Root Cause Analysis Blog

 

Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)

Posted: May 9th, 2018 in Pictures, Root Cause Analysis Tips, TapRooT

Find the Root Cause

I hear people say that 5-Whys is a good root cause analysis system for “simple” incidents. So, I thought I would show a simple incident that was provided as an example by a very experienced 5-Why user and compare it to the analysis that would be performed using TapRooT®.

Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, is the source of the example – a robot failure. He used the example to teach employees the 5-Why technique while he was at Toyota. Here is the example as he described it…

1.    Why did the robot stop?

–    The circuit has overloaded, causing a blown fuse.

2.    Why did the circuit overload?

–    There was insufficient lubrication on the bearings, so they locked up.

3.    Why was there insufficient lubrication on the bearings?

–    The oil pump on the robot is not circulating sufficient oil.

4.    Why is the pump not circulating sufficient oil?

–    The pump intake is clogged with metal shavings.

5.    Why is the intake clogged with metal shavings?

–    Because there is no filter on the pump.

For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.

Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.

TapRooT® Root Cause Analysis

TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with either the TapRooT® 5-Step Process for low-to-medium risk incidents or the the TapRooT® 7-Step Process for major investigations. The 5-Step Process is shown below…

To start investigating the problem, one gathers evidence and draws a SnapCharT® (shown below being drawn by a team in a TapRooT® 2-Day Root Cause Analysis Course).

Notice that the 5-Whys that Mr. Ohno asked in the example above turned out to be mainly the sequence of events leading up to the failure in the  SnapCharT® (shown below).

The SnapCharT® makes the example event easier to understand than the 5-Why example above. Plus, the SnapCharT® goes beyond the 5-Whys by indicating that there was no low oil pressure alarm.

In TapRooT®, if the investigator decides that there is more to learn, the investigator continues to collect evidence (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.

First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?

Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?

The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.

Notice that in TapRooT®, we complete the collection of evidence about what caused the metal filings and what caused the filter to be missing. These were significant issues that were left out of the 5-Why analysis. This type of omission is common in 5-Why analyses – even when experts apply 5-Whys. Thus the problem isn’t with the investigator or their training – it is embedded in the 5-Why system.

Causal Factors

Once one understands what happened, the third step is to identify the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. A simple technique called Safeguard Analysis is used to do this. The four Causal Factors for the Robot Stops incident were identified as:

  1. Mechanic A uses cloth to cover openings in system.
  2. Mechanic A does not report metal shaving contamination.
  3. Mechanic B does not install oil filter.
  4. Operator does not know oil pressure is low.

Where Mr. Ohno only had one root cause, TapRooT® has already identified four Causal Factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys: that it usually focuses on a single cause and misses additional causes (and the needed corrective actions for those root causes that aren’t identified).

TapRooT® Root Causes

In fourth step of the TapRooT® 5-Step Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).

For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend  attending a 2-Day or 5-Day TapRooT® Course.

However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”

This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.

Copyright © 2015 by System Improvements, Inc.
Used by permission. Duplication prohibited.

In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).

Thus, it was determined that if the operator needed an oil pressure display/alarm (displays NI root cause) to make the detection of a problem possible (errors not detectable root cause). If the display/alarm had been present, then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.

The corrective action for these two root causes would be to install a bearing lube oil pressure indicator and a low bearing lube oil pressure alarm to notify the operator of impending equipment problems before the bearing would lock up.

After analyzing just one Causal Factor using the TapRooT® Root Cause Tree® we have found that even an expert like Taiichi Ohno could miss important root causes when using 5-Whys. But there is more. There are still three more Causal Factors to analyze (and then Generic Causes – an optional technique in the 5-Step Process).

Why would you use a root cause tool with known, proven weaknesses? Why would you risk lives, your corporate reputation, and large sums of money on an inferior approach to problem solving? If something is worth fixing, it is worth fixing it right! Learn and apply TapRooT® Advanced Root Cause Analysis to find the real root causes of problems and effectively fix them. Attend an upcoming course to learn more.

