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Issue 80

November 2006

Cover Price: $14.95 Copyright © 2006 by System Improvements, Inc.

All rights reserved. Printed in USA.




Editor: Mark Paradies

Published by: System Improvements, Inc. 238 South Peters Road Knoxville, TN 37923-5224 Phone: (865) 539-2139 e-mail: [email protected]

INPO 8 vs. TapRooT® 10

The INPO 8

In the last newsletter I mentioned that a speaker from the Institute of Nuclear Power Operations (INPO) said that the top 8 error prevention tools are: 1. Procedure use and adherence 2. Questioning attitude/stop when unsure 3. Pre-job brief 4. Effective communications 5. Self-checking 6. Verification practices 7. Place-keeping 8. Peer-checking After I published that newsletter I started thinking ... How does that compare with the best practices that make up the TapRooT® System?

Human Engineering

Human Engineering (sometimes called Human Factors or Ergonomics) is the deliberate design of equipment so that it is usable - or perhaps I should say extremely easy-to-use - by those who work with it: · Operators · Mechanics · Doctors · Nurses · Pilots · Computer Users · Homeowners · Anesthesiologists Why isn't Human Engineering on INPO's list? Perhaps it is because nuclear plants are old. Their human factors design is not easily changed. The 80's post-TMI control room design reviews recommended very limited "paint, tape, and labels" improvements. So INPO may not see the value of this improvement opportunity for old, hard to modify, nuclear power plants.

What's Your Top 10?

Improvements needed at a refinery probably aren't the same as those needed at a hospital several miles away. Each has its own unique set of problems that should be identified either reactively or proactively using TapRooT®. Here's my recommendation for you ... make your own Top 10 list based on the TapRooT® data from your investigations. If you have several years of incident history, you are ready to get started. If you don't, start using proactive audits to collect proactive data. Next, create simple Pareto Charts of your root cause data and see what the top 10 root causes are for particular units or organizations at your plant. Which units or organizations? Again, create simple Pareto Charts (one by cost and the other by injury statistics) of the unit and organization's statistics. Then get started designing and implementing improvement programs to fix these problems. Repeat the review at least once every two years. If you aren't seeing improvement, why not? If you are seeing improvement, the top 10 should change. What? You haven't been to TapRooT® training? SHAME ON YOU! You need the best practices that TapRooT® can highlight. Don't wait. Get to a course before the end of the year! One final note: TRENDING is crucial for tracking performance of your improvements. Learn advanced trending methods by reading Chapter 5 of the TapRooT® Book. Or register for the Advanced Trending Techniques pre-Summit Course, San Antonio, April 23-24, 2007.

7 Cause Categories

All TapRooT® Users know the 7 Basic Cause Categories that make up the back side of the Root Cause Tree®:

TapRooT® Top 10

That initial review made me think ... with all the incidents I've seen in such a broad array of industries, what would be the most important root causes to improve performance across industries? Here's my answer, TapRooT®'s Top 10: 1. Management System, enforcement NI 2. Work Direction, pre-job briefing 3. Human Engineering, monitoring alertness 4. Communications, repeat back not used 5. Human Engineering, labels NI 6. Management System, no SPAC 7. Training, task not analyzed 8. Procedures, procedure use not required 9. Human Engineering, displays NI/ controls NI 10. Management System, corrective action NI

NI = Needs Improvement SPAC = Standards, Policies, or Administrative Controls

Procedures Training Quality Control Communication Management Systems Human Engineering Work Direction

Good implementation of these 7 categories equals good human performance (maybe even great human performance). Almost every human error I analyze has one or more deficiencies in these 7 Basic Cause Categories. So I thought, why not compare INPO's 8 against these categories? The result? There was something from INPO's 8 in every category EXCEPT Training and Human Engineering. Why is training missing from the list? Could it be that the standards for training are so high in the nuclear industry that good training is a foregone conclusion? But Human Engineering ... that's a horse of a different color. I thought, "Maybe INPO is missing something?"

Be Your Best

If I miss one day's practice, I notice it. If I miss 3 days, the audience notices it. If I miss two days, the critics notice it.

As soon as I finished the list I thought ... this list isn't helpful. The list really should be tailored for each organization, every site, or even units within a plant site.

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Concert Pianist Ignace Paderewski

Last Chance

'06 TapRooT® Courses

See to register for a TapRooT® course.

