Author Archives: Mark Paradies

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

Posted: August 16th, 2017 in Current Events, Pictures, Quality, TapRooT

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

ACE – How do you find the root causes?

Posted: August 16th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Ace clipart four aces playing cards 0071 1002 1001 1624 SMU

First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

Posted: August 11th, 2017 in Accidents, Current Events, Investigations, Pictures

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

Posted: August 8th, 2017 in Accidents, Current Events, Investigations, Pictures, Video

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

How Much Do You Believe?

Posted: August 1st, 2017 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT, Training

I was talking to my kids about things they read (or YouTube videos) on the internet and asked them …

How much of what you see online do you believe?

I told them that less than half of what I see or read online is believable (maybe way less than half).

But the next question I asked was more difficult …

How do you know if something is believable? How would you prove it?

This made them think …

I said that I have a lifetime of experience that I can use to judge if something sounds believable or not. Of course, that isn’t proof … but it does make me suspicious when something sounds too good to be true.

They didn’t have much life experience and therefore find it harder to judge when things are too good to be true.

However, we all need to step back and think … How can I prove something?

What does that have to do about accident and incident investigations?

Do you have a built-in lie detector that helps you judge when someone is making up a story?

I think I’ve seen that experienced investigators develop a sense of when someone is making up a story.

We all need to think about how we collect and VERIFY facts. Do we just accept stories that we are told or can we verify them with physical evidence.

The 1-Day TapRooT® Effective Interviewing & Evidence Collection Course that will be held in Houston on November 8th will help you think about your interviews and evidence collection to make your SnapCharT® fact based. In addition to the 1-Day Interviewing Course you can also sign up for the 2-Day TapRooT® Root Cause Analysis Course being held in Houston on November 6-8 by CLICKING HERE.

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Barb Phillips will be the instructor for the Effective Interviewing & Evidence Collection Course. Don’t miss it!

Is There Just One Root Cause for a Major Accident?

Posted: July 26th, 2017 in Accidents, Courses, Investigations, Pictures, Root Cause Analysis Tips, Root Causes, TapRooT

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Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

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

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

Get Both Books and Save

Posted: July 25th, 2017 in Pictures, TapRooT

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There are two new books that explain how to perform TapRooT® root cause analyses.

One is used to investigate low to medium risk incidents. It is titled:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

It is used for fast, simple investigations.

The second is used for major investigations, big fires, oil spills, fatalities, and the such. It is titled:

Using TapRooT® Root Cause Analysis for Major Investigations

It includes all the TapRooT® optional techniques.

Did you know that you can buy both books at the same time and save? To order, CLICK HERE.

Mark Paradies and Kathy Ireland on Worldwide Business – It’s a wrap!

Posted: July 21st, 2017 in TapRooT, Video

Here’s a live Facebook cut from the end of shooting. We’ll post the show dates here.

System Improvements,Inc. is now LIVE on the set of Worldwide Business with kathy ireland!

Posted by Worldwide Business with kathy ireland on Wednesday, July 19, 2017

 

Where is Mark Paradies this Week?

Posted: July 19th, 2017 in Current Events, Video

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Where is Mark? In Los Angeles being interviewed by Kathy Ireland for an upcoming episode of Worldwide Business with Kathy Ireland®.

The topic? Root cause analysis.

When can you watch the show? We will post the times to watch when the release date is announced … stay tuned!

How Long Should a Root Cause Analysis Take?

Posted: July 18th, 2017 in Accidents, Investigations, Pictures, Root Cause Analysis Tips

How long should a root cause analysis take? This is a question that I’m frequently asked. 

Of course, the answer is … It DEPENDS!

Depends on what?

  • How complex is the incident?
  • Are there complex tests that need to be performed to troubleshoot equipment issues?
  • Is everyone available to be interviewed?
  • Is there regulatory coordination/interference (for instance … do they take control of the scene or the evidence)?
  • How far do you want to dig into generic causes?
  • What level of proof do you need to support your conclusions?

However, I believe most investigations should be completed in a couple of weeks or at most a couple of months.

