Category: Investigations

The “Force” was with HSE this time in Star Wars Accident

February 11th, 2016 by

“The actor, Harrison Ford, was struck by a hydraulic metal door on the Pinewood set of the Millennium Falcon in June 2014.”

“The Health And Safety Executive has brought four criminal charges against Foodles Production (UK) Ltd – a subsidiary of Disney.”

“Foodles Production said it was “disappointed” by the HSE’s decision.”

Read more here

 

New TapRooT® Essentials Book is Perfect for Low-to-Medium Risk Incident Investigations

February 10th, 2016 by

In 2008 we wrote the book TapRooT® – Changing the Way the World Solves Problems. In one book we stuffed in all the information we thought was needed for anyone from a beginner to an expert trying to improve their root cause analysis program. It was a great book – very complete.

As the years went on, I realized that everybody didn’t need everything. In fact, everything might even seem confusing to those who were just getting started. They just wanted to be able to apply the proven essential TapRooT® Techniques too investigate low-to-moderate risk incidents.

Finally I understood. For a majority of users, the big book was overkill. They wanted something simpler. Something that was easy to understand and as easy as possible to use and get consistent, high-quality results. They wanted to use TapRooT® but didn’t care about trending, investigating fatalities, advanced interviewing techniques, or optional techniques that they would not be applying.

Therefore, I spent months deciding was were the bare essentials and how they could be applied as simply as possible while still being effective. Then Linda Unger and I spent more months writing an easy to read 50 page book that explained it all. (Yes … it takes more work to write something simply.)

 

EssentialsBook

Book Contents:

Chapter 1: When is a Basic Investigation Good Enough?

Chapter 2: How to Investigate a Fairly Simple Problem Using the Basic Tools of the TapRooT® Root Cause Analysis System

  • Find Out What Happened & Draw a SnapCharT®
  • Decision: Stop or More to Learn?
  • Find Causal Factors Using Safeguard Analysis
  • Find Root Causes Using the Root Cause Tree® Diagram
  • Develop Fixes Using the Corrective Action Helper Module
  • Optional Step: Find and Fix Generic Causes
  • What is Left Out of a Basic Investigation to Make it Easy?

Chapter 3: Comparing the Results of a 5-Why Investigation to a Basic TapRooT® Investigation

Appendix A: Quick Reference: How to Perform a Basic TapRooT® Investigation

By April, the new book and philosophy will be incorporated into our 2-Day TapRooT® Root Cause Analysis Course. But you can buy the new book (that comes with the latest Dictionary, Root Cause Tree®, and TapRooT® Corrective Action Helper® Guide) from our web site NOW. See:

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

I think you will find the book invaluable because it has just what you need to get everything you need for root cause analysis of low-to-medium risk incidents in just 10% of the old book’s pages.

Eventually, we are developing another eight books and the whole set will take the place of the old 2008 TapRooT® Book. You will be able to buy the books separately or in a boxed set. Watch for us to release each of them as they are finished and the final box set when everything is complete. 

Will They Really Find the Root Causes?

February 3rd, 2016 by

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

Monday Accident & Lessons Learned: UK RAIB Report – Collision at Froxfield

January 25th, 2016 by

NewImage

Image of debris on track before the collision, looking east.
Train 1C89 approached on the right-hand track (image courtesy of a member of the public)

 

RAIB has today released its report into a collision between a train
and a fallen bridge parapet at Froxfield, Wiltshire, 22 February 2015

 

At around 17:31 hrs on 22 February 2015, a high speed passenger train (HST), the 16:34 hrs First Great Western service from London Paddington to Penzance, struck and ran over part of the fallen masonry parapet of an overline bridge at Froxfield, Wiltshire.

The train was fully loaded with around 750 passengers and was travelling at a speed of 86 mph (138 km/h) when the driver saw the obstruction. He applied the emergency brake but there was insufficient distance to reduce the speed significantly before the train struck the parapet. The train did not derail and came to a stop around 720 metres beyond the bridge. There were no injuries. The leading power car sustained damage to its leading bogie, braking system, running gear and underframe equipment.

The immediate cause of the collision was that the eastern parapet of Oak Hill Road overline bridge had been pushed off and onto the tracks, by a heavy goods vehicle which had reversed into it. The train had not been stopped before it collided with the debris because of delays in informing the railway about the obstruction on the tracks.

