Author Archives: Dave Janney
Welcome to this week’s root cause tips column. So what is the most important information or criteria in a good root cause analysis? (By the way, this is a trick question)
I started a list:
• A timeline of what happened
• Complete evidence
• Identification of causal factors
• Safeguards analysis (what failed)
• Safeguards Analysis (what worked)
• Root Causes substantiated by evidence
• Generic (system) Causes identified
• Corrective Actions that eliminate the root causes
• Corrective Actions that are implemented
• Corrective Actions that have been verified effective
So what do you think? Have I missed anything? Please comment below if you have any other ideas.
And which are the most important?
Yes, it is a trick question. They are ALL important.
For example, what if you did a really good job of collecting evidence and got good root causes but wrote weak corrective actions? Have you ever seen training as a corrective action for root causes that had nothing to do with training? Of course you have, that’s my point.
What if you had great corrective actions but they were never implemented (or checked to see if they were effective)?
The fact of the matter is you have to have all these things for an effective investigation and root cause analysis. It is easy to miss things, we’re all human and we all have different experiences, knowledge, and biases. But the good news is that this is all built into how TapRooT® functions. Just follow the process and you will have a good root cause analysis.
You must know WHAT happened before you can determine why. This is why evidence collection is so important.
You must know WHY before you can write corrective actions. If you do not have good evidence you will miss causal factors and root causes. ALL root causes have to be substantiated with evidence.
You must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.
Think of it as a chain link fence. If any part of the chain is broken, the fence is compromised, and in this case, so is your investigation.
If you are interested in learning the TapRooT® Root Cause Analysis, our 2-day course offers all the process essentials needed to conduct an investigation including:
- SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
- Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
- Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.
Check out our schedule for a course near you: http://www.taproot.com/courses#2-day-incident
I hope I’ve given you some food for thought. Thanks for visiting our blog and happy investigating.
There is still time to sign up for the safety improvement track at the Global TapRooT® Summit.
In addition to the blockbuster keynote speakers that every track will attend, we have a very special lineup of sessions for the safety track:
Kaizen Events using TapRooT® and the Root Cause Tree®
This session is one from the summit quality track that I added to the safety track. Why? Because in my previous life, I worked in both quality and safety departments, and there are two things I know; first, safety professionals can find great benefit in quality processes and tools, and two, most safety people have not had the benefit of being exposed to quality processes and tools. Kaizen Events are a great way to involve employees in your processes, and I know that for a safety program to be effective, employees must be involved. I am very excited about this session led by Amy Bratkovic.
Your safety message is only useful if people hear it (and understand and believe it)! UK communication’s consultants Clare Solomon and Mark Ormond are not only communication experts, they understand safety and how to specifically tailor messages to your company, environment, and culture. You will not want to miss this session.
The New Standard for OHS Management Systems – ISO 45001
As safety professionals, I know we sometimes wonder why there are ISO standards for quality, risk, environment, and a host of other things, but not safety. Well, it is finally coming. International standards expert Jim Whiting will give an overview of the soon to be released ISO 45001. Many companies require their suppliers to be certified in some of the other ISO standards mentioned, so there is no reason to believe this will not be the case with safety as well. Be on the forefront of this movement by attending this session.
Developing Proactive Performance Measures
Most people become TapRooT® users because they want to do better investigations. That’s great, but would it not be better to prevent incidents in the first place? Before you can fix a problem in your organization, you have to first have the data, and unfortunately, many companies do not collect the right proactive measures. In this session, Mark Paradies, the creator of TapRooT®, will give you plenty to think about when considering what to measure.
How to Stop Normalization of Deviance
Have workarounds and the breaking of rules become accepted, or business as usual in your company? Mark Paradies will discuss the consequences of allowing this to happen and share insight on how to avoid this condition. If you just solved this one problem (albeit a big one!) at your company, this would make the entire summit worth your time.
