Author Archives: Dave Janney
Have you ever performed an audit and got frustrated when you found the same issues as the last audit? I feel your pain….we all have. Why does this happen so much? Because most companies audit programs look a little like this:
Q: What is missing from this picture?
A: Root Cause Analysis, of course!!
Many companies actually have good programs for FINDING problems without having a good program for FIXING problems. If you want problems fixed, root cause analysis has to be part of it. So on the road to improvement, take a DETOUR to Root Cause Land!
For your program to be effective, it should look more like this:
The best way to do root cause analysis on audits? TapRooT®.
We have a new course, TapRooT® for Audits, that we will be holding in Charlotte, NC on May 4-5. Why not join us? For more information and to register, click HERE
We’ve scheduled our new course specifically designed for auditors on May 4-5 in Charlotte, NC.
We have always taught auditing in our courses but we wanted a course that auditors could attend to learn the Essential TapRooT® techniques.
All attendees get a copy of the newly released book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement as well as a Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper®.
I hope to see you there! For more information and to register, please go HERE
Happy Wednesday and welcome to this week’s root cause analysis tips.
Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.
Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.
While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.
PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.
As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.
Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.
Thanks for reading the blog, and best of luck with your improvement efforts.
Here is a video that discusses some root cause tips, common problems with root cause analysis, and how TapRooT® can help. I hope you enjoy!
Like what you see? Why not join us at the next course? You can see the schedule and enroll HERE
Happy Wednesday and welcome to this week’s root cause analysis tips column. This week we will talk about Causal Factors.
The TapRooT® Definition of a Causal Factor is:
“A mistake, error, or failure that directly leads to (or causes) an Incident or fails to mitigate the consequences of the original error.”
This definition is one major thing that distinguishes TapRooT® from some other methods. We don’t just find the first thing that went wrong, we find EVERTHING that went wrong. I’ve had people say to me that “but if I fix the first problem the incident would not have happened.” That is actually true, but if I only focus on the first thing that went wrong (which is sometimes the most obvious), then I do not address everything else that is wrong with my system. It also allows people to fall into the trap of determining “the causiest causal factor” and ignoring everything else.
Consider this diagram:
So when looking for Causal Factors, I find the first error/failure (initiating error), and they look for chances to stop/catch/mitigate. Each time I fail to stop/catch/mitigate, it is a new Causal Factor.
You will also notice that we could have an initiating error later in the timeline was well. It could be completely unrelated but allowed the hazard to reach the target.
Here is an example:
*Someone turns the wrong valve and allows a hazard (this is an initiating error).
*A second check of the valve configuration was not completed as required (a chance to stop/catch the first error).
*Someone lights a cigarette in an unauthorized area (another initiating error).
*Emergency response team did not arrive for 30 minutes (chance to mitigate the consequences).
Each one of these would be a Causal Factor.
Defining Causal Factors does not have to be difficult. The more you do it, the more comfortable you will be. I find that the concept of stop/catch/mitigate can really be helpful in making sure you find ALL the problems that led to an incident.
So thanks for visiting our blog. I hope you don’t have an incident anytime soon, but if you do, I hope you find the information helpful. If you’re interested in learning more about identifying causal factors and finding the root causes of incidents, register for our 2-Day TapRooT® Root Cause Analysis Training.
Happy Wednesday and welcome to this week’s Root Cause Analysis Tips. The topic this week is strength of safeguards.
We teach a lot of great stuff in our TapRooT® courses. In fact, our 5-day course is over 400 slides. In my opinion, this concept is the most important, and this is my favorite slide:
The diagram shows that the best corrective action is to remove the hazard; if we cannot do that, maybe we can reduce it (chemical substitution, for example).
If we can’t do a #1, possibly we can move the target away from the hazard (moving a desk in the warehouse away from forklift traffic, for example).
We keep moving down the list from strongest to weakest. But we start at the top.
So here is my question: If I were to pull out of random stack of investigations from any company, anywhere, what kind of corrective actions do you think I would see? What about your company? If you said 5’s and 6’s, you now know the reason that you have repeat incidents.
Please do not misunderstand me; I am not saying training and supervision are not needed, what I am saying is they are weaker safeguards. They can be good corrective actions and sometimes are the only ones feasible, but we should always start at the top of the matrix and work our way down.
In my last column I talked about layers of protection. Pretty simple, more layers means more protection. However, since all Safeguards are not equal, many layers of weak safeguards does not equal a few layers of strong ones.