Recommendations

RAIB has made four recommendations relating to the following:

  • installation of identification plates on all overline bridges with a carriageway unless the consequence of a parapet falling onto the tracks or a road vehicle incursion at a particular bridge are assessed as likely to be minor
  • enhancing current road vehicle incursion assessment procedures to include consideration of the risk from large road vehicles knocking over parapets of overline bridges (two recommendations)
  • introduction of a specific requirement in a Railway Group Standard relating to the onward movement of a train that is damaged in an incident, so that the circumstances of the incident and the limitations of any on-site damage assessment are fully considered when deciding a suitable speed restriction, especially when there are passengers on board.

RAIB has also identified two learning points, one for police forces regarding the importance of contacting the appropriate railway control centre immediately when the safety of the line is affected and the other for road vehicle standards bodies and the road haulage industry about the benefits of having reversing cameras or sensors fitted to heavy goods vehicles

Notes to editors

  1. The sole purpose of RAIB investigations is to prevent future accidents and incidents and improve railway safety. RAIB does not establish blame, liability or carry out prosecutions.
  2. RAIB operates, as far as possible, in an open and transparent manner. While our investigations are completely independent of the railway industry, we do maintain close liaison with railway companies and if we discover matters that may affect the safety of the railway, we make sure that information about them is circulated to the right people as soon as possible, and certainly long before publication of our final report.
  3. For media enquiries, please call 020 7944 3108.

For the complete report, see:

https://www.gov.uk/government/uploads/system/uploads/attachment_data/file/493315/R022016_160120_Froxfield.pdf

Root Cause Tips – What Should You Investigate?

January 13th, 2016 by
night-office-shirt-mail copy

What if you have more than you can possibly investigate?

Hello and welcome to this week’s root cause analysis tips column.

One of the questions I am asked often is “what should we investigate?”

The answer is it really depends on your company, your numbers, and your resources. I have some ideas, and these apply to anything, but I will use safety as an example.

First of all, your company may have a policy on what has to be investigated; for example, all lost time injuries or all recordable injuries. So you already know you are required to do those. But what if something is not required?

What I say is investigate as much as possible based on your numbers and your resources. If you work at a site that has 10 injuries a year but only 2 are recordable, if you have the resources to do all 10, I certainly would. It is likely the only difference between the 2 and the other 8 is……LUCK.

What if you have more than you can possibly investigate? Then you should do a really good job at categorization, and do investigations on the TRENDS. In other words, I would rather have you do one really good investigation on a trend than dozens of sub-standard investigations. You will use less resources but get better results.

How do you do an investigation on a trend? It is really very simple – instead of mapping out an incident with a SnapCharT®, you map out the process. You can leave the circle for the incident off the chart or you can make the circle the trend itself. The events timeline is simply the way the process flows from start to finish, and this is very easy to do if you understand the process. If you need help from the process owner, an SME, or employee, you can do that too. For conditions, you add everything you know about the process, as well as any data (evidence) available from the reports or other sources. You mark significant issues (the equivalent of causal factors) for things that you know have gone wrong in the past. You can take it a step further any also mark as significant issues things that COULD go wrong (think of this as potential causal factors). You then do your root cause analysis and corrective actions. This is not hard, it is just a different way of thinking.

Just a few more thoughts about what to investigate; basically, anything that is causing you pain. Process delays, customer complaints, downtime, etc. can all be investigated. But by all means, make sure it is worth your time and that there is really something to learn from it. Please don’t investigate paper cuts!

I hope my ideas give you some food for thought. Keep pushing the boulder up the hill and improving your business. Thanks for visiting the blog.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

 

Monday Accident & Lessons Learned: Dust Explosion Prevention

January 4th, 2016 by

Screen Shot 2015 12 16 at 1 13 10 PM

See the link below to the pdf of the Dangerous Goods Safety Significant Incident Report Number 01-15 from the Government of Western Australia Department of Mines and Petroleum.