Stopping Human Error with Type 4 Corrective Actions
Do your correction action reports routinely involve things like training and rules? If so, that may be (I’m being nice here) the reason you have repeat incidents. If you have been to a TapRooT® course, you know that removing or reducing the hazard is the best thing you can do, but that is not always possible. But there are ways to make your people more reliable without putting a host of new rules in place. In this session, human factors expert Dr. Joel Haight will share ideas on how you can strengthen your corrective actions to prevent recurrence.
Process Safety; Comparing Seveso 3 to OSHA PSM
Different standards and regulations have different benefits and best practices included in them. Can we learn from other standards and regulations even if we are not forced to comply with them? Join Belgium Regulator Frank Verschueren as he discusses how these two process safety regulations compare.
So that’s it. Several great sessions. Have I mentioned the keynote sessions? Well, I am going to mention them again. We have everything – someone who worked for the President of the United States, a former NBA player and radio personality, a Professor who has been voted the best speaker at the summit, two gents who investigated serious North Sea Oil and Gas incidents, and last but not least, Captain Phillips.
Wow. And of course there is the party at Jimmy Buffet’s Margaritaville with entertainment from Carl Dixon of The Guess Who and April Wine fame.
You can’t afford to miss this event. Register HERE and select the Safety Improvement Track. See you there!
Nancy Hitchins and I are teaching the 2 day course today deep in the heart of Texas. Here are some pictures of students working on an exercise and Nancy teaching:
Why not join us for us for the next course? You can see the schedule and enroll HERE
Nancy Hitchins and I are teaching the 5 day course this week in Houston. Here are some pictures of the day one morning activities:
Why not join us for the next course? You can see the schedule and enroll HERE
Final exercise pictures from 5 Day TapRooT® Advanced Root Cause Analysis Team Leader training in DohaPosted: March 19th, 2015 in Courses
All of our TapRooT® courses conclude with each investigation team presenting their results from the investigation they brought with them to the management team (the rest of the class). Here are some pictures of the final presentations from today’s ending of the 5 day course in Doha, Qatar:
I hope you will consider joining us for the next course. Our courses in the Middle East always fill several weeks in advance, so do not delay. The next course commences in Dubai on June 7; you can register for the class HERE
I am in Doha this week teaching the 5 day course. Here are some pictures of the students working on the day one SnapCharT® exercise and the day two 14 Step Cognitive interview exercise:
This course did fill several weeks in advance, and we had several people on the waiting list who were not able to attend. We have heavy demand and our courses in the Middle East do fill very quickly, so if you want to join the next course, you should enroll as soon as possible. The next course is the 5 day course in Dubai on June 7.
To view more photos from this course, click HERE.
To see the information and enroll in the course, click HERE
Today marks the end of yet another successful TapRooT® course in Dubai. Here are some pictures of the students doing their final presentations:
This course did fill, so I’m sorry if we could not accommodate you. Out next course in Dubai (5 day course) will be in June. To see the information and register, click HERE
Amber Bickerton and I are teaching the 5 day course this week in Calgary. Here are some pictures of the students working on their investigation interviewing exercise:
Why not join us for the next course? You can see our schedule and register HERE
Thanks to TapRooT® instructor Ralph Blessing for sending this picture of an onsite course being held today for one of my clients in Illinois. In the picture, instructor Ralph Brickey is teaching the students how to find Causal Factors.
By the way, not all of our instructors are named Ralph, but they are all excellent instructors! We can teach any of our courses at your site (10 or more people), and we have instructors throughout the world. If you are interested in holding a course at your site, just e-mail us at firstname.lastname@example.org
Today marks the end of yet another great course in Dubai. Here are some pictures of the students and the final team exercise presentations:
Our next set of courses in the Middle East will be in March; a 2 day in Dubai or a 5 day in Doha. To join one of these courses, register HERE
I am in Dubai this week teaching the five day course. Here are some pictures of the students on day one working on their first exercise, building a SnapCharT®:
VIEW MORE PHOTOS from Dubai (Click here to view more.)