Now for the exceptions…

REGULATORY DELAYS: We helped facilitate a major investigation that was progressing until the regulators took the evidence. They stated that they needed it for their investigation. Their investigation dragged on for over a year. Finally, they announced their findings and released the evidence back to the company. It turned out that none of the evidence sequestered by the government had anything to do with the reason for their investigation being delayed (they were doing complex modeling and videos to demonstrate their conclusions). After about an additional two months, the company investigation was completed. The companies investigation was delayed for over a year unnecessarily. 

SLOW INVESTIGATION DELAYED BY UNCOOPERATIVE PARTICIPANTS: One of the longest root cause analyses I’ve ever seen took four years. The agency performing the investigation is notoriously slow when performing investigations but this investigation was slow even by their standards. What happened? The investigation had multiple parties that were suing each other over the accident and some of the parties would not comply with a subpoena. The agency had to take the unwilling participant to court. Eventually, the evidence was provided but it took almost a year for the process to play out.

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SLOW INVESTIGATION PROCESSES: The most recent bad example is the Alison Canyon Natural Gas Storage leak root cause analysis. The investigation started when the leak was stopped 18 months ago. But the root cause analysis still is not finished. Why? Is seems the process is mired in public hearings. The spokesperson for the California Public Utilities Commission said that the “study” was in the third phase of a five phase process. What was slowing the “study” (root cause analysis and corrective actions) down? Public hearings. Here is what an article in NGI Daily Gas Prices said:

A California Public Utilities Commission spokesperson said the study remains in the third of a five-phase process that is to take more than three years. The third phase is expected to take up to nine months, and the fourth phase more than two months, before the final phase of “integration and interpretation” of the results is issued.

The process is scheduled to take three years! That definitely makes any kind of timely root cause analysis impossible. 

CONCLUSION: Many people complain about the time it takes for a good root cause analysis. But most excessive delays have nothing to do with the root cause analysis process that is chosen. Excessive delays are usually political, due to uncooperative participants, or regulatory red tape. 

Spin A Cause

Don’t try to save time on an investigation by picking the fastest root causes analysis tool (for example … Spin-a-Cause™), rather pick an advanced root cause analysis tool (TapRooT®) that will get you superior results in a reasonable amount of time and effort. 

One more idea…

Learn from smaller but significant incidents to avoid major accidents that have huge public relations and regulatory complications. Learning from smaller incidents can be much faster and save considerable headaches and money. 

What is the Root Cause of the USS Fitzgerald Collision?

Posted: July 17th, 2017 in Accidents, Investigations, Pictures, Root Causes

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As a root cause analysis expert and former US Navy Officer who was qualified as a Surface Warfare Officer (SWO) and was qualified to stand underway steaming Officer of the Deck watches, I’ve had many friends ask me what was the root cause of the collision of the USS Fitzgerald.

Of course, the answer is that all the facts aren’t yet in. But that never keeps us from speculation…

But before I speculate, let’s honor the seven crew members who died as a result of this accident: Dakota Kyle Rigsby. Shingo Alexander Douglass. Ngoc T Truong Huynh. Noe Hernandez. Carlos Victor Ganzon Sibayan. Xavier Alec Martin. Gary Leo Rehm Jr.

Also, let’s note that the reason for good root cause analysis is to prevent fatalities and injuries by solving the problems discovered in an accident to keep a similar repeat accident from happening in the future.

Mia Culpa: It’s been a long time since I stood a bridge watch. I’m not familiar with the current state of naval readiness and training. However, my general opinion is that you should never turn in front of a containership. They are big. Even at night you can see them (commercial ships are often lit up). They are obvious on even a simple radar. So what could have gone wrong?

1. It was the middle of the night. I would bet that one thing that has not changed since I was in the Navy is FATIGUE. It would be interesting to see the Oficer of the Deck’s and the Conning Officer’s (if there was one) sleep schedule for the previous seven days. Fatigue was rampant when I was at sea in the navy. “Stupid” mistakes are often made by fatigued sailors. And who is to blame for the fatigue? It is built into the system. It is almost invisible. It is so rampant that no one even asks about it. You are suppose to be able to do your job with no sleep. Of course, this doesn’t work.

