Root Cause Analysis Blog

 

Friday Joke

Posted: August 3rd, 2018 in Jokes

TapRooT® Around the World: Onsite, Oman, Sohar Aluminium

Posted: August 2nd, 2018 in Career Development, Courses, Meet Our Staff, Performance Improvement, Pictures, TapRooT, TapRooT® Instructor, Training

The Sohar Aluminium project team in Oman learned a lot and had a great class. Many thanks to Randy Creek for sharing these pictures!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

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

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

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.

Remembering An Accident: Sayano-Shushenskaya Hydroelectric Dam

Posted: August 2nd, 2018 in Accidents, Investigations, Pictures, Root Causes, TapRooT

One of the world’s largest hydroelectric plants, Sayano-Shushenskaya Hydroelectric Dam, suffered a catastrophic failure On August 17, 2009, that lead to the death of 75 people, and the pollution of the Yenisei River with 40 tons of oil spilling into it. So how did a major incident like this happen?

On the day of the accident the dam was undergoing major repairs and upgrades. Nine of the ten turbines were operating at full capacity, even the troublesome  #2 turbine. This turbine had previously been offline because of persistent vibrations and maintenance issues, but it was brought back online the previous night. A fire at the Bratsk Power Station caused a drop in electricity production and the decision was made to run Turbine #2 to help with the electrical shortage.

Just before 8:13 am large vibrations were felt by a technician worker on the roof, and according to his recount of the the incident the vibrations gradually grew into a load raw. Shortly after two massive explosion occurred and turbine #2 shoot through the floor 50 feet into the air, and then it came crashing back down. The water that was spinning the turbine was now gushing out at a rate of 67,600 gallons a second. The gushing water produced massive amounts of pressure that ripped the room apart leading to the roofs collapse.

Eventually the gushing water flooded the lower levels and submerged the other turbines. Unfortunately, the plant’s automatic safety system failed to turn off turbines #7 and #9, which were operating at full capacity. This triggered short circuits that left the plant in total darkness adding to the confusion and mayhem.

Several employees struggled to manually close the pen-stock intake gates, and finally succeed at 9:30 am putting an end to the disastrous incident. Because of communication failures and system failures 75 people lost their lives, many were injured, and 40 tons of oil polluted the Yenisei River. Restoring the damage caused by the explosion took years and it cost US$89.3 million to complete.

(Before & After Photo)

To learn more about the Sayano-Shushenskaya Hydroelectric Dam incident click here.

 

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

TapRooT® Root Cause Analysis is taught globally to help industries avoid them. Our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training offers advanced tools and techniques to find and fix root causes re-actively and help identify precursors that could lead to major problems.

To learn more about our courses and their locations click on the links below.
5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training
2-Day TapRooT® Root Cause Analysis Essentials Training

Technically Speaking – July Customer Satisfaction Survey Winner

Posted: August 2nd, 2018 in Technical Support, Technically Speaking

Here at System Improvements, customer satisfaction is very important to us. We strive to ensure our customers’ questions are treated in a timely and efficient manner. This is so important to us that it’s actually part of our Technical Support Mission Statement:

To provide timely, courteous, and effective technical support to System Improvements staff and all TapRooT® customers, achieving customer satisfaction and process efficiency.

In order to ensure we are providing great service, we have implemented a new customer satisfaction rating system, where our customers can rate their experience with our Support Team. The feedback has been extremely valuable to us.

As a thank you to all our customers who take the time to fill out a survey, all respondents are entered into a monthly drawing to win a TapRooT® shirt. Everyone, let’s congratulate Will Armer, of Hess Corporation as the winner for the month of July!

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!

Caption Contest!

Posted: August 1st, 2018 in Contest, Pictures

Alright, who’s ready for the August caption contest? I know I am!

So, here is your chance to win some free TapRooT® swag! All you have to do is follow the easy instructions below.

How would you caption the above photo? Put on your creative hat and read the contest instructions below. Enter as many times as you want, and if you’ve won our contest before, you are still eligible to enter this one! You can’t help it if you are hilarious!

Contest instructions:
1. Create your caption to the photo above in six words or lessAll captions with more than six words will be disqualified.
2. Type your caption in the comments section of this post by August 20, 2018.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Good luck and, most importantly, have fun!

The Reality of High-Reliability Organizations

Posted: August 1st, 2018 in Performance Improvement, Pictures

For the past decade, I’ve seen people write about their ground breaking high-reliability organization research. It often makes me chuckle because I’ve worked in a high-reliability organization and what the researchers “learn” isn’t always what is really going on.

