Category: Investigations

Root Cause Tip Warning: Do not define the impact level of your incident too low or too high

October 19th, 2017 by

 

When defining the Incident during a TapRooT® Root Cause Analysis and its impact to the business (the scope of your investigation), I often hear this statement…

“If we focus on the delay of correcting the problem, then less importance will be placed on what caused the problem.”

Take the scenario of a fire pump failing to turn on during a fire response test. The team originally wanted to focus on the pump failure only. Not a bad idea however, the pump could not be repaired for 2 weeks because of a spare part shortage. I pushed the team to raise the scope and impact of the investigation to Automatic Fire Suppression System out of service for 14 days.

Now this elevation of the incident does not lessen the focus on the pump failure, it does the opposite. A system down for 2 weeks elevates the focus on the pump failure because of impact and also allows the team to analyze why we did not have access to spare pump in a timely manner.

A caution also must be mentioned in that elevating the impact of an incident too high can cause a regulating agency to get involved or/and additional resources to be spent when not required.

Which problem is worse? Elevating a problem too high or not high enough? Your thoughts?

Interviewing & Evidence Collection Tip: Get More Out of Interviews

October 5th, 2017 by

Where can you find a good portion of information to complete your SnapCharT®? Interviews! And how do we obtain interviews? People!

Why do we often forget that we are collecting information from human beings? Remember that an accident investigation may be a stressful event for everyone involved. There may be serious injuries and worries about the repercussions of participating in interviews or worries about whatever discipline the employer may impose in a blame culture.

Throughout the process, treat everyone with sensitivity:

  • Be ready for the interview.
  • Greet the interviewee by name, a firm handshake and a smile.
  • Break the ice by initiating a brief conversation not related to the incident. Put the interviewee at ease by listening to their contributions to the conversation without interruption.
  • Explain the interview process so they know what to expect.
  • Make it a practice to review the notes with the interviewee at the end of the interview. Let them know you will be doing that after explaining the process. They will feel more at ease if they have the opportunity to make any clarifications necessary.

Consideration for people’s fears goes a long way toward earning buy-in and confidence in the process.

What other things do you do to help an interviewee feel comfortable with the interview process? Share your ideas in the comments section below.

Radiation Release – Time for Root Cause Analysis

September 27th, 2017 by

A National Institute of Standards and Technology employee was exposed to radiation when a glass ampule broke.

Time for root cause analysis?

The US Nuclear Regulatory Commission has sent a team to investigate.

See the article at THIS LINK.

Root Cause Audits Prevent Environmental Excursions

September 27th, 2017 by

All too often we hear stories about sewage spills and overflows, causing environmental damage and costing utilities and operators large fines. Sometimes the causes are catastrophic, like hurricanes. Unfortunately most of the time the reason is human performance and equipment malfunctions.

King County in Washington state recently had to pay a $361,000 fine for spilling 235 M gallons of sewage into the Puget sound. An investigation found the causes to be inadequate maintenance, reliability issues and lack of backup equipment. There was also a lack of employee training. Besides the fine, the county has to better monitor emergency bypasses, improve the reliability of equipment and upgrade alarm features in the plant control system.

A closer look reveals an inexpensive float switch was at the core of the issue. In the past this type of switch has repeatedly clogged, jammed and failed. To keep operations going, employees would bend the rod back in place instead of replacing it. All in all direct plant damage is $35M. This is the fourth environmental excursion since 2000, a cost which is not quantified, but large.

Another example is a recent 830,000 gallon sewage release into the Grand River in Ottawa County, Michigan, due to a power outage. Six months ago a broken 45 year old pipe caused a 2 M gallon spill at the same location. Replacement cost of the pipe is $5 M, funds are not available so the utility is patching and hoping for the best.

These are just two recent cases that would have benefited from doing a root cause audit. The methodology is similar to a root cause analysis, except of course it is done before any incident, and aims to find and fix the most impactful risks.

