Root Cause Analysis Blog

 

How far away is death?

Posted: February 8th, 2018 in How Far Away Is Death?, Pictures

Screen Shot 2018 01 17 at 7 21 53 PM

Just one more ladder and …

Why You Should Use the TapRooT® Process for Smaller Investigations

Posted: February 7th, 2018 in Investigations, Root Cause Analysis Tips

“If the hammer is your only tool, all of your problems will start looking like nails.”

Per Ohstrom shares how TapRooT® is used to investigate smaller incidents by demonstrating the methodology. Are you using the 5-Whys to investigate these types of incidents? The 5-Whys won’t take you beyond your own knowledge. Find out how TapRooT® will!

Refresh your knowledge with 2-Day TapRooT® Root Cause Analysis Training

Posted: February 7th, 2018 in Career Development, Career Development Tips, Courses, Testimonials

Stay sharp and keep pace with TapRooT® software technology as well as new developments in incident investigation and root cause analysis. If you haven’t taken a TapRooT® course in a few years, you’ll enjoy the boost that comes with new knowledge and strengthening your skills. Here are some comments from recent attendees:

“The 2-Day course was clear, concise, engaging and interesting.” ~ K. Malcolm

“It was a good refresher after taking the 5-day four years ago.” ~ N. Ferrell

“Hands-on exercises will help on the job.” ~ K. Blackmon

Invest in your career possibilities. Join us for an upcoming course and refresh your knowledge and skills.

Register

Lake Charles, LA, March 6

Lisbon, Portugal, March 8

Sydney, Australia, March 13

Calgary, Canada, March 13

Singapore, March 15

Perth, Australia, March 19

Bogota, Colombia, March 21

Portland, Oregon, March 21

Sao Paulo, Brazil, April 4

 

What is the Fastest Way to Get Fired After an Accident?

Posted: February 7th, 2018 in Accidents, Performance Improvement, Pictures, Training

If you work at a blame-oriented company, the answer to the question above is easy. Just admit that you were the last person to touch whatever went wrong that caused the accident.

Or, if you are in the Navy, all you have to do is to be the CO of a ship that has a collision at sea.

A slower way to get fired is to be the Plant Manager or Division Manager who doesn’t have good answers when he or she is asked by the corporate VP, “What are you going to do to prevent a repeat accident in the future?” Actually, they probably don’t fire someone this high in the organization. Rather, they transfer them to a staff job where they are never heard from again.

What is the best way to avoid being fired? Don’t have the accident in the first place! Instead, have a proactive improvement program that identifies problems, finds their root causes, and effectively fixes them before an accident happens.

Want to learn more about using TapRooT® in a proactive improvement program? Attend Dave Janney’s pre-Summit course: TapRooT® for Audits.

What’s covered in the course?

DAY ONE

  • TapRooT® Process Introduction and Initial Audit
  • SnapCharT® and Exercise
  • Significant Issues and Exercise
  • Root Cause Tree® and Exercise
  • Generic Causes
  • Corrective Actions and Exercise

DAY TWO

  • The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
  • Audit Programs, Trend and Process Root Cause Analysis
  • TapRooT® Software Introduction
  • Frequently Asked Questions about TapRooT®
  • Final Audit Observation Exercise

Don’t miss this course coming up quickly on February 27-27 in Knoxville, TN. Register by CLICKING HERE.

DAveJ

Monday accidents & lessons learned

Posted: February 5th, 2018 in Accidents, Current Events

Packed with 250 commuters and heading to Milan’s Porta Garibaldi station, the Italian Trenord-operated train derailed January 25, 2018, killing three people and seriously injuring dozens. The train was said to have been traveling at normal speed but was described by witnesses as “trembling for a few minutes before the accident.” A collapse of the track is under investigation. Why is early information-gathering important?

Friday Joke: Safety Pizza Party

Posted: February 2nd, 2018 in Accidents, Jokes, Video

This reminds me of a cookout safety lunch celebration. Something in the food went bad many got sick.

Emmett – Newest Addition to the TapRooT® Family

Posted: February 1st, 2018 in Uncategorized

Proud father Garrett Boyd sent us this photo of his newborn son, Emmett…

Emmett

Send Garrett congratulations by leaving comments here…

 

Audit Prep: A Deeper Look at the Definition of a Significant Issue.

Posted: February 1st, 2018 in Instructor Videos, Summit, TapRooT, Video Depot

Here is Dave Janney taking a deeper look into the definition of a significant issue when preparing for an audit.

Carl Dixon at the 2018 Global TapRooT® Summit Reception

Posted: February 1st, 2018 in Accidents, Current Events, Summit, TapRooT, Video

You’ve heard rock star Carl Dixon talk at previous Summits about his comeback from a near-fatal car crash. Don’t miss him playing at the 2018 Global TapRooT® Summit!

Technically Speaking – January Customer Satisfaction Survey Prize Winner

Posted: February 1st, 2018 in Software, 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® polo shirt.
Everyone, congratulate Daren Abbott from Dominion Diamond as the winner for the month of January!