DGS_SIR_0115.pdf

Monday Accident & Lessons Learned: REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS MEASURED IN THE RESERVOIR LEADING TO KICK

December 21st, 2015 by

IOGP SAFETY ALERT

REDUCTION OF FLUID DENSITY BASED ON PRESSURE POINTS
MEASURED IN THE RESERVOIR LEADING TO KICK

Course of events:

  • Drilled 6×7″ hole section, ran screens and set hanger.
  • Displaced from 1.18 SG drilling fluids to 1.05 SG brine.
  • Closed in based on 600 l influx (PP estimated to be 1.09 SG)
  • Circulated out gas and displaced to 1.15 SG brine (using drillers method)

What Went Wrong?

Factors which contributed to the incident:

  • Brine weight reduction
  • Pore pressure prognosis
  • Lack of pressure point coverage of all sands during drilling

Corrective Actions and Recommendations:

  • Several pressure points where taken in the reservoir and these were used to reduce to mud weight from 1,08 sg to 1,05 sg brine. This reduction turned out to result in too great a weight decrease, since there were two small sand zones exposed that where not picked up on the log. It is important not to place to great a reliance on pressure points taken during the section, since there can be small zones that have not been caught on the log that may have a different pressure.
  • Instead of displacing the well to kill mud during the second circulation of the drillers method, the team decided to displace to a higher weight brine. This meant that they would continue operations faster, after the kill, than would have been the case if they displaced to drilling mud.

Source Contact:

safety alert number: 269
IOGP Safety Alerts http://safetyzone.iogp.org

Disclaimer

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

 

Monday Accident & Lessons Learned: FATALITY WHILE TRIPPING PIPE

December 14th, 2015 by

IOGP SAFETY ALERT

FATALITY WHILE TRIPPING PIPE

Country: USA – North America
Location: OFFSHORE : Mobile Drilling Unit
Incident Date: 20 October 2015   
Type of Activity: Drilling, workover, well services
Type of Injury: Struck by
Function: Drilling

NewImage
View of pipe stand in lower fingerboard

 A Deepwater drill crew was tripping in the hole with drill pipe.

As they were transferring a stand of pipe out of the setback area with a hydraracker, the stand caught on a finger at the 51′ lower fingerboard.

As the hydraracker continued to move, tension caused the pipe to bow and the pipe was released from the lower tailing arm with significant force toward the setback area striking and fatally injuring the employee.

What Went Wrong?

This investigation for this event is ongoing.

Corrective Actions and Recommendations:

While this incident is still under investigation, drilling rig operators using fingerboards with latches are recommended to:

  • Review and assess applicability of NOV Product Information Bulletin 85766409 and NOV Safety Alert Product Bulletin 95249112
  • Verify a system is in place to confirm the opening and closing of fingerboard latches (by way of CCTV or spotter)
  • Ensure personnel are kept clear of the setback area 

Safety Alert Nnumber: 268 
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

 

 

Monday Accident & Lessons Learned: IAEA’s Report on the Nuclear Accident at Fukushima

December 7th, 2015 by

For those still interested (the accident occurred in 2011) there is a report out by the IAEA on the Fukushima Nuclear Plant Accident (caused by a tsunami). 

Aside from the info in the report, I find it interesting when a report comes out way after an accident has occurred (in this case more than four years later). 

My question is, is learning possible this late after an accident or has everyone already moved on? Since the regulators have already issued regulatory requirements and many utilities have already taken action … is the report just for historical documentation?

What do you think?

Monday Accident & Lessons Learned: Is Training the Right Corrective Action for this Fatal Accident?

November 30th, 2015 by

Screen Shot 2015 11 29 at 2 07 15 PM

Here is a link to the significant incident report:

http://www.dmp.wa.gov.au/Documents/Safety/MSH_SIR_230.pdf

It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:

Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.” 

In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause. 

What do you think? Was this a training root cause that needs a training corrective action?

Leave your comments below…

Safeguard Analysis for Finding Causal Factors

November 25th, 2015 by

 

A Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening.

Once you’ve gathered all the information you need for a TapRooT® investigation, you’re ready to start with the actual root cause analysis. However, it would be cumbersome to analyze the whole incident at once (like most systems expect you to do). Therefore, we break our investigation information into logical groups of information, called Causal Factor groups. So the first step here is to find Causal Factors.

Remember, a Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening (or at least made it less severe).  So we’re looking for these mistakes or failures on our SnapCharT®.  They often pop right off the page at you, but sometimes you need to look a little harder.  One way to make Causal Factor identification easier is to think of these mistakes as failed or inappropriately applied Safeguards.  Therefore, we can use a Safeguard Analysis to identify our Causal Factors.

