Category: RCA Tip Videos

Management System

July 11th, 2018 by

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Back in 1985, my boss suggested I (Mark Paradies) look at better ways to analyze and trend root causes. I already understood human factors (from training for my master’s degree from the University of Illinois) and equipment reliability (from my experience in the Nuclear Navy). Therefore, I had a good start on the knowledge I needed to develop a system for root cause analysis.

The very first system I developed had a category (today we would call it a Basic Cause Category) of Leadership.

When I showed the system to my boss and he saw the Leadership category, he said:

“You have to take that out.”

He explained that senior management would go nuts if we said there was a leadership issue. We argued for quite a while. I said that management would just have to accept that they, too, could improve. He explained that I had done such a good job NOT having blame categories in the system that I shouldn’t have a blame category for leadership and that’s how the company’s management would view a Leadership category.

Eventually, he convinced me that we could come up with a better name. He wanted to call it “Organizational Factors.” I said that it should be “Management.” He said that was just as bad as Leadership. He wanted to call it “Systems.” I thought that clouded the responsibility for where the changes needed to be made. Finally I suggested “Management System.” It took a while, but he finally agreed.

After several management presentations and several discussions with senior management, we finally got approval for the “Management System” category.

Little did I know that we had invented a term that would be used around the world.

The first place it spread to was INPO (Institute of Nuclear Power Operation). I had interviewed for a job there and they had tried to hire me but I had already taken another job. However, I stayed in contact with Joe Bishop who was in charge of developing the HPES (Human Performance Evaluation System) system for INPO. When they had a version of the system ready, he sent me a copy for review. I commented that they had missed the Management System causes. Sure enough, my work on Management System made it into INPO’s HPES system.

From there, the terminology spread throughout the U.S. nuclear industry and to nuclear plants around the world.

Once I started System Improvements in 1988, the terminology started spreading to other industries. Refining, chemicals, oil exploration and production, and other industries. By the early 1990s, TapRooT® was adopted by industry leaders around the world. And the terminology “Management System” went with it.

Then, I began hearing the term at professional society meetings. People started insisting that to find root causes you needed to find “management system” causes. I thought this was interesting. Where had the term “management system” come from?

I researched the term on the internet and couldn’t find any references prior to the meeting I had with my boss back in 1986. In fact, it looked like the terminology had started to be used in the mid-1990s.

I can’t prove it but I think the terminology came from that meeting with my boss, Rod Satterfield. And that is how the Management System terminology got started.

If you would like to learn more about the Management System, all you need to do is read about it in the TapRooT® Root Cause Tree® Dictionary. You will receive a copy of the dictionary and will learn how to use it in any of our TapRooT® 2-Day or 5-Day Courses.

Cancel your lunch plans! Join TapRooT® today at noon EST!

July 11th, 2018 by

Join TapRooT® professionals Benna Dortch and Ken Reed today at noon EST for TapRooT®’s Facebook Live discussion.

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, July 11

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

Recently, on TapRooT®’s Facebook Live, we learned that only through effective listening will you learn to pick up on the “right” questions to ask in your investigations. TapRooT® Instructor Barb Carr gave us a beginning point:”The first question is the only one you need to know going in: ‘Tell me, from start to finish, what you observed the day of the incident.’” Barb also advises that the next step is to “sit back, listen, and identify which follow-up questions need to be asked.”

Since our listening skills develop with practice, everyone can use help becoming better investigators. Use the video and Vimeo below, featuring TapRooT® professionals Benna Dortch and Barb Carr, to review your skills:


Do your own investigation into our courses and discover what TapRooT® can do for you.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Root Cause Tip: Improve your Investigation Skills

January 4th, 2018 by

Ken Reed and Benna Dortch give answers to some frequently asked questions. This is an awesome segment for investigators of workplace accident/incidents. Join us for a 2-day TapRooT® course to learn more about conducting a root cause analysis and find and fix those problems that are causing incidents at your facility. (If video is not displaying, click the title of this post.)

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.

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.

Are You Writing the Same Corrective Actions?

April 17th, 2017 by

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

Investigative Interviewing Best Practices

June 29th, 2016 by

Last year, I had the privilege of sharing investigative interviewing best practices with attendees at the 2015 Global TapRooT® Summit. This year is even *more* exciting because it’s a brand new course that I’m co-teaching with Alan Smith of Matrix Risk Control (UK).

