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Cause Mapping Webinar archives
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Missed a Webinar? View our collection of archived Webinars below!


Can Root Cause Analysis Help with Weight Loss?

Losing weight is a common resolution people make at the start of a new year. Some people say their weight gain was because they ate too much. Others say they didn’t move enough. In both instances, there’s a cause-and-effect relationship. When discussing a problem, people within your company give different answers to the same Why question. This is normal. Organizing all that information into a clear picture that’s been validated with evidence is what an effective root cause analysis does.

Evaluating Incident Investigations - 5 Checkpoints

Your team has completed an investigation – now what? This Webinar discusses specific ways to evaluate and improve Cause Mapping incident investigations, including tying investigations to work processes, using logical cause-and-effect reasoning, ensuring adequate evidence, and making a plan for implementing effective action items. We review 5 checkpoints to be used to evaluate an incident investigation.

Facilitation Tip: Productive Conversations with Multidisciplinary Teams

This free webinar explains how to facilitate an investigation with a multidisciplinary team and provides some helpful documentation tips you can begin applying in your group. When a big problem happens there’s a lot of information that needs to be collected. It may involve multiple people from different groups. Typically, there’s not one person who knows all the various pieces. Each person may see the problem from their own point of view, but a thorough root cause analysis reveals how all the parts fit together. All the information about the problem, whether it’s collected in group meetings or one-on-one conversations, needs to be validated and organized. Seemingly small details at the outset may be extremely important. This complete understanding is essential for preventing future incidents from occurring.

Facilitating and Documenting a Root Cause Analysis

A problem in your business can be thought of as an “information knot.” Different people from different departments each know part of the problem. The facilitator collects and organizes all of the details in an incident. He or she essentially untangles the knot to provide a complete explanation of what happened and why. An effective facilitator provides clarity. Sometimes people think of a facilitator as the person who leads meetings, but a root cause analysis facilitator manages the entire investigation process. It starts from the time an incident occurs and continues through the analysis and documentation, to the implementation of solutions and the communication of lessons learned. This Webinar explains the basics of facilitation and the role it plays in understanding and preventing problems in your business.

Fishbone Diagram DOs and DON'Ts

The fishbone cause-and-effect diagram is recognized as a standard quality tool around the world. Working from Ishikawa’s original idea, there are five lessons that can improve the way people define a problem, dissect the causes and discover effective solutions.

Forget Human Error. Focus on this instead…

We are all human and therefore must acknowledge that as humans, we are prone to making mistakes. Labeling a problem simply as a case of Human Error is self-evident and shortsighted. Most concerning is that it misleads you from the ultimate purpose of your investigation. Instead, we are stuck with generic action items such as Don't mess up, Be more careful, or Follow the procedure that do little to reduce risk. If you have seen any of these as an output from an investigation then you are all too familiar with this shortcoming. During this webinar, we will challenge some of the conventional methods used to investigate human error that tend to focus on the human condition and leave you little to work with. Instead, we will demonstrate what to focus on during your investigation so that you can improve reliability in spite of the fact that we as humans err.

High Reliability Leadership

This webinar is intended for managers and executives interested in establishing a systematic approach for investigating and preventing problems in their department or across their business unit. It will discuss the application of the Cause Mapping method from front-line problem solving to complete investigations of major incidents.

How Detailed Should a Root Cause Analysis Be?

Do you want to see the forest or the trees? One of the questions we get often is, “How much detail is enough for my root cause analysis?” If there’s not enough detail, it’s easy to miss important elements within the incident. With too much detail, the investigation will get bogged down with trivial issues - wasting time and frustrating those involved. Because problems in your organization are different severities, different problems need to be worked at different levels. If your company has a one size fits all approach, you will under analyze some problems and overanalyze others. This webinar will explain how your investigations can begin simple, then expand, as needed, into a more complete explanation to reveal a variety of different solutions options.

How to Avoid Arguments and Effectively Define Problems

In the problem-solving realm, there is a commonly cited adage that a problem well defined is a problem half solved. This saying highlights both the importance and challenge of a good problem definition. Unfortunately, we see many problem-solving efforts struggle with this critical step of problem-solving. The result is often disagreements, wasted time, and missed opportunities to solve the problem.