First, let me say that my high-reliability organization experience was in Admiral Rickover’s Nuclear Navy. Seven years and two ships – the USS Arkansas and the USS Long Beach – both nuclear powered cruisers. I had close friends on submarines and nuclear-powered carriers. To learn more about the Nuke Navy record and Rickover’s philosophy, read the series of article at:

http://www.taproot.com/archives/54027

So what is the difference between the research and reality? Here are some of the ideas to consider…

1. Real high-reliability organizations vs fake high-reliability organizations.

Rickover’s Nuclear Navy was the original high-performance organization. In my experience, there isn’t anything that comes close. I’ve seen research that described carrier flight deck operations as a high-reliability organization. But from the accidents and injuries I’ve seen or heard about, I just don’t think they meet the standard.

That brings up a question. What is the standard?

I think the answer is ZERO. Rickover’s Nuclear Navy was (and still is even after he is gone for almost forty years) an organization that achieves the amazing record of ZERO reactor safety related accidents. There were no fatalities, no major releases of radioactive material, and no core-melt accidents. And this record was set during Rickover’s leadership when the Navy was running hundreds of reactor at sea every year. Today that’s a record of sixty years of continuous operation of many nuclear reactors without a major reactor related accident.

If you are in the process industry, think of this as all the US refineries having no fires or explosions or significant environmental releases for 60 years.

For carrier aviation to qualify as a high reliability organization, they would have to have zero flight deck related fatalities, explosions, or aviation related crashes on all the US carriers for years. As far as I know, they don’t achieve this record for a single year (usually not a single deployment).

Therefore, if you are going to learn from a high-reliability organization, make sure it is a real high-reliability organization.

2. High-Reliability Organizations aren’t good at everything.

Rickover’s Nuclear Navy record for reactor safety was amazing. However, submarine or nuclear surface ship industrial safety was pretty average. Thus, the same excellence emphasis was not applied to everything.

Let’s use a sports example. If you are a great athlete, you have the chance to excel at a sport. But you probably can’t be good at every sport. The world’s greatest basketball player may not be able to switch over and become the worlds greatest baseball player … or golfer. They might be better than average but they probably won’t be great.

Why? Because being great requires focus. If your focus becomes too broad, you lose your focus and performance slips. Thus, you can talk about high-reliability organizations like they are great at everything, but they probably aren’t. They probably focus their attention to become great.

3. The high COST for exceptional excellence.

You can ask the Nuke Navy sailors about the cost of excellence:

  • 12 to 18 hour days
  • failed marriages
  • burnout

Recruiting the exceptional sailors required to meet the highest standards wasn’t easy (and still isn’t easy). There is a financial bonus to keep Nuke Navy sailors in the Nuke Navy. This is a significant chunk of change to keep the best from being recruited away because the average sailor just didn’t cut it in the Nuclear Navy.

4. Weak Signals

Research about high-reliability organizations describes detecting “weak signals” that indicated problems. Let me put this straight. If you are in a high-reliability organization, those signal aren’t weak. They scream out at you.

The problem is that non-high-reliability organizations have on a double set of hearing protection. Many don’t hear or see the signals until dead bodies pile up at their feet.

There is no secret to hearing the signals. If you know what makes your systems highly reliable, then you make sure that these important factors are looked after, maintained, and nurtured. The Rickover article linked to above lays out these factors for the Nuclear Navy (and they are the same factors that apply in process safety).

Here’s an example…

If the budget is cut so that you start getting a maintenance backlog, that isn’t a weak signal. Management high and low should be hearing the signal (there is a maintenance backlog).

If the budget is cut so much that safety significant maintenance isn’t getting done, the system is screaming at you. (This should be monitored and discussed in weekly management meetings.)

If you are having precursor incidents because of deferred maintenance, the top management (the COO) should know about it and should be demanding changes.

Thus weak signals aren’t weak if you are a high-reliability organization.

And if you think they are weak signals – you aren’t in a high-reliability organization.

That’s a start. I’ll stop here and not belabor the point.

Living high-reliability and
researching high-reliability
are two quite different experiences.

If I was going to get advice about becoming a high-reliability organization (quite a challenge if you aren’t one), I would talk to someone who lived in a high-reliability organization and who also has worked at a non-high-reliability organization. Or, better yet, I would hire that person to help lead the effort. I would not become part of someone’s university research detached from the experience of living in the organization.