If you just did this one thing in your company, I am confident that you would improve a great deal. Remember, corrective actions are the output of your investigation. You can do a great job on the investigation, but if you have weak corrective actions, you are WASTING YOUR TIME.
So please think about it. Thanks for visiting the blog, and enjoy your week.
Happy Wednesday and welcome to this week’s Root Cause Analysis Tip.
The topic this week is the concept of “Defense in Depth.” You may have also heard terms such as Barrier Analysis or LOPA (layer of protection analysis). In TapRooT®, we use the term Safeguards.
Take a look at this diagram (courtesy of Mark Paradies, the creator of TapRooT®):
What the diagram depicts is an incident where several layers of protection have been breached. You may have also heard of Reason’s “Swiss Cheese Model.” In these models we can see that we only have incidents when all layers are breached. So the amount of layers and strength of those layers determine if (and how often) we have incidents. It is also why sometimes things go wrong but we do not have an incident; because one or more layers worked.
So our goal in developing processes is to make sure we have enough layers and that the layers are functioning the way we want. Remember that every Safeguard has a hole in it, it is not infallible. So we want to make the holes as small as possible.
The same applies to corrective actions. Do we need new layers? How can we strengthen existing layers?
The concept is easy. What is difficult is determining just how much is enough.
Risk really is the main driver of that in my view, but business realities come into play as well. The easy ones are the ones on either side of the spectrum. For example, something is fairly difficult but low risk – probably all you need is a procedure and some training (we refer to these as Quasi-Safeguards).
If something is difficult AND high risk, we need a lot of layers, and hopefully many of them are engineering controls.
The hard ones are the ones in the middle; a process is very easy and there is very little chance of a problem… BUT, the risk is very high – in this case determining what you need can be very difficult.
In my November column, I will talk about the strength of Safeguards.
In closing, I urge you to think about Defense in Depth when developing processes. Audit them to make sure the layers are functioning. And if you do have an incident think about Safeguards and Defense in Depth when developing your corrective actions.
Have you been to our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training? Learn more about advanced techniques like Safeguards Analysis, Change Analysis, Critical Human Action Profile (CHAP) and Cognitive Interviewing.
Thanks for visiting the blog, and enjoy your week.
Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.
One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…
First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.
So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):
• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations
If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.
Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:
A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.
The data for the yearly compliance is presented on a Pareto Chart below.
The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:
Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.
I hate to use clichés, but WORK SMARTER NOT HARDER!
Want to learn more? I have a couple of opportunities that might interest you:
If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on August 1-2.
If you are not there yet and want to learn how to collect data and trend, consider the Advanced Trending Techniques Course, also on August 1-2.
Thanks for taking the time to read the blog, and happy investigating/auditing.
Happy Wednesday, and welcome to this week’s root cause analysis column.
This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.
“An Ounce of Prevention is Worth a Pound of Cure.”
Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.
The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place?
Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.
Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:
- Time (perceived at least)
- They don’t have a reason to (not enough pain)
- They do not have the buy-in (management and employee support)
- Procrastination (human nature!)
- They don’t know how (this is where TapRooT® comes in!)
TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.
Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE
This is old news to most (or should be) but OSHA finally published the long awaited rule on injury reporting:
So now that information will become more public will companies improve their records to stay out of view? Some things to think about:
*If they did not care about worker’s safety before, why would they care now?
*Will anyone even pay attention?
*Will management put more pressure on the operation to reduce rates?
*Will management give the operation additional resources to accomplish it?
*Will the media misuse the information? Will it be used politically?
*Did you just become your PR Department’s best bud or worst enemy?
*Will it actually help companies choose better business partners? (many companies have been requiring rates during the RFP process anyway)
*Is everyone else in the organization now throwing in their 2 cents on how you run your business?
I look at this a few ways:
*If you already have a good program and record, this should be of little concern to you from the public information standpoint.
*Assuming that is the case, as a former corporate safety manager, I see this as a HUGE cost for companies to comply. But there has been (and still is) plenty of time to get things in place.
At the end of the day, you cannot control regulations. But can you control your injuries? You bet.
Two of the best ways to lower your injury rates? Do better investigations and audits. Why not join us for a future course? You can see the schedule and enroll HERE
I had a couple of things I wanted to share with our clients who work in quality:
First, Chris Vallee and I will be at the ASQ World Conference on Quality and Improvement starting Sunday. We will be in Booth 507, so please come and see us!
Second, we will be launching our new course, TapRooT® for Audits, at our 2016 Global TapRooT® Summit. The course will be on August 1-2 in San Antonio. I hope you can join us, and don’t forget to stick around for the summit itself on August 3-5. To register, visit HERE
The course will include a copy of our new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.
