Root Cause Analysis Blog

 

‘Equipment Failure’ is the cause?

Posted: February 22nd, 2018 in Accidents, Equipment/Equifactor®, Investigations
Fire, equipment. failure

Drone view of tank farm fire Photo: West Fargo Fire Department

 

 

 

 

 

 

 

On Sunday, there was a diesel fuel oil fire at a tank farm in West Fargo, ND. About 1200 barrels of diesel leaked from the tank.  The fire appears to have burned for about 9 hours or so.  They had help from fire dapartments from the local airport and local railway company, and drone support from the National Guard.  There were evacuations of nearby residents.  Soil remediation is in progress, and operations at the facility have resumed.  Read more about the story here.

The fire chief said it looks like there was a failure of the piping and pumping system for the tank. He said that the owners of the tank are investigating. However, one item caught my attention. He said, “In the world of petroleum fires, it wasn’t very big at all. It might not get a full investigation.”

This is a troublesome statement.  Since it wasn’t a big, major fire, and no one was seriously hurt, it doesn’t warrent an investigation.  However, just think of all the terrific lessons learned that could be discovered and learned from.  How major a fire must it be in order to get a “full investigation?”

I often see people minimize issues that were just “equipment failures.”  There isn’t anyone to blame, no bad people to fire, it was just bad equipment.  We’ll just chalk this one up to “equipment failure” and move on.  In this case, that mindset can cause people to ignore the entire accident, and that determining it was equipment failure is as deep as we need to go.

Don’t get caught in this trap.  While I’m sure the tank owner is going to go deeper, I encourage the response teams to do their own root cause analyses to determine if their response was adequate, if notifications correct, if they had reliable lines of communications with external aganecies, etc.  It’s a great opportunity to improve, even if it was only “equipment failure,” and even if you are “only” the response team.

Technically Speaking – Webinar Wednesdays

Posted: February 22nd, 2018 in Software, Technical Support, Technically Speaking

New to the TapRooT® VI software? Don’t fear, Webinar Wednesdays are here! Yes, it’s Thursday BUT it’s always a good practice to plan ahead!

Webinar Wednesday occurs the fourth Wednesday of every month!  If you have been trained in TapRooT®, and want to optimize your investigations, join us. Every month we will be offering a software-specific webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software.

Get the most out of your investment.
 What you need to know: 
  • When: Webinar Wednesdays occur the fourth Wednesday of every month
  • Time: 2:00-3:30pm Eastern Time
  • Length: 90 minutes
  • Price: $195 per seat
  • Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.

Interested? REGISTER HERE FOR WEBINAR WEDNESDAY MARCH 28th, 2018.

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!

How far away is death?

Posted: February 22nd, 2018 in Accidents

Nuclear Plant Fined $145,000 for “Gun-Decked Logs”

Posted: February 21st, 2018 in Current Events, Human Performance, Performance Improvement, Pictures

When I was in the Navy, people called it “gun-decking the logs.”

In the Navy this means that you falsify your record keeping … usually by just copying the numbers from the previous hour (maybe with slight changes) without making the rounds and taking the actual measurements. And if you were caught, you were probably going to Captain’s Mast (disciplinary hearing).

The term “gun-decking” has something to do with the “false” gun deck that was built into British sailing ships of war to make them look like they had more guns. Sometimes midshipmen would falsify their navigation training calculations by using dead reckoning to calculate their position rather than using the Sun and the stars. This might have been called “gun-decking” because the gun deck is where they turned their homework over to the ships navigator to be reviewed.

NewImage

What happened at the Nuke Plant? A Nuclear Regulatory Commission inspector found that 13 operators had gun-decked their logs. Here’s a quote from the article describing the incident:

“An NRC investigation, completed August 2017, found that on multiple occasions during the three-month period, at least 13 system operators failed to complete their rounds as required by plant procedures, but entered data into an electronic log indicating they had completed equipment status checks and area inspections,” the NRC said in a statement.”

What was the corrective action? The article says:

“The plant operator has already undertaken several corrective actions, the NRC said, including training for employees, changes in the inspection procedures and disciplinary measures for some staff.”

Hmmm … training, procedures, and discipline. That’s the standard three corrective actions. (“Round up the usual suspects!”) Even problems that seem to be HR issues can benefit from advanced root cause analysis. Is this a Standards, Policy, and Administrative Controls Not Used issue? Is there a root cause under that Near Root Cause that needs to be fixed (for example, Enforcement Needs Improvement)? Or is discipline the right answer? It would be interesting to know all the facts.

