Challenge
Our ongoing, sustained effort is to make jobs safer and to reduce (and eventually eliminate) on-the-job injuries. Our mechanics were faced with complex procedures, electrical energy, and the potential for falls and hazards that Otis does not completely control (since we are working on the customer’s site). However, in Russia our mechanics also faced hazardous elevator ?emergency? controls and a lack of regulation that made it more difficult to be safe while working.
Our Otis internal audits (a proactive way to find problems) produced scores that showed that improvement was possible. But how do we analyze and fix the real causes of the problems?

Action
In 1998, one of the corporate staff members attended a course on root cause analysis. The staff member used the systematic root cause analysis techniques he learned to solve problems. He found that a structured process helped identify real problems that were previously being overlooked. He also found that the system, called TapRooT®, helped identify fixable causes for these problems that, when corrected, were effective in improving safety.
In 1999, Otis decided to adopt the TapRooT System around the world. Courses were held in the United States, Holland, Singapore, and Brazil . I was one of the environment, health, and safety professionals that attend the course in Amsterdam . We decided to use the process to analyze our safety problems and develop improvements that would reduce risk to our employees and improve the results of our audits.

Results
We started applying TapRooT to analyze our safety problems in 1999. One of the first problems we attacked was the failure of our mechanics to comply with safety instructions in our procedures. The question and answer process in the TapRooT Root Cause Tree® helped us identify the root causes of the problems with the procedures. This helped us simplify the procedures and make them easier for the mechanics to use.
We also found that we needed to improve the enforcement of the use of safety instructions in the procedures. Supervisors now use their regular conversations with the mechanics to reinforce adherence to the safety instructions. We also instituted safety audits to measure compliance and take additional actions to improve compliance (if needed).
But our efforts were NOT just focused on procedures. We also found that we needed to improve the processes and devices that were being used for isolation of electrical energy and for fall protection.
Because electrical isolation devices are no longer required by law, Otis customers often do not want to pay for these devices. Our root cause analysis showed that these devices were essential for our employees? safety. Therefore, we decided to supply these devices at our own cost to provide the highest possible safety for our mechanics.
Root cause analysis also helped us discover and fix a problem with our fall protection equipment. The old equipment sometimes caused internal injuries due to the sudden jerk when the person?s fall was stopped. We developed new gear that had an extra absorbing mechanism to reduce internal injuries.
Finally, we had problems with the safety of workers on top of elevator cars when the ?emergency call? system (a special problem in Russia ) was used. We developed special procedures based on our root cause analysis to help protect our workers.
We have now used TapRooT for over a year and a half. We have eliminated or reduced hazards and we have improved the usage of our safety instructions.
This improvement can be seen in our audit evaluation scores. Each month and quarter each Otis facility evaluates the risks that employees face and submits a report to corporate headquarters. These reports are then evaluated by a committee and a score is assigned. Better results get a higher score.
In 1999 (our first year of using TapRooT), our average score improved to 173 out of 240 possible points. In 2000, our average score improved still further to 200 out of 240 possible points (a good score by comparison with other European Otis facilities). We believe that using TapRooT to find root causes has been an essential element of our improvement efforts, and we will continue to use it to improve even more in the future.