Root Cause Analysis Blog

 

TapRooT® Around the World: Houston, Texas

Posted: November 13th, 2017 in Courses

We had a great public course in Houston, Texas recently at the Four Points by the Sheraton which is a short walk from fabulous CityCentre. We have two more public courses coming up in Houston. Enjoy fabulous dining options, shopping and a little fun at Bowl & Barrel or Studio Movie Grill at CityCentre and advance your career with root cause analysis training.  Pappasito’s and Pappadeaux’s Seafood are also just a short walk away from the hotel but you can schedule the shuttle at Four Points to take you there if it’s raining.

If you enjoy getting out of your hotel room after a course day and having lots of options for the evening, we have another 2-Day TapRooT® Root Cause Analysis training planned at that location on January 18.  We also have a couple seats open in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training on December 11.

It’s definitely one of my favorite public course training locations!

Monday Accident & Lessons Learned: Passenger train collides with buffer stops

Posted: November 13th, 2017 in Accidents

A passenger train collided with buffer stops. The RAIB reported that the accident occurred becaue the driver was suffering from fatigue and experienced microsleep. Real the full report here.

Join us LIVE on Facebook, Wednesday, November 15 at Noon Eastern

Posted: November 13th, 2017 in Media Room, Summit

Click image to go to our Facebook page.

Here is our upcoming schedule (all live segments will be held on Wednesdays, 12 p.m. Eastern time):

November 15: Learn about our Safety Best Practice Track at the Global TapRooT® Summit with Dave Janney & Benna Dortch.
November 22: Bring all your questions about getting your TapRooT® Team trained! Ken Reed & Benna Dortch have answers!
November 29: Thinking about signing up for our Investigator Best Practices Track? Per Ohstrom & Benna Dortch will share the details of this track!

See you soon!

Caption Contest!

Posted: November 10th, 2017 in Contest

 

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!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by December 15.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter. You must be a subscriber to win!

Have fun!

Caption Contest Winner!

Posted: November 10th, 2017 in Contest

The votes are in an we have a winner for our current caption contest.

Drum roll please…

The winner is Tom S. with

“Mudball, corner pocket.”

Once again, you all made us laugh and the votes were oh-so-close.  Be sure to join us for our next caption contest!

 

Job Postings for Candidates with TapRooT® Skills

Posted: November 9th, 2017 in Career Development, Job Postings

 

Here are some recent postings looking for candidates with TapRooT® Root Cause Analysis skills:

EHS Manager – Fieldcore

Reliability Engineering Supervisor – International Paper

Engineer, Electrical Reliability – Catalyst Paper

Director, Environmental, Health & Safety – UTC Aerospace Systems

It’s not too late to train in 2017 and open your career options for 2018 – sign up for 2017 training!

2-Day TapRooT® Root Cause Analysis Training

November 20 Toronto, Canada

November 21 Adealaide, Australia

November 29 Nashville, TN

December 4 Las Vegas, NV

December 12 Sao Paulo, Brazil

December 14 Perth, Australia

How Far Away is Death?

Posted: November 9th, 2017 in Accidents, How Far Away Is Death?

A worker was dragged with a chain when a meat hook impaled him through the head behind his ear. The worker remained conscious and “jovial” throughout the 2014 incident. Click here to read the story on “Sunshine Coastal Daily.”

Interviewing & Evidence Collection Tip: Preparing Your Accident Investigation Kit

Posted: November 9th, 2017 in Accidents, Root Cause Analysis Tips

 

Last week we talked about being ready for the unexpected to happen, including preparing an accident investigation grab-and-go kit. Let’s flesh that out a little more.

I mentioned that an accident investigation kit can be as simple as forms (such as a form to record initial observations of the witnesses) and a disposable camera. Here are some other ideas that are useful across industries:

Cones

Tape measure

Flashlight

Evidence tags and bags

Tweezers

Work and latex gloves

PPE

Barricade tape

Camera & tripod

Graph Paper

Witness Statement Forms

Paper, clipboard, pen

Copy of  Accident Investigation Policy

What other ideas do you have? Comment below.

Join me and Reb Brickey on February 26 and 27, 2018 in Knoxville, Tennessee for our TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about this topic.

What Does a Patient Want After a Medical Error?