There are just a few steps required to do this:

First, identify your Hazards, your Targets, and any Safeguards that were there, or should have been there.

Now, look for:

- an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;

- an error that allowed a Safeguard to be missing;

- an error that allowed a Safeguard to fail;

- an error that allowed the Target to get too close to a Hazard; or

- an error that allowed the Incident to become worse after it occurred.

These errors are most likely your Causal Factors.

Let’s look at an example.  It’s actually not a full Incident, but a VERY near miss.  This video is a little scary!

Train Pedestrian Incident from TapRooT® Root Cause Analysis on Vimeo.

Let’s say we’ve collected all of our evidence, and the following SnapCharT is what we’ve found.  NOTE:  THIS IS NOT A REAL INVESTIGATION!  I’m sure there is a LOT more info that I would normally gather, but let’s use this as an example on how to find Causal Factors.  We’ll assume this is all the information we need here.

Picture1 Picture2

Now, we can identify the Hazards, Targets, and Safeguards:

Hazard Safeguard Target
Moving Train Fence Pedestrians
Pedestrians (they could have stayed off the tracks)

Using the error questions above, we can see that:

- An error allowed the Hazard to be too large (the train was speeding)

- An error allowed the Targets to get too close to the Hazard (the Pedestrians decided to go through the fence, putting them almost in contact with the Hazard)

These 2 errors are our Causal Factors, and would be identified like this:

Picture3 Picture4

We can now move on to our root cause analysis to understand the human performance factors that lead to this nearly tragic Incident.

Causal Factors are an important tool that allow TapRooT® to quickly and accurately identify root causes to Incidents.  Using Safeguard Analysis can make finding Causal Factors much simpler.

Sign up to receive tips like these in your inbox every Tuesday. Email Barb at editor@taproot.com and ask her to subscribe you to the TapRooT® Friends & Experts eNewsletter – a great resource for refreshing your TapRooT® skills and career development.

Monday Accident & Lessons Learned: What do you think of this Root Cause Analysis…

November 23rd, 2015 by

On November 6, I wrote about a “Safety Pause” at Savannah River Nuclear Solutions.

The last paragraph of the article was:

Let’s hope that the root cause analysis of the incident will explore the management system related failures that led to the reasons for the degraded emphasis on nuclear safety and security that caused the ‘Pause’ to be needed and not be an example of the blame game that points the finger at workers and low level supervisors and their actions.

So here is what the Aiken Standard wrote about the SRNS root cause analysis:

Following a root cause analysis of the incident, Spears said the incident was a result of the work team’s willful procedure violation and its unwillingness to call a time out. As a result, the contractor addressed the job performance of individuals using the SRNS Constructive Discipline Program and took appropriate disciplinary actions, according to SRNS.”

What do you think? Did they look into Management System causes?

If they don’t find and fix the Management System causes … how will they prevent a future repeat of this incident? 

In my experience, very seldom is someone a “bad person” that needs to be corrected using a discipline system. Usually, when someone breaks the rules, it is because a culture of rule breaking (or expediency) has taken hold in order to deal with unrealistic goals or unworkable procedures. 

I don’t think I have ever seen a team of bad people. If a “team” has gone bad (especially if a supervisor is involved), I would bet that the culture of expediency has been promoted. This bunch was just unfortunate enough to get caught in a serious incident and were handy to blame. No reason to look for any Management System causes. 

This is how a culture of expediency exists alongside a culture of blame. 

What can you learn from this incident?

One reason you use the TapRooT® System for root cause analysis is to find Management System root causes and fix them so that your management and employees don’t slip into a culture of expediency and blame. 

WSJ: “I was an Oil Spill Scapegoat”

November 9th, 2015 by

Screen Shot 2015 11 09 at 1 10 13 PM

 

The Wall Street Journal story above raises a great question. How effective is a federal prosecution in improving corporate and employee behavior?

Of course, the article was written by Kurt Mix, the accused, but it seems to raise very valid points that government investigations can go out of control, and that individuals have a very hard time fighting back against “the system.”

Why is the advice of any good attorney to “say nothing” to a criminal investigator before you have an attorney advising you? Because you may not know what serious laws you are breaking by what you see as non-criminal behavior.

Can this “don’t talk” advice make it harder for investigators to find the root causes of an accident? You bet!