2. Where was the CO? I heard that the ship was in a shipping lane. Even though it was the middle of the night, I thought … where was the Commanding Officer? Our standing orders (rules for the Officer of the Deck) had us wake the CO if a contact (other ship) was getting close. If we had any doubt, we were to get him to the bridge (usually his sea cabin was only a couple of steps from the bridge). And the CO’s on the ships I was on were ALWAYS on the bridge when we were in a shipping lane. Why? Because in shipping lanes you are constantly having nearby contacts. Sometimes the CO even slept in their bridge chair, if nothing was going on, just so they would be handy if something happened. Commander Benson (the CO) had only been in his job for a month. He had previously been the Executive Officer. Did this have any impact on his relationship with bridge watchstanders?

3. Where was the CIC watch team?  On a Navy ship you have support. Besides the bridge watch team, you are supported by the Combat Information Center. They constantly monitor the radars for contacts (other ships or aircraft) and they should contact the Officer of the Deck if they see any problems. If the OOD doesn’t respond … they can contact the Commanding Officer (this would be rare – I never saw it done). Why didn’t they intervene?

4. Chicken of the Sea. Navy ships are notorious for staying away from other ships. Many Captains of commercial shipping referred to US Navy ships as “chickens of the sea” because they steered clear of any other traffic. Why was the Fitzgerald so close to commercial shipping?

5. Experience. One thing I always wonder about is the experience of the crew and especially the officers on a US Navy ship. Typically, junior officers stand Officer of the Deck watches at sea. They have from a two to three year tour of duty and standing bridge watches is one of many things they do. Often, they don’t have extensive experience as an Officer of the Deck. How much experience did this watch team have? Once again, the experience of the team is NOT the team’s fault. It is a product of the system to train naval officers. Did it play a factor?

6. Two crews. The US Navy is trying out a new way of manning ships with two crews. One crew is off while the other goes to sea. This keeps the ship on station longer than a crew could stand to be deployed. But the crew is less familiar with the ship as they are only on it about 1/2 the time. I read some articles about this and couldn’t tell if the USS Fitzgerald was in this program or not (the program is for forward deployed ships like the Fitzgerald). Was this another factor?

These six factors are some of the many factors that investigators should be looking into. Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.

Should You Attend a Public TapRooT® Root Cause Analysis Course or Have a Course at Your Site?

Posted: July 12th, 2017 in Courses, Pictures, TapRooT

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People often ask me …

“Is it best to go to a public TapRooT® Root Cause Analysis Courses
or is it better to have a course at my site?”

I also get asked about the type of course they should attend.

Here are some answers to these frequently asked questions…

PUBLIC OR ON-SITE TapRooT® COURSE

PUBLIC: If you only have a few folks who are checking out the TapRooT® Root Cause Analysis System, I recommend attending one of our public courses. See the upcoming schedule by CLICKING HERE. Of course, we hold our courses all over the world, so you probably can find a course near you or in a location that you would really like to visit. In addition, you will meet people from other companies who use TapRooT® or are considering using TapRooT® and you can discuss your efforts to improve performance with them.

ON-SITE: If you have about 10 or more people at a site who need training, I recommend having on-site training. You will save money and your folks won’t have to travel. To get a quote for a course at your site, CLICK HERE.

WHAT COURSE SHOULD I ATTEND

First, you can see a list of all the courses we offer HERE. I usually recommend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training or the 2-Day TapRooT® Root Cause Analysis Training.

5-DAY TapRooT® TRAINING: The 5-Day Course is the most complete. It teaches techniques for simple investigations and major investigations. You get the most practice using all the TapRooT® techniques (you do a major exercise every day) and you get to practice using the TapRooT® Software (you get a trial subscription with the course).

