Author Archives: Mark Paradies

Final Exercise at the 5-Day TapRooT® Advanced Root Cause Analysis Course in Seattle

Posted: August 19th, 2014 in Courses, Pictures, TapRooT

Just before starting the exercise …

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Teams working on their incidents …

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Instructions just prior to the presentations …

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Teams presenting …

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For more information about TapRooT® Root Cause Analysis Courses, see:

http://www.taproot.com/courses

How Far Away is Death?

Posted: August 19th, 2014 in How Far Away Is Death?, Video

Don’t stand under a load (or nearly under a load)! Click this video link below to watch…

WatchtheLoad.mp4

Monday Accident & Lessons Learned: OPG Safety Alert – Well Control Incident – Managing Gas Breakout in SOBM

Posted: August 18th, 2014 in Accidents, Investigations

Safety Alert Number: 258 

OGP Safety Alerts http://info.ogp.org.uk/safety

While drilling at a depth of 4747m, the well was shut-in due to an increase in returns with a total gain of 17bbls recorded. The well kill needed an increase in density from 1.40sg to 1.61sg to achieve a stable situation. With the well open the BHA was pumped out to the shoe and tripped 400m to pick up a BOP test tool to perform the post-kill BOP test.

The BOP and choke manifold test were performed as well as some rig maintenance. The BHA was then tripped into the hole and the last 2 stands were washed to bottom. Total pumps-off time without circulation was 44 hours.

Gas levels during the bottoms-up initially peaked at around 14% and then dropped steadily to around 5%. HPHT procedures were being followed and this operation required circulation through the choke for the last 1/3 of the bottoms up. This corresponds to taking returns through the choke after 162m3 is circulated.

After 124 cubic metres of the bottoms-up had been pumped the gas detector at the bell nipple was triggered. Simultaneously, mud started to be pushed up out of the hole, reaching a height of around 1 joint above the drill floor. The flow continued for around 30 seconds corresponding to a bubble of gas exiting the riser. The pumps and rotation were shut down, followed by closure of the diverter, annular and upper pipe rams. Approximately 2bbls of SBM were lost over-board through the diverter line. The flow stopped by itself after just a few seconds and casing pressure was recorded as zero. No-one was on the drill floor at the time and no movement, damage or displacement of equipment occurred.

After verifying that there was no flow (monitored on the stripping tank) the diverter was opened and 10 cubic metres of mud used to refill the riser, equal to a drop in height of 56m.

The riser was circulated to fresh mud with maximum gas levels recorded at 54%. This was followed by a full bottoms up through the choke.

A full muster of POB was conducted due to the gas alarms being triggered.

What Went Wrong?

Conclusion – An undetected influx was swabbed into the well during the BOP test which was then circulated up inadvertently though a non-closed system breaking out in the riser.

  1. Stroke counter was reset to zero after washing 3 stands to bottom (this resulted in 136 cubic metres of circulation not being accounted for in the bottoms up monitoring).
  2. Review of Monitoring While Drilling Annular Pressure memory logs identified several swabbing events identified – main event was when the BOP test tool was POOH from the wellhead – ESD as measured by APWD dropped to 1.59sg on 10 or 11 occasions.
  3. Swabbing was exacerbated by Kill Weight Mud not having sufficient margin above PP.

Corrective Actions and Recommendations:

  • Take into account all washing to bottom for any circulation where bottoms up is to be via choke.
  • Tool Pushers shall cross check the bottoms up calculation and joint agreement on reset of the stroke counter.
  • All BHA tripping speeds to be modeled so that potential swabbing operations are identified and so that tripping speed limits can be specified.
  • Verify, when possible, actual swabbing magnitude using PWD memory logs (ie after a trip out of the hole).
  • Pumping out (even inside liner/casing) shall be considered in tight tolerance liner/drilling BHA. Modeling shall be used to underpin the decision.

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the OGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Monday Motivation: Vidal Sassoon

Posted: August 18th, 2014 in Pictures

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The only place where success comes before work is in the dictionary. ~ Vidal Sassoon

Root Cause Tip: What Should We Improve Next?