Human Error, Human Performance and Human Factors

How does an organization reduce errors in their operations? There are different schools of thoughts on preventing human error and improving human performance. This webinar covers how the Cause Mapping method is used to investigate errors people make. It will explain different types of errors and provide simple approaches for minimizing human error within your organization.

Introduction to Cause Mapping® - Effective Root Cause Analysis

Learn how to become better at solving problems in your job! During this Webinar, we’ll demonstrate the Cause Mapping method, as well as answer your specific questions about our approach to root cause analysis. The Cause Mapping method is evidence-based cause-and-effect and can be used on day-to-day issues as well as catastrophic incidents. Anyone wanting to become a more effective manager or team member can benefit from this discussion. Take away practical tips that can be implemented immediately!

Investigating Workplace Injuries

This Webinar demonstrates the use of the Cause Mapping method of root cause analysis to investigate workplace injuries. We’ll look at burns, contamination, slips/trips/falls and the most common, hand injuries, to better understand the factors influencing workplace injuries, how to effectively investigate these injuries, and how to reduce the number of injuries in the workplace.

Live Remote Facilitation: How to Dig into Problems Remotely with the Gold King Mine

The ability to solve problems is a valuable skill. Being able to solve problems remotely is more valuable now than ever before. In our Live Remote Facilitation, one of our ThinkReliability instructors will demonstrate how to facilitate an incident without stepping foot on-site or speaking to someone face-to-face. See how to apply the Cause Mapping® method of root cause analysis immediately to your organization’s incidents with tools you already have–whether your team is working from home, from the office or a combination of the two.

Live Remote Facilitation: Manufacturing Robot Injury (Client-Submitted)

The ability to solve problems is a valuable skill. Being able to solve problems remotely is more valuable now than ever before. In our Live Remote Facilitation, instructor and facilitator Renata Martinez works through a conveyor system injury submitted by a client—without stepping foot on-site or speaking to anyone face-to-face. In fact, the client will be interviewed live, during the session, to demonstrate the effectiveness of remote problem-solving. Using this industrial example, see how to apply the Cause Mapping® method of root cause analysis immediately to your organization’s incidents with tools you already have–whether your team is working from home, from the office or a combination of the two.

Prevention vs. Blame: Which Approach Best Reflects Your Organization?

When a problem occurs in a company, it’s important to understand exactly how it happened. Organizations with a blame mentality typically have a difficult time getting details. People with first-hand information are less likely to share facts if they think it will result in disciplinary action, in short, because they don’t want to lose their jobs. Organizations focused on prevention have to make it easier for employees to share what they know so that the analysis is accurate. Management may believe that a prevention focus undermines accountability, but it doesn’t have to. A bias for prevention can actually help define accountability, especially if the specifics within a particular work process have not been clearly defined. In that case, the people closest to the work will have to be involved in both the problem investigation and the solutions. This Webinar covers the basic differences between these opposing approaches and explains the benefits of establishing a prevention culture.

Risk, Reliability, & Root Cause Analysis

This presentation, for both you and your managers, clarifies the connection between risk, reliability and root cause analysis. These three topics can sometimes be vague theories rather than concrete disciplines. Companies inadvertently make problem-solving too complicated. Six-week quality programs that leave people confused, 300 puzzling “cause codes” and frustrating investigations are not just counterproductive, they can be detrimental. It can erode the effectiveness of an organization. Your problems are confusing enough; your problem-solving tools shouldn’t make it worse. Employees who are inundated with techniques, methods and software can lose track of the basics. All problem-solving efforts should be focused on your company’s goals with a bias toward principles.

Six Common Errors in Problem Solving

Organizations apply a variety of tools to solve problems, improve operations and increase reliability—many times without success. Why? More than likely, they make one or a combination of six common errors. Overcoming these errors involves knowing why they happen and how to prevent them. Armed with this knowledge, both employees and managers can improve problem-solving in any organization.