Steps in a root cause audit

Planning for and doing an audit typically follows the following pattern:

  1. Plan the audit, determine the process flow of problems that could turn into significant issues
  2. Perform the audit and record the findings
  3. Define the significant issues (similar to causal factors in a root cause analysis)
  4. Use the Root Cause Tree to analyze each significant issue
  5. Analyze any generic causes for each root cause
  6. Develop preventive fixes
  7. Get approvals, and implement the plan

When done, take a moment to recognize the people that helped, and do not forget to celebrate! To make things easier, it is worthwhile to learn from those that came before you!

We have long experience with investigations and corrective actions that work. A new book by Paradies, Unger & Janney “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement” has practical check lists and advice on auditing and implementing corrective action. Read more and order your personal copy here: http://www.taproot.com/store/TapRooT-and-reg-for-Audits-Book-Set.html

Per Ohstrom is Vice President of Sales at System Improvements, Inc. #TapRooT_RCA

Generic Cause Analysis of the Navy’s Ship Collision/Grounding Problems

September 26th, 2017 by

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First, let me state that the reason I seem to be carried away by the failures of the Navy to implement good root cause analysis is that I spent seven years in the Navy and have compassion for the officers and sailors that are being asked to do so much. Our sailors and officers at sea are being asked to do more than we should ask them to do. The recent fatalities are proof of this and are completely avoidable. The Navy’s response so far has been inadequate at best.

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What should the Navy being doing? A thorough, advanced root cause analysis and generic cause analysis of the collisions and grounding in the 7th Fleet. And if you know me, you know that I think they should be using TapRooT® to do this.

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In TapRooT®, once you complete the analysis of the specific causes of a particular accident/incident, the next step is to identify the Generic Causes of the problems that caused that particular incident. Generic Causes are:

Generic Cause

The systemic cause that allows a root cause to exist.
Fixing the Generic Cause eliminates whole classes of specific root causes.

The normal process for finding generic causes is to look at each specific root cause that you have identified using the Root Cause Tree® and see if there is a generic causes using a three step process. The three steps are:

  1. Review the “Ideas for Generic Problems” section of the Corrective Action Helper® Guide for the root causes you have identified.
  2. Ask: “Does the same problem exist in more places?
  3. Ask: “What in the system is causing this Generic Cause to exist?”

It is helpful to have a database of thoroughly investigated previous problems when answering these question.

TapRooT® Users know about the Root Cause Tree® and the Corrective Action Helper® Guide and how to use them to perform advanced root cause analysis and develop effective corrective actions. If you haven’t been trained to use the TapRooT® System, I would recommend attending the 5-Day Advanced TapRooT® Root Cause Analysis Team Leader Training or reading the TapRooT® Essentials & Major Investigations Books.

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Unfortunately, we don’t have all the data from the recent and perhaps still incomplete Navy investigations to perform a TapRooT® Root Cause Analysis. What do we have? The press releases and news coverage of the accidents. From that information we can get a hint at the generic causes for these accidents.

Before I list the generic causes we are guessing at and discuss potential fixes, here is a disclaimer. BEFORE I would guarantee that these generic causes are accurate and that these corrective actions would be effective, I would need to perform an in-depth investigation and root cause analysis of the recent accidents and then determine the generic causes. Since that is not possible (the Navy is not a TapRooT® User), the following is just a guess based on my experience…

GENERIC CAUSES

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

Some of these problems should be fairly easy to fix in six months to two years. Others will be difficult to fix and may take a decade if there is the will to invest in a capable fleet. All of the problems must be fixed to significantly reduce the risk of these types of accidents in the future. Without fixes, the blood of sailors killed in future collisions will be on the hands of current naval leadership.

POTENTIAL FIXES

5. INAEQUATE CREW TEAMWORK AND CREW TEAMWORK TRAINING

  • Establish a crew teamwork training class oriented toward surface ship bridge watch operations that can be accomplished while ships are in port.
  • Conduct the training for all ships on a prioritized basis.
  • Integrate the training into junior officer training courses and department head and perspective XO and CO training.
  • Conduct underway audits to verify the effectiveness of the training, perhaps during shipboard refresher training and/or by type command staffs.