Posted: August 13th, 2014 in Performance Improvement, Pictures, Root Cause Analysis Tips

Every company I’ve worked with has an existing improvement program.

Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some  still have a long ways to go, but have started their improvement process.

No matter where you are, one question that always seems to come up is …

What should we improve next?

The interesting answer to this question is that your plant is telling you if you are listening.

But before I talk about that, let’s look at several other ways to decide what to improve…

1. The Regulator Is Emphasizing This

Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.

2. Management Hot Topic

Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…

  • A recent accident (at your facility or someone else’s).
  • A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
  • That the CEO has a new initiative.

You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.

3. Industry Initiative

Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.

All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.

So how should you decide what to improve next?

By listening to your plant/facility.

What does “listening to you plant” mean?

To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.

Reactively collecting signals comes from your accident, incident, near-miss investigation programs.

It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.

I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.

Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.

Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).

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Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.

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Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler - see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)

Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.

Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.

 

 

 

Hydrocarbon Process Reports: “Pemex Blast at Ciudad Madero Refinery Kills Four Workers, Injures More”

Posted: August 12th, 2014 in Accidents, Current Events

An oil refinery in Ciudad Madero burst into flames earlier this week killing four workers. After evaluating the situation, officials determined that the refinery was under maintenance and not operating at the time of the fire. What caught fire? How did this happen? Reports indicated that this particular refinery, being the smallest of six in the company, may not have been producing it’s quota for daily production due to refining inefficiencies and infrastructure that went ignored for too long.

Fortunately, this accident forced the government to pass a law for private investments for the National Energy Industry. Consequently, they waited too long to invest in this maintenance and inefficiencies which lead to destruction.

See:

http://www.hydrocarbonprocessing.com/Article/3370103/Latest-News/Pemex-blast-at-Ciudad-Madero-refinery-kills-four-workers-injures-more.html

Amber Bickerton

Posted: August 11th, 2014 in Courses, Pictures, TapRooT

Students are having a great time in Seattle learning how to apply TapRooT® Root Cause Analysis System to solve problems.

Here are a couple of pictures of Ameber Bickerton, one of our newest contract instructors, teaching…

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 Amber is from Calgary and has been involved in safety for 12 years. See her LinkedIn profile at:

https://www.linkedin.com/pub/amber-bickerton/78/797/905

Monday Accident & Lessons Learned: CDC Report on the Potential Exposure to Anthrax

Posted: August 11th, 2014 in Accidents, Current Events, Investigations

Here’s the Executive Summary from the CDC Report:

Executive Summary

The Centers for Disease Control and Prevention (CDC) conducted an internal review of an incident that involved an unintentional release of potentially viable anthrax within its Roybal Campus, in Atlanta, Georgia. On June 5, 2014, a laboratory scientist in the Bioterrorism Rapid Response and Advanced Technology (BRRAT) laboratory prepared extracts from a panel of eight bacterial select agents, including Bacillus anthracis (B. anthracis), under biosafety level (BSL) 3 containment conditions. These samples were being prepared for analysis using matrix-assisted laser desorption/ionization time-of-flight (MALDI- TOF) mass spectrometry, a technology that can be used for rapid bacterial species identification.

What Happened

This protein extraction procedure was being evaluated as part of a preliminary assessment of whether MALDI-TOF mass spectrometry could provide a faster way to detect anthrax compared to conventional methods and could be utilized by emergency response laboratories. After chemical treatment for 10 minutes and extraction, the samples were checked for sterility by plating portions of them on bacterial growth media. When no growth was observed on sterility plates after 24 hours, the remaining samples, which had been held in the chemical solution for 24 hours, were moved to CDC BSL-2 laboratories. On June 13, 2014, a laboratory scientist in the BRRAT laboratory BSL-3 lab observed unexpected growth on the anthrax sterility plate. While the specimens plated on this plate had only been treated for 10 minutes as opposed to the 24 hours of treatment of specimens sent outside of the BSL-3 lab, this nonetheless indicated that the B. anthracis sample extract may not have been sterile when transferred to BSL-2 laboratories.

