Root Cause Analysis Blog

 

Get TapRooT® Trained in Hartford

Posted: May 23rd, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In two days with TapRooT®, you will learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and has proven a professional game changer for many.

TapRooT® is designed for learners at all levels. You will learn to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems. Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. 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.

We’ll meet at the Hilton Garden Inn Hartford North/Bradley Int’l Airport for the 2-Day Root Cause Analysis Training course.

Register here to take the TapRooT® course in Hartford. 

Experience Hartford
Connecticut’s capital, Hartford, is home to beautiful parks, a choice of unique museums, attractions, performing arts and restaurants. See the stunning Connecticut State Capitol, visit the Wadsworth Atheneum, one of the oldest art museums in the U.S., and stroll through the Rose Garden in Elizabeth Park. Best things to do in Hartford include the Connecticut Science Center, the Mark Twain House & Museum and the carousel in Bushnell Park.

Connecticut State Capitol: At 210 Capitol Ave., the marble and granite state capitol building dates from 1871 and is a U.S. National Historic Landmark.

Mark Twain House & Museum: This Victorian Gothic house on Farmington Avenue has 19 rooms and is where Samuel Longhorne Clemens wrote The Adventures of Huckleberry Finn and The Adventures of Tom Sawyer, and where he raised his family.

Wadsworth Atheneum Museum of Art, 600 Main St., was founded in 1842 and opened in 1844, one of the oldest art museums in the U.S. You’ll see French and American Impressionist collections, works by contemporary and modernist artists, landscapes by members of the Hudson River School, American decorative arts, and furniture. The Wadsworth Atheneum is the largest art museum in Connecticut and is listed on the U.S. National Register of Historic Places.

Lincoln Financial Sculpture Walk: Created to honor Abraham Lincoln, the walk includes sculpture installations, murals, and artwork. Noted historian and biographer Doris Kearns Goodwin was instrumental in the launch of the mobile tour, and is the narrator.

Connecticut Science Center: At 250 Columbus Blvd., the Connecticut Science Center is a nine-story science museum with 40,000 square feet of interactive exhibits.

A city park on Asylum Avenue, 102-acre Elizabeth Park is the oldest municipal rose garden in the U.S., with 15,000 rose bushes representing 800 varieties. The Park is also home to an outdoor concert series in the summer, and contains greenhouses, lawns, pathways, a pond, and tennis courts.

Bushnell Park, 30 Arbor St., has its own summer concert series. The park also offers visitors a tour of the Soldiers and Sailors Memorial Arch or a historical tour. You will find food trucks at the park year round with fare such as the bacon marmalade grilled cheese from Whey Station.

Sarah’s Coffee House, 257 Asylum St., is farm-to-table and a local charity supporter along with having terrific coffees, teas, smoothies, and pastries.

Homemade doughnuts, breakfast sandwiches, coffee, and more—Tastease, 70 New Park Ave.—is a local favorite.

Family-owned Tangiers is a restaurant and a grocery, specializing in Middle Eastern and Mediterranean fare, such as spicy falafel, chicken gyro, tabbouleh, baklava.

Mozzicato DePasquale Bakery and Pastry Shop is great for cocktails, an espresso, a pastry.

Sample a German-Polish smokehouse/deli, Adolf’s Meats & Sausage Kitchen, 35 New Britain Ave., for brats, hams, Canadian bacon, kielbasa, and more.

Stop in at Spigot Cafe, 468 Prospect Ave., for ice-cold brews from around the world. Cash only. Feel free to bring food in to have with your beer!

Discover more to explore from our Hartford Pinterest board and begin planning your TapRooT® trip to Connecticut today.

Why is TapRooT® Root Cause Analysis Software the Best Choice?