4. INADEQUATE WATCH SCHEDULES AND PRIORITIZATION OF TASKS FOR UNDERWAY REQUIREMENTS

  • Develop a standard watch rotation schedule to minimize fatigue.
  • Review underway requirements and prioritize to allow for adequate rest.
  • Allow daytime sleeping to reduce fatigue.
  • Minimize noise during daytime sleeping hours to allow for rest.
  • Review underway drills and non-essential training that adds to fatigue. Schedule drills and training to allow for daytime sleeping hours.
  • Train junior officers, senior non-commissions officers, department heads, XOs, and COs in fatigue minimization strategies.
  • Implement a fatigue testing strategy for use to evaluate crew fatigue and numerically score fatigue to provide guidance for CO’s when fatigue is becoming excessive.

3. INADEQUATE TRAINING OF THE CREWS OF THE SHIPS WE HAVE

This corrective action is difficult because a through training requirement analysis must be conducted prior to deciding on the specifics of the corrective actions listed here. However, we will once again guess at some of the requirements that need to be implemented that are not listed above.

a. SEAMANSHIP/SHIP DRIVING/STATION KEEPING

Driving a ship is a difficult challenge. Much harder than driving a car. In my controls and human factors class I learned that it was a 2nd or 3rd order control problem and these types of problems are very difficult for humans to solve. Thus ship drivers need lots of training and experience to be good. It seems the current training given and experience achieved are insufficient. Thus these ideas should be considered:

  • A seamanship training program be developed based on best human factors and training practices including performing a ship driving task analysis, using simulation training, models in an indoor ship basin, and developing shipboard games that can be played ashore or at sea to reinforce the ship handling lessons. These best practices and training tools can be built into the training programs suggested below.
  • Develop ship handing course for junior officers to complete before they arrive at their first ship to learn and practice common ship handling activities like man overboard, coming alongside (replenishment at sea), station keeping, maneuvering in restricted waters, contact tracking and avoidance in restricted waters.
  • Develop an advanced ship handing corse for department heads that refreshes/tests their ship handling skills and teaches them how to coach junior officers to develop their ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance.
  • Develop an advanced ship handling course for COs/XOs to refresh/test their ship handling skills and check their ability to coach junior officers ship handling skills. This course should include simulator training and at sea ship handling practice including docking scenarios, anchoring, restricted waters, and collision avoidance. The course should also include training on when the CO should be on the bridge and their duties when overseeing bridge operations in restricted waters including when to take control if the ship is in extremis (and practice of this skill).
  • Develop a simulator test for junior officers, department heads, XOs, and COs to test their ship handing and supervisory skills to be passed before reporting to a ship.
  • Develop bridge team training to be carried out onboard each ship to reinforce crew teamwork training.

b. NAVIGATION

  • Perform a task analysis of required navigation shipboard duties including new technology duties and duties if technology fails (without shipboard computerized aids).
  • Develop a navigation training program based on the task analysis for junior officers, department heads, XOs, and COs. This program should completed prior to shipboard tours and should include refresher training to be accomplished periodically while at sea.

c. ROOT CAUSE ANALYSIS

  • Develop a department head leadership program to teach advanced root cause analysis for shipboard incidents.
  • Develop a junior officer root cause analysis course for simple (lower risk) problem analysis.
  • Develop a senior officer root cause analysis training program for XOs, COs, and line admiralty to teach advanced root cause analysis and review requirements when approving root cause analyses performed under their command. (Yes – the Navy does NOT know how to do this based on the current status of repeat incidents.)

2. INADEQUATE STAFFING OF THE SHIPS WE HAVE

  • Develop a senior officer (Captain and above) training program to teach when a CO or line responsible admiral should “push back” when given too demanding an operational schedule. This ability to say “no” should be based on testable, numerically measurable statistics. For example, shipboard fatigue testing, number of days at sea under certain levels of high operating tempo, number of days at sea without a port call, staffing levels in key jobs, …
  • Review undermanning and conduct a root cause analysis of the current problems being had at sea and develop an effective program to support at sea commands with trained personnel.