The Important Connection Between RCA & FMEA

Root cause analysis (RCA) is typically used for investigating why a problem did occur so that specific solutions can be implemented to prevent it from occurring again. Failure modes effect analysis (FMEA) is used to understand how a problem could happen in the future, to identify what actions should be taken to prevent it. Connecting these two approaches can improve the way your organization dissects and prevents problems.

Titanic Problems - How to Make Complex Investigations Easier

Understand How to Untangle a Big Problem: A Titanic Problem in your organization is one of those big issues that consists of many little things. All of those little things, when they occur on their own are relatively minor, but when they happen together results in a major incident. A thorough root cause analysis provides a clear explanation of how and why a problem occurred. It untangles the incident to create a much clearer understanding of the details. This makes it easier to identify specific solutions. Big problems are solved by recognizing the little things that can be done to mitigate risk. This Webinar explains a consistent approach for working big and small issues in your business.

What does a complete Cause Map investigation file look like

If you have already attended one of our Excel Documentation Webinars, then you’ve learned how to use the different drawing functions in Excel to build a Cause Map within the Cause Mapping Template. During this 45 minute webinar, we are going to show you how to get the most out of your Cause Mapping Template when it comes to documenting a COMPLETE investigation. In addition to the Cause Map, a complete investigation can include a timeline, visual aids such as photos and diagrams, and a detailed action plan. Using an actual incident, we will demo what a complete Cause Mapping Investigation file contains. We’ll also send you a copy of the Cause Map file to reference during your future Cause Map investigations.

What's missing in your RCA Program?

During this Webinar, you’ll learn more about the basic elements for establishing a comprehensive root cause analysis program: the method; measurements; roles in the investigation process; facilitation, documentation & storage; and review of the entire program.

Where do you slice the cheese? Leveraging the real value of the Swiss Cheese Model to drive down risk

The Swiss cheese model of accident causation is a conceptual model that visually represents how a high severity problem is comprised of a system of breakdowns within an organization. Its value lies in its ability to demonstrate that a problem must pass through “layers of protection” that organizations have already designed and built into their systems and processes. This webinar will explain the important lessons within the model, address criticism, and highlight the most important takeaways that are often overlooked. We will demonstrate how to leverage the valuable lessons the model reveals on risk and reliability into real-world application for your organization.

Steps to Help Avoid Backing Vehicle Incidents

This webinar shows an investigation of a truck backing into an overhead door. As with all our investigations, the analysis begins very simply with just a few why questions. It then expands into a more thorough explanation of exactly how the incident occurred. In this case, we’ll review a 5-Why and a 15-Why Cause Map™ diagram. Understanding how to reactively dissect this type of incident reveals specific solutions that help organizations reduce risk in other areas of their operations.

Pros and Cons of The Hierarchy of Controls

The hierarchy of controls consists of five levels for mitigating hazards. The intent is to help organizations determine the most effective way to manage risk. The hierarchy provides a preferred order for prevention. In this webinar, we'll cover the important insights within the hierarchy of controls and some of the concerns practitioners have when applying the model.

Checklist Basics

Checklists are a simple yet frequently overlooked tool in a company’s daily operations. A checklist is a summary of how a task should be done. People naturally keep a lot of information in their heads about how to perform a particular task, but sometimes a little thing can be missed. A checklist can help reduce those errors because checklists don’t forget. This Webinar covers some checklist basics and shows how they’re used by different organizations to reduce risk.

Connecting Root Cause Analysis and Work Processes Within Your Organization

This Webinar shows how work process and cause-and-effect tie together to complete an investigation. Attendees will see how a process map can be used to identify breakdowns in their work processes. The process map allows investigators to be more specific, leading to more effective solutions.

How to Investigate 'Procedure Not Followed - Introduction'

The term “procedure not followed” is used to explain when a person didn’t follow a defined work process. Many organizations mistakenly believe “procedure not followed” is the end of an investigation. The next question, “Why wasn’t the procedure followed?” is where you find the “good stuff.” Too often, companies don’t do an effective job digging into the details of why a particular procedure wasn’t followed. This Webinar introduces the basics for preventing “procedure not followed” issues in your operations.

