I wanted to take some time today to discuss one of our basic cause categories on the TapRooT® Root Cause Tree®; Work Direction.

Work Direction includes the near root causes of preparation, selection of worker, and supervision during work.


The main focus of my comments is on preparation; however, let me touch on the other two first.

Selection of worker is fairly straightforward; the person(s) is (are) not properly qualified for the task or are in some way not capable of performing the task. It is the supervisor’s responsibility to ensure workers are qualified and capable.

Supervision during work ensures that there is a “reasonable level” of supervision and also includes a very important consideration, crew teamwork. Since “reasonable level” is debatable, there can be differing interpretations and opinions on this, and one must consider that each situation is different. However, in my experience, this root cause can be overused. Every situation or task cannot be expected to have someone there to oversee a trained adult, so be careful not to use that as a crutch and blame lack of supervision for every problem.

Which brings me to preparation; this is everyone’s responsibility, not just the supervisor’s. You have self-directed teams as well as people working alone, and preparation is needed whether a supervisor is present or not. I have seen the tendency to cross off work direction when a supervisor is not directly involved. Remember, someone is always in charge, whether they have the title of supervisor or not.

No preparation is straightforward. Work Package/Permit NI includes JSA/JHA’s and risk assessments as well as things requiring a work package or permit. I often see people trying to fit JSA’s into other areas, but this is where it fits on the tree.

Pre-job briefings are another root cause I feel can be overused, or used as a “crutch.” Briefings can tell people things that are specific to the shift, anything out of the ordinary, any specific risk, crew coordination, etc. However, can the supervisor or person in charge tell a trained adult everything they might need to know today? Here is an example:

Someone made an error because they did not use a required procedure (and they know it is required). A student selects pre-job briefing as a root cause because………..”if the supervisor had told them to use the procedure in the pre-job…..” But they are a trained adult who knows the procedure is required! I think that is taking things a little too far.

The same concept applies to walk-thru NI; I see less abuse on this one, but remember, walk-thrus are for infrequently occurring tasks, not something I do every day.

Make sure you are being very deliberate when going through the Root Cause Tree®, use the dictionary, and of course, the evidence. One of the common things I see among new users is the tendency to “go shopping when they are hungry.” What do I mean by that? Here is the analogy:

When you were a kid, your Mom gave you $20 and said milk, bread, and eggs. You went to the store and got the three items. So far, so good. But on the way to checkout, you passed the cookies…..and the chips…and the candy. The problem is when you got to the checkout you had to pay the bill. And when you got home Mom asked the dreaded question; “where is my change?” In this scenario think of the checkout as your corrective action program and your Mom as the boss. Eventually you must account for everything, and if you load up your corrective action program with cookies, what happens to the important stuff? No one knows……..at least until they try to clean up the open items.

Be careful and happy investigating.