TapRooTŪ Friends & Experts e-Newsletter
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  International Edition
June 22, 2010
 Thanks for being one of our 42,739 subscribers!
In This Issue
Investigations and Accidents/Lessons Learned
Are Fatigued Doctors the Only Answer?
Management Systems: Do You Have One?
The Safety Pyramid and Its Impact on Safety Performance Improvement
An ASQ Discussion on Quality, Root Cause Tree, and the Ishikawa Diagram
Career Development: Take a Vacation!
Wisdom Quote
2010 Summit News: Which Track is Right for You?
TapRooTŪ Around the World
Special 2-Day Courses! Summit Discounts! Wow!
Register for a TapRooTŪ Course
J.O.K.E. of the Week
Editor's Note
Connect With Us ...
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President's Question
mark1The BP/Transocean Deepwater Horizon accident has so much that we should learn, that I have three topics for this week's President's Question.

They are:

1. Corporate Manslaughter? What's Your Opinion?

2. Is the Independent Commission investigating the accident qualified?

3. How long must we wait to learn?

Now let's tackle each topic ...

1.  Corporate Manslaughter? What's Your Opinion?

The spill in the Gulf is perhaps the most discussed accident in American History. It has more press coverage than the Exxon Valdez accident or the nuclear accident at Three Mile Island.

The press seems pretty intent on stirring up acrimony toward BP. And to make matters worse, BP seems pretty inept in their public relations attempts to square things with the American public.

But there is a more serious strain to the debate than I've heard in previous accidents. It's a call from many quarters for criminal charges against BP and senior BP executives. Here are recent blog postings linking to stories that point to the need for, or detail the possibility of, criminal charges:





Now I'd like to hear what you think.

After 11 deaths and untold environmental damage, are criminal charges a good idea? If so, why would criminal charges help and who should be charged?  (Leave your comments at any link above.)

2.  Is the Independent Commission Qualified?

The President has announced the seven members of the Bipartisan Independent Commission to investigate the cause of the Macondo Prospect (Deepwater Horizon) well blowout and to make recommendations for future drilling practices.

Since the mission of this body is so important to the energy future of the US, I thought I'd dig deeper into the commission members' backgrounds. I've written a short summary for each of the members of what I found online. See the descriptions at this blog article and let me know if you think they are qualified:


3.  How Long Must We Wait to Learn?

My final question is about the comment I keep hearing about having to wait until all the investigations are done before we can learn from the BP/Transocean well blowout disaster. See what I had to say at this blog post and leave your comments:


Thanks for your comments.  Good luck improving performance and avoiding accidents at your facilities.

Best regards,


Mark Paradies
System Improvements, Inc.

Investigations and Accidents/Lessons Learned
How Safe Is Safe Enough? - The Question Being Analyzed After The BP/Transocean Deepwater Horizon Accident:  It's a good discussion of the shortcuts taken and how perhaps safety was compromised (Read more).

Top Kill Fails - BP to Try New Plan: 
Various media sources have announced that the "top kill" effort to stop the leaking well in the Gulf has officially failed (Read more).

Bad News After an Accident: BP Can't Get Much Worse Press Than This: 
More "smoking gun" memos (Read more).

More Bad News for BP - Already on Parole from the Texas City Explosion, Fed Now Opening a Criminal Probe of Deepwater Horizon Accident: 
(Read story.)

NTSB Press Release: NTSB Investigating Near Midair Collision of US Airways A319 and Cargolux Airlines International 747 in Alaska:
  (View press release.)

Accident Video from the National Marine Safety Association:  (View video.)

Accident at Fleet Week Demo in New York:  Don't stand in the prop wash of an Osprey (Read more).

For Those Who Want to Know More About Cementing:  (Read more.)