Admiral Rickover’s 7 Rules

Posted: May 9th, 2018 in Performance Improvement, TapRooT

Hyman Rickover 1955

Rule 1. You must have a rising standard of quality over time, and well beyond what is required by any minimum standard.
Rule 2. People running complex systems should be highly capable.
Rule 3. Supervisors have to face bad news when it comes, and take problems to a level high enough to fix those problems.
Rule 4. You must have a healthy respect for the dangers and risks of your particular job.
Rule 5. Training must be constant and rigorous.
Rule 6. All the functions of repair, quality control, and technical support must fit together.
Rule 7. The organization and members thereof must have the ability and willingness to learn from mistakes of the past.

Are you using advanced root cause analysis to learn from past mistakes? Learn more about advanced root cause analysis by CLICKING HERE.

See you today on Facebook Live!

Posted: May 9th, 2018 in Career Development, Career Development Tips, Topic of the Week, Video

Ben Franklin said it best, “An ounce of prevention is worth a pound of cure.” How can being proactive turn your organization around? A root cause audit can address many problems and losses that persistently plague companies. Join today’s Facebook Live discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

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? Today, Wednesday, May 9

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

Newest Aircraft Carrier Breaks Down During Sea Trials

Posted: May 8th, 2018 in Current Events, Equipment/Equifactor®, Video

USS Ford underway for sea trials …

An article in Popular Mechanics said the the USS Ford had to return early from sea trials because of an overheating thrust bearing on one of the four main engines. Bloomberg reported that:

“inspection of the parts involved in the January 2018 incident revealed improperly machined gears at GE’s facility in Lynn, Massachusetts as the ‘root cause.'”

Is “improperly machined gears” a root cause? That would be a Causal Factor and the start of a root cause analysis in the TapRooT® System. And why wasn’t the “improper” machining detected prior to installation and sea trials?

Here is some footage of sea trials (including a brief glimpse of one main shaft turning).

Join TapRooT®’s Facebook Live tomorrow

Posted: May 8th, 2018 in Career Development, Career Development Tips, Topic of the Week, Video

We cannot overstate Ben Franklin’s sage advice in his safety axiom, “An ounce of prevention is worth a pound of cure.” Many problems and losses that persistently plague companies can be best addressed by proactively performing a root cause audit. Join the discussion between TapRooT® professionals Benna Dortch and Dave Janney as they evaluate audits and proactive improvements and how they figure in your organizational planning.

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 9

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

Last week, Michelle Wishoun and Benna Dortch discussed how to efficiently navigate our TapRooT® blog and the significantly positive impact it can have on your professional career. Connect to this important discussion via our Vimeo.

TapRooT® TV – How To Find Content on our Blog and How to Arrange TapRooT® Training from TapRooT® Root Cause Analysis on Vimeo.

Come learn with us in Cape Town!

Posted: May 7th, 2018 in Career Development, Courses, Local Attractions, Training

Broaden your horizons and enhance your career in Cape Town!

Mark your calendar and pack your bag to join us in Cape Town for a TapRooT® training course sure to change the way you think about solving problems. In just 5 days, you’ll learn TapRooT® to find and fix the root causes of incidents, accidents, quality problems, precursors, operational errors, hospital sentinel events and 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.

Whether you’re a TapRooT® expert or a beginner, there is always something new and exciting to learn at our 5-Day course. Once you’ve completed the course, you will receive a training certificate and a 90-day subscription to TapRooT® VI. Be sure to bring a safety incident or quality issue when you attend the course. The reports may be a written report, or you have extensive knowledge of an incident without a written report. We will divide into teams of 2-4 people, with each team analyzing a different problem.

Experience Cape Town
Start your exploration with a early morning trek up Table Mountain and take in panoramic views of the city. Ascend the mountain by hiking or via cable car. You’ll be atop one of the New Seven Wonders of the World!

Cape Town is brimming with adventure, culture, and culinary arts. The original city of South Africa, Cape Town was established in 1652 as a refueling station for ships sailing the Spice Route. As it gave birth to civilization, the city is called “the Mother City” by locals and travelers.

If peacefulness, beauty, recreation, nature, and bird-watching are high on your list, jog, hike, or picnic at Kirstenbosch National Botanical Garden or Green Point Park. Cycle, fish, swim or get into water sports at a beach or nature reserve such as West Coast National Park. Find more gardens and parks here.

From aboard a Ceres Rail Company steam train, glimpse the picturesque Ceres Valley landscape.