Posted: May 23rd, 2018 in Software, TapRooT

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If you are looking for the best root cause analysis software, here are some things to consider:

  1. How the software works is important, but the root cause analysis system that the software uses is probably THE MOST IMPORTANT part of picking your software. No matter how well a bad root cause tool is implemented in software … it is still a bad root cause analysis tool. Therefore, you should look for a world-class root cause analysis tool.
  2. It’s all in the cloud, baby! The days of software just working on one operating system are over. Now your software should be cloud-based and available on a multitude of devices. Mac or PC, laptop or tablet, even phones should be supported.
  3. Able to connect with other software. Does the software play well with others? The root cause analysis software should be able to connect with other ESHQ (Environment, Safety, Health, Quality), human resource, or performance monitoring systems.
  4. Custom reports. Reports the way that you and your management want them. Easy to develop and save. No special software required.
  5. Trends. Advanced trending techniques that help you measure and predict performance.

Sounds great. But where can you find these features? The TapRooT® Version VI Software (of course).

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First, the TapRooT® VI Software is based on the world-class TapRooT® Root Cause Analysis System. If you don’t know why TapRooT® stands head and shoulders above other root cause systems, you should attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and find out. Learn to use SnapCharT® to investigate what happened and organize your evidence. Use Equifactor® to troubleshoot equipment failures. Use Safeguard Analysis to find all the Causal Factors. Use the Root Cause Tree® to find the real, fixable causes of human performance and equipment issues. and Use the Corrective Action Helper® Module to develop effective fixes.

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Second, TapRooT® VI Software is cloud-based. You can subscribe as an individual; you can host the TapRooT® VI Software on your network; or we can host the software for your whole company. TapRooT® VI is device independent. Mac, tablet, smartphone. No problem. CONTACT US for more information.

Third, TapRooT® VI Software has an API. This allows easy connections to other software. Talk to our IT guys to find out more. Call 865-357-0080 or CLICK HERE.

Fourth, need a custom report? No problem when you are using TapRooT® VI Software. Have a look at these articles to get some ideas … http://www.taproot.com/?s=custom+report.

Fifth, we have been teaching advanced trending techniques for 20 years and they are built into the TapRooT® VI Software. Here’s a short video on exporting trending data to Excel.

But there is more to consider when picking your root cause analysis software. Consider this: How good is the training? How good is the software support?

TapRooT® Training is highly rated by students around the world. See samples of what they have to say HERE.

What abut our software support? Outstanding! Our knowledgeable support staff is happy to help you figure things out.

Want more information about TapRooT® VI Software? Let’s do an online demo. CONTACT US to learn more.

“People are SO Stupid”: Horrible Comments on LinkedIn

Posted: May 23rd, 2018 in Accidents, Human Performance, Root Cause Analysis Tips

 

 

How many people have seen those videos on LinkedIn and Facebook that show people doing really dumb things at work? It seems recently LinkedIn is just full of those types of videos. I’m sure it has something to do with their search algorithms that target those types of safety posts toward me. Still, there are a lot of them.

The videos themselves don’t bother me. They are showing real people doing unsafe things or accidents, which are happening every day in real life. What REALLY bothers me are the comments that people post under each video. Again concentrating on LinkedIn, people are commenting on how dumb people are, or how they wouldn’t put up with that, or “stupid is as stupid does!”

Here are a couple examples I pulled up in about 5 minutes of scrolling through my LinkedIn feed.  Click on the pictures to see the comments that were made with the entries:

 

 

 

 

 

 

 

 

 

 

 

Click on picture to watch Video

 

 

 

 

 

 

 

These comments often fall under several categories.  We can take a look at these comments as groups

“Those people are not following safety guideline xxxx.  I blame operator “A” for  this issue!”

Obviously, someone is not following a good practice.  If they were, we wouldn’t have had the issue, right?  It isn’t particularly helpful to just point out the obvious problem.  We should be asking ourselves, “Why did this person decide that it was OK to do this?”  Humans perform split-second risk assessments all the time, in every task they perform.  What we need to understand is the basis of a person’s risk assessment.  Just pointing out that they performed a poor assessment is too easy.  Getting to the root cause is much more important and useful when developing corrective actions.