What is covered in the course? Here is a course outline:

Day One

  • Class Introductions and Background of TapRooT®
  • SnapCharT® Basics
  • SnapCharT® Exercise
  • Define Causal Factors
  • Intro to Root Cause Tree®
  • Root Cause Analysis Exercise 1 – Class Walkthrough
  • Root Cause Analysis Exercise 2 – Team Use of the Root Cause Tree®
  • Developing Corrective Actions
  • Corrective Action Exercise

Day Two

  • Software Tips
  • Generic Causes/Systemic Problems
  • Enhanced Corrective Actions
  • Preparing for Your Investigation
  • Collecting Information
  • Interviewing
  • Interviewing Exercise
  • Interviewing Exercise Root Cause Analysis

Day Three

  • Management System and Changing Behavior
  • Equipment Troubleshooting and Equifactor®
  • Human Engineering
  • CHAP & Exercise
  • Change Analysis
  • Change Analysis Exercise
  • Analyzing Training Problems
  • Putting It All Together
  • Work Direction
  • Aviation Pilot Error Root Cause Analysis Exercise

Day Four

  • Testing Your Human Factors Knowledge
  • Proactive Improvement
  • Auditing Using Safeguard Analysis
  • Trending
  • Analyzing Procedure Issues
  • Operations Root Cause Analysis Exercise
  • Presenting to management
  • Start Final Exercise – SnapCharT®

Day Five

  • Continue Final Exercise
  • Final Exercise Presentations (Class end by 1 PM)

2-DAY TapRooT® TRAINING: The 2-Day TapRooT® Training teaches the essential root cause analysis techniques needed to investigate low to medium risk incidents. The course outline below provides you with the details of the course:

Day One

  • Class Introduction
  • TapRooT® System Overview
  • SnapCharT® Basics – Gathering information
  • SnapCharT® Exercise
  • Define Causal Factors
  • Intro to Root Cause Tree®
  • Root Cause Tree® Exercise
  • Root Cause Team Exercise
  • Developing Fixes
  • Corrective Action Exercise

Day Two

  • Software Overview
  • Generic Causes/Systemic Issues
  • Causal Factors – Additional Practice
  • Reporting/Management Presentation
  • Frequently Asked Questions
  • Final Exercise – Putting What You’ve Learned to Work

OTHER COURSES: These are just two of the courses we offer. For other courses including Trending, Proactive Improvement, and Information Collection and Interviewing, see: http://www.taproot.com/courses

COURSE GUARANTEE: When was the last time you attended training with a money back guarantee? Here is our training guarantee:

GUARANTEE

Attend this course, go back to work, and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked and
if you and your management don’t agree that the corrective actions that you recommend
are much more effective, just return your course materials/software
and we will refund the entire course fee.

That’s it. It’s just that simple. We are confident our training will help you find and fix the causes of your problems and we have hundreds of thousands of users worldwide who have attended our training and agree.

So don’t wait. Sign up for one of our public courses or get a course scheduled at you site to see how much TapRooT® Root Cause Analysis can help your company save lives, stop injuries, improve quality, improve equipment reliability, and boost operations performance. We know you will be pleased.

Should Helicopter Go Back in Service Before the Root Cause Analysis of a Crash is Finished?

Posted: July 12th, 2017 in Accidents, Current Events, Investigations, Pictures

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Finishing a root cause analysis before returning the Super Puma to service in the North Sea is the issue that the Unite union is upset about.

The UK and Norwegian Civil Aviation Authorities have authorized the flights but several oil companies are reluctant to resume using the helicopters before the root cause analysis is complete.

For the whole story, see: http://www.bbc.com/news/uk-scotland-north-east-orkney-shetland-40567877

Can bad advice make improvements more likely?

Posted: July 12th, 2017 in Current Events, Investigations, Performance Improvement, Root Cause Analysis Tips, TapRooT

Here is what a consultant recently wrote in a blog article that was republished on LinkedIn:

“The 5 WHY analysis is a simple and very effective technique.”

What do I think about 5 Whys? It is simple but it is NOT effective. Proof of the lack of effectiveness is all over the place. See these articles to find out just some of what I’ve written about the effectiveness of 5 Whys in the past:

 An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

Under Scrutiny (page 32)

If your root cause analysis is having problems, don’t double down on 5 whys by asking more whys. The problem is the root cause analysis system (5 Whys) and not your ability to ask why effectively.

The problem is that the techniques wasn’t designed with human capabilities and limitations in mind.