But be ready for difficulties and major change. Talking about high-reliability is much easier than living high-reliability.

Just my advice … take it or leave it.

TapRooT® Training in Calgary

Posted: August 1st, 2018 in Career Development, Courses, Local Attractions, Performance Improvement, Training

Register here for TapRooT® Training on September 24, 2018, in Calgary, Canada: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Register here for TapRooT® Training on November 29, 2018, in Calgary, Canada: 2-Day TapRooT® Root Cause Analysis Training

Exposure to the 2-Day TapRooT® Root Cause Analysis Training in Calgary will equip you to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include: SnapCharT®, Root Cause Tree® & Corrective Action Helper®. In the Calgary 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training course, you’ll learn the Essential Techniques—including SnapCharT®, Root Cause Tree® & Corrective Action Helper®—plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis, and Proactive Improvement.

A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Calgary, you will want to get out and about. Below, to route you on the road to Calgary, we’ve included highlights of this Canadian city. Be sure to discover even more gems to explore on our Calgary Pinterest board.

Experience Calgary

Magnificent Canadian Rockies & Alaskan Cruise 2018 (13 destinations) - Scenic Luxury Cruises & Tours

Located in the Canadian province of Alberta, Calgary is the gateway to the Canadian Rockies and Banff National Park. It’s also jam-packed with adventures, nightlife, foodie experiences, spectacular natural beauty, and urban mojo.

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Prince’s Island Park stretches along the Bow River, encompassing walking paths and bike lanes that line the riverbanks. You’ll catch sight of gardens and horse-drawn carriages along the pathway known as “River Walk,” which runs into the East Village and links with other bike paths. The bright red pedestrian Peace Bridge on the park’s west end is noted as a top architectural achievement.

In summer, it’s a playground; during the winter, it’s for downhilling, snowboarding, or cross country—the Canada Olympic Park, or WinSport. Built for the 1988 Calgary Winter Olympics and a year-round training ground for Olympians, the park offers mountain biking, a bobsled track, a ski-jump zip-line, and a luge.

Venture to 17 Avenue S.W., often called “the Red Mile,” to find bistros, coffee shops, boutiques, and terrific patios for al fresco dining.

Check out an amazing sculpture, “Wonderland,” on Centre Street and 6 Avenue.

Taste Calgary

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Take advantage of extraordinary dining experience to add to your taste of Calgary. Whether you’re after a well-crafted brew or a palate-pleasing, chef-prepared experience, Calgary has your order.

River Cafe: Resting on the riverbanks, the cafe is popular for brunch, lunch, or dinner.

Eau Claire Market: At the entrance to Prince’s Island Park, the market hosts many restaurants as well as a food court, movie theater, and shops.

National Beer Hall: Stop in for an impressive selection of brews, good service and fare, and a fun atmosphere. Multiple locations.

Earls: Relish brunch, cocktails and happy hour, or the ever-expanding menu at the different locations around town.

The Metropolitan Grill: Bright, contemporary, and casual dining on Stephen Avenue—the grill serves up everything from steak to lobster mac and cheese.

Charcut Roast House: Known for its Alberta beef and prime rib, the Charcut Roast House prides itself on pleasing every palate.

Teatro: Expect to leave satisfied in this eatery featuring seasonal Mediterranean fare and international wines in a circa-1911 bank building. Reservations suggested.

Register here for TapRooT® Training on September 24, 2018, in Calgary, Canada: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Register here for TapRooT® Training on November 29, 2018, in Calgary, Canada: 2-Day TapRooT® Root Cause Analysis Training

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

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

It’s TapRooT® Time! Join Us Today at Noon EST

Posted: August 1st, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, Topic of the Week, Video

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements for your work, your job, your company, and your life.

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, August 1

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 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.

TapRooT® Around the World: Brazil

Posted: July 31st, 2018 in Courses, TapRooT, TapRooT® Instructor

Many thanks to TapRooT® Instructor, Marcelo Marquez, for sending in these great course photos!

Explore Knoxville & Learn TapRooT® Root Cause Analysis

Posted: July 31st, 2018 in Career Development, Courses, Local Attractions, Performance Improvement, Pictures, TapRooT, Training

Register here for TapRooT® Training on October 15, 2018, in Knoxville, Tennessee: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Exposure to the 5-Day TapRooT® Root Cause Analysis Training course in Knoxville will expand your professional knowledge. In two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include SnapCharT®, Root Cause Tree® & Corrective Action Helper®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply!