1. INADEQUATE NUMBER OF SHIPS FOR THE USA FOREIGN POLICY COMMITMENTS

  • Develop a numerically valid and researched guidance for the number of ships required to support deployed forces in the current operating tempo.
  • Use the guidance developed above to demonstrate to the President and Congress the need for additional warships.
  • Evaluate the current mothball fleet and decide how many ships can be rapidly returned to service to support the current operating tempo.
  • Review the mothballed nuclear cruiser and carrier fleet to see if ships can be refueled, updated, and returned to service to support current operating tempo and create a better nuclear surface fleet carrier path.
  • Establish a new ship building program to support a modern 400 ship Navy by 2030.
  • Establish a recruiting and retention program to ensure adequate staff for the increased surface fleet.

Note that these are just ideas based on a Generic Cause Analysis of press releases and news reports. Just a single afternoon was spent by one individual developing this outline. Because of the magnitude of this problem and the lives at stake, I would recommend a real TapRooT® Root Cause Analysis of at least the last four major accidents and a Generic Cause Analysis of those incidents before corrective actions are initiated.

Of course, the Navy is already initiating corrective actions that seem to put the burden of improvement on the Commanding Officers who don’t have additional resources to solve these problems. Perhaps the Navy can realize that inadequate root cause analysis can be determined by the observation of repeat accidents and learn to adopt and apply advanced root cause analysis and support it from the CNO to the Chiefs and Junior Officers throughout the fleet. Then senior Navy officials can stand up and request from Congress and the President the resources needed to keep our young men and women safe at sea.

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Monday Accidents & Lessons Learned: Five People Die After Using Weight Loss Balloons

September 18th, 2017 by

 

According to the Food & Drug Administration’s report, five people have died since 2016 after being treated with weight loss balloon devices. The science behind this technology is that the balloon takes up space in the stomach after being filled with solution and this leaves less room in the stomach for food. The balloon is left in the patient’s stomach for six months while the patient learns to eat differently.

The five deaths occurred within a month of balloon placement.  We know that four of the deaths involved a balloon from the same manufacturer. However, nothing has been found linking the deaths to the medical device. In the TapRooT® System, an investigator would examine an incident like this by first creating a sequence of events. Once the sequence of events is completed,  more information would be collected.  For example:

Did the patient understand the risks?

Was the patient closely monitored by the healthcare team for possible deteriorations?

Did the patient understand which symptoms required medical assistance?

These are just a few of the types of questions that should be answered to help determine all the Causal Factors. There could be multiple things that went wrong. TapRooT® doesn’t stop at Causal Factors. Each Causal Factor is taken through the TapRooT® Root Cause Tree to find the Root Causes. Just like there may be (and probably is) more than one Causal Factor, there is probably more than one Root Cause that needs to be fixed to prevent this from happening again.

Mark Paradies recently posted an article that may be helpful in a situation like this, “Root Cause Analysis for the FDA.”

It takes some deep diving to understand all of the lessons learned here. Learn more about how to prevent unnecessary deaths like this in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

Root Cause Analysis for the FDA

September 13th, 2017 by

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

August 30th, 2017 by

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Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis:

As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

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Should you use TapRooT® to find the root causes of “simple” problems?

August 30th, 2017 by

Everybody knows that TapRooT® Root Cause Analysis is a great tool for a team to use when investigating a major accident. But can you (and should you) use the same techniques for a seemingly simple incident?

Lots of people have asked us this question. Instead of just saying “Yes!” (as we did for many years), we have gone a step further. We have created guidance for someone using TapRooT® when investigating low-to-moderate risk incidents.

Can you get this guidance? YES! Where? In our new book:

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

TapRooT Essentials Book

For “simple” incidents, we just apply the essential TapRooT® Techniques. This makes the investigation as easy as possible while still getting great results. Also, because you perform a good investigation, you can add your results to a database to find trends and then address the Generic Causes as you collect sufficient data.

Also, this “simple” process is what we teach in the 2-Day TapRooT® Training. See our upcoming public 2-Day TapRooT® Courses here:

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

Now … WHY should you use TapRooT® to analyze “simple” problems rather than something “simple” like 5-Whys?