So the next time you think that a criminal investigation is the answer to improve safety performance, maybe you should think again.

Monday Accident & Lessons Learned: Well Kick Due to Liner Top Seal Failure

November 9th, 2015 by

IOGP SAFETY ALERT

WELL KICK DUE TO LINER TOP SEAL FAILURE

After several attempts and a dedicated leak detection run, the 7” and 5” x 4-1/2” liner were inflow tested successfully to max difference of +10 bar.

Ran completion in heavy brine and displaced well to packer fluid (underbalanced).

Rigged up wireline pressure control equipment to install plug and prong in tubing tailpipe. While RIH with the plug on WL, a sudden pressure increase was observed in the well. Pressure increased to 125 bar on the tubing side.

Attempted to bleed off pressure, but pressure increased to 125 bar immediately.

Continued operation to install plug, pressure up tubing and set production packer.

Performed pump and bleed operation to remove gas from A-annulus. The general gas alarm was triggered during his operation due to losing the liquid seal on the poorboy degasser.

Continued pump and bleed operation until no pressure on tubing and A-annulus side, and the tubing and A-annulus were tested successfully.
NewImageWhat Went Wrong?

Failure of the 5″ liner hanger and 5″ tie-back packer.

Corrective Actions and Recommendations:

Difficult to bleed out gas in a controlled way due to sensitive choke and no pressure readings from poorboy degasser.

When performing pump and bleed operations, line up to pump down one line and take returns in a different line to optimize the operation.

Consider adequacy of the testing of the 5″ liner hanger.

Safety Alert Number: 267
IOGP Safety Alerts http://safetyzone.iogp.org/

Disclaimer:

Whilst every effort has been made to ensure the accuracy of the information contained in this publication, neither the IOGP nor any of its members past present or future warrants its accuracy or will, regardless of its or their negligence, assume liability for any foreseeable or unforeseeable use made thereof, which liability is hereby excluded. Consequently, such use is at the recipient’s own risk on the basis that any use by the recipient constitutes agreement to the terms of this disclaimer. The recipient is obliged to inform any subsequent recipient of such terms.

This document may provide guidance supplemental to the requirements of local legislation. Nothing herein, however, is intended to replace, amend, supersede or otherwise depart from such requirements. In the event of any conflict or contradiction between the provisions of this document and local legislation, applicable laws shall prevail.

Elements of a Credible Effective Root Cause Analysis

November 4th, 2015 by

Many people ask “What makes a good RCA?”. This question as stated is difficult to answer due to the fact that “good” is a very subjective term. What is good for one may not be good enough for another and vice versa. But, if we replace one simple word in that question we can make it a much more objective question. By changing that term to “credible” and/or “effective,” now we have a good starting point as both these terms have investigative standards and principles behind them. Let’s start with some definition:

Credible: This term is defined as “able to be believed; convincing.” Let’s focus on an investigation for our example and ask what would make our investigation able to be believed? One simple answer comes to mind, the ability to see the relationship between our Root Causes, our Causal Factors, and our Incident. That “Specific” relationship as we call it is dependent on the data collected in an investigation and ability for your audience to be able to connect those “dots” if you will.

Effective: This term is defined as “successful in producing a desired or intended result”. This focuses on the outcome of an action and what the desired results or end point is. For investigations the outcome or desired result is to implement fixes and Corrective Actions that will in the future reduce the risk of or remove the risk of a reoccurrence. The audience’ ability to see the effectiveness of the Corrective Actions is key.

So if we add both these words together and use them in combination to define an investigation we can now see how to answer the initial question.

Credible Root Cause Analyses

Let’s begin with the word credible and provide some guidance for our TapRooT® Users. When I look at and review any investigation the credibility is established for me in two techniques, the SnapCharT® and the Root Cause Tree®.

SnapCharT®

Let me put this as simply and as plainly as I can, when building your chart the team should put ALL information into that SnapCharT®. No matter how insignificant something may seem, or how common place something may be it should be on the chart for transparency and for use during the analysis on the Root Cause Tree®. Anytime you make a conscious effort to leave information off the chart you open yourself up for questions and you reduce the ability of your audience to “connect the dots” as mentioned above. This lowers your credibility significantly.