5-Why Case Study: Start Simple, then Expand the Incident Investigation

During this case study Webinar, we review an actual incident of an ‘Eye Injury’ to show the issues around tool selection, personal protective equipment, procedures and a delayed response to medical treatment. Every investigation can begin with a few simple Why questions that can expand into a more thorough analysis. We will show you how better solutions get forfeited if the analysis stops too early.

5-Why DOs and DON’Ts

A widely known tool that is regularly misused. An accurate 5-Why provides a simple way to start a cause-and-effect analysis. This Webinar covers some important DOs and DON’Ts that will explain how the technique is confused and how it should be used. Topics will include:
• 5-Why Basics and Benefits
• Drawbacks and Misuse of a 5-Why
• Does a 5-Why align with a Cause Map®?

How a 5-Why Expands Into a Complete Investigation: Deepwater Horizon

Every investigation, regardless of its complexity, can begin with a simple 5-Why. Bigger incidents will be broken down into more detail. Even as the investigation expands into a larger analysis it does not contradict the initial 5-Why. Smaller incidents have few parts and bigger incidents have more parts, but the cause-and-effect principle doesn't change. It can be applied consistently to all incidents.

How a 5-Why Expands Into a Complete Investigation

Every investigation, regardless of its complexity, can begin with a simple 5-Why. Bigger incidents will be broken down into more detail. Even as the investigation expands into a larger analysis it does not contradict the initial 5-Why. Smaller incidents have few parts and bigger incidents have more parts, but the cause-and-effect principle doesn't change. It can be applied consistently to all incidents.

Introduction to 5-Why for Frontline Professionals

Typically, your frontline people are the first to experience problems in your company. Oftentimes small anomalies are overlooked or unreported to management because they seem normal to the frontline - it always does that. A thorough incident investigation reveals signals that had been missed for days, months and sometimes even years.
There’s a huge amount of frontline information and insight available if a company knows how to access it. Frontline employees should be problem-solving lookouts for your organization. The closer problem analysis is moved to the day-to-day work, the better an organization’s ability to respond and reduce the likelihood of catastrophic events. This is one of the advantages of 5-Why for the frontline. This webinar will contrast the conventional approach to 5 Whys with our 5-Why Cause Mapping method, and we’ll explain how you can apply it to your organization.

What is the Difference Between 5-Why for Frontline and Cause Mapping® Fundamentals?

We’re often asked, “What is the difference between the 5-Why for Frontline and Cause Mapping® Fundamentals workshops?” or “Which workshop is best for my group?” In this webinar, our instructor will talk through the goals and objectives of these workshops, identify the roles that will benefit from the training, share what you can expect your learners to know how to do after the workshop, and answer any questions you might have about the workshop process.

Advanced Cause Mapping Tools in Excel: Graphics & Diagrams

In this Webinar, we'll teach you how to create graphics and diagrams to aid in the understanding of your incidents using only tools available in Excel.

Creating and Using Cumulative Cause Maps

While most Cause Maps are built to investigate one specific issue, a Cumulative Cause Map provides a way to collect multiple failures on one map. The basics of cause-and-effect remain the same for a Cumulative Map, but the analysis builds a little differently. This Webinar will show the basics of building a Cumulative Cause Map and different ways organizations can use them.

How to Build an Investigation File as a Report

Our updated template in Excel makes it easier to save your entire investigation in easily sharable formats. In this webinar we will walk you through the different ways to compile the results of your investigation into a condensed, easily sharable report – whether you’re looking for Excel, PowerPoint, Word or a Summary PDF, we’ve got you covered.

Presenting an Investigation to Management

In this webinar, we’ll explain how to effectively present your Cause Map™ diagram and investigation findings to your colleagues or managers. We’ll address what to include in your summary, what points to emphasize, the order of presenting information as well as what language to use to have the most impact.

Timelines & Graphs: Tools to Organize Investigation Information

The most common start to an investigation is understanding the sequence of events. A timeline is a key tool in organizing the details of an incident chronologically. In this Webinar, we'll teach you how to create timelines and graphs to aid in the understanding of your incidents using only tools available in Excel.