2007 TapRooT® Course Schedule

See the blog entry at: for our complete draft '07 TapRooT® Course schedule. When the hotels are confirmed, the course will appear on the schedule at: January/February Canada/US courses: 5-Day Lake Charles Jan 22-26

Attorney vs. Process Improver

People see problems from a different perspective. For example, I was talking to an attorney the other day about a problem. When he approached the problem's "cause" it was to determine who was at fault and where the blame could be placed. His interest was in liability. Who pays? And his focus was on presenting an argument that was best for his client. Using the facts was a means to an end. And if he was successful, the end was that his client wasn't at fault. Compare that approach to the approach of a process improvement expert. They look at blame as an impediment to finding out what really happened. Their focus is on what happened and WHY it happened. They are looking for root causes that can be fixed to improve performance. They really aren't interested in who is at fault or "Who pays?" They want to know what to do to prevent the problem from happening again. These two approaches are almost diametrically opposed to each other. So what can you learn from these two viewpoints? Each viewpoint is based on the problem that the professional is trying to solve. So what do you do? You need to improve but you also need to protect your company from excessive liability. I prefer a long-term view. I choose to find root causes and fix them and then deal with the liability. Perhaps (depending on state laws), I can use legal privilege to keep all the information I find from the opposition. For more lessons from the courtroom that impact investigations and root cause analysis, attend the TapRooT® Summit. Judge Andrew Napolitano, New Jersey Supreme Court Judge and Fox News contributor will present, Accident Investigation Lessons from the Courtroom. For more Summit info see:

2-Day TapRooT® Incident Investigation & Root Cause Analysis Training

1.6 CEUs 2 CIH CM Points $995 LEAMINGTON SPA, UK Nov 8-9 KNOXVILLE (Wait List) Nov 14-15 EDMONTON, Canada (W.L.) Nov 20-21 NIAGARA FALLS, Canada Nov 27-28 DUBAI, UAE Nov 27-28 CHARLESTON, SC Dec 6-7

5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training

4 CEUs 5 CIH CM Points $2295 Includes TapRooT® Software! Previous 2-Day course attendees save $500 when attending a 5-day SINGAPORE Nov 6-10 ABERDEEN, Scotland Nov 13-17 NAIROBI, Kenya Nov 20-24 PERTH, Australia Nov 20-24 HOUSTON (Almost Full) Dec 4-8

Galveston Equifactor® Galveston 2-Day Baton Rouge 5-Day San Diego 5-Day Calgary 2-Day Charlotte 2-Day Halifax Equifactor® Halifax


Jan 29-30 Jan 29-31 Feb 1-2 Feb 5-9 Feb 19-23 Feb 20-21 Feb 26-27 Feb 26-28

Corrective Action

Remember the stories about Ford Explorers rolling over when their Firestone tires blew out? Firestone reports that 6.3 million tires were replaced. But was this corrective action good enough? One independent safety consultant says that as many as 200,000 of the Radial ATX and Wilderness AT tires may still be in use as spares. He says, "These are bad tires that are now worse." It seems there has been a rash of rollover crashes when these tires were used after a flat occurred. A NHTSA random check of older Ford SUV's found that 10% still had these dangerous tires as spares. So what is the lesson learned? When you implement a corrective action, how do you make sure that your fix gets applied everywhere there is a problem?

3-Day TapRooT® / Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

3-Day: 2.4 CEUs $1890 Includes TapRooT® Software! EDMONTON, Canada Nov 20-22 DUBAI, UAE Nov 27-29 CHARLESTON, SC Dec 6-8

Note: Previous TapRooT® Course attendees can attend just the last day of the Equifactor® Course for only $995 (and get the software).

Monday Accident & Lessons Learned

Every Monday there is a new accident and lesson learned posted at: Here's a sample of the accidents posted in the past few months: Nosocomial Infections BP Pipeline Corrosion Fall Protection Fatality BP Texas City Refinery Explosion Most Hazardous Jobs (fatality stats) Buncefield, UK Tank Farm Explosion Bhopal Investigation Lessons Learned

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Refinery Success

Congratulations to Flint Hills Resources' Corpus Christi refining complex. They completed 10 million work-hours (over 5 years) without a lost time injury. How did they get so safe? They have two VPPPA programs at the site and they use TapRooT® to find the root causes of the few problems they discover.

Management Presentation Advice

Never insult an alligator until you've crossed the river. Cordell Hull

Get a quote for on-site TapRooT® Training - Call 865-539-2139.