This course did fill, so I’m very sorry if we were not able to accommodate you this time. Our next courses in the region will be in March; the 2 day course in Dubai and 5 day course in Doha. To see the schedule and register, click HERE
I am in Vancouver this week teaching the 5 day course. Here are some pictures of students working on day one exercises:
Why not join us for a future course? You can see the schedule and register HERE
Kevin McManus and I are teaching the 5 day course in Portland this week. Here are some pictures from day one:
Why not join us for a future course? You can view the schedule and register HERE
Hello and welcome to this week’s root cause analysis tip. This week the topic is doing better investigations.
The most important thing you can do for better investigations is to use TapRooT®! But assuming you already do that, here are some more tips that I hope will help.
The first thing to think about is preparation – does your company have an investigation policy and does everyone know their roles and responsibilities? In other words, do you have a plan? The time to develop your plan is not after you have had a major incident! You can refer to Appendix A of the TapRooT® book for a sample plan; however, I would imagine most of you already have a plan at your company, so your preparation is simple – read the plan and understand it.
Think about Notification – Who, and under what circumstances? Let senior management know someone’s working on the investigation. You can share the preliminary information as well. Set expectation that it may take some time. They’ll often back off and let you do your job if you tell them these things.
Plan your investigation – what kind of photos, documents, equipment reliability data do you need? Plan what data to collect and how you’re going to collect that data.
So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart. Interviewing is an important part of evidence collection. Follow our 14-Step interview process, it’s in the book. The best way to interview is to let the person tell their story, they may answer your questions without you even needing to ask. If you only ask questions, you’ll only get the answers to your questions and nothing else.
View Part 2 of Dave’s tip on Performing Better Investigations!
or check out other short videos in our root cause tip series:
What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)
TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)
Steve Swarthout and I are teaching the 5 day course this week in Niagara Falls. Here are some pictures of Steve teaching and students working on their first exercise:
Why not join us for a future course? You can see the schedule and register HERE
Welcome to this week’s root cause tips. This week I would like to talk about the SnapCharT®
As you know, the SnapCharT® is the tool I use to plan my investigation, document my evidence, and present the incident to management. It’s a powerful yet easy tool to help in each of these areas.
First, let’s talk form. One of the common problems I see when people first start developing a SnapCharT® is trying to get too much information in a small space. I normally start the first page with no more than 4-5 events across the top of the page. As you continue to develop your timeline, you will soon know if you need to more pages, but the software also knows and will create the page for you. It is much easier to add your evidence if you leave plenty of room to work. If you try to put 10 events at the top of your page you will soon run out of space for your evidence. Your chart will be cluttered, hard to digest, and impossible to present with. I want to see a lot of evidence, but I want it to be organized and look good. This will make it much easier to read and understand it as I use the information later for my root cause analysis.
I’ve already said there should be a lot of evidence on the chart. Everything you know about the incident should be there. If you have been to a TapRooT® course before, you know that we always do a final exercise, and as part of the exercise the instructor will approve your causal factors. When I do this, sometimes the discussion begins with a student saying “let me tell you what happened” at which point I say STOP! – I should be table to tell what happened by reading your SnapCharT®! As I review it and start to ask questions, answers pour out of the team, but some of that information is not on the chart. Make sure everything is there. That way you will not forget anything when you do your analysis, and you will get fewer questions when presenting. And, make sure everything on the chart is factual.
Next, wording matters. Don’t be vague, be very specific. Don’t say it was hot; say it was 90 degrees. Use job titles or functions instead of names to reduce blame. Be very clear with your wording so someone who knows nothing about the incident can tell from your wording exactly what you mean. Get good at using the words ‘”did not” to describe things that were supposed to happen but did not; this will make causal factor identification much easier later in the process.