Highway Incident: A Good Safeguard or A Bad Safeguard?  Is the design of the toll "ramp" a good safeguard or a bad safeguard? (Read more).

thumbsupYour opinion counts! Leave your comments to the articles above on our weblog, and when you find that one is particularly helpful, press the "thumbs up" icon so we have a better idea of what information is relevant to you for future e-Newsletters.  Questions?  Contact the Editor at editor@taproot.com.
Are Fatigued Doctors the Only Answer?
by Mark Paradies
Doctor Pic
 An article in USA Today tries to justify fatigued doctors by showing some problems that reduced work hours might create. 

Instead of applying techniques to fix these new problems, they imply that fatigued (error prone) doctors may be the only answer.

For example, they quoted an article written by two Vanderbelt surgeons that claimed that more than 80 hour work weeks were required to allow surgical trainees to learn techniques, dexterity, and stamina required in their profession (Read more).
Management Systems:  Do You Have One?
by Dave Janney
When we talk about management systems, what we mean is a structured way to manage the business and assess (and improve) performance.  There are many kinds of management systems:  quality management systems; environmental management systems; safety management systems; etc.  While the components of these systems may be different, the approach is the same.  And root cause analysis is an important part of making sure these systems run the way they are intended (Read more).

dave janneyDave Janney is a Senior Associate at System Improvements.  He will be leading two sessions at the 2010 TapRooT Summit:  "Be a Safety STAR: How a VPP Program & TapRooTŪ Can Be Combined for Excellent Safety Performance" and "Using TapRooTŪ for Regulatory Safety Compliance."  Learn more about Dave and these sessions on the Summit Best Practice Presenter webpage:  http://www.taproot.com/summit.php?t=speakers
The Safety Pyramid and Its Impact on Safety Performance Improvement
Conference Safety Board

Mark Paradies talked about the Heinrich Pyramid (Safety Pyramid) at the European Safety Committee of the Conference Board recently.

He is providing his presentation about the safety pyramid and its impact on safety performance improvement as a resource to you.  Receive a download of his talk on the Root Cause Analysis Blog:  Free Download
An ASQ discussion on Quality, Root Cause Tree, and the Ishikawa Diagram (also called Fishbone Diagrams or Cause-and-Effect Diagrams)
by Chris Vallee
Dave Janney and I recently had a great opportunity personally talking one to one to over 450 plus ASQ (American Society for Quality) Members in St. Louis at the ASQ World Conference. There were 1,000 plus members present but I want to focus on the one-on-one discussions in this tip of the week.

Discussion Tip 1: "The TapRooTŪ Root Cause Tree is definitely more than a Fish-Bone and 5-Why tool!"

A Director of Quality walked up to our booth and looked at the back of our Root Cause Tree. Seeing some of the Basic Cause Categories such as: Human Engineering, Management System, Training, Work Direction ... He stated, "that looks a little like the Categories on the Ishikawa Diagram, what is the difference? Why would I as an expert need to use it?" (Read more.)

Chris Vallee.2Chris Vallee is a Senior Associate at System Improvements.  He invites you to join in the discussion on TapRooTŪ Root Cause Analysis Users and Friends Group on LinkedIn.  This article is part of a new weekly series on Quality Manufacturing. 
Career Development:  Why a Vacation is Good for Career Development!
by Barb Phillips

Work consists of whatever a body is obliged to do.
Play consists of whatever a body is not obliged to do.
~ Mark Twain

What will happen if all we ever do in life is what we are obliged to do ...

I shudder at that thought, but there are many people who live that way.

A vacation promotes our career development. There are many reasons that it's important to take a vacation from work other than the obvious reason: burnout.

Here are a few:

Vacations Improve Job Performance: Uninspired? Can't seem to get started on an important project? The psychological benefits that come with regular vacations increase quality of life and personal morale, and that leads to increased quality of work and creativity! You have a choice to drag yourself through the next project and do it halfway, or take a vacation break and come back and blow that project out of the water. Which do you think is better for your next performance review?