Tips & Tricks for using the Cause Mapping Template

This FREE Webinar will demonstrate how powerful the drawing tool within Excel can be to document, communicate and share your entire investigation within our Excel Cause Mapping template without having to invest in new expensive, complicated software.

The Updated Cause Mapping Template: What you need to know

Learn about the updated version of our Cause Mapping® template in Microsoft Excel (released June 2020). In addition to updating the look of the template, we’ve added some additional improvements that continue to evolve how one can facilitate a complete investigation using a program that’s already on your computer.

Facilitating and Documenting a Root Cause Analysis (RCA)

Sometimes people think of a facilitator as the person who leads meetings, but a root cause analysis facilitator manages the entire investigation process. An effective facilitator provides clarity. A facilitation starts from the time an incident occurs and continues through the analysis and documentation, to the implementation of solutions and the communication of lessons learned. This webinar explains the basics of facilitation and the role it plays in understanding and preventing problems in your business.

50 Years After Apollo 13: Learning From What Went Well

Fifty years ago, an explosion on the Apollo 13 spacecraft shifted its mission from a moon landing to a rescue. Made famous in a movie starring Tom Hanks as Commander Jim Lovell, the three astronauts aboard the damaged spacecraft and the NASA team on Earth had to employ creative problem-solving strategies… and quickly. “You sit back and find out what you have to work with and who can help you do the work,” Lovell said. Although the situation was dire, an impressive feat of ingenuity, teamwork and leadership led to the crew’s safe return to Earth on April 17, 1970 in what NASA later called, “a successful failure.” This 45-minute case study webinar will use firsthand insights from former NASA employees to explore how understanding the cause-and-effect relationships within an incident can reveal additional effective solution opportunities and work process improvements.

A Deeper Look into Distraction-related Accidents

Have you ever checked your phone while driving? You think to yourself, “it will just take a moment.” We’ve likely all been guilty of it at some point. And despite knowing that we’re not supposed to do it – it’s against the law in most states and we understand that the distraction increases our risk of having an accident – we still do it. So, why? During this webinar, we’re going to dig into what causes people to be distracted. We’ll talk about distractions related to technology, but we’ll also talk about other forms of distractions and what we can do to try to minimize their impact.

A Better Way To Share Lessons Learned: Company Case Study Webinar

This Webinar explains the benefits of using a Client Specific Case Study within your organization to teach lessons learned and incorporate problem solving best practices. We will take you through an example Cause Mapping Workbook to show you what a case study covers. We will finish by explaining how you can use this powerful tool within your organization. Learn more about our Company Case Study Webinars and how you can get started on one for your group.

Don't Stop with ‘Human Error’ - Learn How to Explain your Problems: Hawaii Missile Alert Case Study

Many organizations mistakenly believe that an investigation is complete once they’ve arrived at the widely used bucket of ‘human error.’ But that’s not a sufficient explanation of an issue. It’s just a generic category that tells us people were involved. This webinar uses the January 2018 Hawaii Missile Alert incident as an example of how to analyze, document and present a complete investigation.

Earthquake, Tsunami Lead to Nuclear Accident: Fukushima Daiichi

The earthquake and tsunami that struck Japan on March 11, 2011, caused a catastrophic chain of events that led to significant damage and radiation release from the Fukushima Daiichi nuclear power plant. This Webinar will discuss the causes of the disaster, the current situation, and what has been, and still is being done to attempt to protect life and the environment in the area.

Fires & Industrial Explosions

This Webinar discusses how the fire triangle, fire tetrahedron and dust explosion pentagon can be presented as a Cause Map to aid in finding solutions to reduce the risk of fires and chemical explosions, using case studies from several different industries. This Webinar also discusses how an organization’s goals determine the solutions implemented to prevent future incidents.