I try to assemble all my evidence directly below the event in a straight line so it is very easy to read and is arranged into nice groups of information. It is permissible to have two rows of information if it makes sense to do that, but I find that this is not always needed. When it is, make sure each row of information goes together in a logical group; for example, you might have a group with all the training information and another group with all the policy information. If you have been to a 5 day TapRooT® course, you might remember when we talk about procedures we say “the burden of written communication is on the writer, not the reader.” SnapCharT®s are no different!
Optionally, you might elect to put safeguards on your chart. Resist the temptation to only put failed safeguards. In fact, showing safeguards that worked on your chart for your management presentations is a great way of showing two things; what is working in the business, and that the incident could have been worse.
If you have been to a TapRooT® course, you have heard this before, but it is worth repeating – draw your lines last! If you draw your lines too early and you end up having to move things around, you will end up having to delete them. Don’t work any harder than you need to.
The last thing I want to address is the use of colors. It is fine to use colors if you want, but be careful and use light colors. If you use a dark color, it may look fine on your computer, but when you go to present people may not to be able to read it on the screen. I have seen people show causal factors in a different color in their presentations, and that is a great way to bring that information out. I say that you cannot go wrong with black and white. Then again, I am obsessed with simplicity, and I know not everyone is wired that way. Do what makes sense for you.
So that’s it for this week. I hope some of this information is helpful. Thanks for readying the blog, and happy investigating.
Derek Rutherford and I are teaching the 5 day course this week in Munich. We are off to a great start on day one, here are some pictures from this morning:
We hold courses all over the world, so why not join us for a future course? You can view the schedule and register HERE
Dan Verlinde and I are teaching the 5 day course this week in Gatlinburg. Here are some pictures of the students working on day one root cause exercises:
Wny not plan to join us for the next course? You can see the schedule and register HERE
Hello and welcome to this week’s root cause tip.
Root Cause Analysis is no different than any other program at your company in that it requires management support. And to get support you must first have understanding.
In a perfect world, managers understand root cause analysis because they have been trained, so the best thing you can do is convince them to attend training. If you are having an onsite TapRooT® course, open it to more people, including managers. Even those who might not actually do investigations should understand the process and how root causes were determined, that way when they see a report later they will understand. A two day TapRooT® course would be fine for managers in that situation.
If you can’t convince them to attend, show them an example of a completed investigation and how you drove the evidence down to root cause and got to corrective actions. If you can show how you solved an important and/or ongoing problem, that will make your case much stronger. Which brings me to another point; sometimes you have to show people that you do have problems that need to be solved, so use your metrics to do that. Incidents, near misses, audit findings, hazard reports, and many other sources of data are available to you to make the case. If people do not see a compelling reason to change, they won’t.
Managers must also understand that blame and discipline is like fixing your problems one person at a time. Until you can show them to how to get to the true root cause level, they might not understand this.
Managers speak the language of money. If they understand just how much money is being saved by improving, they will be your advocates.
Managers should also understand how root cause analysis ties in to the organization’s goals; maybe it is cost reduction or maybe it is a key metric other than money. Show how your efforts make a difference.
This is food for thought but more so a call to action. Tell your managers today how important root cause analysis is, educate them, and enlist their support. You will be glad you did. Thanks for reading this week’s root cause analysis tip, and happy investigating.
I am teaching the 5 day course in Doha this week. Here are some pictures of the day one exercises and the day two cognitive interviewing exercise:
Our next courses in the Middle East will be in Doha in October and Dubai in December. Both courses all already half full, so if you want to attend, you should register as soon as possible. You can register HERE
I am in Dubai this week teaching the 2 day course. Here are some pictures of the students working on first day activities:
This course filled, so I’m sorry if we could not accomodate you. Our courses in the Middle East fill so if you want to join us this year, you should register as soon as possible. You can see the schedule and register HERE
I am in Philadelphia this week teaching the 2 day course. Here are some pictures of day one activities:
Why not join us for the next course? You can see the schedule and register HERE
Derek Rutherford and I are teaching the 5 day course in London this week. Here are some pictures from day one activities:
Why not join us for the next course? To see our schedule and register, click HERE