Vacations Strengthen Family Bonds and Give Employees a Firm Foundation: Do you know more about your co-worker's children than your own? This is a sure sign you need a vacation! Family vacations contribute to the good health of our families by strengthening the bonds created by shared moments, encouraging unity and family togetherness, and building and sharing common values. Employees with healthy family relationships are:

  • better at coping with stress
  • more resilient
  • more content with their lifestyle
  • supported by their families in ways that build higher self esteem
  • more optimistic

Vacations Decrease Stress: Stress alone makes for a miserable day, and prolonged stress will eventually lead to physical health issues. Studies prove that a vacation will actually lower our stress levels up to five weeks later.

Vacations Reduce Sick Time: Research indicates that three days after a vacation, a person's physical complaints and quality of sleep improves and these benefits are also still present five weeks later. Don't let sick time eat up your vacation time!

VacationBefore you pack up your desk and announce that you'll be away for two weeks (although if you can do it, go for it!), a long weekend totally free from work can be a mini-vacation -- so close the laptop, turn off the cellphone and claim the career development benefits of a vacation break!

(P.S. Don't forget, we often hold advanced root cause analysis courses in great locations for a mini vacation. Train, refresh a day or two, and return to work better than ever!)

Employment Opportunities

Project Manager - Root Cause Analyst - Seattle, Washington (View opening).

Job Openings for People with TapRooTŪ Root Cause Analysis Skills (View openings).

P.S. Thinking about registering for a course to add to your personal resume?  Our worldwide calendar of public courses can be found at:  http://www.taproot.com/courses.php

BarbBarb Phillips is the Editor of the TapRooTŪ Friends & Experts e-Newsletter.  She will be presenting on the Improvement Program track at the 2010 TapRooTŪ Summit.  Register for this track and learn best practices in self improvement for your future, character driven success, how to change behaviors by praising character traits, how to identify proactive performance indicators, using training simulation to improve performance and more! 

Visit the Summit website for more details:  http://www.taproot.com/summit.php
Wisdom Quote

"The definition of insanity:  doing things the same way and expecting a different result."
~ Author Unknown

2010 TapRooTŪ Summit News
Tie StringDates to Remember

TapRooTŪ Summit:  October 27-29, 2010
Special 2-Day PreSummit Courses:  October 25-26, 2010
Live Music/Costume Party:  October 27, 2010
TapRooTŪ 7th Annual Scramble Charity Golf Tournament:  October 29, 2010

The Summit Hotel and Host City are:
The Westin Riverwalk, San Antonio, Texas
Learn more:  http://www.taproot.com/summit.php

What do our attendees say?  (View video.)


2010 Summit Tracks!

Not sure which track to register for?  Here is some information to help you with your decision -- but keep in mind each track is completely customizable, (i.e., you can replace any best practice session with a session from another track by simply clicking the "modify" button):