“Operators were not paying attention / being careful.”

No kidding.  Humans are NEVER careful for extended periods of time.  People are only careful when reminded, until they’re not.  Watch your partner drive the car.  They are careful much of the time, and then we need to change the radio station, or the cell phone buzzes, etc.

Instead of just noting that people in the video are not being careful, we should note what safeguards were in place (or should have been in place) to account for the human not paying attention.  We should ask what else we could have done in order to help the human do a better job.  Finding the answers to these questions is much more helpful than just blaming the person.

These videos are showing up more and more frequently, and the comments on the videos are showing how easy it is to just blame people instead of doing a human performance-based root cause analysis of the issue.  In almost all cases, we don’t even have enough information in the video to make a sound analysis.  I challenge you to watch these videos and avoid blaming the individual, making the following assumptions:

  1.  The people in the video are not trying to get hurt / break the equipment / make a mistake
  2.  They are NOT stupid.  They are human.
  3.  There are systems that we could put in place that make it harder for the human to make a mistake (or at least make it easier to do it right).

When viewing these videos in this light, it is much more likely that we can learn something constructive from these mistakes, instead of just assigning blame.

Join TapRooT®’s Facebook Live Today at Noon EST!

Posted: May 23rd, 2018 in Career Development Tips, Topic of the Week, Video

Join TapRooT® professionals Mark Paradies and Benna Dortch today for our Facebook Live discussion: Avoid Big Problems by Paying Attention to the Small Stuff.

Here’s a sample of the content: What is a precursor incident? A precursor incident is an incident that has low to moderate consequences but could have been much worse if . . .

Join Mark and Benna today to see what comes after the “if.”

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, May 23

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

Two Incidents in the Same Year Cost UK Auto Parts Manufacturer £1.6m in Fines

Posted: May 22nd, 2018 in Accidents, Investigations, Performance Improvement, Pictures

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Faltec Europe manufactures car parts in the UK. They had two incidents in 2015 related to health and safety.

The first was an outbreak of Legionnaires’ Disease due to a cooling water system that wasn’t being properly treated.

The second was an explosion and fire in the manufacturing facility,

For more details see:

http://press.hse.gov.uk/2018/double-investigation-leads-to-fine-for-north-east-car-parts-manufacturer-faltec-europe-limited/

The company was prosecuted by the UK HSE and was fined £800,000 for each incident plus £75,159.73 in costs and a victim surcharge of £120.

The machine that exploded had had precursor incidents, but the company had not taken adequate corrective actions.

Are you investigating your precursor incidents and learning from them to prevent major injuries/health issues, fires, and explosions?

Perhaps you should be applying advanced root cause analysis to find and fix the real root causes of equipment and human error related incidents? Learn more at one of our courses:

2-Day TapRooT® RooT® Cause Analysis Course

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

Want to see our courses in Europe? CLICK HERE.

You can attend our training at our public courses anywhere around the world. See the list by CLICKING HERE.

Would you like to sponsor a course at your site? Contact us for a quote by CLICKING HERE.

Connect with TapRooT® in Hamburg

Posted: May 22nd, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

In five days with TapRooT®, you can learn how to conduct an investigation and develop effective Corrective Actions. A TapRooT® course is a career booster and can be a professional game changer for you.

From beginners to experts, TapRooT® is designed for learners at all levels. 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 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 expertise 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.

We’ll gather and kick off the 5-Day TapRooT® Advanced Root Cause Analysis Training at the Courtyard by Marriott Hamburg Airport on June 11. You may want to make plans to explore your host city while you’re there. See our travel tips below.

Register here for the course.

Hamburg—Germany’s second-largest city and seaport—offers you lots to explore. Walk along the harbor, see the sights, and plot your Hamburg game plan.

