Category: Investigations

What is the Root Cause of the USS Fitzgerald Collision?

July 17th, 2017 by

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

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

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

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

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

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

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

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

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

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

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

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

Interviewing and Evidence Collection Tip: 3 Goals for Packaging Physical Evidence

July 13th, 2017 by

 

When it comes to packaging physical evidence during evidence collection, there are three distinct goals.

  1.  Protect employees from hazardous evidence.  There may be biohazards associated with the evidence being packaged or the evidence may have sharp edges that could harm an employee who tries to handle it.  Protecting employees from hazardous evidence is a consideration when packaging it.  Label the evidence to clearly warn anyone who handles it of the hazard.
  2. Protect the evidence.  Protect the evidence from loss, contamination or deterioration when packaging it.  This may include packing the evidence in a container that is not too large or small, drying the evidence before packing it if it is wet or storing it in proper temperature.
  3. Label the evidence properly. Labeling the evidence properly includes: a) a description of what is contained in the packaging; b) where it was when it was collected; c) chain of custody; d) a unique identifier, such as a number, so that it not confused with other evidence.

Packaging physical evidence is important to preserving it for the duration of the investigation.  With these three goals in mind, you’ll be off to a good start.

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.

Thanks for joining me for this week’s tip!  See you next week!

 

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

July 12th, 2017 by

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

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

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

Can bad advice make improvements more likely?

July 12th, 2017 by

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

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

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

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

What’s Fundamentally Wrong with 5-Whys?

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

Under Scrutiny (page 32)

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

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

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

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

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

TapRooT® Root Cause Analysis Leadership Lessons

Interviewing and Evidence Collection Tip: Interviews are Valuable People Evidence

July 6th, 2017 by

Evidence collected from interviews is an important component of evidence collection.

Evidence collected from interviews is an important component of evidence collection.

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.

When people think about evidence collection, sometimes they focus on paper evidence (such as collecting policies, procedures, permits, HR records), physical evidence (such as collecting broken equipment and fluid samples), or recording evidence (such as taking or collecting photographs and videos).  They don’t always think of interviewing as evidence, and in spite of the fact that this weekly column is called “Interviewing and Evidence Collection,” interviewing is evidence collection.

Most of the time in a workplace incident investigation, the majority of the evidence will come from people evidence, especially interviews. Often, evidence collection will start there and guide the investigator to collect other types of evidence.

People evidence includes information about those involved with the incident as well as information from those who may not have been there but may have knowledge to provide (example: an expert witness).

We’ve spent a lot of time developing the TapRooT™ 12-Step Interview Process which is a very effective method of getting both quality and quantity of information from an interviewee. This technique is taught in both our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and our 1-Day Effective Interviewing and Evidence Collection Techniques Course.

Today, we want to offer you some free resources to help you collect valuable people evidence through interviews:

Video:  The Cognitive Interview

Video: How to Interpret Body Language

Top 3 Worst Practices in Root Cause Analysis Interviewing

Thanks for joining me for this evidence collection tip.  See you next week!

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

July 5th, 2017 by

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

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

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

1. The first story heard is analyzed as fact.

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

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

2. Assumptions become facts.

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

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

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

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

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

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

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

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

4. The illusion of progress.

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

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

NO!

As Alfred A. Montapert said:

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

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

5. Complacency – Just another investigation.

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

The result? Complacency.

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

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

6. Bad habits become established practice.

Do people do more simple investigations or major investigations?

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

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

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

DON’T LET BAD PRACTICES INFECT YOUR CULTURE.

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

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

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

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

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

Now perform your Basic and Major investigations with TapRooT®

June 27th, 2017 by

TapRooT® is a robust root cause analysis system. When you have those major accidents and need an effective and thorough investigation, TapRooT® is the go-to solution. But what about those smaller, simpler, less complex incidents? Is it worth applying such a complex system for such a simple problem? Well, we think all problems are worth a thorough investigation, but we also realize you can only give up so much time on seemingly less serious incidents. Which is why the folks at TapRooT® decided to make a simpler version of our root cause analysis process so that you can still get the best results in less time.

Check out this video of Ken Reed, TapRooT® instructor and expert, to learn more.

 

7 Traits of a Great Root Cause Analysis Facilitator

June 27th, 2017 by

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

That’s about it.

