Teaching TapRooT® Root Cause Analysis and Equifactor® for the last 10 years, I often get this question…

“The tool/component broke while we were using it. Why can’t we just select Equipment Difficulty on the TapRooT® Root Cause Tree®?”

Simple, you have to pass the test below first

NOTE: If the failure was caused by:

  – improper operation;

  – improper maintenance;

  – installation errors;

  – failure to perform scheduled preventive maintenance;

  – programming errors;

  – use for a purpose far beyond the intention of the design; or

  – a design that causes a human performance difficulty

then the failure is NOT an Equipment Difficulty, but rather the failure is a Human Performance Difficulty

Trust me! If a tool, piece of equipment or product breaks, you know the manufacturer, vendor and supplier are going to push back to see if it was used properly and meets the warranty. Shouldn’t you ask first? We say yes!

During my 18 years in aviation in fuel systems troubleshooting and executive jet assembly, we used to have a phrase…

“Our mechanics or assemblers that grew up on the farm are our best and worst mechanics. They can get anything mechanical to work.”

Now there are signs that tools might not be the right ones for the job or that the job was not designed with good Human Engineering in mind. First test… look into the toolboxes in the field.

✔Are the tools modified
✔Are the tools old and worn
✔Are there tools from home

Okay, so tools are easier to see being misused, like a screw driver being used as a scraper or a pry bar, but what about equipment/components being used like a…

✔ Compressor
✔ Switch
✔ Valve
✔ Bottle

Now we must dig a little deeper in our TapRooT® Root Cause and Equifactor® Analysis. We start by mapping out our SnapCharT® (Sequence of Events with supporting Conditions) using system schematics to ensure we know what occurred with the equipment, people and system being operated. A knowledgeable system operator can elaborate on events and conditions such as:

✔ Energized open, mechanically closed
✔ Dynamic or static energy
✔ System work arounds and deficiencies

Why you may ask is this knowledge vital? If an operator knows how the light turns on when you flip a light switch on, then when system does fail, it is easier to start and understand the SnapCharT®.

To pass the first two tests while facilitating TapRooT® Root Cause Analysis, whether for a low to moderate level issue or a major incident, bring along that knowledgeable operator or engineer that can answer the following…

improper operation;
improper maintenance;
installation errors;
failure to perform scheduled preventive maintenance;
programming errors;
use for a purpose far beyond the intention of the design; or
a design that causes a human performance difficulty

Good luck and be safe! Please get rid of those unsafe tools and processes.

LEARN MORE in our 2-day TapRooT® Root Cause Analysis Training.