While in Knoxville, you will want to get out and about. Below, to route you on the road to Knoxville, we’ve included highlights of this southeastern city. Be sure to discover even more local gems to explore on our Knoxville Pinterest board, and look for regional highlights on our East Tennessee Pinterest board

Image result for knoxville tn

Experience Knoxville

Ah, Knoxville in the fall. So much for you to see and savor, including nature’s paintbox of brilliant fall colors. Knoxville is a friendly city—its hospitality inviting you to open up to sporting events and nightlife, artists and art, live music and concerts, Broadway performances. Take advantage of our region’s breathtaking scenic drives and take a hike to immerse yourself in spectacular natural beauty. Experience an embarrassment of foodie havens, some mighty fine shopping, and the warmest Southern hospitality around. Sample our downtown winery and distilleries or hop on a Knox Brew Tour.

Here’s a smattering of suggestions for exploring, having good times, and making memories in the Marble City.

Image result for downtown knoxville tn

Downtown Knoxville

1. Knoxville Visitors Center, 301 S. Gay St., Knoxville, TN 37902: This building dates to 1925 and besides information about our fair city, you’ll find award-winning WDVX and its famous Blue Plate Special.

Image result for market square knoxville

2. Market Square
3. Krutch Park (adjacent to Market Square)
4. East Tennessee Historical Society
5. Old City
6. Blue Slip Winery
7. Knox Whiskey Works

Image result for postmodern spirits knoxville

8. PostModern Distilling
9. Boyd’s Jig & Reel
10. Knoxville Museum of Art
11. World’s Fair Park
12. Volunteer Landing Park
13. Women’s Basketball Hall of Fame

Image result for the university of tennessee in the fall

The University of Tennessee

15. The University of Tennessee, 2704 Kingston Pike, Knoxville, TN 37919,
and Neyland Stadium
16. The McClung Museum of Natural History & Culture

Other fun attractions 

17. Zoo Knoxville
18. Knoxville Botanical Garden

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19. Great Smoky Mountains National Park
20. Cades Cove
21. Maple Hall Bowling
22. World’s Fair Park Sunsphere
23. Ijams Nature Center

24. Navitat Canopy Experience
25. The Muse

26. Cruze Farm Ice Cream
27. Pete’s Coffee Shop
28. Mast General Store

Here’s where to park, sorted by location.

Register here for our Knoxville 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

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

Investigating Even the Smallest Problems using TapRooT®

Posted: July 31st, 2018 in Investigations, Performance Improvement, Root Cause Analysis Tips

 

Many companies think about using TapRooT® only when something really significant occurs. Things like major environmental releases, or serious injuries, or expensive quality control issues. These are considered Major Investigations in TapRooT®.

Some companies are also using TapRooT® on less complex, lower risk problems. Problems such as a dropped object, a small spill from a container, or a minor first aid case might be investigated using the Simple Investigation process in TapRooT®.

However, what about REALLY simple problems? Does it make sense to perform entire TapRooT® investigations for just a simple problem that you spot on the job site? Actually, TapRooT® is EXCELLENT at helping you quickly find root causes for even small issues, before they become incidents or near misses. Think about the benefits of finding, analyzing, and fixing these tiny problems:

  • They are pretty easy to find
  • They are pretty easy to fix
  • They are pretty inexpensive to fix
  • They have the opportunity to prevent major issues in the future

Chris Vallee and I talked a bit about this on our last TapRooT® Live session.  Take a look here and let us know what you think.

Join TapRooT® Tomorrow for Facebook Live at Noon EST

Posted: July 31st, 2018 in Career Development Tips, Human Performance, Meet Our Staff, Performance Improvement, Topic of the Week, Video

Make plans now to join our knowledgeable TapRooT® professionals tomorrow for the weekly Facebook Live discussion that brings you insights and improvements for your workplace life.

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? Wednesday, August 1

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 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.

Caption Contest Winner!

Posted: July 30th, 2018 in Contest, Pictures

And this months caption contest winner is…. Drrrrrrrrrrrrrrrrrum-roll……

Congratulations Steve. K. !!

Won with the comment, “Drop goes the diesel.”

 

This month’s contest was an extremely close race. In no particular order, here are some of our honorable mentions.