Posted: November 8th, 2017 in Medical/Healthcare

Of course, a patient would prefer that a medical error NEVER happens. Thus most people want the hospital they attend to have a great performance improvement program that proactively PREVENTS errors from occurring. However, even with the best programs, an error is still possible (even if it is highly unlikely).

A study in the JAMA Internal Medicine says that patient’s and their families want physicians and hospitals to communicate with them to explain what the facility is doing to prevent similar future incidents. We are going to try harder is not enough. They want real root cause analysis with effective corrective actions.

The study said that “Patients and families strongly desired to know what the hospital did to prevent recurrences of the event, but 24 of 30 reported receiving no information about safety improvement efforts.”

So what do patient’s want?

  • Adequate compensation
  • Friendly communication
  • To be heard by the physician and the hospital.
  • How the hospital/physician would prevent future errors

If you don’t have advanced root cause analysis you can’t meet the patient’s expectation.

Maybe it is time to learn about TapRooT® and start your facilities journey to world-class root cause analysis and performance improvement?

Where is the nearest TapRooT® Training?

Posted: November 7th, 2017 in Courses, Current Events, Pictures, TapRooT

Iraq

We hold public TapRooT® Courses all over the world. See our upcoming courses at:

http://www.taproot.com/store/Courses/

If you have 10 or more people to train, you could probably save money by having an on-site course for your folks. Get a quote by CLICKING HERE.

Italy

More Proof that Hospitals Need to Improve Root Cause Analysis

Posted: November 6th, 2017 in Medical/Healthcare, Performance Improvement

What would you think if your hospital received a “D” in a Leapfrog hospital rating? THIS ARTICLE points out three hospitals in the Atlanta area that received the worst Leapfrog scores.

My response would be that they need better root cause analysis. With advanced root cause analysis they would be finding the causes of infections, treatable complications, unnecessary blood clots, collapsed lungs, air or gas bubbles in the blood, and other preventable errors.

Effective root cause analysis is the basis for an effective performance improvement program. Without effective root cause analysis, a hospital is doomed to repeat their errors because they are guessing at solutions.

Want to find out more about the 5-Day Advanced Root Cause Analysis Training? See:

http://www.taproot.com/courses#5-day-root

Monday Accidents & Lessons Learned: Review of a Comprehensive Review

Posted: November 6th, 2017 in Accidents, Current Events, Documents, Human Performance, Investigations, Performance Improvement, Pictures

ComprehensiveReview_Final.pdfReportScreenShot

What will it take for the US Navy surface fleet (or at least the 7th Fleet) to stop crashing ships and killing sailors? That is the question that was suppose to be answered in the Comprehensive Review of Recent Surface Force Incidents. (See the reference here: Comprehensive+Review_Final.pdf). This article critiques the report that senior Navy officials produced that recommended changes to improve performance.

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If you find yourself in a hole, stop digging!!
Will Rogers

The report starts with two and a half pages of how wonderful the US Navy is. The report then blames the crews for the accidents. The report stated:

In each incident, there were fundamental failures to responsibly plan, prepare and execute ship activities to avoid undue operational risk. These ships failed as a team to use available information to build and sustain situational awareness on the Bridge and prevent hazardous conditions from developing. Moreover, leaders and teams failed as maritime professionals by not adhering to safe navigational practices.

It also blamed the local command (the 7th Fleet) by saying:

Further, the recent series of mishaps revealed weaknesses in the command structures in-place to oversee readiness and manage operational risk for forces forward deployed in Japan. In each of the four mishaps there were decisions at headquarters that stemmed from a culturally engrained “can do” attitude, and an unrecognized accumulation of risk that resulted in ships not ready to safely operate at sea.

Now that we know that more senior brass, the CNO, the Secretary of the Navy, the Secretary of Defense, the Congress, or the President (current or past) have nothing to do with the condition of the Navy, we can go on to read about their analysis and fixes.