Want to learn to apply advanced root cause analysis to solve these kinds of problems? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Courses. See the upcoming public courses by CLICKING HERE. Or CLICK HERE to contact us about having a course at your site.

Summit Details for Attendees

Posted: February 20th, 2018 in Pictures, Summit

Are you attending the 2018 Global TapRooT® Summit? Here is some important information…

Knoxville Convention Center layout…

The address is: 701 Henley Street, Knoxville, TN 37902.

The security/lost and found number there is: 865-251-6040.

Emergency muster site during the Summit …

Summit Schedule

Bring Business Cards … You need these for networking.

Dress for Summit … Business Casual. Definitely bring a coat or sweater because it can be cold in February and March in East Tennessee. Here is a picture of “Business Casual” from the internet …

I thought it was too dressy. I found this “do and don’t” photo and had a laugh …

Then I thought … Why not show a photo of people from a past Summit!

Food: Breakfast and lunch are supplied at the Summit and at the pre-Summit courses.There will also be food and drink at the Wednesday night reception. We will try as best as possible to accommodate special meal requests but … you don’t get your own private chef!

Reception on Wednesday: Plan to attend the Wednesday night TapRooT® Summit Reception. There will be live music, food, and drinks. It is a great place to meet and make friends. Your spouse is invited, too. Carl Dixon and band will provide musical entertainment.

Be On Time: Don’t miss the OPENING WELCOME at 8 AM on Wednesday. You will have three people looking to meet you during THE NAME GAME and a reward for completing the game. Also, you will get a ticket for a prize drawing whenever you are on time for a session.

Breakfast Activities: Breakfast on Thursday and Friday is from 8 to 9. On Thursday, the breakfast activity will be a Version 6 TapRooT® Software trial. If you want to learn more about the TapRooT® Software, come to breakfast at 8 AM. On Friday, we will prepare for the keynote presenter, Mike Williams, with a review of the Deepwater Horizon accident.

DON’T LEAVE EARLY! Friday is an important day at the Summit. The Gap Analysis Session will help you design the improvements your company needs. You will go back to work with a planned mission to improve. PLUS the final speaker is Mike Williams – the real life hero from the movie Deepwater Horizon. We are doing a question-and-answer format; so if you have questions about the accident, get answers from someone who was there. Don’t schedule your flight until the afternoon. Or stay until Saturday and have time to meet and talk with Mike after his presentation.

Follow us on Twitter and use the hashtag #taprootsummit (Learn more.)

If you have any questions about anything regarding the Summit, call our office at: 865-539-2139.

Are you planning to attend the 20th Annual IHI/NPSF Patient Safety Congress in Boston?

Posted: February 20th, 2018 in Medical/Healthcare, Root Causes, Training


Per Ohstrom and I are looking forward to going to Boston, May 23 – 25, for the 20th Annual IHI/NPSF Patient Safety Congress. If you’re attending, please make a note to stop by the Exhibit Hall and visit us in Booth #316.

Healthcare facilities need multiple levels of analysis to truly identify the causes of patient safety related incidents. We’d love to talk to you about how TapRooT® offers robust data gathering tools and consistent objective root cause analysis to help you build the most effective corrective actions that will address and prevent problems. These tools all working in harmony with your systems will create a much safer environment for patient care.

We hope to see you there!

Five great reasons to register for our 2-Day TapRooT® Root Cause Analysis Training today!

Posted: February 20th, 2018 in Courses, Testimonials, Training

    
There’s no one better to ask about why you should take TapRooT® Training than someone who has. Here are some recent  comments our course attendees made about the our 2-Day TapRooT® Root Cause Analysis Training.

You’ll:

1. Have a new perspective on how to identify errors or equipment failures that contributed to an incident.
“Taught me to look at [causal factors] differently than I have in the past.” ~ J. Cooper

2. Create managements reports with ease.
“[There’s a] good tool in the software to create reports.” ~ W. Wiech

3. Learn the power of finding root causes with a well-planned, systematic process.
“[Learned] incident investigation in a more structured way.” ~ L. Wolter

4. Receive hands-on training.
“Frequent activities helped to apply knowledge and reinforce learning.” ~ A. Ranger

5. Learn to ask better questions.
“Successfully completed report on an industry incident that was unfamiliar. Forced the group to ask better questions.” ~ S. Oleksyn

Join us for an upcoming course:

Lake Charles, Louisiana – March 6

Lisbon, Portugal – March 8

Charlotte, North Carolina – March 19

Bogota, Colombia – March 21

 

VIEW ALL upcoming 2-day trainings around the world.