  • “Yup. It’s definitely a boy!” – Tom. S.
  • “I am Optimus… erm, maybe not.” – Andy Hampson
  • “Hi-potential near miss incident.” – Suman Sarker
  • “Cleanliness is next to godliness!” – Daniel
  • “Yes it’s safe, I’m wearing PPE.” – Dennis Egginton
  • “We always do it like this.” – Goran Mihalic

Thank you to everyone who participated in this months Caption Contest. I truly enjoy managing the Caption Contest and reading all your funny comments. It’s a great way to start my day, so again thank you!

 

Keep an eye out for next months new August Caption Contest! Remember, just because you’ve won in the past doesn’t mean you can’t win again.

Monday Accidents & Lessons Learned: Zooming to “Too Low Terrain”

Posted: July 30th, 2018 in Accidents, Career Development Tips, Great Human Factors, Human Performance, Performance Improvement

When the Electronic Flight Bag (EFB) platform—frequently a tablet device—was introduced as a human-machine interface into the aviation industry and the cockpit, the platform proved to  facilitate improvements for both pilots and the aviation community, but the human-machine interface has encountered operational threats in the early years of EFB utilization.

NASA’s Aviation Safety Reporting System (ASRS) has received reports that describe various kinds of EFB anomalies. One routine problem occurs when a pilot “zooms,” or expands the screen to enlarge a detail, and unknowingly “slides” important information off the screen, making it no longer visible. A second type of problem manifests itself in difficulty operating the EFB in specific flight or lighting conditions. Yet a third wrinkle relates to EFB operation in a particular flight phase.

Let’s look at what happened in an A319 when “zoom” went awry:

Prior to departure, an A319 crew had to manage multiple distractions. An oversight, a technique, and a subtle EFB characteristic all subsequently combined to produce a unrecognized controlled flight toward terrain.

“We received clearance from Billings Ground, ‘Cleared … via the Billings 4 Departure, climb via the SID.’ During takeoff on Runway 10L from Billings, we entered IMC. The Pilot Flying (PF) leveled off at approximately 4,600 feet MSL, heading 098 [degrees]. We received clearance for a turn to the southeast … to join J136. We initiated the turn and then requested a climb from ATC. ATC cleared us up to 15,000 feet. As I was inputting the altitude, we received the GPWS alert, ‘TOO LOW TERRAIN.’ Immediately, the PF went to Take Off/Go Around (TO/GA) Thrust and pitched the nose up. The Pilot Monitoring (PM) confirmed TO/GA Thrust and hit the Speed Brake handle … to ensure the Speed Brakes were stowed. Passing 7,000 feet MSL, the PM announced that the Minimum Sector Altitude (MSA) was 6,500 feet within 10 nautical miles of the Billings VOR. The PF reduced the pitch, then the power, and we began an open climb up to 15,000 feet MSL. The rest of the flight was uneventful.

“On the inbound leg [to Billings], the aircraft had experienced three APU auto shutdowns. This drove the Captain to start working with Maintenance Control. During the turn, after completion of the walkaround, I started referencing multiple checklists … to prepare for the non-normal, first deicing of the year. I then started looking at the standard items. It was during this time that I looked at the BILLINGS 4 Departure, [pages] 10-3 and 10-3-1. There are no altitudes on … page [10-3], so I referenced [page] 10-3-1. On [page] 10-3-1 for the BILLINGS 4 Departure at the bottom, I saw RWY 10L, so I zoomed in to read this line. When I did the zoom, it cut off the bottom of the page, which is the ROUTING. Here it clearly states, ‘Maintain 15,000 or assigned lower.’ I never saw this line. When we briefed prior to push, the departure was briefed as, ‘Heading 098, climb to 4,600 feet MSL’; so neither the PF nor the PM saw the number 15,000 feet MSL. The 45-minute turn was busy with multiple nonstandard events. The weather was not great. However, that is no excuse for missing the 15,000-foot altitude on the SID.”

The award-winning publication and monthly safety newsletter, CALLBACK, from NASA’s Aviation Safety Reporting System, shares reports, such as the one above, that reveal current issues, incidents, and episodes.

Circumstances can crop up anywhere at any time if proper sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to apprehend, find, and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

Career Opportunities for Candidates with TapRooT® Skills

Posted: July 30th, 2018 in Career Development, Courses, Job Postings, TapRooT, Training

When you have the expertise of TapRooT® training on your resume, you’re communicating to others the level of your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis convey competency to the prospective employer. If you have TapRooT® training and skills, explore your professional advancement through one of these global opportunities.