What system was developed with a human factors perspective? The TapRooT® Root Cause Analysis System. Read more about how TapRooT® was designed here:

http://www.taproot.com/products-services/about-taproot

Or get the book that explains how TapRooT® can help your leadership improve performance:

TapRooT® Root Cause Analysis Leadership Lessons

Are you a member of the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends?

Posted: July 11th, 2017 in Current Events, Performance Improvement, Root Cause Analysis Tips, TapRooT

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Sometimes people ask me what TapRooT® Users are doing about a particular issue. I recommend they ask the question on the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends.

There are over 3000 group members and it’ a great place to post a question or your opinions.

To join the group, see: https://www.linkedin.com/groups/2164007

 

What happens when root cause analysis becomes too simple? Six problems I’ve observed.

Posted: July 5th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT, Video

I’ve had many people explain to me that they understand that for serious incidents, they need robust root cause analysis (TapRooT®) because … finding effective fixes is essential. But for simple incidents, they just can’t invest the same effort that they use for major investigations.

I get it. And I agree. You can’t put the same level of effort into a simple incident that you put into a major accident. But what happens when the effort you put into a simple incident is too little. What happens when your simple investigation becomes too simple?

Here are the results that I’ve observed when people perform “too simple” investigations.

1. The first story heard is analyzed as fact.

People doing simple investigations often take the first “story” they hear about a simple incident and start looking for “causes”. The shortcut – not verifying what you hear – means that simple investigations are sometimes based on fairy tales. The real facts are never discovered. The real root causes are unknown. And the corrective actions? They are just ideas based on a fantasy world.

The result? The real problems never get fixed and they are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb.

2. Assumptions become facts.

This is somewhat similar to the first issue. However, in this case the investigator fills in holes in the story they heard with assumptions. Because the investigator doesn’t have time to collect much info, these assumptions become facts and become the basis for the root cause analysis and corrective actions.

The result? Just like the first issue, real problems never get fixed. The real, undiscovered problems are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb #2.

3. Skip root cause analysis and go straight to the fixes.

When you don’t have time for the investigation, why not just skip straight to the fixes? After all … we already know what caused the incident … right?

This is a frequent conclusion when people THINK they already know the answers and don’t need to bother with a troublesome investigation and root cause analysis to fix a “simple” problem.

The problems is that without adequate investigation and root cause analysis … you don’t really know if you are addressing the real issues. Do you feel lucky? Well do ya punk? (A little Clint Eastwood imitation.)

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The result? You are depending on your luck. And the problem you may not solve may be more powerful than a .44 magnum … the most powerful handgun in the world.

OK … if you want to watch the scene, here it is …

4. The illusion of progress.

Management often thinks that even though they don’t give people time to do a good investigation, simple investigations are better than nothing … right?

Management is buying into the illusion of progress. They see some action. People scurry around. Fixes are being recommended and maybe even being implemented (more training). So things must be getting better … right?

NO!

As Alfred A. Montapert said:

Do not confuse motion and progress.
A rocking horse keeps moving but does not make any progress
.”

The result? If people aren’t finding the real root causes, you are mistaking the mistake of assuming that motion is progress. Progress isn’t happening and the motion is wasted effort. How much effort does your company have to waste?

5. Complacency – Just another investigation.

When people in the field see investigators make up facts and fixes, they know the real problems aren’t getting fixed. They see problems happening over and over again. They, too, may think they know the answers. Or they may not. But they are sure that nobody really cares about fixing the problems or management would do a better job of investigating them.

The result? Complacency.

If management isn’t worried about the problems … why should I (the worker) be worried?

This contributes to “the normalization of deviation.” See this LINK is you are interested.

6. Bad habits become established practice.

Do people do more simple investigations or major investigations?

If your company is like most, there are tons of simple investigations and very few major investigations. What happens because of this? The practices used in simple investigations become the practices used in major investigations.

Assumptions, shortcuts, made up fixes and more become the standard practice for investigators. The things they learned in a root cause analysis class aren’t what they practice. What gets practiced (the bad practices) becomes the standard way that business is done.

The result? The same poor standards that apply to simple investigations infect major investigations. Major investigation have the same poor root cause analysis and corrective actions seen in the simple investigations.

DON’T LET BAD PRACTICES INFECT YOUR CULTURE.