Why the Incident Happened

The overriding factor contributing to this incident was the lack of an approved, written study plan reviewed by senior staff or scientific leadership to ensure that the research design was appropriate and met all laboratory safety requirements. Several additional factors contributed to the incident:

  • Use of unapproved sterilization techniques

  • Transfer of material not confirmed to be inactive

  • Use of pathogenic B. anthracis when non-pathogenic strains would have been appropriate for

    this experiment

  • Inadequate knowledge of the peer-reviewed literature

  • Lack of a standard operating procedure or process on inactivation and transfer to cover all procedures done with select agents in the BRRAT laboratory. What Has CDC Done Since the Incident Occurred CDC’s initial response to the incident focused on ensuring that any potentially exposed staff were assessed and, if appropriate, provided preventive treatment to reduce the risk of illness if exposure had occurred. CDC also ceased operations of the BRRAT laboratory pending investigation, decontaminated potentially affected laboratory spaces, undertook research to refine understanding of potential exposures and optimize preventive treatment, and conducted a review of the event to identify key recommendations.

To evaluate potential risk, research studies were conducted at a CDC laboratory and at an external laboratory to evaluate the extent to which the chemical treatment used by the BRRAT laboratory inactivated B. anthracis. Two preparations were evaluated: vegetative cells and a high concentration of B. anthracis spores. Results indicated that this treatment was effective at inactivating vegetative cells of B. anthracis under the conditions tested. The treatment was also effective at inactivating a high percentage of, but not all B. anthracis spores from the concentrated spore preparation.

A moratorium is being put into effect on July 11, 2014, on any biological material leaving any CDC BSL-3 or BSL-4 laboratory in order to allow sufficient time to put adequate improvement measures in place.

What’s Next

Since the incident, CDC has put in place multiple steps to reduce the risk of a similar event happening in the future. Key recommendations will address the root causes of this incident and provide redundant safeguards across the agency, these include:

  • The BRRAT laboratory has been closed since June 16, 2014, and will remain closed as it relates to work with any select agent until certain specific actions are taken

  • Appropriate personnel action will be taken with respect to individuals who contributed to or were in a position to prevent this incident

  • Protocols for inactivation and transfer of virulent pathogens throughout CDC laboratories will be reviewed

  • CDC will establish a CDC-wide single point of accountability for laboratory safety

  • CDC will establish an external advisory committee to provide ongoing advice and direction for laboratory safety

  • CDC response to future internal incidents will be improved by rapid establishment of an incident command structure

  • Broader implications for the use of select agents, across the United States will be examined.

    This was a serious event that should not have happened. Though it now appears that the risk to any individual was either non-existent or very small, the issues raised by this event are important. CDC has concrete actions underway now to change processes that allowed this to happen, and we will do everything possible to prevent a future occurrence such as this in any CDC laboratory, and to apply the lessons learned to other laboratories across the United States. 

Monday Motivation: Zig Ziglar

Posted: August 11th, 2014 in Pictures

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People often say that motivation doesn’t last.
Well, neither does bathing – that’s why we recommend it daily. ~ Zig Ziglar

Pictures from the Final Exercise at the Lake Tahoe 2-Day Incident Investigation and Root Cause Analysis Course

Posted: August 6th, 2014 in Courses, Pictures, TapRooT

Here are pictures of hard working teams using TapRooT® to find the root causes of incidents that they brought to the class…

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Can you “picture” yourself using advanced root cause analysis (TapRooT®) to solve your companies toughest problems? If you haven’t been to a course yet, sign up now. See upcoming courses at:

http://www.taproot.com/store/Courses/

Changes to Newsletter Publications

Posted: August 6th, 2014 in Current Events

RETIREMENT OF THE ROOT CAUSE NETWORK™ NEWSLETTER

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After 121 issues, we’ve decided to retire the Root Cause Analysis Network™ Newsletter and publish all of our root cause analysis information in our weekly TapRooT® Expert and Friends Newsletter. This means you will occasionally  see longer content (CLICK HERE for an example) on this blog and in the weekly newsletter.