 

 

Deepwater Horizon … The Movie

Posted: February 20th, 2018 in Accidents, Current Events, Documents, Pictures, Summit, Video

Last night, to prepare for the 2018 Global TapRooT® Summit, I watched the movie Deepwater Horizon.

I’m interviewing Mike Williams (who was played by Mark Wahlberg in the movie … see the trailer above).

I have a hard time watching the movie. The needless death of those men and the needless pain and suffering of the rest of the crew was totally avoidable.

What we do at System Improvements is to teach people to use TapRooT® Root Cause Analysis to find and fix the root causes of problems BEFORE major accidents happen. This could have been done BEFORE the Deepwater Horizon accident. I sometimes think that I didn’t do enough to get people who don’t use TapRooT® to fix problems and improve performance. If only I could have convinced BP and Transocean to use TapRooT®, maybe the accident would have been prevented.

That’s why we hold the TapRooT® Summit each year. It is one more way to bet people fired up about performance improvement and stopping major accidents.

Hope to see you next week at the Summit and spend an hour talking to a survivor of the Deepwater Horizon accident.

Mike Williams 442x450

If you want to watch the movie before the Summit, you can download it at Amazon by CLICKING HERE.

Or you can read the Presidential Commission report, by clicking on this link: DEEPWATERPresidentCommission.

Ot read the Chemical safety Board Executive Summary report: CSB BP Deepwater Horizon Exec Summary.

Career Opportunities for Candidates with TapRooT® Skills

Posted: February 20th, 2018 in Job Postings

Are you professionally trained in investigative problem solving and root cause analysis? Are you TapRooT® trained in troubleshooting and identifying root causes of issues and incidents? If so, browse through these openings to advance your professional development.

Safety Specialist II – III

Associate-Senior Engineer Nuclear (Electrical)

QHSSE Advisor

Service Delivery Coordinator

The advantage of training speaks volumes on your resume, and the career you’ve prepared for will stand out to employers worldwide who are looking for candidates with TapRooT® training and skills. Check out these upcoming courses.

Lisbon, Portugal, March 8, 2018, 2-Day TapRooT® Root Cause Analysis Training

Dubai, UAE, March 18, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Charlotte, NC, March 19, 2018, 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Portland, OR, March 21, 2018, 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, March 21, 2018, 3-Day TapRooT® Equifactor®

Brisbane, Australia, March 26, 2018, 1-Day TapRooT® Equifactor®

Twitter Contest

Posted: February 20th, 2018 in Uncategorized

This year at the 2018 Global TapRooT® Summit we will be hosting a Twitter contest. To enter to win you will need to have a twitter account, follow our Twitter page (@TapRooT_RCA), and use the hashtag #taprootsummit.

You might be asking what should I post!? Well here are some suggestions.

Pictures of:

  • You and your friends at the Summit
  • Summit activities
  • 30th Anniversary Party
  • Keynote Speakers
  • Breakfast/Lunch Buffet

Or you can send us status updates about:

  • Your travels to the 2018 Global TapRooT® Summit
  • What you’ve learned/favorite Breakout Session
  • Fun and exciting things you’ve done around Knoxville, TN

Or simply just tell us about your experience at the 2018 Global TapRooT® Summit.

The more you tweet using the the hashtag #taprootsummit the greater your chances of winning!

We will announce the winner Thursday March, 1 before the Keynote Speaker Vincent Phipps. You must be PRESENT to win.

Caption Contest Winner!

Posted: February 20th, 2018 in Contest, Pictures

Alright everyone, the caption contest is over! There were a lot of great, funny, and creative entries. I asked the staff here to vote on the winner, and because we had so many hilarious entries it was a really close call.

And the winner of this caption contest is…

Steve K. with “Burning Man’s in August, silly.”

I also want to give a shout out to TWO honorable mentions.

“This girl is on firrrreeee…” (to the tune of Adele Fire) ~ Amy Shute.

Love that song!

“Look Ma…..No Hands!!!!!” ~ Claude

Haha! I can hear it now.

I want to thank everyone for playing along. Don’t forget just because you won past Caption Contest doesn’t mean you can’t enter to win. The more captions you come up with the greater your chances of win!

Stay tuned for the next Caption Contest coming soon after the 2018 Global TapRooT® Summit.