Visit St. George’s Cathedral, referred to as the “People’s Cathedral” for its role in the resistance against apartheid. The cathedral was designed by Sir Herbert Baker and is the oldest cathedral in Southern Africa and mother church of the Anglican Diocese of Cape Town.

Take a 30-minute walk through Silvermine Nature Reserve and take in the hidden waterfall in the reserve’s southeastern area. Or immerse yourself in a 90-minute city walk through some of Cape Town’s most noted historic culture: Two free walking tours,  the Historic City Tour and the Vibrant Bo-Kaap Tour, start at the City Sightseeing ticket office at 81 Long Street (stop 5, look for the bright red umbrellas).

Shop, dine at, and stroll the V&A (Victoria & Albert) Waterfront; check out the iconic Old Clock Tower while you’re there.

 

Cape Town Eateries

Venture to Long Street’s Royal Eatery for a burger you likely will not soon forget. Select among 50 gourmet burgers, or go for  pizza or vegetarian  in this casual, colorful restaurant.

Relax in the laid-back vibe of Black Sheep Restaurant and feast on honest, uncomplicated, good food made with the best local ingredients.

Relish lunchtime in a Cape Dutch National Monument situated on a lagoon in West Coast National Park. Indulge in local flavors—a blend of Portuguese, Dutch, Norwegian, Italian, and Malay influences—translated through savory, traditional dishes at Geelbek Restaurant.

While you’re at the V&A Waterfront, Balducci’s great vibe and generous wine list accent its great offerings—from steak to pizza and sushi to pasta.

Check out more deliciousness in Cape Town here.

Plot your sightseeing with help from our Cape Town Pinterest board.

Register for the 5-day course in Cape Town here.

Hazards and Targets

Posted: May 7th, 2018 in Accidents, Current Events, Human Performance, Performance Improvement, Pictures, Root Causes, TapRooT

Most of us probably would not think of this as a on the job Hazard … a giraffe.

Screen Shot 2018 05 07 at 9 40 49 AM

But African filmmaker Carlos Carvalho was killed by one while working in Africa making a film.

Screen Shot 2018 05 07 at 9 42 38 AM

 Do you have unexpected Hazards at work? Giant Asian hornets? Grizzly bears? 

Or are your Hazards much more common. Heat stroke. Slips and falls (gravity). Traffic.

Performing a thorough Safeguard Analysis before starting work and then trying to mitigate any Hazards is a good way to improve safety and reduce injuries. Do your supervisors know how to do a Safeguard Analysis using TapRooT®?

Career Opportunities for Candidates with TapRooT® Skills

Posted: May 7th, 2018 in Career Development, Courses, Job Postings, Training

If you’re TapRooT® trained, rely on your expertise to speak volumes about how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis will communicate competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step into a new career through one of these global opportunities.

Senior Process Engineer

Reliability Engineer

Patient Safety Program Coordinator

Environmental Safety & Health Manager

HES Operations Specialist 

Patient Safety Assistant Coordinator (PSAC)

PipelineRisk/Integrity Engineer

Senior Process Engineer

Safety 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.

Cape Town, South Africa, May 14, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

Monday Accidents & Lessons Learned: Failing the Mind-Check of Reality

Posted: May 7th, 2018 in Accidents, Human Performance

 

When an RV-7 pilot studied the weather prior to departure, he considered not only the weather but also distractions and personal stress. His situational awareness and decision-making were influenced by these considerations, as you can see in his experience:

“I was cleared to depart on Runway 27L from [midfield at] intersection C. However, I lined up and departed from Runway 9R. No traffic control conflict occurred. I turned on course and coordinated with ATC immediately while airborne.

“I had delayed my departure due to weather [that was] 5 miles east…and just north of the airport on my route. Information Juliet was: “340/04 10SM 9,500 OVC 23/22 29.99, Departing Runway 27L, Runways 9L/27R closed, Runways 5/23 closed.” My mind clued in on [Runway] 09 for departure. In fact, I even set my heading bug to 090. Somehow while worried mostly about the weather, I mentally pictured departing Runway 9R at [taxiway] C. I am not sure how I made that mistake, as the only 9 listed was the closed runway. My focus was not on the runway as it should have been, but mostly on the weather.