Would you like to see good practices for performing simple investigations? Here are two options:

1. Attend a TapRooT® 2-Day Root Cause Analysis Course. See the the dates and location of upcoming public courses here:

http://www.taproot.com/store/2-Day-Courses/

2. Read the new book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

“Human Error” by Maintenance Crew is “Cause” of NYC Subway Derailment. Two Supervisors Suspended Without Pay.

Posted: June 29th, 2017 in Accidents, Current Events, Human Performance, Pictures, Root Causes

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The New York Daily News says that a piece of track was left between the rails during repair of track on the NYC subway system. That loose track may have caused the derailment of an eight car train.

The rule is that any track less than 19.5 feet either be bolted down or removed. It seems that others say that the “practice” is somewhat different. This piece of track was only 13.5 feet long and was not bolted down.

But don’t worry. Two supervisors have been suspended without pay. And workers are riding the railed looking for other loose equipment between the rails. Problem solved. Human error root cause fixed…

7 Traits of a Great Root Cause Analysis Facilitator

Posted: June 27th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, Summit, TapRooT

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After decades of teaching TapRooT® and being consulted about many investigations, I’ve met lots of root cause analysis facilitators. Some were good. Some were not so good. Some were really superior. Some were horrible. Therefore, I thought it might be interesting to relate what I see that separates the best from the rest. Here are the seven traits of the BEST.

1. They don’t jump to conclusions. The worst investigators I’ve seen think they know it all. They already have their minds made up BEFORE the first interview. They START the investigation to prove their point. They already know the corrective action they are going to apply … so all they have to do is affirm that the causes they already have assumed ARE the cause they find.

What do the best investigators do? They start by seeing where the evidence leads them. The evidence includes:

  • Physical evidence,
  • Paper evidence (documentations),
  • People evidence (interviews), and
  • Recordings (videos/pictures/tapes/computer records).

They are great at collecting evidence without prejudice. They perform “cognitive interviews” to help the interviewee remember as much as possible. (See the new book TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about cognitive interviews. The book should be released in August. Get the book with the course being held in November in Houston.)

The best investigators may have some technical knowledge, but they know when they need help to understand what the evidence is telling them. Therefore, they get technical experts when they need them.

2. They understand What before Why. The worst investigators start by asking WHY? Why did someone make a mistake? Why did the part fail? Why didn’t the guilty party use the procedure? These “why” questions tend to put people on the defensive. People start justifying what they did rather than sharing what they know.

The best investigators start with what and how. They want to understand what happened and how those involved reacted. What did they see as the problem? What were the indications they were observing? Who did they talk to and what did they say? What was happening and in what order did it happen?

People don’t get defensive about what and how questions. They are much more likely to share information and tell the truth. And these questions help develop an excellent SnapCharT® that helps the root cause analysis facilitator develop a “picture” of what happened.

3. They are not looking for the single root cause. The worst investigators are always looking for THE root cause. The smoking gun. The one thing that caused the problem that can be corrected by a simple corrective action. THE root cause that they are looking for.

The best investigators know that most accidents have multiple things that went wrong. They facilitate their team to understand all the causal factors and how these causal factors came together to cause that particular incident.

These root cause facilitators use their SnapCharT® and Safeguard Analysis to show how the problems came together to cause the incident. This can help show management how latent condition are hidden traps waiting to produce an accident that previously seemed impossible.

4. They dig deeper to find root causes. The worst investigator stop when they identify simple problems. For the worst investigators, HUMAN ERROR is a root cause.

The best investigators know that human error is just a starting point for a root cause analysis. They go beyond equipment failure and beyond human error by using effective investigative techniques that help them go beyond their own knowledge.

For example, if there is an equipment failure they consult the Equifactor® Troubleshooting Tables to find out more about the failure. This helps them get to the bottom of equipment problems. They often find that equipment failures are caused by human error.

For human performance related causal factors they use the Human Performance Troubleshooting Guide of the Root Cause Tree® to help them determine where they need to dig deeper into the causes of human error.

The best investigators don’t accept false stories. They have a good BS detector because false stories seldom make a sensible SnapCharT®.