This can also lead to issues when your audience tries to understand the relationship between the Root Causes you have chosen on the Root Cause Tree® and the information on the SnapCharT®. This relationship should be as “transparent” as possible and the audience should not have to work to figure out the relationship. There should be a direct link between data on the chart and the Root Causes from the Root Cause Tree®.

Nurse 1Nurse 2
Above you see two examples of the same Causal Factor. The one on the left shows very little detail about the issue or problem, the one on the right shows all the data known about the same issue. Which one do you believe will help your audience and investigative team understand the problem?

Root Cause Tree®

Once the thorough “transparent” SnapCharT® is completed and the investigation move into the Root Cause Tree® to analyze your Causal Factors, documentation is the key to credibility. Three statements that can kill credibility are: “I believe,” “I think,” and “I am pretty sure,” Each one of these statements provides your audience with doubt as to what you truly know. This is why I always recommend the use of the Root Cause Tree® Dictionary and Analysis Comments in the Root Cause Tree® for documentation. This provides the connection and the defendable path for you and your audience.

As the Tree is analyzed the investigation should have data from the SnapCharT® to confirm each selection on the Root Cause Tree® as well as one or many questions answered as a yes from the Dictionary. Take that data (cut and paste) and put that into the Analysis Comments in the TapRooT® Software to document “why” you answer yes, and to show the audience your reasoning.

1 copy
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2.
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Simply right click on the item and open the Root Cause Tree® Dictionary, highlight and copy the question or questions you get a yes to. Then use the same Rt-click menu to select the Analysis Comments Field.

AnalysisCommentField copy 2
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Paste the copied text into this field and then describe the information from the SnapCharT® that gives you the yes. Click OK and that information is stored with your Root Cause Tree®. To access this information you can use the same Rt-click menu and select Analysis Comment again, or in the reports section for that investigation select the Root Cause Tree® Comment Report. This will contain all comments associated with each Causal Factor and Root Cause Tree®.

RCTCommentReport copy
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This provides you with not only documentation for every step in the process but also with the “I know because” answer to any question that may arise. If data can be provided at any point in the Root Cause Analysis to show the “whys”, there is very little debate as to the credibility of the analysis. People may not like your answers, but they cannot deny them.

Effective Investigations

We have explored the “Credibility” of analyses so now we need to look at the Effective portion. We concluded that this measure is tied to the effectiveness of the Corrective Actions we present and implement. An analysis by itself cannot be effective without corrective and preventative actions that solve the Root Causes and prevent or reduce the likelihood of recurrence in the future.

When developing our Corrective Actions for the Root Causes we find during our analyses we have to consider the following items for each action:

Implementation: The act of putting the specific action in place in our systems and organization

Verification: This is a short-term measure of implementation. How are we going to ensure that what we proposed as the Corrective Action was implemented properly.

Validation: This is a long-term measure of effectiveness. This plan is based around the question, “What will success look like?” built with a plan to measure the progress (or regression) towards that outcome.

Most companies do a pretty effective job of the Implementation phase, implementing actions for every root cause. But in follow-up to these actions they do nothing; seemingly they wash their hands of the issue and say they are done. Implementation by itself does not ensure success. The two measurements above are very important because the provide some level of oversight for the actions and are a quality control check to make sure the actions hit the mark. If for any reason the Validation shows that the action is not having the desired effect the action needs to be revisited and revised if necessary starting the cycle again.

If Corrective Actions are implemented and not measured you increase the risk of the implementation falling short, or the action itself not actually having a positive impact on your systems and employees.

Summary

In the end, the credibility of your analysis is dependent on the data you collect, the quality (not quantity) of the data, and how it is used to confirm any answers found on the Root Cause Tree®. The effectiveness is dependent on the success of the corrective actions implemented and the longer term sustained success of the changes in the system to stop future recurrence. By following the 7-Step Process flow, and the Core techniques highlighter here within the TapRooT® process the system will guide you through these steps and aid you in successfully providing your management with a very Credible and Effective Investigation.

Want to learn more?

Our 5-Day TaprooT® Advanced Root Cause Analysis Team Leader Training provides all of the essentials to perform a root cause analysis plus advanced techniques.  You also receive a single user copy of TapRooT® software in the 5-day course.  The software combines incident identification, analysis, and dynamic report writing into one seamless process.