If you are not familiar with Alan’s impressive credentials, go here and learn about him and the best practice session he is teaching at the Summit.  You’ll also want to watch his keynote presentation from the 2015 Summit here.

We still have a couple seats left in our Interviewing & Evidence Collection Techniques Course, San Antonio, Texas, August 1-2.  If you have questions, give me a call on my direct line: 865.357.0176!

Hope you enjoy this best practices video from last year’s Interviewing & Evidence Collection Techniques Course.  Attendees at the course blew me away with their intelligent questions and thoughtful responses during our Q&A at 8 a.m.!

Come to the 2016 Global TapRooT® Summit and learn to solve your most pressing issues!

TapRooT® Users Share Best Practices at the Summit!

June 20th, 2016 by

Our Global TapRooT® Summit attendees help one another by sharing best practices. We’d love to hear from you this year! Learn more about joining us in San Antonio the first week of August at the Summit website!

(Click post title if video is not displaying.)

Using Safeguards Analysis to Find Root Causes

June 17th, 2016 by

Here is a great best practice tip from TapRooT® User, Jeff Linstedt from our last Global Summit.

https://vimeo.com/157205462

Come to the 2016 Global TapRooT® Summit and learn to solve your most pressing issues!

Preparedness: Responding To An Accident

June 15th, 2016 by

Part One

 

Part Two

In these videos (Part One and Part Two above), Alan Smith introduces fascinating case studies of serious incidents he has been involved in and lessons learned. He is the former Head of Major Crime Operations – Grampian Police, Scotland. As a career detective, he was the lead investigator in numerous homicide investigations. He is a Certified TapRooT® Instructor/Facilitator and has in-depth experience in numerous offshore tragedies including Piper Alpha and the MV Bourbon Dolphin. He is an Accredited Senior Investigator in Counter Terrorism and Kidnap and Ransom. Alan is the former Chair of the Scottish Senior Investigating Officer’s Conference.

Alan will be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit, August 1 & 2, San Antonio. He will also be leading a special session you don’t want to miss: Risk Assessing the Perfect Murder.

It’s not too late to register for the 2016 Global TapRooT® Summit!

Equifactor® for the Win!

June 10th, 2016 by

We love how this client recognizes the value of equipment troubleshooting training!  Don’t miss our Equifactor® 2-day course, a Pre-Summit Course scheduled for August 1-2, 2016 in San Antonio, Texas!

Proactive Improvements in Healthcare

June 9th, 2016 by

We’re so impressed with how a large retail pharmacy approached a problem and their corrective actions not only improved their processes but also earned an impressive award! What can you proactively improve at your facility? How can we help?

If you’d like to learn more about how to be proactive in healthcare, check out our Medical Track at the 2016 Global TapRooT® Summit, August 3-5, San Antonio, Texas.

Grading Your Investigations

March 10th, 2016 by

How do you grade an incident investigation? Here’s an Excel spreadsheet to use…

RateRootCauseAnalysis03082016.xlsx

How do you use the spreadsheet? Here’s a video from last year’s Summit …

Grading Your Investigation from TapRooT® Root Cause Analysis on Vimeo.

Would you like to learn this and hear about someone who has been using it to improve their company’s investigations? Go to the Grading Your Investigations Breakout Session (Wednesday – 1:30-2:30) at the 2016 Global TapRooT® Summit.

Improve Communications of Lessons Learned

December 18th, 2015 by

Here is a great best practice tip from TapRooT® User, Rodney Bhagwandass.

(Click post title if video is not displaying.)

TapRooT® User Best Practice Tip

December 1st, 2015 by

Here is a root cause tip from one of our users, Sam Dillow, that can be used across industries. TapRooT® users share best practices at the Summit, and it is one of many highlights of our conference.

Thanks for the tip, Sam!

(CLICK HERE if the video is not displaying.)

Improve Your Investigations with this Free Tool

September 16th, 2015 by

Jack Frost discusses an idea to improve investigations he learned during Mark Paradies’ best practice session at the 2015 Global TapRooT® Summit.
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DOWNLOAD the free tool he refers to HERE.

And make plans to join us at the next Global TapRooT® Summit, August 1 – 5, 2015 in San Antonio, Texas!

How to Influence Positive Change in the Workplace

February 12th, 2015 by

(Click the title of this post if the video is not displaying.)