“Contributing factors were:

1. Weather

2. No other airport traffic before my departure. (I was looking as I arrived at the airport and completed my preflight and final weather checks)

3. Airport construction. For a Runway 27 departure, typical taxi routing would alleviate any confusion

4. ATIS listing the closed runway with 9 listed first

5. Quicker than expected takeoff clearance

“I do fly for a living. I will be incorporating the runway verification procedure we use on the jet aircraft at my company into my GA flying from now on. Sadly, I didn’t make that procedural change in my GA flying.”

Thanks to NASA’s Aviation Safety Reporting System (ASRS) for contemporarily sharing experiences that offer valuable insight, contributing to the growth of aviation wisdom, lessons learned, and an uninhibited accounting of reported incidents. ASRS receives, processes, and analyzes these voluntarily submitted reports from pilots, air traffic controllers, flight attendants, maintenance personnel, dispatchers, ground personnel, and others entailing actual or potential hazards.

We encourage you to use the TapRooT® System to 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.

A tip for ensuring accuracy of your investigation findings

Posted: May 4th, 2018 in Root Cause Analysis Tips

Gary Gardner shares an idea at the 2018 Global TapRooT Summit.

 

TapRooT® Root Cause Analysis is Heading to Portland, OR

Posted: May 4th, 2018 in Career Development, Courses, Local Attractions, TapRooT

Mark your calendars and pack your bags we are heading to Portland, OR to teach a 5-Day TapRooT® Advance Training Course on July 16, 2018. You will learn to find and fix the root causes of incidents, accidents, quatlity problems, operational errors, hospital sentinel events, precursor incidents, and much more! You will also learn how to use the Root Cause Tree®, Corrective Action Helper®, and SnapCharT®, plus additional advanced topics such as CHAP, Human Engineering, Interviewing, Safeguard Analysis and Proactive Improvement. Once attendees complete the course they will receive a training certificate and a 90-day subscription to TapRooT® VI.  Whether you’re a TapRooT® expert or a beginner there is always something new and exciting to learn at our 5-Day course.

Make sure to bring a safety incident or quality issue when you attend the course. The reports may be a written report or you have extensive knowledge of an incident without a written report. We will divide into teams of 2-4 people, with each team analyzing a different problem.

Experience Portland:

Portland, OR is situated below the constantly snow capped Mount Hood, and is know for its well maintained parks and Eco-friendliness. The cities official nickname is the “City of Roses” due to all of the rose bushes planted in the city. Here you will experience big city excitement with small town charm. Portland is a city you wont soon forget. So, take a break from you course work and enjoy all Portland has to offer.

Dining:

  • Jake’s Famous Crawfish is a historic restaurant that opened in 1892 and is must try while visiting.
  • Huber’s Cafe is another Portland restaurant that has been open for over a 100 years. Here you will find a traditional hearty menu with an old Portland charm dining experience. The restaurant is known for it delicious food, breath taking stain glassed ceiling, and its’ Spanish Coffee that is prepared table side with flare.
  • Looking for something to satisfy your sweet tooth? Then Ruby Jewel is your destination. Here you will find all-natural hand crafted cream and ice cream sandwiches that are made daily.

Entertainment:

  • Pioneer Courthouse Square was once an old run down parking lot, but it has been transformed into a busy urban park. It host over 300 events a year! If you’re not sure what to do just ask one of the green-clad Sidewalk Ambassadors you will find camped out near the park.
  • The Lan Su Chinese Garden is a popular place to visit. It is a walled Chinese garden that’s as big as a full city block. Fun fact, Portland’s sister city is Suzhou, China.
  • Washington Park is full of fun activities all in one easy location! You can visit the Oregon Zoo, Portland Japanese Garden, International Rose Test Garden, and much more.

There is so much do and see I couldn’t possibly write a blog post long enough to cover it all. So check out our Pinterest page to view our Portland board full of exciting things to do and places to eat. Also, watch this informative video on Portland, OR to learn all about this unique and vibrant city.

 

Register here to advance your professional career in Portland, OR.

Can’t make it to Portland? That’s okay click on the links below to view all of our upcoming courses.
2-Day TapRooT® Essentials Training Course
5-Day TapRooT® Advanced Training Course

Cyber Attack Root Cause Analysis

Posted: May 4th, 2018 in investigation, Root Cause Analysis Tips, Root Causes, Video

(if you can’t see the video, here’s a link)

Yes .. It happened right here in Knoxville! A cyber attack on the county computer system on election night!