How a 5-Why Expands Into a Complete Investigation: Deepwater Horizon

Every investigation, regardless of its complexity, can begin with a simple 5-Why. Bigger incidents will be broken down into more detail. Even as the investigation expands into a larger analysis it does not contradict the initial 5-Why. Smaller incidents have few parts and bigger incidents have more parts, but the cause-and-effect principle doesn't change. It can be applied consistently to all incidents.

How to conduct a root cause analysis of an incident with multiple factors - NYC helicopter crash Case Study

On March 11, 2018, a sightseeing helicopter lost power and came down in the East River in New York City. The pilot survived, but all five passengers drowned. It’s a tragic example of how multiple factors come together to produce a disaster. The webinar shows each slice in the Swiss Cheese accident model. We’ll explain the unfortunate way in which different details connected within this horrible issue. Each webinar attendee will receive a two-page PDF with (4) 5-Whys and a 15-Why Cause Map. It’s based on the National Transportation Safety Board (NTSB) preliminary report.

The Importance of Establishing and Following Procedures – Mississippi Oilfield Explosion

On June 5, 2006, a hydrocarbon tank exploded in Raleigh, MS after workers were welding near it, killing 3. This tragic incident highlights the importance of not only having established procedures but also training employees to follow those procedures. Join us for this webinar to see how a Cause Map can be built to analyze this accident and review some of the lessons that can be learned from it.

Reduce Your Risk of COVID-19 Infection: How a Cause Map™ Diagram Makes Sense of a Complex Issue

As COVID-19 continues to spread rapidly, we are inundated with information on this deadly virus and how to avoid becoming infected. As with any complex issue, the ability to thoroughly explain WHY and HOW it occurred can provide a multitude of opportunities for us to mitigate our risk. During this free 45-minute webinar, ThinkReliability instructor Aaron Cross will use current research to provide a detailed analysis of the COVID-19 virus and how it can cause infection. More importantly, we hope to provide a better understanding of how the recommended preventative solutions work together to reduce your risk of infection.

Root Cause Analysis Healthcare Case Study: Awake for Organ Donation

To the shock of the medical team, a patient opened her eyes on the operating table while being prepped for the organ donation in October 2009. The patient, who had overdosed, was prepped for donation after cardiac death (DCD), despite her scans not meeting brain death requirements. Thankfully, the procedures were stopped prior to any incision. This webinar goes over the five major breakdowns within the incident using the Cause Mapping method of root cause analysis. The near-miss healthcare case study analysis expands from a 5-Why Cause Map into a more thorough 18-Why Cause Map that shows the different options for mitigating risk in future incidents.

Root Cause Analysis Case Study: The Chernobyl Accident

On April 26, 1986, reactor #4 at the Chernobyl Power Plant exploded, spreading radioactive contamination that led to severe immediate and long-term effects. During this webinar, we will review how an incident like the Chernobyl disaster can be captured in varying levels of detail. Using basic and detailed Cause Map™ diagrams, the instructor will demonstrate how a complex issue may be broken down into parts in order to create a thorough explanation. The webinar will review the incident (what happened) and key findings (why it happened).

Root Cause Analysis Case Study: Concorde Crash

On July 25, 2000, a Concorde Supersonic jet crashed near Paris, France killing all 109 people on board in addition to 4 on the ground. A tire on the left side disintegrated while the aircraft was accelerating during take-off and struck the underside of the wing, rupturing a fuel tank. Fuel poured from the tank and ignited. The Concorde had already reached a velocity where it could not stop safely by the end of the runway so it lifted off the runway with flames hanging from the left wing. This Webinar discusses the causes of the disaster, including several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.

Root Cause Analysis Case Study: Hubble Telescope

This Webinar presents a case study of the issues facing the Hubble Telescope. There are several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.

Root Cause Analysis Case Study: I-35 Bridge Collapse

During the design of a structure, the analysis can be simplified by knowing which components are weaker, which are stronger and then designing to the weaker components. When assumptions aren’t verified, they can result in a compounded error 40 years later. In the case of the I-35 bridge collapse, an assumption of a part’s strength meant it was never rechecked or inspected, and ultimately resulted in the collapse of the Minneapolis bridge, the deaths of 13 people, and injury to 145. This Webinar is a root cause analysis case study of what led up to the disaster on August 1, 2007.