Because:

  1. Even though the incident may seem simple, you want to find and fix the real root causes and not just focus on a single causal factor and end up with “human error” as a root cause (as happens many times when using 5-Whys).
  2. When you use TapRooT® for simple incidents, you get more practice using TapRooT® and your investigators will be ready for a bigger incident (if you have one).
  3. You want to solve small problems to avoid big problems. TapRooT® helps you find and fix the real root causes and will help you get the great results you need.
  4. The root causes you find can be trended and this allows analysis of performance to spot Generic Causes.
  5. Your management and investigators only learn one system, cutting training requirements.
  6. You save effort and avoid needless recommendations by applying the evaluation tool step built into the simple TapRooT® Process. This stops the investigation of problems that aren’t worth investigating.

That’s six good reasons to start using TapRooT® for your “simple” investigation. Get the book or attend the course and get started today!

Interesting Story – Was Quarry Employee Responsible for His Own Death?

August 24th, 2017 by

Jim Whiting, one of our TapRooT® Instructors in Australia, set me this article:

MCG Quarries blames Sean Scovell, 21, for his own death in 2012

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Read the article. What do you think? Where does self responsibility end and management responsibility start? What would your root cause analysis say?

Second Navy Ship Collides – What is going on?

August 23rd, 2017 by

First, god bless the missing and dead sailors and their families and shipmates who experienced this, the second crash in the past two months.

I’ve waited a couple of days to comment on this second Navy collision with fatalities because I was hoping more information would be released about what happened to cause this collision at sea. Unfortunately, it seems the Navy has clamped down on the flow of information and, therefore, no intelligent comments can be made to compare the collision of the USS John S. McCain with the earlier collision of the USS Fitzgerald.

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What do we know?

  • They are both similar Navy DDG’s with the same staffing levels (only 23 officers).
  • They were both in a shipping channel.
  • They both hit (or were hit by) a merchant ship.
  • The crew was trained to the same Navy standards.

That’s about it.

Of course, we know what they did to those involved in the previous accident (see my previous article HERE).

Was the timing of this second collision just bad luck?

We could use the Navy’s collision statistics to answer that question. Of course, you would have to agree about what is a collision. Would a grounding count? Would there have to be injuries or a fatality?

We would then use the advanced trending techniques that we teach in our pre-Summit trending course to see if the second collision was so close in time to the first that it indicated a significant increase in the collision frequency. To learn about these techniques, see:

http://www.taproot.com/taproot-summit/pre-summit-courses#AdvancedTrendingTrending

Since we don’t have facts (and will probably never get them), what is my guess? The things I would consider for this accident are the same as for the last. Look into what happened including:

  1. Fatigue
  2. Where was the CO?
  3. What did the CIC watch team do?
  4. Experience/training of the bridge and CIC team.

What should the Navy do? A complete, detailed TapRooT® Investigation.

Admiral Richardson (formerly the head of the Navsea 07 – the Nuclear Navy) has the right words about the analysis the Navy is performing. What is missing? A systematic guide for the investigators and prevent them from jumping to conclusions.

In a TapRooT® Investigation, we would start collecting facts and developing a SnapCharT® to truly understand what happened. Next we would identify all the causal Factors before we started analyzing their root causes using the Root Cause Tree® Diagram. Next, we would consider the generic causes and then develop effective (SMARTER) corrective actions. Unfortunately, this will be hard to do because of the Navy’s tradition of blame.

Some of my friends have been asking if I thought that some type of sabotage was involved. Some sort of hacking of the combat systems. In my experience, unless it was extremely foggy, you should be able to use your eyes and the simple bridge radar to navigate. You don’t need fancy technology to keep you from colliding. Simple “constant bearing decreasing range” tells you a collision is coming. To prevent it you turn or slow down (or perhaps speed up) to get a bearing rate of change to bring the other ship down whichever side is appropriate (use the rules of the road).

The trick comes when there are multiple contacts and restricted channels. That’s when it is nice to have someone senior (the Commanding Officer) on hand to second check your judgment and give you some coaching if needed.

Most of the time you spend of the bridge is boring. But when you are steaming in formation or in a shipping channel with lots of traffic, it quickly goes from boring to nerve-racking. And if you are fatigued when it happens … watch out! Add to that an inexperience navigation team (even the Commanding Officer may be inexperienced) and you have an accident waiting to happen.

Is that what happened to the USS John S. McCain? We don’t know.