We also decided that we will start republishing articles from the over 20 years of great writing in the Root Cause Network Newsletters™ as blasts from the past. That will help new readers catch up on some of the great ideas that we’ve shared over the years and that are still as good as the day they were published. Look for the first of these articles in September.

To make sure that you get the TapRooT® Expert and Friends Newsletter, CLICK HERE to register. Also, tell others who need the latest root cause analysis ideas to register at the link above.

Best Regards,

Mark Paradies
Editor of the Root Cause Network™ Newsletter
President, System Improvements 

Pictures from the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course at Lake Tahoe

Posted: August 5th, 2014 in Courses, Pictures, TapRooT

The students below are hard at work reading the Root Cause Tree® Dictionary to discover why someone would break a rule. Ever wonder why people break the rules? Then maybe you should attend one of our 2-Day or 5-Day TapRooT® Courses!

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View more photos from Tahoe here:  http://www.taproot.com/archives/45935

Hydrocarbon Processing Reports: “Propylene leak blamed for fatal Taiwan gas blasts”

Posted: August 5th, 2014 in Accidents, Current Events, Investigations

A fatal gas blast in Taiwan’s biggest port city, Kaohsiung included 24 fatalities and 271 injured, four of which were policemen and fire fighters. Some of the nearby, uninjured residents assisted the injured by assembling makeshift stretchers, while the remaining 1,212 residents were relocated to safer grounds.

What was the root cause of this massive explosion? Local officials are still investigating. As of right now, their assessment is that there was a gas leak in a sewage pipeline that contained propylene, a gas used to make plastic and fabrics. This incident has been described as an “earthquake-like explosion” that knocked out thousands of local residents power and gas supply.

There are two main propylene producers in the area as well as two large oil refineries that are under investigation. All the sewage pipes in the city are being checked for further evidence and to see which company the particular pipe line that exploded is linked to. Until then, each of these companies have experienced stock share drops and are taking as many precautionary measures as possible to prevent a second explosion.

See the story at:

http://www.hydrocarbonprocessing.com/Article/3367621/Latest-News/Propylene-leak-blamed-for-fatal-Taiwan-gas-blast.html

Monday Accident & Lessons Learned: RAIB Investigation of Uncontrolled evacuation of a London Underground train at Holland Park station 25 August 2013

Posted: August 4th, 2014 in Accidents, Current Events, Investigations, Pictures

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Here’s the summary of the report from the UK RAIB:

At around 18:35 hrs on Sunday 25 August 2013, a London Underground train departing Holland Park station was brought to a halt by the first of many passenger emergency alarm activations, after smoke and a smell of burning entered the train. During the following four minutes, until the train doors still in the platform were opened by the train operator (driver), around 13 passengers, including some children, climbed out of the train via the doors at the ends of carriages.

The investigation found that rising fear spread through the train when passengers perceived little or no response from the train operator to the activation of the passenger emergency alarms, the train side-doors remained locked and they were unable to open them, and they could not see any staff on the platform to deal with the situation. Believing they were in danger, a number of people in different parts of the train identified that they could climb over the top of safety barriers in the gaps between carriages to reach the platform.

A burning smell from the train had been reported when the train was at the previous station, Notting Hill Gate, and although a request had been made for staff at Holland Park station to investigate the report, the train was not held in the platform for staff to respond. A traction motor on the train was later found to have suffered an electrical fault, known as a ‘flash-over’, which was the main cause of the smoke and smell.

A factor underlying the passengers’ response was the train operator’s lack of training and experience to deal with incidents involving the activation of multiple passenger emergency alarms.

The report observes that London Underground Limited (LUL) commenced an internal investigation of the incident after details appeared in the media.