Patient Safety Analyst

Safety Representative HSE

Field Engineer II

Field Engineer II

Principal Engineer/Manager

Field Operations Excellence Leader 

Associate- Senior Engineer Nuclear

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

Nashville, Tennessee, August 13, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

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

Calgary, Canada, September 24: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Aberdeen, Scotland, October 8, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Dubai, UAE, October 14: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Singapore, Singapore, November 15, 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.

Get TapRooT® Trained in San Antonio

Posted: July 29th, 2018 in Career Development, Courses, Local Attractions, Performance Improvement, TapRooT, Training

Register here for TapRooT® Training on October 3, 2018, in San Antonio, Texas: 2-Day TapRooT® Root Cause Analysis Training

The 2-Day TapRooT® Root Cause Analysis Training in San Antonio will exponentially expand your professional knowledge. In two days, you will learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and other types of problems. Essential Techniques include SnapCharT®, Root Cause Tree®, & Corrective Action Helper®. A TapRooT® course is a career booster and can be a professional game changer for you. You’ll be amazed at how much you learn that you can immediately apply.

While in San Antonio, you will want to check out the city. To route you on the road to San Antonio, we’ve included highlights below of this enchanting city in Texas. Be sure to discover even more gems to explore on our San Antonio Pinterest board.

Experience San Antonio

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Boat down the San Antonio River for the best way to delve into the heart of this city. Meander along the 2.5-mile-long San Antonio River Walk. Pick what you want to explore among the mix of shops, bars, and more.

The Alamo: This must-see piece of American history was originally known as Mision San Antonio de Valero and represents a pivotal event in the Texas Revolution.

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The San Antonio Zoo: In Brackenridge Park, this 35-acre zoo has a collection of over 3,500 animals representing 750 species.

1. The King William Historic District dates back to the 1790s, when the land that once belonged to the Mission San Antonio de Valero (now known as The Alamo) was made available for native settlers in the area or sold at auction, according to the Office of Historical Preservation. Photo: 871519, Courtesy / Lonely Planet Images

Destination: Southtown. Head to South Alamo Street to discover where the locals go for cool arts experiences, robust bars and restaurants, quirky shops, and great coffee. Get a glimpse of the King William district’s historic homes and terrific views of the River Walk and its residential neighborhoods. Southtown shops and galleries are a unique scene. Keep going until you’ve arrived at the Blue Star Arts Complex and mix with the arts and crafts, the museum, and the brewpub. There are also bikes for rent here.

Taste San Antonio

Southtown is long on food, too. Here, you can find European cuisine at La Frite, Latin fare at Azuca, and fancier eateries, like Monterey or farm-to-fork Feast. If it’s simply Tex-Mex you’re craving,  head to Tito’s!

Bella on the River: On the River Walk, this locally owned restaurant features Southern European fare with a Mediterranean flare. Try the pan-seared scallops or the antipasto. Live jazz is played most nights here.

Nightlife: Try neighborhood favorites The Friendly Spot and La Tuna, fun for relaxing with brews and tunes. Check out the Alamo Eats Food Truck Bar for more of a food focus. If you’re after margaritas, go to Rosario’s. Tuck into appetizers, a mojito, and the hip bar vibe at Restaurant Bliss

Register here for our San Antonio 2-Day TapRooT® Root Cause Analysis Training course.

TapRooT® is global to meet your needs. If you need other times or locations, please see our full selection of courses.

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

How Do You Get to Brazil?

Posted: July 29th, 2018 in Career Development, Courses, Local Attractions, TapRooT, Training

Come to Brazil and learn TapRooT® through one of these courses in the fascinating city of Sao Paulo:

Did you know Christ the Redeemer Statue in Rio de Janeiro is one of the 7 Wonders of the World?

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Brazil is known for spectacular beaches, the flamboyantly colorful Carnival, and its symbolic statue of Christ the Redeemer at the peak of Corcovado Mountain.

    • Brazil is also home to Sao Paulo, the financial hub of Brazil and where world-renowned Pele played at the legendary stadium Pacaembu.

    • Did you know each Brazilian city has at least one soccer stadium?
  • It’s been called “one of the most beautiful bridges in the world” and “the bridge with the complicated name”—Octavio Frias de Oliveira bridge, or Ponte Estaida, over the Pinheiros River in Sao Paulo is known for its unique architecture. This national landmark is the only bridge in the world with an X-shaped supporting structure, with the cruciform prop supporting two crossing roads of different heights. The bridge’s nighttime lights are spectacular.

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    Fun fact: Brazil has more species of monkeys than anywhere else on earth.