The report states that individual root cause analysis of US Navy crashes were meant to examine individual unit performance and did NOT consider:

  • Management Systems (Doctrine, Organization, Leadership, Personnel)
  • Facilities and Material
  • Training and Education

The “Comprehensive Report” was designed to do a more in-depth analysis that considers the factors listed above. The report found weaknesses in all of the above areas and recommended improvements in:

  • Fundamentals
  • Teamwork
  • Operational Safety
  • Assessment
  • Culture

The report states:

The recommendations described in this report address the skills, knowledge, capabilities, and processes needed to correct the abnormal conditions found in these five areas, which led to an accumulation of risk in the Western Pacific. The pressure to meet rising operational demand over time caused Commanders, staff and crew to rationalize shortcuts under pressure. The mishap reports support the assertion that there was insufficient rigor in seeking and solving problems at three critical stages: during planning in anticipation of increased tasking, during practice/rehearsal for abnormal or emergency situations in the mishap ships, and in execution of the actual events. This is important, because it is at these stages where knowledge and skills are built and tested. Evidence of skill proficiency (on ships) and readiness problems (at headquarters) were missed, and over time, even normalized to the point that more time could be spent on operational missions. Headquarters were trying to manage the imbalance, and up to the point of the mishaps, the ships had been performing operationally with good outcomes, which ultimately reinforced the rightness of trusting past decisions. This rationalized the continued deviation from the sound training and maintenance practices that set the conditions for safe operations.

The report mentions, but does not emphasize, what I believe to be the main problem:

The findings in chapters four through eight and appendix 9.10 underscore the imbalance between the number of ships in the Navy today and the increasing number of operational missions assigned to them. The Navy can supply a finite amount of forces for operations from the combined force of ships operating from CONUS and based abroad; this finite supply is based both on the size of the force as well as the readiness funding available to man, train, equip and sustain that force. Headquarters are working to manage the imbalance. U.S. Navy ships homeported in the continental United States (CONUS) balance maintenance, training and availability for operations (deployments and/or surge); the Pacific Fleet is re-examining its ability to maintain this balance for ships based in Japan as well. Under the Budget Control Act of 2011 and extended Continuing Resolutions, the ability to supply forces to the full demand is – and will remain – limited.

The report does not say how many more ships the 7th Fleet or the US Navy needs.

The report also stated:

The risks that were taken in the Western Pacific accumulated over time, and did so insidiously. The dynamic environment normalized to the point where individuals and groups of individuals could no longer recognize that the processes in place to identify, communicate and assess readiness were no longer working at the ship and headquarters level.

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This could be used as a definition of normalization of deviation. To read more about this, see the article about Admiral Rickover’s philosophy of operational excellence and normalization of deviation by CLICKING HERE.

Normalization of deviation has been common in the US Navy, especially the surface fleet, with their “Git er Dun” attitude. But I’m now worried that the CNO (Chief of Naval Operation), who was trained as a Navy Nuke, might not remember Admiral Rickover’s lessons. I also worry that the submarine force, which has had its own series of accidents over the past decade, may take shortcuts with nuclear safety if the emphasis on mission accomplishment becomes preeminent and resources are squeezed by Washington bureaucrats.

NewImage

The military has been in a constant state of warfare for at least 15 years. One might say that since the peacekeeping missions of the Clinton administration, the military has been “ridden hard and put up wet” every year since that mission started. This abuse can’t continue without further detrimental effects to readiness and performance in the field.

The report summary ends with:

Going forward, the Navy must develop and formalize “firebreaks” into our force generation and employment systems to guard against a slide in standards. We must continue to build a culture – from the most junior Sailor to the most senior Commander – that values achieving and maintaining high operational and warfighting standards of performance. These standards must be manifest in our approach to the fundamentals, teamwork, operational safety, and assessment. These standards must be enforced in our equipment, our individuals, our unit teams, and our fleets. This Comprehensive Review aims to define the problems with specificity, and offers several general and specific recommendations to get started on making improvements to instilling those standards and strengthen that culture.

This is the culture for reactor operations in the Nuclear Navy. But changing a culture in the surface fleet will be difficult, especially when any future accidents are analyzed using the same poor root cause analysis that the Navy has been applying since the days of sail.

NewImage

After the summary, the report summarizes the blame oriented root cause analysis that I have previously reviewed HERE and HERE.

Another quote from the report that points out the flaws in US Navy root cause analysis is:

Leadership typically goes through several phases following a major mishap: ordering an operational pause or safety stand down; assembling a team to determine what happened and why; and developing a list of discrete actions for improvement. Causes are identified, meaningful actions taken, and there has been repeated near- term success in instilling improved performance. However, these improvements may only have marginal effect in the absence of programs and processes to ensure lessons are not forgotten. Still, all levels of command must evaluate the sufficiency of internal programs and processes to self-assess, trend problems, and develop and follow through on corrective actions in the wake of mishaps.”