RAIB has made six recommendations to LUL. These seek to achieve a better ergonomic design of the interface between the train operator and passenger emergency alarm equipment, to improve the ability of train operators to respond appropriately to incidents of this type, and to ensure that train operators carryradios when leaving the cab to go back into the train so that they can maintain communications with line controllers. LUL is also recommended to review the procedures for line controllers to enable a timely response to safety critical conditions on trains and to ensure continuity at shift changeover when dealing with incidents. In addition, LUL is recommended to review the training and competencies of its staff to provide a joined-up response to incidents involving trains in platforms and to reinforce its procedures on the prompt and accurate reporting of incidents so that they may be properly investigated.

Monday Motivation: Thomas J. Watson

Posted: August 4th, 2014 in Pictures

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If you want to achieve excellence, you can get there today.
As of this second, quit doing less-than-excellent work. ~ Thomas J. Watson

Benchmark Your Root Cause Analysis Efforts

Posted: July 30th, 2014 in Performance Improvement, Root Cause Analysis Tips, Root Causes

BENCHMARKING ROOT CAUSE ANALYSIS

I’ve had many people ask me to comment on their use of root cause analysis. How are they doing? How do they compare to others? So I thought I’d make a simple comparison table that people could use to see how they were doing (in my opinion). I’ve chosen to rate the efforts as one of the following categories …

  • Bad
  • Better
  • Even Better
  • Excellent

For each of these categories I’ve tried to answer the following questions about the efforts so that you could see which one most closely parallels your efforts. The questions are:

  • Who?
  • What?
  • When?
  • Where?
  • To What Extent?
  • Under What Conditions?

BAD

This is one step above no effort to find root causes.

Who performs the root cause analysis? The supervisor involved.

What do they use to perform the root cause analysis? 5-Why’s or no technique at all.

When do they perform the root cause analysis? In their spare time. (They must do their regular job and do the root cause analysis at the same time.)

Where do they perform the root cause analysis? Mainly in their office – they may do a few simple interviews with employees out in the plant but they don’t have a quiet, private room for interviewing.

To what extent do they pursue root causes? Usually as far as they think management will push them to go. If they can find a piece of equipment or a person to blame, that is far enough. The corrective actions can be to fix the equipment or to discipline the person and that is all that is needed.

Under what conditions do they perform the root cause analysis? They are in a hurry because management needs to know who to punish. Or the punishment may come before the root cause analysis is completed. They also know that if they can’t make a good case for someone else being blamed, they may get blamed for not having done a thorough pre-job risk assessment (call it a job safety analysis, pre-job brief, or pre-job planning if those terms fit better at your company). One more thing to worry about is that they certainly can’t point out any management system flaws or they may become a target of management’s wrath.

PROBLEMS WITH BAD

The problems with a BAD root cause analysis effort is that the solutions implemented seldom cause improvement. You frequently see very similar incidents happen over and over again due to uncorrected root causes.

Also, the root cause analysis tends to add to morale problems. People don’t like to be blamed and punished even if they may think that it was their fault. They especially don’t like it when they feel they are being made a scape goat.

Finally, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident that results in a fatality (or even worse, multiple fatalities). In almost every major accident, there were chances to learn from previous smaller issues. If these issues had been addressed effectively with a thorough root cause analysis and corrective actions, the major accident would have never occurred.

 

BETTER

Better is better than bad, but still has problems.

Who performs the root cause analysis? The supervisor involved.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? In their spare time. (Similar to BAD.)

Where do they perform the root cause analysis? Mainly in their office. (Similar to BAD.)

To what extent do they pursue root causes? They use the Root Cause Tree® and find at least one root cause for at least a few of the Causal Factors.

Under what conditions do they perform the root cause analysis? They are trained in only the minimum knowledge to use TapRooT®. Sometimes they don’t even get the full 2-Day TapRooT® Course but instead are given a “short course” which should be “good enough” for supervisors. (Supervisors don’t have time to attend two days of root cause analysis training.) They often treat the Root Cause Tree® as a pick list and don’t use (or perhaps don’t have a copy of) the Root Cause Tree® Dictionary to use to guide their root cause analysis. Also, they may not understand the importance of having a complete SnapCharT® to understand what happened before they start trying to find out why it happened (using the Root Cause Tree®). And they probably don’t use the Corrective Action Helper® to develop effective corrective actions. Instead, rely on the well understood three standard corrective actions: Discipline, Training, and Procedures.