    Se Cathedral and square Free things to do in Sao Paulo

    Sao Paulo See Metropolitan Cathedral (Catedral da Se): Statuesque palms line the square, framing this neo-Gothic Roman Catholic Archdiocese. The structure and its Renaissance-styled dome are inspired by the Cathedral of Florence, and more than 800 tons of unique marble were used to construct the building. All the furniture, mosaics, and sculpture were transported by ship from Italy.

    Patio do Colegio, or “Courtyard of the College,” is Sao Paulo’s oldest building and a historical Jesuit church and school. The Pátio do Colégio is home to the Museu Anchieta, which features a fascinating collection of artifacts and records from the 16th century.

    The Julio Prestes Cultural Center: The Julio Prestes Cultural Center, or the Sala Sao Paulo, was once a train station. With its terrific acoustics and a cool, adjustable ceiling, the hall is a copy of Vienna’s Great Musikverein Hall. The Symphony Orchestra of São Paulo (OSESP) performances are some of the most-attended events in the city. A visit here pairs well with some of the other area attractions: Pinacoteca, Museu da Arte Sacra (Sacred Art Museum), and the Parque da Luz

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Pedra Grande: Take a hike on the trail; paraglide the skies over Sao Paulo; take in panoramic views—all from this gem in the middle of the city.

Botanical Garden Of Sao Paulo: With exotic flora, the garden is conservatory of luxuriant landscapes and impressive collections of ornamentals, trees, and groves, as well as many lakes. See the orchid collection; visit the bamboo groves; dine at the great restaurant.

Get a Taste of Brazil

Try what the locals love: Bacalhau is a Brazilian-adopted Portuguese dish containing onions, olives, tomatoes, potatoes, and herbs. Fried fish cakes (bolinho de bacalhau) are consumed with gusto (and often with beer). Tiny tasty rolls (pão de queijo) eaten typically for breakfast—you would call them “cheese bread”—with a cup of coffee with milk (pingado), found in Brazilian bakeries.

Experience the falafels, crispy on the outside and filled with goodness, at Tent of the Nile (Tenda do Nilo).

Taste an African-influenced fritter (acarajé) at Star City

Indulge your sweet tooth at Casa Mathilde.

Have an afternoon or evening drink at Frank Bar.

Dive into a coxinha at Bar do Luiz Fernandes.

Savor feijoada, Brazil’s beans-and-pork stew.

Swing into Caso do Sabor for a tropical chocolate experience, from those who best know cocoa beans and cacao.

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As you can see, there’s adventure awaiting you in Sao Paulo, Brazil. Discover even more to explore in our Brazil Pinterest board and our Sao Paulo Pinterest board.

Take a life-changing trip to Sao Paulo, Brazil. Become accomplished in TapRooT®, learning to find and fix the root causes of incidents, accidents, quality problems, near misses, operational errors, hospital sentinel events and other types of problems.

Register now for an experience in Sao Paulo that will both broaden you and further your career and professional development:

Friday joke

Posted: July 27th, 2018 in Jokes

Technically Speaking – Adding Team Members

Posted: July 26th, 2018 in Software, Technical Support, Technically Speaking

While using the TapRooT® VI software you may have noticed the Team Members Tab in your taproot6.com account or the Sharing Tab if your company is using the Enterprise edition. You can use this feature to add the name of any Team Members that are helping on the investigation.

View the PDF below to learn how to add these Team Members.

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!

TapRooT® Around the World: Onsite Course, NGC, in Trinidad & Tobago

Posted: July 25th, 2018 in Career Development, Courses, Meet Our Staff, Performance Improvement, Pictures, TapRooT, TapRooT® Instructor, Training

Here’s a peek into a recent in-house 2-Day TapRooT® Root Cause Analysis Training course at NGC, the National Gas Company of Trinidad and Tobago. Through TapRooT® Training with instructors Ralph Blessing and Heidi Reed, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events, and many other types of problems.

Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Many thanks to TapRooT® instructor Heidi Reed for sharing these pictures of a great classroom experience!

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

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

Johannesburg, South Africa, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Monterrey, Mexico, August 27, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Bogota, Colombia, August 29, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis Course

Perth, Australia, September 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

Brisbane, Australia, September 04, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

Denver, CO, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Amsterdam, Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, GA, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Manchester, United Kingdom, October 01, 2018: 2-Day TapRooT® Root Cause Analysis Training

San Antonio, TX, October 03, 2018: 2-Day TapRooT® Root Cause Analysis Training

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

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.