What is the root cause? The county is having an outside contractor look into it.

Can you use the TapRooT® Root Cause Analysis System to do a root cause analysis of a cyber security attack. Yes! People have been doing it for decades.

Friday Joke

Posted: May 4th, 2018 in Jokes

Technically Speaking – April Customer Satisfaction Survey Winner

Posted: May 4th, 2018 in Software, TapRooT, 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® polo shirt.
Everyone, let’s congratulate the user, Brent Ross, from AECI as the winner for the month of April!

What is Senior Leadership’s Role in Root Cause Analysis

Posted: May 2nd, 2018 in Performance Improvement, TapRooT

Screen Shot 2018 04 30 at 3 40 59 PM

Senior leadership wants root cause analysis to uncover the fixable root causes of significant accidents and precursor incidents AND to recommend effective fixes to stop repeat incidents.

But what does senior leadership need to do to make sure the happens? What is their role in effective root cause analysis? Here’s a quick list:

  • Best root cause system
  • Insist that it is used
  • Be involved in reviews
  • Insist on timely implementation of fixes
  • Check status of the implementation of fixes
  • Use trends to manage
  • Steer system to be more proactive

Let’s look at these in slightly more detail.

Best root cause system: Because so much is riding on the effective performance of a root cause system, leaders knows that second best systems aren’t good enough. They don’t want to bet their company’s future on someone asking why five times. That’s why they feel assured when their team uses advanced root cause analysis to find and fix the real root causes of problems. CLICK HERE to find out more about advanced root cause analysis.

Insist that it is used: One common theme in companies that get the most from their performance improvement programs is that senior leaders ASK for investigations. When they see a problem, they insist that the advanced root cause analysis process is used to get to the root causes and develop effective fixes. When middle management and employees see senior leadership asking for investigations and root cause analysis, they want to be involved to help the company improve.

Be involved in the reviews: When senior leaders ask for investigations, it’s only logical that they would want to review the outcome of the investigation they asked for. But it goes beyond being present. Senior management knows what to look for and how to make the review process a positive experience. People often get rewarded for good investigations. When the review process is a positive experience, people want to participate and have pride in their work.

Insist on timely implementation of fixes/Check status of the implementation of fixes: You might not believe this but I’ve seen many examples of companies where they performed root cause analysis, developed fixes, and then were very slow to implement them. So slow that the incident repeated itself, sometimes several times, before any fix was implemented. Good senior leadership insists on prompt implementation of fixes and makes sure they are kept up to date on the progress of implementation.

Use trends to manage: Good root cause analysis efforts produce statistics that can help leaders manage. That’s why senior leadership understands the use of advanced trending techniques and gets reports on the latest root cause trends.

Steer system to be more proactive: Would you rather wait for an accident or incident to find your next improvement opportunity? Or would you rather target and audit or assessment and have them apply advanced root cause analysis to develop effective improvements? The best senior leaders know the right answers to these questions.

That’s it! Senior leaders use proactive improvement and investigations of precursor incidents and major accidents (which rarely happen) to find where improvement needs to happen. They are involved with the system and use it to keep their company ahead of the competition. They are updated about the status of fixes and current trends. They reward those who make the system work.

Does that sound like your facility? Or do you have an improvement opportunity?

Tips, Tricks, & Tools: Discover how TapRooT®’s blog can help you

Posted: May 2nd, 2018 in Career Development, Topic of the Week, Video, Website Info and Updates

Tune into TapRooT®’s Facebook Live today. Join TapRooT® professionals Benna Dortch and Michelle Wishoun as they discuss the TapRooT® blog and how its contents can make a significant difference in your professional life. Among blog features to be discussed are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

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 2

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

If you missed last week’s Facebook Live session with TapRooT®’s Benna Dortch and Barb Carr as they discussed the benefits of hands-on learning, catch up on the discussion via the Vimeo below. Feel free to comment or ask questions on our Facebook page.

TapRooT® TV – Benefits of Hands On Learning from TapRooT® Root Cause Analysis on Vimeo.