Instead of thinking that the lessons from previous accidents have somehow been forgotten, a more reasonable conclusion is that the Navy really isn’t learning appropriate lessons and their root cause analysis and their corrective actions are ineffective. Of course, admitting this would mean that their current report is, also, probably misguided (since the same approach is used). Therefore they can’t admit one of their basic problems and this report’s corrective actions will also be short lived and probably fail.

The 33 people (a large board) performing the Comprehensive Review of Recent Surface Force Incidents were distinguished insiders. All had either previous military/DoD/government affiliations or had done contracting or speaking work for the Navy. I didn’t recognize any of the members as a root cause analysis expert. I didn’t see this review board as one that would “rock the boat” or significantly challenge the status quo. This isn’t to say that they are unintelligent or are bad people. They are some of the best and brightest. But they are unlikely to be able to see the problems they are trying to diagnose because they created them or at least they have been surrounded by the system for so long that they find it difficult to challenge the system.

The findings and recommendations in the report are hard to evaluate. Without a thorough, detailed, accurate root cause analysis of the four incidents that the report was based upon (plus the significant amount of interviews that were conducted with no details provided), it is hard to tell if the finding are just opinions and if the recommendations are agenda items that people on the review board wanted to get implemented. I certainly can’t tell if the recommended fixes will actually cause a culture change when that culture change may not be supported by senior leadership and congressional funding.

NewImage

One more point that I noticed is that certain “hot button” morale issues were not mentioned. This could mean that certain factors effecting manning, training time wasted, and disciplinary issues aren’t being addressed. Even mentioning an example in this critique of the report seems risky in our very sensitive politically correct culture. Those aboard ships know examples of the type of issues I’m referring to, therefore, I won’t go into more detail. If, however, certain issues won’t be discussed and directly addressed, the problems being created won’t be solved.

Finally, it was good to see references to human factors and fatigue in the report. Unfortunately, I don’t know if the board members actually understand the fundamentals of human performance.

For example, it seems that senior military leadership expects the Commanding Officer, the Officer of the Deck, or even the Junior Officer of the Deck to take bold, decisive action when faced with a crisis they have never experienced before and that they have never had training and practice in handling. Therefore, here is a simple piece of basic human factors theory:

If you expect people to take bold, decisive action when faced with a crisis,
you will frequently be disappointed. If you expect that sailors and officers
will have to act in a crisis situations, they better be highly practiced
in what they need to do. In most cases, you would be much better off to
spend time and energy avoiding putting people in a crisis situation.

My father was a fighter ace in World War II. One of the things he learned as he watched a majority of the young fighter pilots die in their first month or even first week of combat was that there was no substitute for experience in arial combat. Certainly early combat experience led to the death of some poor pilots or those who just couldn’t get the feel of leading an aircraft with their shots. But he also observed that inexperienced good pilots also fell victim to the more experienced Luftwaffe pilots. If a pilot could gain experience (proficiency), then their chances of surviving the next mission increased dramatically.

An undertrained, undermanned, fatigue crew is a recipe for disaster. Your best sailors will decide to leave the Navy rather than facing long hours with little thanks. Changing a couple of decades of neglect of our Navy will take more than the list of recommendations I read in the Comprehensive Review of Recent Surface Force Incidents. Until more ships and more sailors are supplied, the understaffed, undertrained, under appreciated,  under supported, limited surface force that we have today will be asked to do too much with too little.

That’s my critique of the Comprehensive Review. What lessons should we learn?

  • You need to have advanced root cause analysis to learn from your experience. (See About TapRooT® for more information.)
  • Blame is not the start of a performance improvement effort.
  • Sometimes senior leaders really do believe that they can apply the same old answers and expect a different result. Who said that was the definition of insanity?
  • If you can’t mention a problem, you can’t solve it.
  • People in high stress situations will often make mistakes, especially if they are fatigued and haven’t been properly trained. (And you shouldn’t blame them if they do … You put them there!)
  • Just because you are in senior management, that doesn’t mean that you know how to find and fix the root causes of human performance problems. Few senior managers have had any formal training in doing this.

Once you have had a chance to review the report, leave your comments below.

Join us LIVE on Facebook, Wednesday, November 8 at Noon Eastern

Posted: November 6th, 2017 in Investigations, Media Room

Click image to go to our Facebook page.

