Category: Video

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!

What happens when root cause analysis becomes too simple? Six problems I’ve observed.

July 5th, 2017 by

I’ve had many people explain to me that they understand that for serious incidents, they need robust root cause analysis (TapRooT®) because … finding effective fixes is essential. But for simple incidents, they just can’t invest the same effort that they use for major investigations.

I get it. And I agree. You can’t put the same level of effort into a simple incident that you put into a major accident. But what happens when the effort you put into a simple incident is too little. What happens when your simple investigation becomes too simple?

Here are the results that I’ve observed when people perform “too simple” investigations.

1. The first story heard is analyzed as fact.

People doing simple investigations often take the first “story” they hear about a simple incident and start looking for “causes”. The shortcut – not verifying what you hear – means that simple investigations are sometimes based on fairy tales. The real facts are never discovered. The real root causes are unknown. And the corrective actions? They are just ideas based on a fantasy world.

The result? The real problems never get fixed and they are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb.

2. Assumptions become facts.

This is somewhat similar to the first issue. However, in this case the investigator fills in holes in the story they heard with assumptions. Because the investigator doesn’t have time to collect much info, these assumptions become facts and become the basis for the root cause analysis and corrective actions.

The result? Just like the first issue, real problems never get fixed. The real, undiscovered problems are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb #2.

3. Skip root cause analysis and go straight to the fixes.

When you don’t have time for the investigation, why not just skip straight to the fixes? After all … we already know what caused the incident … right?

This is a frequent conclusion when people THINK they already know the answers and don’t need to bother with a troublesome investigation and root cause analysis to fix a “simple” problem.

The problems is that without adequate investigation and root cause analysis … you don’t really know if you are addressing the real issues. Do you feel lucky? Well do ya punk? (A little Clint Eastwood imitation.)

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The result? You are depending on your luck. And the problem you may not solve may be more powerful than a .44 magnum … the most powerful handgun in the world.

OK … if you want to watch the scene, here it is …

4. The illusion of progress.

Management often thinks that even though they don’t give people time to do a good investigation, simple investigations are better than nothing … right?

Management is buying into the illusion of progress. They see some action. People scurry around. Fixes are being recommended and maybe even being implemented (more training). So things must be getting better … right?

NO!

As Alfred A. Montapert said:

Do not confuse motion and progress.
A rocking horse keeps moving but does not make any progress
.”

The result? If people aren’t finding the real root causes, you are mistaking the mistake of assuming that motion is progress. Progress isn’t happening and the motion is wasted effort. How much effort does your company have to waste?

5. Complacency – Just another investigation.

When people in the field see investigators make up facts and fixes, they know the real problems aren’t getting fixed. They see problems happening over and over again. They, too, may think they know the answers. Or they may not. But they are sure that nobody really cares about fixing the problems or management would do a better job of investigating them.

The result? Complacency.

If management isn’t worried about the problems … why should I (the worker) be worried?

This contributes to “the normalization of deviation.” See this LINK is you are interested.

6. Bad habits become established practice.

Do people do more simple investigations or major investigations?

If your company is like most, there are tons of simple investigations and very few major investigations. What happens because of this? The practices used in simple investigations become the practices used in major investigations.

Assumptions, shortcuts, made up fixes and more become the standard practice for investigators. The things they learned in a root cause analysis class aren’t what they practice. What gets practiced (the bad practices) becomes the standard way that business is done.

The result? The same poor standards that apply to simple investigations infect major investigations. Major investigation have the same poor root cause analysis and corrective actions seen in the simple investigations.

DON’T LET BAD PRACTICES INFECT YOUR CULTURE.

Would you like to see good practices for performing simple investigations? Here are two options:

1. Attend a TapRooT® 2-Day Root Cause Analysis Course. See the the dates and location of upcoming public courses here:

http://www.taproot.com/store/2-Day-Courses/

2. Read the new book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Technically Speaking – Optional Techniques to Direct Investigations

June 29th, 2017 by

Utilizing the Root Cause Tree® early when building a SnapCharT® helps focus and drive questions to better determine causal factors and ultimately reveal the Root Cause.

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!

Now perform your Basic and Major investigations with TapRooT®

June 27th, 2017 by

TapRooT® is a robust root cause analysis system. When you have those major accidents and need an effective and thorough investigation, TapRooT® is the go-to solution. But what about those smaller, simpler, less complex incidents? Is it worth applying such a complex system for such a simple problem? Well, we think all problems are worth a thorough investigation, but we also realize you can only give up so much time on seemingly less serious incidents. Which is why the folks at TapRooT® decided to make a simpler version of our root cause analysis process so that you can still get the best results in less time.

Check out this video of Ken Reed, TapRooT® instructor and expert, to learn more.

 

Simple 5-Whys becomes complex 5-Whys – Why not use TapRooT® Root Cause Analysis?

May 31st, 2017 by

This video doesn’t really address the problems with 5-Whys but it sure does make it more complex.

They suggest that you can brainstorm root causes. You can’t brainstorm what you don’t understand.

For a more complete discussion of why people have problems with 5-Whys, see:

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

And for a better way to find root causes see:

About TapRooT®

To get a book that will help you understand how to really find the root causes of low-to-medium risk problems, see:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html 

Ready for an On-Line Risk Assessment?

May 9th, 2017 by

Have you ever watch NAPO videos? Here is one about an on-line risk assessment tool …

Get more information at:

https://oiraproject.eu/en

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

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Dave JanneyDave Janney

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