What we do know is that the Navy’s typical blame and shame response with a safety stand down thrown in won’t address the root causes – whatever they may be – of these accidents.

The Navy seldom releases the results of their investigations without heavily redacting them. What we do know is that previous  investigations of previous collisions were heavy on blame and included little in the way of changes to prevent fatigue or or inexperienced watch standers. The fact is that the corrective actions from previous collisions didn’t prevent this string of collisions.

What can you do? Advise anyone you know in a position of responsibility in the Navy that they need advanced root cause analysis to improve performance. The young men and women that we send to sea deserve nothing less. Navy brass needs to end the blame game and coverup and implement truly effective corrective actions.

Why is getting the best root cause analysis training possible a great investment?

August 23rd, 2017 by

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Why do you train employees to investigate accidents, incidents, quality problems, equipment failures, and process upsets? Because those events:

  • Cost Lives
  • Cause Injuries
  • Ruin the Reputation of Your Product and Company
  • Cause Regulatory Issues (and Big Fines)
  • Cause Expensive Downtime
  • Cause Missed Schedules and Delayed Shipments

You want to learn from past problems to prevent future issues. Its even better if you can learn from small problems to prevent big accidents.

Therefore, you invest in your employees education because you expect a return on your investment. That return is:

  • No Fatalities
  • Reduced Injuries (Better LTI Stats)
  • A Reputation for Excellent Product Quality
  • Good Relations with Your Regulators and Community
  • Excellent Equipment Reliability and Reduced Corrective Maintenance Costs
  • Work Completed on Schedule
  • Shipments Go Out On Time and On Budget

When you think about your investment in root cause analysis training, think about the results you want. Review the diagram below (you’ve probably seen something like it before). Many managers want something for nothing. They want fast, free, and great root cause analysis training. But what does the diagram say? Forget about it! You can’t even have fast-great-cheap (impossible utopia). They usually end up with something dipped in ugly sauce and created with haste and carelessness! (Does 5-Why training ring a bell?)

NewImage(from Len Wilson’s blog)

What should you choose? TapRooT® Training. What does it do for you? Gives you guaranteed return on your investment.

What? A guarantee? That’s right. Here is our TRAINING GUARANTEE:

Attend a 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.

How can we make such an iron-clad guarantee? Because we have spent almost 30 years developing the world’s best root cause analysis system that has been tested and reviewed by experts and used by industry leaders. Over 10,000 people each year are trained to use TapRooT® to find and fix the root causes of accidents, quality problems, and other issues. Because of this extensive worldwide user base, we know that TapRooT® will help you achieve operational excellence. Thus, we know your investment will be worthwhile.

Plus, we think you will be happy with the investment you need to make when you see the results that you will get. What kind of results? That depends on the risk you have to mitigate and the way you apply what you learn, but CLICK HERE to see success stories submitted by TapRooT® Users.

Don’t think that the return on investment has to be a long term waiting game (although long term investments are sometimes worthwhile). Read this story of a FAST ROI example:

One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.

I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.

That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s about a 40000% instant ROI.

How much value can you achieve from your investment in great root cause analysis? Consider these issues:

  • How much is human error costing your company?
  • If the EPA fines you $100,000 per day for an environmental permit violation, how much could it cost?
  • What is your reputation for product quality worth?
  • How much is just one day of downtime worth to your factory?
  • How much would a major accident cost?

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I’m not asking you to take my word for how much great root cause analysis training (TapRooT® Training) will help your company. I’m just asking you to give it a try to see how much it can help your company.

Just send one person to one of our 2-Day or 5-Day TapRooT® Courses. Then see how they can help solve problems using the TapRooT® Techniques. I know that you will be pleased and I’ll feel good about the lives you will save, the improvements in quality that you will make, and the improved bottom line that your company will achieve when you get more people trained.

See the list of upcoming public TapRooT® Training being held around the world:

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

 Or contact us for a quote for a course at your site:

http://www.taproot.com/contact-us

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

August 18th, 2017 by

USS Fitzgerald

The Navy has taken the first action to avoid future collisions at sea after the crash of the USS Fitzgerald. The only question that remains is:

Why did it take Rear Admiral Brian Fort two months to determine who the Navy would punish?