Hamburg highlights
Visit the port. See Hamburg and feel its maritime vibes on a boat tour. View the fish market, pass contemporary seaside architecture and the Elbe beach, touring across the port and back.

Honored as a Historic Landmark of Civil Engineering in Germany, the Old Elbe Tunnel was the first river tunnel on the European continent. Access the entry point from the harbor, walking to Steinwerder and back to St. Pauli in a few minutes.

Marvel at the Museum Ships—such as Rickmer Rickmers and Cap San Diego—Hamburg’s heralded historical ships, moored by the harbor.

If you’re a fan of model ships, U-boats and military history, visit International Maritimes Museum Hamburg, with the world’s largest private collection of maritime treasures, in historic Speicherstadt.

Appreciate the art and architecture of the oldest parish church in Hamburg, St. Peter’s Church, just a few blocks from Town Hall. Bronze lion-head door handles grace the west portal and date from 1342. A gothic mural that dates from 1460 is in the north portion of the church. The bell tower is up 544 steps and offers a grand view over Rathausmarkt, the Town Hall market, and Alster Lake.

Impressive sandstone Town Hall, also called Rathaus or City Hall, houses the senate and parliament among its 647 rooms. Note the staircase made of Sardinian marble, a commentary on the course of human life.

Check out Miniatur Wunderland, the largest model railway in the world. Close to the miniature wonderland, the canal of Nikolaifleet is one of the oldest spots in Hamburg, where you can see well-preserved Old Hamburg townhouses.

St. Pauli is a unique quarter in Hamburg, a great place to walk around and absorb the street art, get a drink, and shop.

Fun fact: Hamburg has more bridges than Venice.

Hop on a double-decker bus for a fun city tour. Take in the Landungsbrücken, the breathtaking harbor, historical Speicherstadt, modern HafenCity, famous Reeperbahn, the ‘Michel,” the Alster, Town Hall, museums, and villas.

Want more action? Take a beach walk on the Elbstrand, bike by Alster Lake, and kayak Hamburg’s canals.

Relax in the Rissen district, by the Elbe River on the Wittenberg shore. Nearby, explore the Wittenberg lighthouse.

Relish the views from the bistro and the collections in noted art museum, Hamburger Kunsthalle.

Taste Hamburg
Nosh at Barefood Deli. This bright, cozy atmosphere was introduced by a famous German actor and is family-owned. Homemade beer and wine, Sunday brunch, DJs in the evening—food and fun for everyone.

Dine with a view of Hamburg harbor at Fischereihafen, where fish dishes rule the day.

Another great fish eatery is Schabi’s Fischimbiss, where you can pick your own fish, eat inside or out, and enjoy the experience.

Insider tip: If you’re more interested in exploring than sitting down to dine, pop into a Hamburg grocery store for cheap-and-go items. Groceries often give out generous samples, so keep your eyes open!

You can see it from the Elbe bridges: Entenwerder 1. What a view from this pontoon eatery! Public Coffee Roasters is next door, so the cappuccino, espresso and coffee are amazing.

In a former pharmacy, the Brooklyn Burger Bar’s offerings are fresh and homemade.

Taste chocolate at Chocoversum. Learn about the process and create your own chocolate bar.

Enjoy Luicella’s Ice Cream in the St. Georg or St. Pauli locations.

Taste Scandinavia at Karlsons, where the Norwegian apple pancake is but one of the offerings you’ll long remember.

Klimperkiste is a bar and an eatery, so you don’t have to choose. Good for all night or a nightcap.

Discover more to explore from our Hamburg Pinterest board and begin planning your TapRooT® trip to Germany today. Download the handy, free Hamburg app here.

Join TapRooT®’s Facebook Live tomorrow!

Posted: May 22nd, 2018 in Career Development Tips, Topic of the Week, Video

Join TapRooT® professionals Mark Paradies and Benna Dortch tomorrow for our Facebook Live discussion: Avoid Big Problems by Paying Attention to the Small Stuff.