Don’t forget to use the hashtag… #taprootsummit

Posted: January 31st, 2018 in Summit

 

The question has been asked and the answer is “yes” – we will be using a conference hashtag again this year (#taprootsummit) .. so if you are a tweeter (or a would be tweeter) please remember to use the conference hashtag in your tweets. It’s a lot of fun!

Are you registered for the 2018 Global TapRooT® Summit February 26 to March 2, Knoxville, Tennessee? We’d love to hear some tweets in February about what you’re looking forward to doing after you arrive in Knoxville!

  • Ever had free time after a conference day but needed to know some of the best places to eat in an unfamiliar place? Tweet out your question to #taprootsummit after hours!
  • Ever forgot when a registration desk was open or where to even register? Tweet out your question to #taprootsummit after you arrive!
  • Ever wondered if you could start networking with some of the attendees or make a friend before you even arrived? Tweet out to #taprootsummit that you’re attending!

These are just a few fun ideas. During the last conference our attendees had a blast communicating on Twitter and sharing images of the event.

Have questions? Tweet them out! Don’t forget the hashtag… #taprootsummit !

How to Make Incident Investigations Easier

Posted: January 31st, 2018 in Investigations, Root Cause Analysis Tips

Ken Reed talks about the differences between an investigation for a low-to-moderate incident and a major incident. Find out how TapRooT® makes both types of investigation easier to manage.

Want to learn how to investigate a major/minor incident with all of the advanced tools? Sign up for an upcoming 5-day training!

Want to start with just the essential skills for performing a root cause analysis on a minor or major investigation? It’s a great place to start with a minor investment of time. Sign up for an upcoming 2-day training!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

Posted: January 31st, 2018 in Accidents, Courses, Current Events, Equipment/Equifactor®, investigation, Investigations, Performance Improvement, Root Cause Analysis Tips, Root Causes, TapRooT

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Where Do You Get Ideas To Improve Root Cause Analysis?

Posted: January 31st, 2018 in Courses, Performance Improvement, Pictures, Root Cause Analysis Tips, Summit, TapRooT, Training, Video

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Mark Ed 2

 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

L M Astronaut

Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

Linda1988

Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

Bestpractice

People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

New Name Gives Nod to 1982 Knoxville World’s Fair

Posted: January 31st, 2018 in Summit, Uncategorized

Visitors and Knoxvillians will enter an updated building and a new phase in the life of the formerly named Knoxville Convention and Exhibition Center, now known as the World’s Fair Exhibition Hall. The area underneath the downtown Holiday Inn is undergoing a 2.1 million renovation, to include a new roof and remodeled restrooms. The rename and remodel of the hall will be celebrated with a new logo displaying the 1982 World’s Fair flame and international flags in Rubik’s Cube fashion.

The 2018 Global TapRooT® Summit will be hosted in Knoxville Convention Center, February 26 – March 2. Register now to change the way you do business and solve problems.

Road Trip: Find Yourself in Knoxville

Posted: January 30th, 2018 in Summit

You’re never quite the same after a memorable road trip. Curiosity can seize you on a trip, yes, even on a business trip. The 2018 Global TapRooT® Summit is in Knoxville, Tennessee. You have some free time to wander. Time to check out the life and lifestyles. Make new contacts or new friends. Put on a foodie hat and eat like a boss. Pick up souvenirs.

Here, in Knoxville, we invite you to open yourself up to a city that brims with 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. Save time to sample our downtown winery and distilleries, and hop on a Knox Brew Tour.

Here’s a smattering of suggestions for exploring and good times.

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.
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
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
14. First Friday Knoxville

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
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.

4 Signs You Need to Improve Your Investigations

Posted: January 29th, 2018 in investigation, Investigations, Performance Improvement, Summit, TapRooT

If you want to improve your root cause analysis beyond simple techniques that yield incomplete results that don’t stop problems, you are probably ready for step one … implementing the TapRooT® Root Cause Analysis System.

But many find that after they implement the TapRooT® System, they still have room to improve their investigations. Here are four signs that you’re ready for step two:

  1. Investigator Bad Habits – Before your investigators were trained to use TapRooT®, they probably had some other method they used to find “the root cause.” The bad habits they learned probably aren’t completely corrected in a single 2-Day or 5-Day TapRooT® Root Cause Analysis Course. They may have previously been trained that there was only one root cause. They might not know how to interview or collect information (facts). They may need practice drawing complete SnapCharT®s or identifying all the Causal Factors. Therefore, they may need more training or some coaching to complete the development of their skills.
  2. Insufficient Time & Resources – Even if you are a great investigator, you need time to collect evidence and complete your investigation. If you have too little time and if you don’t have adequate resources, the TapRooT® Training alone can’t make your investigations excellent.
  3. Inadequate Investigation Review – Investigators need feedback to improve their skills. Where do they get expert feedback? It could come from management if they are experts in root cause analysis. If management doesn’t understand root cause analysis, the feedback they get may not improve future results. Therefore, you should probably implement a “peer review” before management review occurs. The “peer review” will be done by one or more root cause analysis experts to identify areas for improvement BEFORE the investigation is presented to management. The best peer reviews are conducted while the investigation is being performed. Think of this as just-in-time coaching.
  4. Insufficient Practice – Even with great training to start with, people become “rusty” if they don’t practice their skills. Of course, you don’t want to have more serious incidents to get more experience for your investigators. What can you do? Three things … a) Use the TapRooT® System to investigate less serious but potentially serious incident. The new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, can show you how to do this without wasting time and effort. b) Use the TapRooT® System to prepare for, perform, and analyze the results of audits. Learn how to do this in the upcoming pre-Summit course, TapRooT® for Audits. Or get the book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. c) Have a refresher course for your investigators (contact us for info by CLICKING HERE) or have them attend a pre-Summit Course and the Global TapRooT® Summit to refresh their skills.

Are you ready for step two? Would you like to learn more about improving your implementation of TapRooT® and changing the culture of your companies investigations and root cause analysis? Then get registered for the 2018 Global TapRooT® Summit.

NewImage

FIRST, Mark Paradies, President of System Improvements and TapRooT® author will be giving a keynote address titled: How Good is Your TapRooT® Implementation. Learn how to apply best practices from around the world to improve your use of TapRooT® Root Cause Analysis.

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SECOND, Jack Frost, Vice President HSE of Matrix Service Company, will be giving a Best Practice Track talk titled: Improving Safety Culture Through Measuring and Grading Investigations. In this session he will discuss using an evaluation matrix to grade your investigations and coach your investigators to better root cause analysis.

Screen Shot 2018 01 25 at 10 01 23 AM

You can download the matrix that Jack uses here: http://www.taproot.com/content/wp-content/uploads/2015/04/RateRootCauseAnalysis11414.xlsx.

Don’t be satisfied. Continually improve your root cause analysis!

Monday Accident & Lessons Learned: How Long Should a Root Cause Analysis Take?

Posted: January 29th, 2018 in Accidents, Current Events, Investigations, Pictures

Screen Shot 2018 01 27 at 2 48 07 PM

On January 25th, The Atlanta Journal-Constitution reported that Georgia Power had not identified the cause of the December 17th electrical fire that shut down power to large portions of Atlanta’s Hartsfield-Jackson Airport. The article reports that the service disruption caused massive passenger disruptions and will cost $230,000 to repair. Delta says that the disruption from the fire and an early December snow storm will cost the airlines $60 million dollars.

Obviously this incident is worth preventing and needs an effective root cause analysis. It has been over a month since the fire. The questions is … how long should a root cause analysis take? A month, three months, a year, three years?

Of course, the answer varies depending on the type of the incident but what do you think is reasonable?

Leave your comments by clicking on the Comment link below.

Career Opportunities for Candidates with TapRooT® Skills

Posted: January 29th, 2018 in Career Development, Job Postings

Where do you see your career going? Are experiences that fuel your fire factored into your plans? Explore these current opportunities for job seekers with TapRooT® skills:

EHS Manager

Engineer, Maintenance & Reliability

HSE Manager, Improvement & Assurance

HSE Site Supervisor

Machinery Engineer

We have upcoming TapRooT® courses in these locations. Register today and advance your career!

Singapore, March 15, 2018, 2-Day TapRooT® Training

Newcastle, Australia, March 26, 2018, 2-Day TapRooT® Essentials

Houston, Texas, April 9, 2018, 2-Day TapRooT® Techniques

Sao Paula, Brazil, May 21, 2018, 5-Day TapRooT® Advanced Training

CSB to Investigate Fatal Well Explosion in Oklahoma

Posted: January 27th, 2018 in Accidents, Current Events, Investigations

I don’t know when the CSB became the drilling investigator but here is their press release announcing the investigation…

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CSB Will Investigate Fatal Well Explosion in Oklahoma

Washington D.C. January 25, 2018 – The U.S. Chemical Safety Board announced today that it will be moving forward with a full investigation into the fatal gas well explosion near Quinton, Oklahoma. The explosion fatally injured five workers.

Upon notification of the incident, the CSB deployed two investigators to gather additional facts  to assist the Board in making  a decision regarding the scope of the investigation. Investigators arrived on site Wednesday morning and met with the lease holder for the well and the drilling operator.  CSB investigators will continue to meet with well service providers and the well site consultant company that had employees on site at the time of the incident. Evidence preservation and collection is the initial focus of the investigation.

The CSB is an independent, non-regulatory federal agency whose mission is to drive chemical safety change through independent investigations to protect people and the environment. The agency’s board members are appointed by the President and confirmed by the Senate.

CSB investigations examine all aspects of chemical incidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems. For more information, contact public@csb.gov.

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