After all, they knew who the CO, XO, and Command Master Chief were and they could just check the watch bill to see who was on the bridge and in CIC. That shouldn’t take 60 days. Maybe it took them that long to get the press release approved.

The Navy’s Top Secret root cause analysis system is:

Round up the usual guilty parties!

Here is what the Navy press release said:

“The commanding officer, executive officer and command master chief of the guided-missile destroyer USS Fitzgerald (DDG 62) were relieved of their duties by Vice Adm. Joseph Aucoin, Commander, 7th Fleet Aug, 18. 

Additionally, a number of officer and enlisted watch standers were held accountable. 

The determinations were made following a thorough review of the facts and circumstances leading up to the June 17 collision between Fitzgerald and the merchant vessel ACX Crystal.”  

Yet here is a part of the announcement from the Navy’s PR Officer:

“It is premature to speculate on causation or any other issues,” she said. “Once we have a detailed understanding of the facts and circumstances, we will share those findings with the Fitzgerald families, our Congressional oversight committees and the general public.”

The emphasis above was added by me.

It is premature to speculate on causes BUT we already know who to blame because we did a “thorough review of the facts.”

Now that all the BAD sailors have been disciplined, we can rest easy knowing that the Navy has solved the problems with seamanship by replacing these bad officers and crew members. There certainly aren’t any system causes that point to Navy brass, fleet-wide training and competency, or fatigue.

As I said in my previous article about this collision:

“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.”

With blame and punishment as the first corrective action, I don’t hold out much hope for real improvement (even though the Navy has a separate safety investigation). Perhaps that’s why I can’t help writing a scathing, sarcastic article because the Navy has always relied on blame after collisions at sea (rather than real root cause analysis). Our young men and women serving aboard Navy ships deserve better.

I won’t hold my breath waiting for a call from the Navy asking for help finding the real root causes of this tragic accident and developing effective corrective actions that would improve performance at sea. This is just another accident – much like the previous collisions at sea that the Navy has failed to prevent. Obviously, previous corrective actions weren’t effective. Or … maybe these BAD officers were very creative? They found a completely new way to crash their ship!

My guess is that Navy ships are being “ridden hard and put up wet” (horse riding terminology).

My prediction:

  1. The Navy will hold a safety stand down to reemphasize proper seamanship. 
  2. There will be future collisions with more guilty crews that get the usual Navy discipline.

That’s the way the Navy has always done it since the days of “wooden ships and iron men.” The only change … they don’t hang sailors from the yard arm or keel haul them in the modern Navy. That’s progress!

Bless all the sailors serving at sea in these difficult times. We haven’t done enough to support you and give you the leadership you deserve. Senior naval leadership should hang their heads in shame.

ACE – How do you find the root causes?

August 16th, 2017 by

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

Can Regulators Use TapRooT® Investigation Tools?

August 15th, 2017 by

Regulator Inspection Investigation

I had a question recently from one of our friends who works as a regulator in his country. He was wondering about the advantages of using TapRooT® as a regulator as opposed to an industry user. I think this is a great question.  We often think about doing incident investigations for ourselves, but how do you help those you oversee as a regulating body?

As a government agency, you have great potential to affect the safety and health of both your employees and those you oversee.

  • Just attending the TapRooT® training will give your staff the basic understanding of true, human-performance based root causes.  It gives your team a new perspective on why people make poor decisions, and just as importantly, why people make good decisions.  This understanding will guide your thinking as to why problems occur.   Once this perspective is clear, your team will no longer be tempted to just blame the individual for problems.  They will think more deeply about the organizational issues that are causing people to make bad decisions.
  • The training will give you the tools to perform accurate, consistent investigations.  You can have confidence in knowing that your team has discovered not one or 2 issues, but all the problems that led to an incident.
  • Your investigations and investigation report reviews using TapRooT® will be based on human performance expertise, helping to eliminate your team’s biases.  EVERYONE has biases, and using TapRooT® helps keep you focused on the true reasons people make mistakes.
  • You will also have the tools to be able to more accurately assess the adequacy of the investigations and corrective actions that are submitted to you by those you oversee.  You can see where they are doing good investigations, and where they probably need to improve.  The corrective actions that are suggested by those you oversee are often poorly written and do not address the real reasons for the incident.  The TapRooT® training will ensure you are seeing effective corrective actions.
  • If your agency conducts trending of the their results, you’ll be able to produce consistent, trendable data from your investigations.  If you ensure your industry constituents are also using TapRooT®, the data you receive from them will also allow for more accurate trending results.
  • Finally, you can use the TapRooT® tools learned during the course to perform proactive audits of your industry partners.  When you perform onsite inspections, you can ensure you are looking for the right problems, and assigning effective corrective actions for the problems encountered.  Instead of just looking for the same problems, the tools allow you to look deeper at the processes you are inspecting to find and correct potential issues before they become incidents.