PROBLEMS WITH BETTER

The problems with a BETTER root cause analysis effort is that people claim to be doing a thorough TapRooT® root cause analysis and they aren’t. Thus they miss root causes that they should have identified and they implement ineffective fixes (or at best, the weakest corrective action – training). The results may be better than not using TapRooT® (they may have learned something in their training) but they aren’t getting the full benefit of the tools they are using. Their misuse of the system gives TapRooT® a bad name at their site.

Also, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident (just like the BAD example above).

 

EVEN BETTER

Even better is the minimum that you should be shooting for. Don’t settle for less.

Who performs the root cause analysis? A well trained investigator. This investigator should have some independence from the actual incident.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? They either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.

Where do they perform the root cause analysis? They probably use a regular conference room to conduct interviews away from the “factory floor”.

To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest. This includes developing a thorough SnapCharT®, Safeguards Analysis to identify or confirm Causal Factors, the Root Cause Tree® and the Root Cause Tree® Dictionary to find root causes. And Safeguards Analysis and the Corrective Action Helper® to develop effective fixes.

Under what conditions do they perform the root cause analysis? They have support from management, who are also trained in what is required to find root causes using TapRooT®. They have experienced experts to consult with for difficult root cause analysis process questions. If it is a major investigation, they have the help of appropriate investigation team members and the root cause analysis effort is performed with a real time peer review process from another experienced TapRooT® facilitator.

PROBLEMS WITH EVEN BETTER

There aren’t too many problems here. There is room for improvement but the root cause analysis process and fixes are generally very effective. Smaller problems tend to be fixed effectively and help prevent major accidents from occurring.

The one issue tends to be that as performance improves, investigators get less and less experience using the TapRooT® techniques. New investigators don’t get the practice and feedback they need to develop their skills.

 

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EXCELLENT

Read Chapter 6, section 6.3, of the TapRooT® Book for a complete description of what an excellent implementation of TapRooT® looks like. This kind of TapRooT® implementation should be your long term root cause analysis effort goal. The following is a brief description of what Chapter 6 covers.

Who performs the root cause analysis? For major investigations, a well trained facilitator with a trained team. For more minor investigations, a trained investigator. The site investigation policy should clearly identify the investigative effort needed based on the actual and potential consequences of the particular incident.

What do they use to perform the root cause analysis? TapRooT®.

When do they perform the root cause analysis? Per the company’s pre-planning, the investigator and team either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.

Where do they perform the root cause analysis? For a major investigation an appropriate room is set aside for the team and they use a regular conference room to conduct interviews away from the “factory floor”.

To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest.

Under what conditions do they perform the root cause analysis? The management sponsor has pre-approved a performance improvement policy that covers the investigation process. managers, facilitators, and all employees involved are trained per the policy standards. A no blame or “just” culture has been established and the purpose of the investigation is understood to be performance improvement.

PROBLEMS WITH EXCELLENT

You can’t be excellent without a senior management sponsor and management support. And being excellent is a never ending improvement process.

Also, as performance improves, investigator get less experience with reactive investigations. Therefore, proactive use of TapRooT® must be an integral part of any EXCELLENT TapRooT® root cause analysis effort. Proactive use of TapRooT® is covered in Chapter 4 of the TapRooT® Book and an example of proactive use of TapRooT®, the after action review, is provided HERE.

 

BENCHMARK

How did your root cause analysis efforts compare? What do you need to improve? Even if you are EXCELLENT, you need to continuously improve your efforts. For even more improvement ideas and benchmarking, consider attending the 2015 Global TapRooT® Summit in Las Vegas on June 1-5. For more information, see:

http://www.taproot.com/taproot-summit

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