Here’s a sample of the content: What is a precursor incident? A precursor incident is an incident that has low to moderate consequences but could have been much worse if . . .

Join us tomorrow for what comes after the “if.”

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live:

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

When? Tomorrow, Wednesday, May 23

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

What does a bad day look like?

Posted: May 22nd, 2018 in Bad day

“When you don’t consult an architect, designer or contractor, this is the type of home renovation you’re bound to get. Did it never occur to them to match the exteriors?”

ASSE (Safety 2018) is almost here!

Posted: May 22nd, 2018 in Current Events

The best safety conference of the year. I can’t wait.

If you are attending the conference, please stop by and see us at booth 843. Barb and I will be there. The first 500 people will get a special gift, so don’t miss out!

See you in San Antonio!

Thanks to all my Linkedin Connections

Posted: May 22nd, 2018 in Current Events

I have reached 20,000 Linkedin connections! Thank you for your support!

If we are not yet connected, please send me a REQUEST

Technically Speaking – Helpdesk Humor

Posted: May 21st, 2018 in Software, Technical Support, Technically Speaking

Would you consider this a good Safeguard? Of course not! Thinking of implementing new safeguards at the company you work for? Get some great ideas at one of our upcoming TapRooT® training courses. Take a look at your next course here.

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!

Monday Accidents & Lessons Learned: The Worst U.S. Maritime Accident in Three Decades

Posted: May 21st, 2018 in Accidents, Great Human Factors, investigation, Investigations

The U.S.-flagged cargo ship, El Faro, and its crew of 33 men and women sank after sailing into Hurricane Joaquin. What went wrong and why did an experienced sea captain sail his crew and ship directly into the eye of a hurricane? The investigation lasted two years. 

One of two ships owned by TOTE Maritime Inc., the El Faro constantly rotated between Jacksonville, Florida, and San Juan, Puerto Rico, transporting everything from frozen chickens to milk to Mercedes Benzes to the island. The combination roll-on/roll-off and lift-on/lift-off cargo freighter was crewed by U.S. Merchant Marines. Should the El Faro miss a trip, TOTE would lose money, store shelves would be bare, and the Puerto Rican economy would suffer.

The El Faro, a 790-foot, 1970s steamship, set sail at 8:15 p.m. on September 29, 2015, with full knowledge of the National Hurricane Center warning that Tropical Storm Joaquin would likely strengthen to a hurricane within 24 hours.

Albeit with modern navigation and weather technology, the aging ship, with two boilers in need of service, with no life vests or immersion suits, was equipped with open lifeboats that would not be launched once the captain gave the order to abandon ship in the midst of a savage hurricane.

As the Category 4 storm focused on the Bahamas, winds peaking at 140 miles an hour, people and vessels headed for safety. All but one ship. On October 1, 2015, the SS El Faro steamed into the furious storm. Black skies. Thirty to forty foot waves. The Bermuda Triangle. Near San Salvador, the sea freighter found itself in the strongest October storm to hit these waters since 1866. Around 7:30 a.m. on October 1, the ship was taking on water and listing 15 degrees. Although, the last report from the captain indicated that the crew had managed to contain the flooding. Soon after, the freighter ceased all communications. All aboard perished in the worst U.S. maritime disaster in three decades. Investigators from the National Transportation Safety Board (NTSB) were left to wonder why.

When the NTSB launched one of the most thorough investigations in its long history, they spoke with dozens of experts, colleagues, friends, and family of the crew. The U.S. Coast Guard, with help from the Air Force, the Air National Guard, and the Navy, searched in a 70,000 square-mile area off Crooked Island in the Bahamas, spotting debris, a damaged lifeboat, containers, and traces of oil. On October 31, 2015, the USNS Apache searched and found the El Faro, using the CURV 21, a remotely operated deep ocean vehicle.

Thirty days after the El Faro sank, the ship was found 15,000 feet below sea level. The images of the sunken ship showed a breach in the hull and its main navigation tower missing. 