TapRooT® gives you confidence that the results of your investigations, and those of those you oversee, result in fixable root causes and effective corrective actions.

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

August 11th, 2017 by

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

August 8th, 2017 by

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

Interviewing and Evidence Collection Tip: Why Sketch the Scene?

August 3rd, 2017 by

Sketch the scene after video and photography.

So, an incident occurred and you’re moving along in your evidence collection efforts.  You’ve recorded the scene with both video and photography. You’re feeling pretty good about your documentation.  Is there any reason to also sketch the scene?

Yes, there are – and here are two very good reasons:

1. Sketching the scene on paper is valuable because photographs and video can make objects appear closer together or farther apart than they really are.  If the evidence needs to have proportional measurements included in it, sketch it!

2. Sketches can be used in sensitive situations.  For example, if the recordings (photographs and videos) of an accident scene are disturbing to witnesses, you can use sketches of the scene when interviewing them.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

How Much Do You Believe?

August 1st, 2017 by

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!

Interviewing and Evidence Collection: Prepare to Record the Scene

July 27th, 2017 by

In TapRooT®, we use a mnemonic to quickly remember what types of evidence we may want to collect after an incident occurs: 3 Ps & an R. This stands for:

People evidence
Paper evidence
Physical evidence and
Recording evidence.

Recordings may include any photographs or video you capture. It may also include archived recordings such as computer data or security video.

Today, I have some quick reminders about things to consider in preparation of recording the scene (video or photographs).

First, ensure the battery is fully charged. I know, this is elementary right? Well, it is until you don’t do it and the battery dies in the middle of recording.

Second, remember to turn on the time and date display functions.  Then, you will have an automatic record of when the video was recorded or the photographs were taken without writing it down anywhere.

Third, clear the area of people.  Why? You do not want to record any embarrassing or inaccurate statements on video,  and you don’t want to place people at the scene who were not there originally on video or in a photograph.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

Is There Just One Root Cause for a Major Accident?

July 26th, 2017 by

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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.

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

Interviewing and Evidence Collection Tip: The #1 mistake when collecting Paper evidence

July 20th, 2017 by

 

In TapRooT®, we use a mnemonic to quickly remember what types of evidence we may want to collect after an incident occurs: 3 Ps & an R. This stands for:

People evidence
Paper evidence
Physical evidence and
Recording evidence.

Today we are going to discuss the #1 mistake investigators make when collecting Paper evidence. Paper evidence may include all sorts of things including:

  • regulatory paperwork
  • activity specific paperwork
  • personnel paperwork
  • policy and procedure paperwork and
  • equipment manuals.

What do you think the biggest mistake is when it comes to collecting Paper evidence… given all of the paper that we have in our workplaces?

The #1 mistake is: Collecting too much paper that is not relevant to the investigation!

You don’t need to collect every piece of paper at your facility. How do you know what you don’t need? By looking at your SnapCharT®! You need all the paper that supports your timeline of events and supports the facts.  If you use the TapRooT® software, you can easily upload .pdfs of this paperwork and highlight relevant pages in your report to management.

Don’t make the mistake of collecting so much paper that what you need for evidence is somewhere at the bottom of the stack. Use your SnapCharT® to guide you and keep your paper evidence organized in the TapRooT® software.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

 

How Long Should a Root Cause Analysis Take?

July 18th, 2017 by

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. 

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