Mistakes trending mistakes

Do you trend: · Lost Time Injuries · Medical Treatment Cases · Major Production Upsets · Equipment Failures · Customer Complaints · Sentinel Events · Major Service Interruptions · Quality Incidents · Major Audit Findings If so, you are probably trying to trend infrequently occurring statistics. Most people make mistakes trending infrequently occurring statistics, including: · Using trending techniques that don't work for infrequently occurring stats. · Inventing reasons for perceived trends that aren't really trends and then wasting resources fixing the made-up reasons for the imagined adverse trends (thus wasting resources that should be applied elsewhere). · Using complex and incorrect formulas to assess trend data. · The inability to explain to management what is a trend and what isn't a trend and to get management to see trends as part of their measurement and improvement programs. · Failure to develop proactive, forwardlooking trending programs. Does your facility have any of these problems? Do you need the latest trending techniques that can be applied to everyday, real-world, industrial and service industry data? Then attend the:

8 Special Courses

San Antonio, TX April 23-24

Mark Paradies handpicked 8 special courses for people interested in improving performance (especially TapRooT® Users) and scheduled them prior to the 2007 TapRooT® Summit:


San Antonio, TX April 25-28

Are you interested in learning BEST PRACTICES in the areas of:

Stopping Human Error Risk Analysis & Risk Management Best Practices Innovation and Creative Solutions Advanced Trending Techniques How to Interview & Gather Evidence Getting the Most From Your TapRooT® Software TapRooT®/Equifactor® Equipment Failure Root Cause Analysis Course TapRooT® Incident Investigation and Root Cause Analysis Course

These pre-Summit courses are only $995 per person. Register three or more to save $100 per person. Save $200 off the course tuition by registering for the pre-Summit Course and the Summit. For more information about these special pre-Summit Courses see:

Investigation & Root Cause Proactive Improvement Human Error/Changing Behavior Safety & Risk Management Lean/Process/Quality Improvement Maintenance/Equipment Reliability Corrective Action Program Medical Error Reduction TapRooT® Instructor Certification TapRooT® Software Techniques

Then attend the TapRooT® Summit.

Courage at Work

Courage is not limited to the battlefield or the Indianapolis 500 or bravely catching a thief in your house. The real tests of courage are much quieter. They are inner tests, like remaining faithful when nobody's looking, like enduring pain when the room misunderstood. is empty, like standing alone when you're Charles Swindoll

Advanced Trending Techniques Course

The course is being held on April 23-24, 2007, in San Antonio, Texas - just prior to the TapRooT® Summit. The cost? Only $995. And the mistakes you will discover and fix by applying advanced trending will help your company save hundreds, thousands, or even millions of times the cost of the tuition. See:

Certified TapRooT® Instructors: Maintain Your Certification

Certified TapRooT® Instructors at TapRooT® Licensed facilities must attend advanced training (one of the courses above) and the Summit at least once every two years to maintain their certification. If you are a Certified TapRooT® Instructor and you didn't attend the '06 Summit in Gatlinburg, you need to attend a pre-Summit Course on April 23-24 and the Summit on April 25-28 to maintain your certification. For more info about the Summit see:

and click on the Advanced Trending Techniques course link for more info. Register now, class size is limited.

Investigating accidents, incidents, sentinel events, equipment failures, and quality issues requires courage. Courage to challenge the way work is performed. Courage to ask questions that people hope won't be asked. Courage to point out ways that management can improve the way the facility is managed. Remember, when you think you face the challenge of confronting people and making them change ... look for a different path. Try to find a way to make yourself an ally of those you think must change. Your objective is to help them see the same vision that is so obvious to you. Before you can do this you must be able to see how they view the problem and then help them arrive at the same conclusion that you now see as obvious. When you are working as a team - rather than as adversaries - the chances of success are much higher.

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For more info about TapRooT® On-Site or Public Courses see or call 865-539-2139.

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Issue 80 ­ November 2006

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TAPROO T® SOFTWARE PURCHASED WITHOUT A COURSE Software (Individual User) includes TapRooT® Book, TapRooT® Root Cause Tree®, SnapCharT®, and Equifactor® TAPROO T® SOFTWARE PURCHASED WITH A COURSE TapRooT® Software 2003 (Individual User) Includes TapRooT® Root Cause Tree®, SnapCharT®, and Equifactor® BOOKS TapRooT® Book (with Dictionary & Laminated Tree) TapRooT® Book (with SPANISH Dictionary & SPANISH Laminated Tree) Upgrade for TapRooT® Book (for TapRooT® Manual Registered Users) Machinery Failure Analysis & Troubleshooting by Heinz Bloch Miscellaneous Products Blue Oval Stickies (1 order equals 10 pads with 50 sheets per pad) Green Circle Stickies (1 order equals 10 pads with 50 sheets per pad) 1 Pad of TapRooT® Root Cause Tree® (Must be a Registered User) 10 Pads of TapRooT® Root Cause Tree® (Must be a Registered User) 100 Pads of TapRooT® Root Cause Tree® (Must be a Registered User) Spin-A-CauseTM TapRooT® Polo Shirt Men's or Women's S M L XL TapRooT® T-Shirt S M L XL XXL TapRooT® Windbreaker S M L XL TapRooT® Baseball Cap TapRooT® Click-A-Cause Ink Pens TapRooT® Toothpaste Squeezers




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