Finally came the crucial discovery when a submersible robot retrieved the ship’s voyage data recorder (VDR), found on Tuesday, April 26, 2016, at 4,600 meters bottom. This black box held everything uttered on the ship’s bridge, up to its final moments.

The big challenge was locating the VDR, only about a foot by eight inches. No commercial recorder had ever been recovered this deep where the pressure is nearly 7,000 pounds per square inch.

The 26-hour recording converted into the longest script—510 pages— ever produced by the NTSB.  The recorder revealed that at the outset, there was absolute certainty among the crew and captain that going was the right thing to do. As the situation evolved and conditions deteriorated, the transcript reveals, the captain dismissed a crew member’s suggestion that they return to shore in the face of the storm. “No, no, no. We’re not gonna turn around,” he said. Captain Michael Davidson then said, “What I would like to do is get away from this. Let this do what it does. It certainly warrants a plan of action.” Davidson went below just after 7:57 p.m. and was not heard again nor present on the bridge until 4:10 a.m. The El Faro and its crew had but three more hours after Davidson reappeared on the bridge, as the recording ends at 7:39 a.m., ten minutes after Captain Davidson ordered the crew to abandon ship.

This NTSB graphic shows El Faro’s track line in green as the ship sailed from Jacksonville to Puerto Rico on October 1, 2015. Color-enhanced satellite imagery from close to the time the ship sank illustrates Hurricane Joaquin in red, with the storm’s eye immediately to the south of the accident site.

The NTSB determined that the probable cause of the sinking of El Faro and the subsequent loss of life was the captain’s insufficient action to avoid Hurricane Joaquin, his failure to use the most current weather information, and his late decision to muster the crew. Contributing to the sinking was ineffective bridge resource management on board El Faro, which included the captain’s failure to adequately consider officers’ suggestions. Also contributing to the sinking was the inadequacy of both TOTE’s oversight and its safety management system.

The NTSB’s investigation into the El Faro sinking identified the following safety issues:

  • Captain’s actions
  • Use of noncurrent weather information
  • Late decision to muster the crew
  • Ineffective bridge resource management
  • Company’s safety management system
  • Inadequate company oversight
  • Need for damage control plan
  • Flooding in cargo holds
  • Loss of propulsion
  • Downflooding through ventilation closures
  • Need for damage control plan
  • Lack of appropriate survival craft

The report also addressed other issues, such as the automatic identification system and the U.S. Coast Guard’s Alternate Compliance Program. On October 1, 2017, the U. S. Coast Guard released findings from its investigation, conducted with the full cooperation of the NTSB. The 199-page report identified causal factors of the loss of 33 crew members and the El Faro, and proposed 31 safety recommendations and four administrative recommendations for future actions to the Commandant of the Coast Guard.

Captain Jason Neubauer, Chairman, El Faro Marine Board of Investigation, U.S. Coast Guard, made the statement, “The most important thing to remember is that 33 people lost their lives in this tragedy. If adopted, we believe the safety recommendations in our report will improve safety of life at sea.”

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 21st, 2018 in Career Development, Courses, Job Postings, Training

When you are TapRooT® trained, you can rely on your expertise to convey the level to which you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis communicate competency to the potential employer. If you have invested yourself in TapRooT® training and skills, explore professional advancement with confidence through one of these global opportunities.

Patient Safety Program Coordinator (PSPC)

Associate – Senior Engineer Nuclear (Electrical)

Safety & Health Specialist

Pipeline Risk/Integrity Engineer

EHS Drilling Specialist

Safety Manager

Safety Professional

Patient Safety Program Coordinator

Patient Safety Analyst

QHSSE Advisor

Safety & Health Specialist

HES Manager

If you are not yet TapRooT® trained, becoming TapRooT® trained in troubleshooting and identifying root causes of issues and incidents is the proven path to develop your skill sets and training. Pursue your goals through these TapRooT® courses to advance your professional development.