Even the smallest acts can have a profound effect. Angela Hatt shares about how to encourage a safety change. What small act can you perform today to make your workplace better?

Mark your calendar to join us August 1 – 5, 2016 at the Global TapRooT® Summit to network with professionals like Angela who are committed creating positive change!

Root Cause Analysis Video Tips: Best Practices in Process Quality

February 5th, 2015 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Chris Vallee. He shares a great process quality tip and news about his upcoming Process Quality & Corrective Action Track at the 2015 Global TapRooT® Summit, June 3-5, 2015 in Las Vegas, Nevada!

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Was this tip helpful?

Check out more short videos in our series:

Equifactor® – Are You Using it to Prevent Equipment Failures? (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

Root Cause Analysis Video Tip: TapRooT® Resources That Will Help You Be Proactive.

November 19th, 2014 by

Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.

For more information regarding our Public and Onsite TapRooT® Courses, click here.

Want to join us at the Global TapRooT® Summit? Click here for more information and registration.

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Was this tip helpful? Check out more short videos in our series:

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

 

Root Cause Analysis Video Tips: Equifactor®…Are you using it to prevent equipment failures?

November 5th, 2014 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Ken Reed. He briefly discusses the importance of using Equifactor® proactively in order to prevent equipment failures from ever happening.  Among the many uses of TapRooT®, using it proactively is one of the most important. Keep the investigations to a minimum if you can help it!

For more information on Equifactor® and the courses we offer for it, click here.

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Was this tip helpful? Check out more short videos in our series:

Be Proactive with Dave Janney (Click here to view tip.)

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

 

Root Cause Analysis Video Tips: How TapRooT® Can Help with The Joint Commission Requirements

October 15th, 2014 by

This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.

Click here for more information regarding our TapRooT® courses around the world.

And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.

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Was this tip helpful? Check out more short videos in our series:

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

Root Cause Analysis Video Tips: What Makes a World Class Root Cause Analysis System?

October 6th, 2014 by

We hope you enjoy this new format of our Instructor Root Cause Tips. Today we have Ken Reed, TapRooT®/Equifactor® Instructor and Partner, discussing “What Makes a World Class Root Cause Analysis System?”. Be sure to pay attention to the 7 Strengths of TapRooT® that he discusses.

Click here to learn more about our courses where you can learn root cause analysis and implement in your own workplace.

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Was this tip helpful? Check out more short videos in our series:

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Champion Technologies)

September 24th, 2014 by

Trevor Archibald of Champion Technologies shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he keeps his investigation teams’ skills fresh and up-to-date:

If you’re at work and don’t have time to watch the video, here’s his tip:

“My name’s Trevor Archibald. I work with Champion in Canada. It was written into my performance contract this year to improve the quality of our investigations. And one of my activities in meeting that goal is holding three workshops a year. We’ve got two dozen folks trained in TapRooT® – [we’ll be] bringing them back in here three times a year, putting them through a smaller 1-day workshop, giving them some investigations, doing it all over again. In addition to that I’ve written about a dozen things you all have said here so I’ll be adding that in as well.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Video Tips – Doing Better Investigations (Part 2)

August 27th, 2014 by

Last week we discussed how to improve your investigation by preparing well. This week we’ll dive into evidence collection.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart.

We teach several evidence collection techniques in our courses….

The 3 P’s and the R:
• People
• Plant
• Paper
• Recordings

Interviewing (TapRooT® book, Chapter 3)

Optional techniques:
• Equifactor® (for equipment problems) – TapRooT® book, Chapter 9
• Change Analysis (what has changed or what is different) TapRooT® book, Chapter 11
• CHAP (critical human action profile) TapRooT® book, Chapter 12

Trust me, if you have a good comprehensive SnapCharT® your analysis will be easy and you will find all the root causes. Without that, you will miss something, your corrective actions will be lacking, and your incidents will recur.

Once you have your chart complete, your causal factors identified, and have completed your root cause analysis, it is time for the output of your investigation – corrective actions. Don’t forget our SMARTER technique and use the Corrective Action Helper® for good ideas. Safeguards Analysis is also a great tool for developing corrective actions.

I could go on all day about this, but the key thing I want to bring out here is you MUST have a good SnapCharT®. If you focus on that the rest should fall into place nicely.

Click here to view Part 1 of this video.

or check out other short videos in our root cause tip series:

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

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