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Words that I hate to hear when asked to help with an investigation: “I am surprised this incident did not happen earlier!” Rarely have I seen an incident where there is not a history of the same problems occurring.  Think of it like a math equation:

X + Y (A) = The Incident

A company’s issues are just waiting for the right math equation to occur at the right time. What are some of the common factors that populate the equation above?

  • Audit Findings (risk or compliance)
  • Near Misses (or some cases, Near Hits)
  • OSHA Non-Recordable(s)
  • Defects (caught before the defect reached the customer)
  • Project Delays
  • Procurement Issues
  • Behavior Based Safety Entries

This list of variables is infinite and dependent on the industry and service or product that your company provides. Should you be required to perform a full root cause analysis on each and every write-up or issue listed above to prevent an Incident? Not, necessarily.

Instead, I recommend that you start looking at what would be a risk to employees, customers, environment, product/service or future company success if you combined any of your issues in the same timeline or process of transactions (in TapRooT® our timeline is called a SnapCharT®). For example, take the 3 issues listed below that have a higher potential of incident occurrence when combined in the right equation.

Issue 1: Audit finding for outdated procedures found in a laboratory for testing blood samples.

Issue 2: Behavior Based Safety Write-up entered for cracked and faded face shields

Issue 3: Older Blood Analyzer has open equipment work orders for service issues.

Combining the 3 items above could cause a contaminated blood sample, exposure of contaminated blood to the lab worker or a failed test sample to the patient.

If the cautions about your future combination of known issues are not heeded then please do not acted surprised after the future Incident occurs.

Want to learn about causal factors? It’s not too late to sign up for our Advanced Causal Factor Development Course, August 1-2, 2016, San Antonio, Texas.