Bogota, Colombia, May 28, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Perth, Australia, May 30, 2018: 2-Day TapRooT® Root Cause Analysis Training

Gatlinburg, Tennessee, June 4, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Aberdeen, Scotland, June 6, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, June 11, 2018: 2-Day TapRooT® Root Cause Analysis Training

Auckland, New Zealand, July 16, 2018: 2-Day TapRooT® Root Cause Analysis Training

Milwaukee, Wisconsin, July 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Lake Tahoe, Nevada, July 25, 2018: 2-Day Root Cause Analysis Training

Sao Paulo, Brazil, August 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Adelaide, Australia, August 21, 2018: 2-Day TapRooT® Root Cause Analysis Training

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

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 or 865.357.0080.

Why Use the TapRooT® Root Cause Analysis Method for Quality?

Posted: May 21st, 2018 in Career Development Tips, Topic of the Week, Uncategorized, Video

If you missed the Quality Problem-Solving session on Facebook Live with TapRooT® professionals Benna Dortch and Chris Vallee, here is another opportunity to get in on the discussion.

Why use the TapRooT® Root Cause Analysis Method for Quality from TapRooT® Root Cause Analysis on Vimeo.

Chris has brought our clients a keener understanding of “quality” with his expertise. Here is a sample:

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine, etc.) or recalls that may be impacting us today (air bags). These recalls all have a major theme—a company made something and somebody got hurt or worse. This is a theme of “them versus those” perception.

Stop and ask, When is the last time quality and safety were discussed as one topic in your current company’s operations?

You received a defective tool or product …
You issued a defective tool or product …
A customer complained …
A customer was hurt …

Each of the occurrences above often triggers an owner for each type of problem:

The supplier …
The vendor …
The contractor …
The manufacturer …
The end user …

We can stop and ask, Who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development, or corrective action implementation?

This is where we create our own internal silos for problem-solving; each problem often has its own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments’ training and experiences.

Does anyone else see a problem or an opportunity here?

Circle your calendar for Facebook Live this Wednesday and connect with us:

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

When? Wednesday, May 23

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

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

Friday Joke

Posted: May 18th, 2018 in Jokes

2018 Global TapRooT® Summit Best Practices – Implement a Dedicated Investigation Team

Posted: May 17th, 2018 in Best Practice Presentations, investigation, Summit, Video

After you’ve attended a TapRooT® course and learned how to use the techniques, the real challenge begins! How do you actually start a real investigation? What do you need to know in order to efficiently lead a team of investigators? And what do team members require to optimally focus on the actual investigation process?

At the 2018 Global TapRooT® Summit, attendees listened and learned about implementing best practices for a dedicated investigation team. Shelley Hassen, HSE Assurance & Compliance Manager, Willbros, a leading contractor in specialty energy infrastructure, was an informative part of this discussion, as you will learn from this Vimeo.

 

 

For another look at Shelley’s insights into best practices, see the blog, Success Story Contest: Saving Time, Resources & Effort with Single User Software.

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

Root Cause Tip: Repeat-Back Strengthens Positive Communication

Posted: May 17th, 2018 in investigation, Investigations, Root Cause Analysis Tips

Misunderstood verbal communication can lead to a serious incident.

Risk Engineer and HSE expert, Jim Whiting, shared this report with us recently highlighting four incidents where breakdowns in positive communications were factors. In each circumstance, an operator proceeded into shared areas without making positive communication with another operator.

Read: Positive communication failures result in collisions.

Repeat-back (sometimes referred to as 3-way communication) can reinforce positive communication. This technique may be required by policy or procedure and reinforced during training on a task for better compliance.

Repeat-back is used to ensure the information shared during a work process is clear and complete. In the repeat back process, the sender initiates the communication using the receiver’s name, the receiver repeats the information back, and the sender acknowledges the accuracy of the repeat back or repeats the communication if it is not accurate.