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

Join us for Facebook Live tomorrow: What TapRooT®’s blog can do for you

Posted: May 1st, 2018 in Career Development, Courses, TapRooT, Topic of the Week, Website Info and Updates

Join TapRooT® professionals Benna Dortch and Michelle Wishoun as they discuss the TapRooT® blog and how its contents can make a significant difference in your professional performance and development.

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 2

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

Among blog features to be discussed are:

  • TapRooT® Training Courses are designed to further your professional development. TapRooT® is the best method for performing investigations and doing root cause analysis. Our courses are scheduled across diverse global locations, or we can come to your facility. Take advantage of city-specific Local Attraction blogs paired with TapRooT® Pinterest boards to help you explore your host location
  • Technically Speaking is a weekly series highlighting various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor

TapRooT®’s blog also brings you wisdom, testimonials, Friday humor, insights into what a bad day is all about, and how far away death may be. Through our Accident blog posts, we delve into a current incident or a near-miss. Browse our Root Cause Analysis blog to pick out your favorite posts.

Testimonial Tuesday

Posted: May 1st, 2018 in Career Development, Courses, TapRooT, Testimonials

Are you interested in attending one of our TapRooT® courses? Here are some recent comments we received from our clients that have attended a 5-Day or 2-Day TapRooT® Training course.

TapRooT® Root Cause Analysis Training Testimonials for our 2-Day and 5-Day courses:

  • “Very well instructed, great team/group dialogue with industry players.” – Dylan
  • “Excellent way of data analysis.” – Sheeth
  • “I have learned better ways of writing better corrective actions.” – Victor
  • “Interesting examples on how multiple root causes can exist.” – Mike

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

Career Opportunities for Candidates with TapRooT® Skills

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

As someone who is TapRooT® trained, you can rely on your expertise to speak volumes about how seriously you’ve taken your career development. Professional training and skill sets in investigation, problem-solving, and root cause analysis will communicate competency to the potential employer across the desk from you. If you have TapRooT® training and skills, step into a new career through one of these global opportunities.

Asset & Operating Integrity (A&OI) Engineer – RBU

EHS Coordinator

EHS Coordinator

EHS Manager II

EHS/Quality Manager

EHS Regional Director

Environmental Safety & Health Manager

Patient Safety Analyst – BSN

Quality Assurance Specialist

Regional EHS Director

Regional EHS Director

Safety Professional (REMC)

Senior Engineer

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

Toronto, Canada, May 7, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Sao Paulo, Brazil, May 21, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

Brisbane, Australia, May 22, 2018: 2-Day TapRooT® Root Cause Analysis Training

Cork, Ireland, May 23, 2018: 2-Day TapRooT® Root Cause Analysis Training

Pittsburgh, Pennsylvania, May 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

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

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

Monday Accidents & Lessons Learned: When There Is No Right Side of the Tracks

Posted: April 30th, 2018 in Accidents, Great Human Factors, investigation

On Tuesday, February 28, 2017, a wall section began to collapse at the top of a cutting above a four-track railway line between the Liverpool Lime Street and Edge Hill stations in Liverpool, England. From approximately 5:30 pm until 6:02 pm, more than 188 tons of debris rained down from the embankment wall collapsing across all four tracks. The Liverpool Lime Street is the city’s main station, one of the busiest in the north of England.

With the rubble downing overhead power lines and damage to infrastructure, all mainline services to and from the station were suspended. The collapse brought trains to a standstill for three hours, with a necessary evacuation of three trains. Police, fire, and ambulance crews helped evacuate passengers down the tracks. Two of the trains were halted in tunnels. Passengers were stranded on trains at Lime Street station due to power outage resulting from the collapse. A passenger en route to Liverpool from Manchester Oxford Road reported chaos at Warrington station as passengers tried to find their way home.

A representative from Network Rail spoke about the incident, “No trains are running in or out of Liverpool Lime station after a section of trackside wall, loaded with concrete and cabins by a third party, collapsed sending rubble across all four lines and taking overhead wires with it. Early indications suggest train service will not resume for several days while extensive clear-up and repairs take place to make the location safe. More precise forecasts on how long the repairs will take will be made after daybreak tomorrow.”

Read more about the incident here.

We invite you to use the TapRooT® System to 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.

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