Behavior Change & Stopping Human Error
Register for this track if you are interested in learning these best practices:
  • Combining TapRooTŪ with INPO's Error Prevention Tools to Improve Human Performance
  • Influencing without Authority
  • Coaching Skills to Sustain Behavior Change
  • Human Factors & Behavior Change Best Practices
  • Measuring Fatigue Using FACT
  • Using Mistake Proofing to Stop Human Error
  • Lesson Learned About Human Factors & Generic Causes from Recent Airline Incidents
  • Practice Fixing Human Performance & Behavior Problems: An Interactive Exercise Session
  • Planning Your Improvements
Corrective Action Program
Register for this track if you are interested in learning these best practices:
  • Getting "Outside the Box" Corrective Actions
  • Closing the Loop: Corrective Action Effectiveness Reviews
  • Sticky Corrective Actions
  • Using TapRooTŪ for Regulatory Safety Compliance
  • Making Bad Corrective Actions SMARTER
  • Advanced Ideas for Corrective Actions
  • Corrective Actions for Culture Problems (Fixing Employee Communications NI + More)
  • Coach for Improved Corrective Action Development & Implementation
  • Planning Your Improvements
Healthcare Quality, Patient Safety, Sentinel Event
Register for this track if you are interested in learning these best practices:
  • Sharing Improvement Ideas
  • Safety Culture & Healthcare Performance
  • Healthcare Literacy & Patient Knowledge Impact of Sentinel Events
  • TapRooTŪ Integration Into Healthcare Information Technology
  • High Performance Ideas for Leading Improvement
  • TapRooTŪ User Best Practice Session
  • Using Mistake Proofing to Improve Patient Safety
  • Quality in Life and Work
  • Planning Your Improvements
Improvement Program
Register for this track if you are interested in learning these best practices:
  • Self Improvement for Your Future
  • Character Driven Success
  • Changing Behavior By Praising the 49 Character Traits
  • How To Set-Up and Sustain a Continuous Improvement System
  • Lessons Learned about Excellence & Safety from Admiral Rickover
  • What Are Your Proactive Performance Indicators
  • Using Training Simulation to Improve Performance
  • Planning Your Improvements
Investigation, Troubleshooting & Root Cause Analysis
Register for this track if you are interested in learning these best practices:
  • Success Stories from TapRooTŪ Users
  • Legal Aspects of TapRooTŪ Investigations
  • Lifecycle of an Incident
  • Investigation Ideas
  • Ideas for Leading Investigation Teams
  • TapRooTŪ User Best Practice Session
  • Police Tips for Leading Investigation Teams
  • Leading Successful Investigations: Drawing on UK Experience
  • Planning Your Improvements
Latin American TapRooTŪ Users
Register for this track if you are interested in learning best practices in the Spanish language including:
  • Latin Users Problems & Ideas for Corrective Actions
  • Safety Management Systems and Advanced Root Cause Analysis in Latin America
  • TapRooTŪ Software
  • Planning Your Improvements
  • and five more best practice sessions!
Safety & Risk Management
Register for this track if you are interested in learning these best practices:
  • Improving Incident Investigation and Safety in the BW Fleet
  • Communicating with Management About Risk
  • Ahead of the Law: OSHA Enforcement Problems & Solutions
  • Using TapRooTŪ for Regulatory Safety Compliance
  • How Does Your Corporate Culture Effect Your Investigations?
  • Advanced Ideas for Corrective Actions
  • Be a Safety STAR: How a VPP Program & TapRooTŪ Can Be Combined for Excellent Safety Performance
  • Quality in Life and Work
  • Planning Your Improvements
TapRooTŪ Software Super Users
Register for this track if you are interested in learning these best practices:
  • Bridging the Gap - From Software Installation to Successful Implementation
  • My Web Implementation: A TapRooTŪ Software User's Perspective
  • What's New in the TapRooTŪ Software
  • Using the TapRooTŪ Software Essential Techniques: From SnapCharTŪ to Corrective Actions
  • TapRooTŪ Software Behind the Scenes: Development for Continuous Software Improvement
  • TapRooTŪ User Best Practice Session
  • Trending Using the TapRooTŪ Software
  • A Software User's Forum
  • Planning Your Improvements
Certified TapRooTŪ Instructor
Certified TapRooTŪ Instructors will keep up-to-date with this great line-up:
  • TapRooTŪ Instructor Update
  • Legal Aspects of TapRooTŪ Investigations
  • What's New in the TapRooTŪ Software
  • What Makes a Good Instructor Great?
  • Ideas for Leading Investigation Teams
  • TapRooTŪ User Best Practice Session
  • Police Tips for Leading Investigation Teams
  • Leadership Responsibilities for Each Step of the TapRooTŪ 7-Step Process
  • Planning Your Improvements
Special Topics
In last week's e-Newsletter we highlighted "Special Topics."  Special Topics is not a track, but a list of options to choose from if you'd like to replace a best practice session on your track to meet your goals.  Special topics include:
  • Medical TapRooTŪ Instructor Update
  • Prioritizing Improvements
  • Sustainable Development
  • What Does Management Need to Know About Root Cause Analysis (Discussion Session)
  • Asset Management Problems and Solutions
  • Solving Equipment Reliability Problems
  • PowerPoint Tips & Tricks
  • Know the Law When Dealing with MSHA After a Serious Accident
If you need help customizing your schedule, contact us at info@taproot.com or 865.539.2139.