All Root Cause Analyses Are NOT Created Equal

September 30th, 2015 by

I saw an article about a hospital error that injured a patient. The article said they were going to perform a root cause analysis. It’s strange how a simple line in an article can get me WORKED UP.

Why am I WORKED UP? I know that many root cause analyses are BAD.  What defines bad root cause analysis?

  • The look to place blame.
  • They look to cover up mistakes.
  • They look for easy answers.
  • They jump to conclusions.
  • They pick their favorite root causes.
  • They don’t improve performance.

That’s a BAD list. But I see it all the time.

In fact, that’s why I started to work inventing TapRooT®. I wanted to solve those problems. And for many TapRooT® Users, we have.

But there still is a long way to go.

There are still people who think that 5-Whys is a good system (some would even say an advanced system) for finding root causes.

Some don’t recognize the drawback of using cause and effect to analyze problems. That there is a tendency to find the answer that you want to find (rather than looking at the evidence objectively).

Some think that just filling out a form is good enough. Somehow this will prevent mistakes and save lives.

WELL I HAVE NEWS FOR THEM … It hasn’t worked for years and it won’t start working tomorrow!

The definition of insanity is to keep doing things the same way and to expect a different result.

Don’t be insane!

It is time to try TapRooT® and see how it can help guide you to the real, fixable causes of problems.

We guarantee our courses.

Here is the guarantee:

Attend the 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.

If you are investigating serious problems, then attend a 5-Day TapRooT®  Advanced Root Cause Analysis Team Leader Course. Here’s more information about the course: http://www.taproot.com/courses#5-day-root

Here are our upcoming public courses being held around the world:

http://www.taproot.com/store/5-Day-Courses/

Accident/Incident Investigation Statistics … Typical Corrective Actions + More

September 22nd, 2015 by

Found an interesting old (2000) report from the UK HSE about incident/accident investigations. They had a contractor perform surveys about accident/incident investigation tools and results.

TYPE OF INVESTIGATION SYSTEM

It seems that homegrown investigation systems or no system were the most frequently used to investigate accidents/incidents.

CORRECTIVE ACTIONS

With that type of investigation system, it should be no surprise that the three top corrective actions were:

  1. Tell them to be more careful/aware.
  2. Training/refresher training
  3. Reinforce safe behavior (Is that discipline?)

That’s what we found back in the early 1990’s.

Think it has changed any today?

HOW MUCH TIME SPENT INVESTIGATING?

Another interesting fact. How long did people typically spend doing investigations?

  • 42% took 5 hours or less
  • 35% took 5 to 20 hours
  • 18% took over 20 hours

Of course this is an old UK survey. Does it match up with your current experience?checklist-41335_640

INVESTIGATION TRAINING

One third of those polled had NO accident/incident investigation training. Most of the rest just had general health and safety training as part of IOSH or NEBOSH courses. Also, most people performing investigations were not dedicated health and safety professionals.

What do you think? Is this similar to your experience at your company?

EXAMPLES

The report then provided a review of example investigations that the researchers had reviewed. As an expert in root cause analysis, these were awful but typical. many just filled out a form. Others grilled people and decided what they thought were the causes and the corrective actions.

HOW ARE YOU DOING?

Are you 15 years behind with no system, no training, and bad results?

Then you need to attend a TapRooT® Course. See: http://www.taproot.com/courses

Have you started to improve but still have a long way to go? You might want to attend one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Courses. See: http://www.taproot.com/store/5-Day-Courses/

Are you good to great but you want to be even better? The plan to attend the 2016 Global TapRooT® Summit in San Antonio, TX, on August 1-5. We’ll be posting more details about the Summit soon.

Monday Accident & Lessons Learned: Restart Risk After an Accident

September 7th, 2015 by

After an accident, what is the risk that you face if you restart production before you find and fix the root causes of an accident? Starting too soon may risk the chance of another disaster.

Of course, that depends on the risk profile of the accident in question and your operations.

SpaceX is keeping their Falcon 9 rocket grounded for a couple more months after a June explosion of their booster rocket that was carrying supplies to the international space station.

Troubleshooting after the accident points to a failed strut that was holding a bottle of helium in place that, when it failed, caused an over-pressure of the second-stage rocket. See the story here.

Do you analyze the risk of restarting production after an incident or accident? Perhaps this is something your management should consider?