Root Cause Analysis Case Study: Kansas City Hotel Walkway Collapse

This Webinar examines a case study of the hotel walkway that collapsed on July 17, 1981, killing 111 in Kansas City. There are several specific lessons on risk, reliability and root cause analysis that can be applied within your organization.

Root Cause Analysis Case Study: Lessons from Flight 1549 for your Organization

Root cause analysis identifies the underlying causes of why an incident occurred. Typically it’s used when something’s gone badly, but it can also be applied to something that’s gone well. A complete review of Flight 1549 includes both why the aircraft ditched in the river and why all 155 onboard survived. Losing both engines, ditching an aircraft and evacuating passengers in a river may not be part of your daily operations, but those scenarios contain valuable lessons for any organization interested in reducing risk, preventing problems and improving the reliability of their operations.

Root Cause Analysis Case Study: Lessons from Space Program Disasters

During this Webinar we look at 3 disasters that have occurred in the US Space Program. On January 27, 1967, all three crew-members were killed in a fire aboard Apollo 1. On January 28, 1986, Challenger broke up mid-flight, killing its seven crew members. On February 1, 2003, Columbia disintegrated upon re-entry, killing its crew of seven. During the Webinar, we will examine specific lessons that can be applied to your organization.

Root Cause Analysis Case Study: Loss of the Space Shuttle Challenger

On the morning of January 28, 1986, during the tenth flight of Space Shuttle Challenger, NASA’s first space shuttle disaster. A mere 73 seconds after liftoff, the space shuttle broke apart over the Atlantic Ocean, taking the lives of all seven crew members. In this webinar, we'll use this catastrophic event as a case study for understanding how a cause-and-effect based root cause analysis can be applied to complex, catastrophic incidents.

Root Cause Analysis Case Study: Mars Climate Orbiter

The Mars Climate Orbiter was launched on December 11, 1998. The mission of the Mars Climate Orbiter was to function as an interplanetary satellite and service as a communication relay for the Mars Planetary Lander. Working together, the Mars Climate Orbiter and Mars Planetary Lander were planned to map Mars’ surface, profile the structure of the atmosphere, try to detect surface ice reservoirs and dig for traces of water beneath the surface. Eleven years ago, on September 23, 1999, the $125 million dollar Mars Climate Orbiter was lost during the attempt to establish orbit around Mars.

Root Cause Analysis Case Study: Super Bowl Delayed by Power Loss

The original Tacoma Narrows Bridge was nicknamed “Super Bowl XLVII in 2013 became a bit more exciting than anticipated when the stadium in New Orleans had a partial loss of power in the third quarter of the football game--delaying the game. In this webinar, we use the Cause Mapping method of root cause analysis to better understand why the Super Bowl was delayed and determine possible solutions to prevent such a delay in the future.

Root Cause Analysis Case Study: Tacoma Narrows Bridge Collapse

The original Tacoma Narrows Bridge was nicknamed “Galloping Gertie” because it experienced large up and down movement on windy days. On November 7, 1940, the bridge’s up and down movement changed to a never before seen twisting mode, which increased until the cables snapped and the bridge was destroyed a little more than four months after it opened. This Webinar examines the collapse of the bridge using the Cause Mapping root cause analysis methodology to discover the causes that led to the bridge’s failure.

Root Cause Analysis Case Study: Texas City Refinery Explosion

This webinar shows a simple way a complex incident can be broken down into its different contributing factors. Every investigation, regardless of severity, can begin with a few simple Why questions then expand as needed to thoroughly explain the issue.
On March 23, 2005, a massive explosion at the Texas City refinery 40 miles southeast of Houston resulted in 15 fatalities and over 180 injures. A summary of this incident provides some basic facts – too much liquid was added to a tower resulting in a release to the atmosphere that ultimately ignited. As with any incident, key lessons about reducing operational risk are concealed within the details. Discovering those details takes some digging, which is the intent of a root cause analysis.

