As a TapRooT® Instructor and Incident Facilitator, I hear these phrases occasionally:
We did our investigation and could not find any root causes.
Nothing was done wrong, so we have no corrective actions to implement.
I hear these phrases often from people not familiar with the TapRooT® Root Cause process. But sometimes … even us experienced users need a little nudge. So if you get stuck …
1. After identifying the worst thing that happened or the specific problem that you need to focus on, ask a few key questions up front based on your industry:
Manufacturing: What were the quality escapes?
EHS or Process Safety: What were the uncontrolled energies and exposures?
Project Planners: What were the bottlenecks or gaps in the project?
Medical: What were the patients’ hazards or exposures?
Note: We are not brainstorming here nor are we troubleshooting yet, we are just defining the problem.
What error allowed the bacteria to be there or grow too large?
What error allowed a safeguard to control the bacteria to fail or be missing?
I will not go through all the questions that you learned to ask, but just asking these first two questions tells us that we need to track the bacteria in our timeline, look for evidence and take samples of bacteria growth.
This technique works, because it forces the facilitator to break down the problem. This incident (in the example above) could have easily been a ventilator-associated pneumonia issue. Bacteria, Bundling and Secretions are just some of the hazards and exposures that had to be present for this incident to occur, and they need to be in our timeline, (we call a timeline a “SnapCharT®”).
3. Once we map out the events in our SnapCharT®, define our Causal Factors, and perform our Root Cause Analysis, we may find that no one broke a rule or policy and still allowed the bacteria to grow. The simple answer is that processes were not adequate.
Yes I know that some hazards are very difficult to control, (like fleshing eating bacteria from a lake that enters through a cut on a human body), but once identified, we still use the safeguard analysis process to increase hazard risk reduction for the future.
Also, during the root cause analysis, please ensure that you do not lightly review the human engineering basic cause category. Some of your root causes for seemingly mysterious issues are identified here.
I hope this helps get your investigation jump-started.
Category: Root Cause Analysis Tips
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