Politician Calls for Root Cause Analysis

September 4th, 2015 by

This is not the Friday Joke.

Root cause analysis has become so popular that politicians are now calling for companies to complete a root cause analysis and implement corrective actions.

NewImage

Massachusetts Governor Charlie Baker wrote a letter to Entergy Nuclear Operations calling on them to “… perform an appropriate root cause analysis …” of safety issues the NRC had announced “… and to complete all necessary repairs and corrective actions.”

The letter was in response to an unplanned shutdown at the Pilgrim nuclear power plant in Plymouth, Massachusetts caused by a malfunctioning main steam stop valve (one of eight valves that is designed to shut off steam from the reactor to the turbine that generates electricity). The valve had failed shut.

For all those not in the nuclear industry, note that in the nuclear industry, a failure of one of eight valves that failed in the safe direction (shut) and that has backup safety systems (both manual and automatic) can get a public letter from the Governor and attention from a federal regulator. Imagine if you had this level of safety oversight of your systems. Would your equipment reliability programs pass muster?

The response from Entergy to the Governor noted that, “We have made changes and equipment upgrades that have already resulted in positive enhancements to operational reliability.” (Note that these fixes occurred in less than a week after the original mechanical failure.)

For more about the story, see: http://www.wbur.org/2015/09/03/baker-pilgrim-nuclear

Note the local NPR story at the link above is inaccurate in its description of the problem and the mechanical systems.

For those interested in improving equipment reliability and root cause analysis, consider attending one of our 3-Day TapRooT®/Equifactor® Equipment Troubleshooting and Root Cause Analysis Courses. See the upcoming course list at:

 http://www.taproot.com/store/3-Day-Courses/

Now for the biggest question … 

When will government authorities start applying root cause analysis
to the myriad of problems we face as a nation and start implementing appropriate corrective actions?

Root Cause Tip: What is the minimum investigation for a simple incident?

September 2nd, 2015 by

NewImage

What is the minimum investigation for a simple incident?

Before you can answer this question, you need to decide the outcome you are looking for. For example:

  • Do you just want to document the facts? 
  • Would you be happy with a simple corrective action that may (or may not) be effective?
  • Do you need effective corrective actions to prevent repeats of this specific incident?
  • Do you want to prevent similar types of incidents?

The answers to these questions depend on two factors that determine risk:

  1. What were the consequences of this incident and could things have happened slightly differently and had much worse consequences?
  2. What is the likelihood that this type of incident will happen again?

Of course, before you start an investigation, answering these two questions may be difficult. Before you start an investigation, you don’t really know what happened! But in spite of this lack of knowledge, someone must decide if an incident is worth investigating and the resources to dedicate to the investigation.

I’ve seen simple incidents that, when investigated, revealed complex problems that could have caused a serious accident. Therefore, if a thorough investigation is not performed, the investigator may never know what they could have discovered. That’s why I caution management that something that seems simple may not be simple.

However, some incidents ARE simple. I’ve seen many incidents that people were investigating that were similar to this one:

An employee stumbles, falls, and sprains
his wrist while walking down a flat sidewalk.
He had on simple shoes with adequate tread.
He was not particularly preoccupied
nor was he entirely paying attention to each step
(just normal walking).

How much can be learned by investigating this incident? Probably not much. I would suggest that even though the person sprained his wrist, this incident should not be investigated beyond a simple recording of the facts so that the incident could be recorded for safety records (OSHA logs in the USA) and included in future incident trending. 

You might ask:

“But what if the employee had stumbled and fell in front of an oncoming car and the employee killed?”

In that case, because of the consequences, a detailed major investigation would be required.

In either case, the TapRooT® Root Cause Analysis System could be used to complete the investigation. 

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix complex accidents, quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and effective corrective actions. 

I’m in the process of writing a new set of TapRooT® Books. The first one I’m writing is about investigating simple incidents using the basic tools of TapRooT®.

To give you a sneak preview, if you decide to investigate an incident, the minimum technique to use is a SnapCharT®.

From the initial SnapCharT®, the investigator must decide if the incident is worthy of further effort (can something worthwhile be learned).

What’s next? What do you do if you decide to go beyond the initial SnapCharT®?

You will have to wait for the new book to be released early next year to find out what we are recommending. But I can give you a hint ,,, It won’t be asking why five times!

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