5. They find root causes that are fixable. The worst investigators find root causes that management really can’t do anything to prevent. For example, telling people to “try harder” not to make a mistake IS NOT an effective corrective action to stop human errors.

The best investigators know that their are many ways to improve human performance. They understand that trying harder is important but that it is not a long-term solution. They look for human factors related fixes that come from human performance best practices. They know that the Root Cause Tree® can help them find problems with:

  • Procedures
  • Training
  • Quality Control
  • Communications
  • Management Systems
  • Human Engineering
  • Work Direction

And that by implementing best practices related to the root causes they identify, they can reduce the probability of future human errors.

6. They recommend effective corrective actions. The worst investigators recommend the three standard corrective actions for almost every problem:

  1. MORE TRAINING
  2. COUNSELING (tell them to be more careful and fire them if they get caught making the mistake again)
  3. If you are desperate, WRITE A PROCEDURE

That’s about it.

The best investigators start by understanding the risk represented by the incident. Higher risk incidents deserve higher order corrective actions. The highest order is to remove the Hazard. Other corrective actions may be related to strengthening the Safeguards by implementing human performance best practices. Sometimes these corrective actions may include training and procedures but that is seldom the only corrective actions recommended.

7. They know what they are doing. The worst investigators don’t really know what they are doing. They haven’t been trained to find root causes or the training they had was superficial at best. (Can you ask “Why?” five times?)

The best investigators are accomplished professionals. They’ve been in advanced root cause analysis training and have practiced what they have learned by performing many simple investigations before they were asked to jump into a major investigation. Even if they have several major investigations under their belt, they continue to practice their root cause analysis skills on simple investigations and on proactive audits and assessments.

Beyond practicing their skills, they attend the only worldwide summit focused on root cause analysis and investigation facilitation – The Global TapRooT® Summit. At the Summit they benchmark their skills with other facilitators from around the world and share best practices. Think of this as steel sharpening steel.

GOOD NEWS. The knowledge and skills that make the best investigators the best … CAN BE LEARNED.

Where? Have a look at these courses:

http://www.taproot.com/courses

And then plan to attend the 2018 Global TapRooT® Summit in Knoxville, Tennessee, on February 26 – March 2 to sharpen your skills (or have those who work for you sharpen their skills).

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Top 10 Reasons People Don’t Use TapRooT®

Posted: June 23rd, 2017 in Jokes, Pictures, TapRooT

10. Why do a root cause analysis when you can just discipline people.

9. Job security – they want more incidents to investigate.

8. They learned a system back in the 60’s and why should they try anything new.

7. Their company has no mistakes to investigate.

6. They don’t like tapping noises.

5. They would rather use their massive brainpower.

4. They are trying to get fired.

3. They just say that everything is human error.

2. They don’t grow trees.

1. They use Spin-A-Cause.

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How do you plan your root cause analysis?

Posted: June 20th, 2017 in Investigations, Pictures, Root Cause Analysis Tips, TapRooT

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General George Patton said:

“A good plan today is better than a perfect plan tomorrow.”

But for many investigations, I might ask … Do you have any plan at all?

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Copyright © 2016 by System Improvements, Inc. Duplication prohibited. Used by permission.

Planning is the first step in the TapRooT® 7-Step Major Investigation Process. We even recommend a simple plan for simple investigations.

You may have read the earlier article about using a SnapCharT® to plan your investigation (see: http://www.taproot.com/archives/58488)

What else can help you plan your investigation? Here’s a list:

  • Have an investigation policy that specifies team make up and other factors that can be predefined.
  • Make sure that people on the scene are trained to preserve evidence and to obtain witness statements.
  • Consider PPE requirements for team members visiting the scene.
  • Collect any recorded evidence (cell phone recordings).
  • Maintain a chain of custody for evidence.
  • Do you need legal or PR assistance for your team?

That’s just a few ideas. There is a whole chapter about planning in the new book: TapRooT® Root Cause Analysis for Major Investigations.

When you order the new book you will also get the latest copies of theRoot Cause Tree®, the Root Cause Tree® Dictionary, and the Corrective Action Helper® Guide – all of which were recently updated.

Order your copy by CLICKING HERE.

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