The Pursuit of Happiness

Posted: February 19th, 2018 in Career Development, Career Development Tips

What does happiness mean to you? Often we find that answer in what we are pursuing: better relationships, an ideal career, a comfortable lifestyle. But what if chasing happiness makes us more unhappy? One researcher learned just that! Emily Esfahani Smith researched how to live a meaningful and fulfilling life and believes there are 4 basic pillars. The first, second and third are no surprise but the fourth pillar may be something you’ve never considered before that just may change the course of your life for the better.

Join Us for Facebook Live Wednesday, February 21 at Noon EST

Posted: February 19th, 2018 in Media Room, Topic of the Week

So… you took a TapRooT® course.  Is there anything you can do now to continue performance improvement? Join Dave Janney and Benna Dortch as they discuss training options that can boost your career on Facebook Live.

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

When? Wednesday, February 21, 2018

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

Monday Accident & Lesson Learned: Quick action by mother prevents toddler from falling through hole in moving train

Posted: February 19th, 2018 in Accidents, Investigations


A child was rescued from death when his mom grabbed him before he fell through a hole in a moving train.  In a 39-page report published by the Rail Accident Investigation Board, it was revealed that “The child entered the toilet, and as the door opened and the child stepped through it, he fell forward because the floor was missing in the compartment he had entered.” Read the report here.

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

Posted: February 16th, 2018 in Summit, TapRooT, Technically Speaking

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

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

Friday joke

Posted: February 16th, 2018 in Accidents, Jokes

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

Posted: February 15th, 2018 in Accidents, investigation, Investigations, RCA Tip Videos, Root Cause Analysis Tips, Video, Video Depot

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.

Frequently Asked Questions Page of the 2018 Global TapRooT® Summit Web Site

Posted: February 14th, 2018 in Summit

What are some of the most frequently asked questions about the Global TapRooT® Summit? See the FAQ page by clicking below.

Screen Shot 2018 01 15 at 4 43 28 PM

Support your Investigation Results with Solid Evidence Collection

Posted: February 13th, 2018 in Investigations, Summit

We have a couple of seats left in the “TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” 2-day Pre-Summit course, February 26-27 in Knoxville, Tennessee. My co-instructor, Reb Brickey and I are excited to share methods of collection that will help you stop assumptions in their tracks!

Evidence collection techniques help investigators focus on the facts of an investigation. We will talk about pre-planning, different types of evidence to keep in mind as well as spend a good part of the second day learning about and practicing interviewing techniques. The course begins with an interesting case study and attendees break into investigation teams and work toward solving the evidence collection puzzle for the accident presented.

Class size is limited to ensure an ideal learning environment, so register now for the 2-day course only or for the 2-day course plus the 3-day Global TapRooT® Summit.

 

2018 Global TapRooT® Summit: The Secret Ninth Track

Posted: February 13th, 2018 in Summit

When you are choosing your track from the 8 learning tracks on the 2018 Global TapRooT® Summit schedule, you will notice that the very first option is “Alternative Sessions.”

Sometimes people wonder, “Is that the secret ninth track?”

Well… it could be.

Alternative sessions are best practice sessions that we think will appeal to our Summit attendees as a whole. So, you could sign up for the track as a whole. However, most people register for one of the eight tracks listed below it and then choose to switch a session or two with a session presented in Alternative Sessions. For example, if you registered for the Software Track but recently attended our TapRooT® VI Software Webinar (you clever Superuser you!), you may decide to spend your time in the Alternative Session “Making Sense of Complex Investigations” instead.

Alternative Sessions are options so you can fully customize your Summit track to be exactly what you want it to be. And who doesn’t love choices?

Do you have a question about customizing your Summit schedule so it’s a perfect fit? Give is a call at 865-539-2139 or send an email to info@taproot.com.

LEARN MORE about the 2018 Global TapRooT® Summit.

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

Posted: February 13th, 2018 in Courses, TapRooT, Training


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

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

Register for an upcoming course:

Monterrey, Mexico – March 5

Charlotte, North Carolina – March 19

New Orleans, Lousiana – April 16

Edmonton, AB Canada – April 23

Las Vegas, Nevada – April 23

 

Join Us for Facebook Live, Wednesday, February 14 at Noon EST

Posted: February 13th, 2018 in Media Room, Topic of the Week

Why do we work so hard on root cause analysis? Because we want effective corrective actions! Join Ken Reed and Benna Dortch as they discuss innovative correction actions on Facebook Live.

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

When? Wednesday, February 14, 2018

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

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Success Stories

The healthcare industry has recognized that improved root cause analysis of quality incidents…

Good Samaritan Hospital

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

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