Why Does Blame “Make Sense”?

Posted: July 25th, 2018 in Accidents, Human Performance, Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Think about a recent accident …

  • a ship runs aground
  • a refinery has a major fire
  • an oil well has a blowout and explosion
  • a pharmaceutical plant makes a bad batch of drugs and it gets by the QA process and customers are harmed

One thing that you can be sure of in ALL of the accidents above is that:

someone screwed up!

You never have a major accident if all the Safeguards function as designed. And guess what … we depend on human actions, in many cases, as a significant or sometimes as the ONLY Safeguard.

Therefore, when an accident happens, there is usually at least one human action Safeguard that failed.

If you are in a blame oriented organization, the obvious answer is to BLAME the individual (or team) that failed to prevent the accident. If you can find who is to blame and punish them, you can get back to work.

It MAKES SENSE because “if only they had done their job …” the accident would not have happened. Punishing the individual will set an example for everyone else and they will try harder not to make mistakes.

Sure enough, when the same accident doesn’t happen again right away, management believes they fixed the problem with blame and punishment.

I was thinking of this the other day when someone was talking to me about an investigation they had done using TapRooT®. They had recently adopted TapRooT® and, in the past, had frequently blamed people for accidents.

In this case, a worker had made a mistake when starting up a process. The mistake cost the facility over $200,000. The operator thought that she probably was going to be fired. Her apprehension wasn’t reduced when someone told her she was going to be “taprooted.”

She participated in the investigation and was pleasantly surprised. The investigation identified a number of Causal Factors including her “screw up.” But, to her surprise, they didn’t just stop there and blame her. They looked at the reasons for her mistake. They found there were three “root causes” that could be fixed (improvements that could be made) that would stop the mistake from being made in the future.

She came away realizing that anybody doing the same job could have made the same mistake. She saw how the investigation had improved the process to prevent future similar mistakes. She became a true believer in the TapRooT® System.

When you discover the real fixable root causes of human performance related Causal Factors, BLAME DOES NOT MAKE SENSE. In fact, blame is counter productive.

If people see that the outcome of an investigation is usually blame and discipline, it won’t take long until most incidents, if at all possible, become mystery incidents.

What is a mystery incident?

A refinery plant manager told me this story:

Back early in his career, he had been an engineer involved in the construction and startup of a major facility. One day when they were doing testing, the electrical power to some vital equipment was lost and then came back on “by itself.” This caused damage to some of the equipment and a delay in the startup of the plant. An investigation was performed and no reason for the power failure or the reason for the power coming back on could be found. No one admitted to being in the vicinity of the breaker and the breaker was closed when it was checked after the incident.

Thirty years later they held an unofficial reunion of people who had worked on the project. At dinner, people shared funny stories about others and events that had happened. An electrician shared his story about accidentally opening the wrong breaker (they weren’t labeled) and then, when he heard alarms going off, re-shutting the breaker and leaving the area. He said “Well, I’m retired and they can’t punish me for it now.”

That electrician’s actions had been the cause of the incident. The refinery manager telling the story added that the electrician probably would have been fired if he had admitted what he had done at the time. The refinery manager then added that, “It is a good thing that we use TapRooT® and know better than to react to incidents that way. Now we look for and find root causes that improve our processes.”

Are you looking for the root causes of incidents and improving processes?

Or are you still back in the “bad old days” blaming people when a mistake happens?

If you haven’t been to a TapRooT® Course, maybe you should go now and see how to go beyond blame to find the real, fixable root causes of human error.

See our upcoming TapRooT® Courses by clicking on THIS LINK.

Or contact us to get a quote for a course at your site by CLICKING HERE.

And if your management still thinks that blame and punish is a good idea, maybe you should find a way to pass this article along (without being identified and blamed).

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

Posted: July 25th, 2018 in Career Development Tips, Meet Our Staff, Performance Improvement, RCA Tip Videos, Root Cause Analysis Tips, TapRooT, Topic of the Week, Video

Join our Facebook Live session today as TapRooT® professional Ken Reed discusses, How to Use TapRooT® to Analyze a Single, Small Problem. As Ken observes, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

There is a full spectrum of possible uses of TapRooT® in your improvement programs. Use TapRooT® for:

  • Really large, complex, high-risk incidents (Major Investigations)
  • Smaller, less complex problems (Low-to-Medium Risk Incidents)
  • A very simple problem found, for example, during an audit (single Causal Factor)

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 25

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

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 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.

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