There are many reasons why communications are misunderstood. Workers make assumptions about an unclear message based on their experiences or expectations. A sender may choose poor words for communication or deliver messages that are too long to remember. The message may not be delivered by the sender in the receiver’s primary language. A message delivered in the same language but by a worker from a different geographical region may be confusing because the words do not sound the same across regions.

Can you think of other reasons a repeat-back technique can be helpful? Please comment below.

See you today for TapRooT® Facebook Live at noon Eastern

Posted: May 16th, 2018 in Career Development Tips, Presentations, Topic of the Week, Video

Tune into TapRooT®’s Facebook Live today as we talk with TapRooT® Senior Associate Chris Vallee about Quality Problem Solving. 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, May 16

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

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

Avoid Big Problems By Paying Attention to the Small Stuff

Posted: May 16th, 2018 in Accidents, Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

What does a bad day look like?

Posted: May 15th, 2018 in Bad day, Pictures

“Joke’s on you! The neighbors actually have a flying car, and thus no need for a driveway that smoothly goes into the garage. Psssh, tires are sooooo 2015, right?”

TapRooT® Around the World: Bogota, Colombia

Posted: May 15th, 2018 in Courses, Pictures, TapRooT, Training

Many thanks to Diana Munevar for these TapRooT® training photos from a three-day TapRooT® training course led by Hernando Godoy and Piedad Colmenares in Bogota, Colombia! Looks like they are having fun and learning a lot!

Put yourself in this picture. Advance your career and your development through TapRooT® training!

We are global to meet your needs. Register today for a TapRooT® Training course and gain advantage, experience, and expertise from our professional instructors. Below is a sample of our upcoming courses.

July 16 – Auckland, New Zealand, 2-Day TapRooT® Root Cause Analysis Training

July 17 – Milwaukee, Wisconsin, 2-Day TapRooT® Root Cause Analysis Training

July 25 – Lake Tahoe, Nevada, 2-Day Root Cause Analysis Training

August 08 –  Sao Paulo, Brazil, 2-Day TapRooT® Root Cause Analysis Training

August 13 – Nashville, Tennessee, 2-Day TapRooT® Root Cause Analysis Training

August 27 – Monterrey, Mexico, 5-Day TapRooT® Advanced Root Cause Analysis Training

September 12 – Newcastle, Australia, 2-Day TapRooT® Root Cause Analysis Training

September 26 – Amsterdam, Netherlands, 2-Day TapRooT® Root Cause Analysis Training

October 14 – Dubai, UAE, 5-Day Advanced Root Cause Analysis Training

 If you’re interested in pursuing a TapRooT® course that is near you or for a specific date, look further via these two links:

2-Day TapRooT® Root Cause Analysis Training

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

Testimonial Tuesday

Posted: May 15th, 2018 in Courses, Testimonials

TapRooT® is a world-class software system designed to help investigators solve every day hurtles. TapRooT® take the investigator beyond his or her knowledge to choose root causes that are “outside the box” of common root causes such as writing poor procedures or inadequate training. To learn more about our courses and what people have to say about them continue reading.

Here’s what clients had to say about our 2-Day course:

  • “This course met my expectations, will be back for a 5-Day training.” – Charles
  • “The Final Team Exercise was thought provoking and tied concepts learned all together.” – John
  • “RCA will be greatly improved.” – Huckeaberry

Interested in our 5-Day? Here’s what our clients had to say:

  • “I learned new ways to gather information, in line of questions.” – Davis
  • “I like the optimal tools especially CHAP®.” – Gias
  • “This is a powerful process, if it is followed through it will eliminate many preconceived thoughts.” – Kyle
  • “I liked the use of safeguard hierarchy. This can help me make “stronger” corrective actions after the investigation.” – Inger

We take your course evaluations seriously. Without them, we couldn’t continue to improve and grow as a company. So, thank you for your valuable feedback!

Looking for a course near you? Find a course location by clicking on the links below.

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

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