By the way, the new course is not just for quality people, it is for anyone who wants to learn to use TapRooT® for audits. Safety, Quality, Food Safety, Operations, it does not matter. And you do not to be previously trained in TapRooT® to attend.
If you already know how to use TapRooT® for auditing, but work in Quality and want to learn more about process improvement, Chris will be teaching the TapRooT® Quality Process Improvement Facilitator Course at the summit as well.
Hello and welcome to this week’s root cause analysis tips column. So what are the 3 Things You MUST Do When Finding an Incident’s Root Causes?
- You must know WHAT happened before you can determine why.
- You must know WHY before you can write corrective actions.
- You must FIX the root causes.
Let me elaborate:
You must know WHAT happened before you can determine why.
Too many investigators try to jump ahead and try to determine why things happened in an incident. But until you have all the facts, this is premature, and can lead to missing important data and letting the investigator’s bias drive the rest of the investigation. In the beginning of your investigation, you want to understand what happened. This is why evidence collection is so important.
Remember the old TV show Dragnet? The star of the show, Joe Friday, had a famous line:
“Just the facts, Ma’am, just the facts.”
Once you understand the facts, you can then move to why.
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. Your root cause analysis results are based on two things; the evidence you collected, and the guidance in the Root Cause Tree® Dictionary. If you do not have both, you do not have a strong case.
This is actually the easy part of TapRooT®, because the dictionary is all based on research.
Last but not least, 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.
How many times have you seen a corrective action that has nothing to do with the root cause? The Corrective Action Helper® has a check at the beginning of each section to make sure you are clear on what you are fixing. It does not matter how good something sounds, it has to directly apply to the root cause it is fixing. Otherwise it is extra work for no gain. And it likely means another investigation in the future.
And of course, it has to be implemented. Do you have a way to follow-up to make sure? And do you have a plan to judge the effectiveness?
Corrective actions are the OUTPUT of your investigation. Good investigations with weak corrective actions are a WASTE OF TIME.
Hopefully this gives you some things to think about. Thanks for visiting the blog, and if you want to learn how to do good investigations, join us at a future course.
CLICK HERE to view our upcoming course list.
We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.
TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.
Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.
TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:
TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Corrective Actions and Exercise
The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise
Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”
We hope to see you in the course! To register:
REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).
REGISTER for this 2-day course only (August 1 – 2, 2016).
We are busy preparing for this year’s summit, which will be held August 3-5 (with pre-summit courses on August 1-2) in San Antonio, Texas.
I’m very excited about the lineup for this year’s Safety Track. We have some great speakers and topics:
7 Deadly Sins of Human Performance – Mark Paradies, Creator of TapRooT®
Weatherford’s Global Journey to HSE and Quality Improvement with TapRooT® – Mitch Miller, David Smith, Shawn Holden
Proactive Use of TapRooT® – Dave Janney
Interviewing Behaviors & Body Language – Barb Phillips
Marathon Galveston Bay – Ken Bloch
Arc Flash Loss Prevention – Scott King and Terry Butler
TapRooT® in What If Analysis – Joel Solomon
In addition to the speakers in the safety track, all tracks with attend the keynote sessions each morning and afternoon, with top-notch speakers. We also have the famous Wednesday night reception with great food and drinks and featuring live entertainment from Carl Dixon (of the Guess Who, April Wine, and Coney Hatch). And the best part of the summit? Getting to meet other like-minded professionals; we hear every year from attendees that the Global TapRooT® Summit is the best networking opportunity of the year.
So please join us for the Safety Track at this yea’s summit. For more information and to register, go HERE
See you in San Antonio!
Dr. Sami Amarneh and I are teaching the 5 day course this week in Dubai. Here are some pictures of day 1.
It started with an unbelievable sunrise (my iphone pictures do not do justice):
Picture of Sami teaching:
And pictures of students working on their first exercise:
Why not join us for a future course? You can see the schedule and enroll HERE
Hello and welcome to this week’s root cause analysis tips column.
One of the questions I am asked often is “what should we investigate?”
The answer is it really depends on your company, your numbers, and your resources. I have some ideas, and these apply to anything, but I will use safety as an example.
First of all, your company may have a policy on what has to be investigated; for example, all lost time injuries or all recordable injuries. So you already know you are required to do those. But what if something is not required?