Here is our upcoming November schedule (all live segments will be held on Wednesdays, 12 p.m. Eastern time):

November 8: We have exciting news to share about our Keynote Speakers! Join Mark Paradies & Benna Dortch.
November 15: Learn about our Safety Best Practice Track at the Global TapRooT® Summit with Dave Janney & Benna Dortch.
November 22: Bring all your questions about getting your TapRooT® Team trained! Ken Reed & Benna Dortch have answers!
November 29: Thinking about signing up for our Investigator Best Practices Track? Per Ohstrom & Benna Dortch will share the details!

See you soon!

Caption Contest

Posted: November 4th, 2017 in Contest

Thanks for all the entries in October’s caption contest! Our staff will be voting for their favorites this week and I’ll be announcing a winner and posting a new contest by November 10. Stay tuned!

TapRooT® Around the World: Bogota, Colombia

Posted: November 3rd, 2017 in Courses

Thank you, Diana Munevar, for these awesome training photos of 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in Bogota, Colombia.

 

 

 

 

 

 

 

Get in the Picture!

Register for one of our upcoming 5-day Advanced Root Cause Analysis Team Leader Trainings!

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

December 4: Edmonton, AB

December 11: Houston Texas

TapRooT® Around the World: Louisiana

Posted: November 3rd, 2017 in Courses

Thanks to Tommy Garnett for sending in these photos of the good folks at Marathon working hard in Garyville, LA.

Interested in bringing TapRooT® to your company for training? Inquire here.

Interested in sending your team to a TapRooT® course? Check our course schedule here.

 

Human Factors Issue in USS John S McCain Crash Not Specifically Identified in Navy Report

Posted: November 3rd, 2017 in Accidents, Current Events, Human Performance, Investigations, Pictures, Root Causes

The report issues by the US Navy had enough details to identify a human factors issue in the steering system of the USS John S McCain. However, the report identified the main issue as a training problem. I think they missed a significant human factors issue in this investigation. The following details explain what I mean.

Here is a quote from the report:

“At 0519, the Commanding Officer noticed the Helmsman (the watchstander steering the ship) having difficulty maintaining course while also adjusting the throttles for speed control. In response, he ordered the watch team to divide the duties of steering and throttles, maintaining course control with the Helmsman while shifting speed control to another watchstander known as the Lee Helm station, who sat directly next to the Helmsman at the panel to control these two functions, known as the Ship’s Control Console. See Figures 3 and 4. This unplanned shift caused confusion in the watch team, and inadvertently led to steering control transferring to the Lee Helm Station without the knowledge of the watch team. The CO had only ordered speed control shifted. Because he did not know that steering had been transferred to the Lee Helm, the Helmsman perceived a loss of steering.”

McCainHelm

“Steering was never physically lost. Rather, it had been shifted to a different control station and watchstanders failed to recognize this configuration. Complicating this, the steering control transfer to the Lee Helm caused the rudder to go amidships (centerline). Since the Helmsman had been steering 1-4 degrees of right rudder to maintain course before the transfer, the amidships rudder deviated the ship’s course to the left.Additionally, when the Helmsman reported loss of steering, the Commanding Officer slowed the ship to 10 knots and eventually to 5 knots, but the Lee Helmsman reduced only the speed of the port shaft as the throttles were not coupled together (ganged). The starboard shaft continued at 20 knots for another 68 seconds before the Lee Helmsman reduced its speed. The combination of the wrong rudder direction, and the two shafts working opposite to one another in this fashion caused an un-commanded turn to the left (port) into the heavily congested traffic area in close proximity to three ships, including the ALNIC. See Figure 5.”

McCainCollision

“Although JOHN S MCCAIN was now on a course to collide with ALNIC, the Commanding Officer and others on the ship’s bridge lost situational awareness. No one on the bridge clearly understood the forces acting on the ship, nor did they understand the ALNIC’s course and speed relative to JOHN S MCCAIN during the confusion.Approximately three minutes after the reported loss of steering, JOHN S MCCAIN regained positive steering control at another control station, known as Aft Steering, and the Lee Helm gained control of both throttles for speed and corrected the mismatch between the port and starboard shafts. These actions were too late, and at approximately 0524 JOHN S MCCAIN crossed in front of ALNIC’s bow and collided. See Figure 6.”

McCainCollision2

Also, from the report:

“Because steering control was in backup manual at the helm station, the offer of control existed at all the other control stations (Lee Helm, Helm forward station, Bridge Command and Control station and Aft Steering Unit). System design is such that any of these stations could have taken control of steering via drop down menu selection and the Lee Helm’s acceptance of the request. If this had occurred, steering control would have been transferred.”