Root Cause Analysis Case Study: Unaccompanied Minor

Over the course of two days, a U.S. airline placed an unaccompanied minor on the wrong flight on two different occasions. On June 13th, a child flying alone and under the supervision of the airline was scheduled to fly from Houston to Charlotte. Instead, she ended up in Fayetteville. One day later, a second occurrence with the same airline, this time out of Boston. Instead of going to Cleveland, this unaccompanied girl ended up in Newark, NJ. This root cause analysis case study will focus on the failures that occurred within the work processes and emphasizes the use of process maps to help identify where the breakdowns occurred and how to identify specific solutions to prevent recurrence.

Root Cause Analysis Case Study: Wrong Runway

On the morning of August 27, 2006, a flight scheduled to travel to Atlanta International Airport attempted to take off using the wrong runway at Lexington Airport. The runway was too short and the plane wasn’t able to achieve the velocity needed for lift-off, causing it to crash, killing 49. This Webinar discusses the causes of the crash, using the Cause Mapping method of root cause analysis to illustrate lessons learned that can be applied across all disciplines.

Valdez Oil Spill: Things Aren't Always What They Seem

Most of us know something about the Valdez Oil Spill, and most of what we know is from the 30-second soundbites from the news that focused the majority of their coverage on the captain and his history with alcohol. This Webinar reviews all of the causes of the Valdez Oil Spill in Alaska; the details may surprise you. View to learn more about the incident and how the Cause Map was built.

When Lessons Aren’t Learned: A review of industrial incidents with similar causes

One of the hardest parts of any incident is when the causes are similar to a previous incident. It leads you to think- We’ve already had this incident, why weren’t we able to prevent it? During this webinar, we’re going to review a few industrial incidents in which lessons were not learned and we’ll discuss how those lessons could have prevented similar incidents. We’ll also talk about methods to identify lessons learned and turn those into best practices for any industry.

Healthcare Case Study - Surgical Fires

This Webinar will discuss what causes surgical fires and some methods to reduce the risk of surgical fires while examining some case studies of actual surgical fires using the Cause Mapping method of root cause analysis.

Healthcare Case Study - Blood Incompatibility

This Webinar looks at one of the National Quality Forum’s “Never Events” relating to Blood Incompatibility. “Never events” are so named because the events included should never happen at healthcare facilities. Learning about incidents relating to blood incompatibility and the procedures designed to prevent them can reduce the risk of these types of incidents happening at your facility.

Healthcare Case Study - Healthcare-Acquired Infections

This Webinar discusses the causes of healthcare-acquired infections (HAIs) and lessons learned implemented by various healthcare facilities to reduce these infections. The Webinar includes discussions of case studies of actual cases of health-care acquired infections.

Healthcare Case Study - Medication Errors

According to The Joint Commission, “Errors associated with medications are believed to be the most common type of medical error and are a significant cause of preventable adverse events.” Accordingly, medication errors have been named as one of the “”never events”” (i.e., events that should never happen). This Webinar looks at potential causes of medication errors using the Cause Mapping method, and will look at process-based solutions to preventing these types of errors.

Healthcare Case Study - Patient Falls

Healthcare facilities are coming under increased scrutiny for medical errors, including “never events” as developed by the National Quality Forum. The Cause Mapping method of root cause analysis can be used to determine what went wrong and how to fix it in the case of medical errors, AND to prevent these errors from happening in the first place. This Webinar discusses the causes and solutions of patient deaths associated with a fall (one of the “never events”) including case studies of actual patient falls.

Healthcare Case Study - Wrong-Site Surgeries

This Webinar discusses the causes and solutions of wrong-site surgeries (one of the “never events”) including case studies of actual wrong-site surgeries, providing useful information to medical practitioners and administrators alike.

Preventing Radiation Treatment Overdoses: Cause Mapping Case Studies

Learn about what causes radiation treatment overdoses and some methods to reduce the risk of overdoses while we examine some case studies of actual radiation treatment overdoses using the Cause Mapping method of root cause analysis.

Bring Cause Mapping® Root Cause Analysis training to your site

Schedule a workshop at your location to train your team on how to lead, facilitate, and participate in a root cause analysis investigation.