Other Summit News:

George Burk2010 Summit Speaker Featured in Newspaper Articles:   The Canon City Daily Record recently published two articles about Summit best practice speaker, Capt. George A. Burk (Read more).

Register for the Summit online: 
TapRooTŪ Around the World
Nairobi, Kenya Class Photos: 5 Day Root Cause Analysis Course (View photos)

TapRooTŪ Root Cause Analysis Class in Bogotá, Colombia (View photos)

Teaching a 2-Day TapRooTŪ Incident Investigation and Root Cause Analysis Course
in Dublin, Ireland (View photos, video and final exercise)
Special 2-Day Courses!  Summit Discounts!  Wow!
Don't miss out!  Most of these courses will only be offered once this year!

October 25 and 26, 2010 mark the dates for our special 2-Day Courses!  This year these exclusive courses taught by our global instructors will be held in San Antonio, Texas.  Schedule for the TapRooTŪ Summit immediately following a special 2-day course, and save $200 on your registration (Multi-attendee discounts:  3 or more people who register for a special 2-Day Course together save $100 each.  3 or more people who register for the Summit and Special 2-Day Course together save $400 each)!

Choose from this list of Special 2-day Pre-Summit Courses:

A Police Enquiry into a Death in the Work Place - Corporate Responsibility

Improving Your Organization's Safety Culture

2-Day TapRooTŪ Incident Investigation & Root Cause Analysis Course

(Spanish) 2-Day TapRooTŪ Incident Investigation & Root Cause Analysis Course 

Special 2-Day Equifactor Equipment Troubleshooting and Root Cause Analysis Course

Advanced Trending Techniques

Advanced TapRooTŪ Techniques

How to Interview & Gather Evidence

Stopping Human Error

Risk Analysis and Management Best Practices

Hazard Recognition Best Practices

Getting the Most from Your TapRooTŪ Software

LEARN MORE on our course page:  http://www.taproot.com/courses.php

Limited space is available! 

Register for a TapRooTŪ Course

(View Course Description

AUSTRALIA, Adelaide: June 28-29 and July 26-27

AUSTRALIA, Brisbane:  July 22-23 and September 22-23

AUSTRALIA, Darwin:  July 1-2

AUSTRALIA, Kalgoorlie:  September 6-7

AUSTRALIA, Mackay:  August 16-17

AUSTRALIA, Melbourne:  July 19-20 and September 20-21

AUSTRALIA, Perth:  July 15-16 and August 9-10 and September 9-10

AUSTRALIA, Singleton:  July 28-29

AUSTRALIA, Sydney:  August 5-6 and September 20-21

BRAZIL, Sao Paulo:  August 4-5

ENGLAND, Birmingham:  October 13-14

INDONESIA, Batam: September 2-3

MALAYSIA, Kuala Lumpur:  August 9-10 and September 29-30

NEW ZEALAND, Christchurch:  August 19-20

SINGAPORE, Singapore:  August 4-5 and August 12-13

(View Course Description)

SOUTH AFRICA, Cape Town:  August 23-27

Brisbane:  August 16-20

AUSTRALIA, Perth:  August 23-27

AUSTRALIA, Singleton:  August 23-27

CHINA, Hong Kong:  September 6-10

MEXICO, Monterrey:  September 20-24

SCOTLAND, Aberdeen:  September 20-24

View our worldwide calendar of courses at:


J.O.K.E. of the Week
Editor's Note
Dear Readers,

There is a lot of information in this week's edition so I'll keep this note short and sweet!  Thank you for your thoughts and comments on the Root Cause Analysis blog.  We read each and every comment, and appreciate your feedback.  If you haven't jumped into one of the conversations on the weblog yet, I invite you to do so.  Your voice, whether commenting to the President's Question or adding a little more humor to the J.O.K.E. of the week, is what makes the weblog a great online community for all of us!

Best regards,

Barb Phillips

Barbara Phillips
System Improvements, Inc.
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