What I say is investigate as much as possible based on your numbers and your resources. If you work at a site that has 10 injuries a year but only 2 are recordable, if you have the resources to do all 10, I certainly would. It is likely the only difference between the 2 and the other 8 is……LUCK.
What if you have more than you can possibly investigate? Then you should do a really good job at categorization, and do investigations on the TRENDS. In other words, I would rather have you do one really good investigation on a trend than dozens of sub-standard investigations. You will use less resources but get better results.
How do you do an investigation on a trend? It is really very simple – instead of mapping out an incident with a SnapCharT®, you map out the process. You can leave the circle for the incident off the chart or you can make the circle the trend itself. The events timeline is simply the way the process flows from start to finish, and this is very easy to do if you understand the process. If you need help from the process owner, an SME, or employee, you can do that too. For conditions, you add everything you know about the process, as well as any data (evidence) available from the reports or other sources. You mark significant issues (the equivalent of causal factors) for things that you know have gone wrong in the past. You can take it a step further any also mark as significant issues things that COULD go wrong (think of this as potential causal factors). You then do your root cause analysis and corrective actions. This is not hard, it is just a different way of thinking.
Just a few more thoughts about what to investigate; basically, anything that is causing you pain. Process delays, customer complaints, downtime, etc. can all be investigated. But by all means, make sure it is worth your time and that there is really something to learn from it. Please don’t investigate paper cuts!
I hope my ideas give you some food for thought. Keep pushing the boulder up the hill and improving your business. Thanks for visiting the blog.
Sign up to receive tips like these in your inbox every Tuesday. Email Barb at email@example.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.
Yes, I know we are not quite into the new year yet, but we have been busy planning the next summit (August 1-5 in San Antonio TX).
As the coordinator of the safety track, I am really excited about the line-up we have for speakers. I will be posting information about the track and the different sessions on the blog as the date nears.
One session I am very excited about is a talk on Arc Flash Safety by Scott King and Terry Butler from Hallam-ICS. With relatively new NFPA guidelines, this is a hot (no pun intended) topic from a compliance standpoint. More importantly, it is a major consideration from a safety standpoint, so whether your country complies with NFPA 70E or not, this is a talk you will not want to miss. The talk is scheduled for Thursday, August 4th at 1:50. We hope to see you there.
In the meantime, if you are interested in getting some of your people trained in this important topic, here is a link to an upcoming event Hallam-ICS is holding in February:
Thanks for reading the blog and we look forward to seeing you in San Antonio!
I am in Iceland this week teaching the 5 day course. The class has been having a great time learning about TapRooT® and each night we take the 4 hour tour in our quest to see the Northern Lights, which we have not yet seen. Maybe tonight!
But not to worry, today during our final exercise we looked out the window of the classroom, and who do we see? David Cameron, the PM of the United Kingdom, who is making the first head of state visit from the UK to Iceland since Churchill.
So if you want some excitement in your life, you should attend a TapRooT® course!
This week I would like to ask the question…what is the difference between a safety incident and a quality problem?
Before you answer that, let me tell you that this is a trick question.
The answer is……drum roll please: there is NO DIFFERENCE. The difference in a safety problem vs. a quality problem is the consequence; there is no difference in the approach you take in investigating.
In TapRooT®, the first thing we always do is to create a SnapCharT®. And the first thing we do when creating a SnapCharT® is to define the incident with a circle. This defines the scope of your investigation. Your circle could contain anything that creates pain for your company and that you would like to prevent from happening again. Examples of things that might go in your circle:
• Lost time injury
• Recordable injury
• Vehicle accident
• Facility damage
• etc. etc.
• Defective product (not sent to customer)
• Defective product (sent to customer)
• Customer complaint
• Delayed shipment
• etc. etc.
Once you have defined the incident, you map out what happened, define the causal factors, perform root cause analysis, and develop corrective actions.
So start thinking about different ways your company can use TapRooT®. I’ve mentioned Safety and Quality, but there are many more. equipment reliability, environment, security, project delays; the list is really endless.
The more ways you can use TapRooT®, the better ROI you will get from your training. I know from experience when different disciplines in an organization start speaking the same language, there are some great intangible benefits as well. So if you are a safety manager, drag your quality manager with you to training next time. You will be glad you did.
Thanks for visiting the blog and best wishes for your improvement efforts.
Would you like to receive tips like these in your inbox? Our eNewsletter is delivered every Tuesday and includes root cause tips, career development tips, current events and even a joke. Contact Barb at firstname.lastname@example.org to sign up for the TapRooT® Friends & Experts eNewsletter.
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