone you know in a position of responsibility in the Navy that they need advanced root cause analysis to improve performance. The young men and women that we send to sea deserve nothing less. Navy brass needs to end the blame game and coverup and implement truly effective corrective actions.

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

August 16th, 2017 by

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

How to Be a Great Root Cause Facilitator (Part 2)

August 9th, 2017 by

In the second part of this series, Benna Dortch, Ken Reed and Mark Paradies, Creator of TapRooT®, discuss more important and valuable traits of a great root cause facilitator. If you want some best practice tips to help you improve your investigations and just be better at your job, watch this series.

 

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

August 8th, 2017 by

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

How to Effectively Perform a Cognitive Interview for an Incident Investigation

August 7th, 2017 by

In this video, TapRooT® Instructor, Barb Phillips, discusses the benefits of an effective cognitive interview when gathering evidence for your incident investigations.

Interested in learning more about planning your investigations and gathering evidence correctly? Take our one day course in Houston this November.

How to Be A Great Root Cause Facilitator (Part 1)

August 2nd, 2017 by

In this new series, Benna Dortch and Ken Reed discuss the most important and valuable traits of a great root cause facilitator. Take note and implement them at work to be a more effective investigator. There is always room for improvement!

How to Be a Great Root Cause Facilitator (Part 1) from TapRooT® Root Cause Analysis on Vimeo.

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

Technically Speaking – User Settings Menu

July 27th, 2017 by

In an effort to make our new TapRooT® users aware of the great features introduced in TapRooT® VI, we want to highlight some of our previous posts about TapRooT® VI features. Let’s take another look at User Settings.

If you are unable to view this video we have included a downloadable document that outlines this feature.

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, doesn’t mean it has to be complicated!

Mark Paradies and Kathy Ireland on Worldwide Business – It’s a wrap!

July 21st, 2017 by

Here’s a live Facebook cut from the end of shooting. We’ll post the show dates here.

System Improvements,Inc. is now LIVE on the set of Worldwide Business with kathy ireland!

Posted by Worldwide Business with kathy ireland on Wednesday, July 19, 2017

 

Where is Mark Paradies this Week?

July 19th, 2017 by

Screen Shot 2017 07 17 at 10 44 23 AM

Where is Mark? In Los Angeles being interviewed by Kathy Ireland for an upcoming episode of Worldwide Business with Kathy Ireland®.

The topic? Root cause analysis.

When can you watch the show? We will post the times to watch when the release date is announced … stay tuned!

The Importance of Planning Your Investigations

July 18th, 2017 by

When you start any major project, you should start by creating a plan, understanding where you’re going and knowing what you need to do along the way. It’s the same with root cause analysis investigations. A plan can make all the difference in the outcome and effectiveness. Did you know TapRooT® has an amazing planning tool called the SnapCharT®? Check out this video to learn more about it:

 

Interested in learning more about planning your investigations and gathering evidence correctly? Take our one day course in Houston this November.

How to Avoid Investigator Bias

July 13th, 2017 by

If you use 5 Why’s or Fishbone, ever wonder why you continue to get the same few root causes or why your investigations don’t seem to be very effective? That’s because there is heavy investigator bias in those root cause analysis techniques. TapRooT® is an advanced system that has years of human factors research to allow you to be unbiased and effective.

How to Avoid Investigator Bias from TapRooT® Root Cause Analysis on Vimeo.

Technically Speaking – Revisiting the New TapRooT® VI Toggles

July 13th, 2017 by

In an effort to make our new TapRooT® users aware of the great features introduced in TapRooT® VI, we want to highlight some of our previous posts about TapRooT® VI features. Here is a look at the new toggles found in the TapRooT® VI software.

If you are unable to view the video or want a copy of this information to store locally on your computer, click on the link below the document to download the white paper to your machine.

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, doesn’t mean it has to be complicated!

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