“When taking control of steering, the Aft Steering Helmsman failed to first verify the rudder position on the After Steering Control Console prior to taking control. This error led to an exacerbated turn to port just prior to the collision, as the indicated rudder position was 33 degrees left, vice amidships. As a result, the rudder had a left 33 degrees order at the console at this time, exacerbating the turn to port.”

“Several Sailors on watch during the collision with control over steering were temporarily assigned from USS ANTIETAM (CG 54) with significant differences between the steering control systems of both ships and inadequate training to compensate for these differences.”

“Multiple bridge watchstanders lacked a basic level of knowledge on the steering control system, in particular the transfer of steering and thrust control between stations. Contributing, personnel assigned to ensure these watchstanders were trained had an insufficient level of knowledge to effectively maintain appropriate rigor in the qualification program. The senior most officer responsible for these training standards lacked a general understanding of the procedure for transferring steering control between consoles.”

The Navy report concludes that this problem was related to training. Although training may have been an issue, training was made much more difficult (complex) by a poorly human factored design. The design didn’t consider the user.

In my experience (I was a 1st Lieutenant on a cruiser – the USS Arkansas, CGN-41), Seaman who are Boatswains Mates are the least technically inclined sailors on the ship. These are the people who stand this type of watch. The job of guiding a long heavy ship, turning it, and keeping it on course using a rudder mounted on the stern can be a thing of beauty when an experienced helmsman knows what they are doing. But not everyone standing the watch is that good. Obviously this sailor was having trouble compensating for current (obvious when you see how far he was steering off the ordered track in Figure 6 above).

On the ships that I served aboard (30 years ago), the steering and helm systems appeared quite simple. There was only one console on the bridge to steer from and only one place on the bridge to indicate the ships speed input that was communicated to the throttleman in the engine room. You could shift steering to aft steering, but this was mainly a process of them manually taking over from the bridge. You would then communicate helm orders via sound powered phones.

Also, speed orders could be manually communicated from the lee helm to the throttleman in engineering via sound powered phones.

In the old days, the lee helm was always manned and there would be no “shifting of controls” as occurred in this collision. Instead, if the helmsman was having problems, the Boatswain Mate of the Watch (the supervisor of these watch stations) could step in to provide advice, or, if needed, take over for the less experienced helmsman. In theory, the Boatswain Mate of the Watch was a more experienced helmsman and could be counted on to correct any problem the helmsman had experienced.

However, on these modern cruisers there is an addition order of difficulty. They have made the Navy ships much more like commercial ships that can be steered from various locations. Also, the two jobs of helmsman and lee helmsman can be performed by a single individual. In theory, this can reduce the number of watch standers and perhaps make the steering of the ship easier.

I think the reality is quite different. The computerized controls have reduced the control that a helmsman has and added complexity that can lead to errors. I would like to do a complete human factors review of the system, but I would bet that the steering modes, locations of control, and the controls used to change control locations are not obvious and, thus, contributed to this accident. That is a human factors problem … NOT a training problem.

This is just one specific example of the lack of thorough root cause analysis that I saw in the US Navy report on the collision (that I wrote about yesterday). It shows the need for better US Navy root cause analysis to fix the real system problems.

If you would like to learn a system that includes an expert system to help investigators identify human factors issues, attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Training Courses. See our upcoming public course dates and locations by CLICKING HERE.

Technically Speaking – October Customer Satisfaction Survey Prize Winner

Posted: November 3rd, 2017 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 Bill Strecker, from Westar Energy as the winner for the month of October!

TapRooT® Around the World: China

Posted: November 2nd, 2017 in Courses

TapRooT® was in China recently for an onsite course with the good people of Husky Oil. Thanks to Karl Berendt for these awesome photos!

Interested in bringing TapRooT® to your company for training? Inquire here.

Interested in sending your team to a TapRooT® course? Check our course schedule here.

TapRooT® Around the World: Christchurch, New Zealand

Posted: November 2nd, 2017 in Courses

Thanks to Karl Berendt for these course photos from a recent public course in New Zealand! Great looking group!

 

 

 


 

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November 20 – Toronto, Canada

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November 29 – Nashville, TN

December 4 – Las Vegas, NV

December 14 – Perth, Australia

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