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

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

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

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

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

Where? Have a look at these courses:

http://www.taproot.com/courses

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

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Interviewing and Evidence Collection Tip: How to Package Physical Evidence

June 21st, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  We refer to four basic categories of evidence in our Interviewing & Evidence Techniques training:

  1. People
  2. Paper
  3. Physical
  4. Recordings

Some investigations only require evidence that does not need special packaging such as training records, policies and procedures (paper evidence) and/or interviews of the people who were there (people evidence). While a workplace investigation is not the same as a criminal investigation where physical evidence often requires forensic examination, there are definitely situations where collecting physical evidence is helpful to the root cause investigation.  Here are a few basic tips:

Packaging: Most physical evidence can be stored in paper containers, like envelopes and boxes. There is a plethora of websites that sell packaging material designed specifically for evidence. Wet evidence (such as fabric) should be air dried before packaging because moisture causes rapid deterioration and risks environmental contamination, like mold.   Allow wet evidence to dry thoroughly and then package it. Then store the evidence at room temperature. If the item is not wet and does not need to “breathe” (for example, the evidence is a collection of bolts), you can also use plastic containers for storage.

Sharp objects:  Package sharp objects in a way to ensure the safety of those handling it.  Packaging may include metal cans, plastic or hard cardboard boxes so long as the object will not protrude.

Size: Ensure the packaging is of adequate size. If the packaging is too small for the item, it may fail over time.  If it’s too large, it could become damaged when it moves around the container.

Avoid using staples to seal evidence envelopes:  Staples can damage the evidence.  Tape across the entire flap of an envelope to seal it.

Don’t forget to tag and mark evidence containers so that you will be able to easily identify what is stored in each container at a later date.

If you’re interested in learning more about Interviewing & Evidence Collection, I hope you will join me in Houston, Texas in November for a 3-day root cause analysis + interviewing and evidence collection course or 1-day  interviewing and evidence collection training.

How do you plan your root cause analysis?

June 20th, 2017 by

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General George Patton said:

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

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

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

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

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

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

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

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

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

Order your copy by CLICKING HERE.

Monday Accident and Lessons Learned: Incorrect Pressure Gauge

June 19th, 2017 by

Incorrect Pressure Gauge

Correct Pressure Gauge

The IOGP recently released that in September 2015, the incorrect pressure gauge was used on a high pressure supply line causing a high pressure release. When investigating, they found that the two gauges are identical in appearance, were stored in the same place and were stored in the incorrect place for convenience purposes. What are the corrective actions? Better storage of all pressure gauges, check all gauges before installing them, and check all current gauges to ensure they are being used correctly.

What are your thoughts on this incident? The investigation? The corrective actions?

(Resource: IOGP Safety Alerts)

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

Flint Water Crisis: 5 Michigan Officials Charged with Involuntary Manslaughter

June 15th, 2017 by

 

Yesterday, five Michigan officials were charged with involuntary manslaughter related to the Flint, Michigan water crisis. Recall that in 2014, Flint switched its water source from Detroit to the Flint River in part to save money. It didn’t take long before residents noticed a difference in the way their water tasted and smelled.  The water caused some residents to get life-threatening Legionnaires disease and the medical community identified higher levels of lead in children’s blood (this type of exposure to lead can lead to developmental issues).

Learn more on NPR.

News stories like this are tragic because they are avoidable.  TapRooT® Root Cause Analysis shifts thinking from ineffective blame to effective solutions.  TapRooT® can be used proactively too to avoid these types of devastating problems from ever happening.

Learn more in our 2-day or 5-day root cause analysis courses.

 

TapRooT® Optional Root Cause Analysis Tools

June 14th, 2017 by

All TapRooT® Users are familiar with the SnapCharT®, Safeguard Analysis, the Root Cause Tree® and Dictionary, and the Corrective Action Helper® Guide. But do you know about the optional TapRooT® Tools:

  • Equifactor®
  • CHAP
  • Change Analysis

These optional techniques are usually applied in more complex investigations.

Equifactor® is used to troubleshoot equipment problems. We found that many people try to understand the root causes of equipment failures BEFORE they really understand the basic reasons for the failure. That’s why we partnered with Heinz Bloch to develop the Equifactor Troubleshooting Tables and Software. 

CHAP is used for a deep dive on human performance issues. Once again we found that people tended to jump into asking “why” before they understood all the details about a human error. That’s why we developed CHAP to help people collect information about the human action before they start asking why things went wrong.

Change Analysis is an older technique that was derived from the work of Charles Kepner and Benjamin Tregoe. The technique helps identify changes that could have contributed to the equipment failure or human error. 

How can you learn to apply these optional techniques to improve your root cause analysis? Attend one off our 5-Day TapRooT® Root Cause Analysis Team Leader Courses. To see the locations and dates of our public TapRooT® 5-Day Courses being held around the world, CLICK HERE.

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Don’t have time to travel to a course but you do have time for some reading? Then order the TapRooT® Root Cause Analysis for Major Investigations book by CLICKING HERE.

Interviewing and Evidence Collection Tip: What Evidence Should You Collect First?

June 14th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Today, let’s talk about what evidence to focus on first during the flurry of activity that occurs after an accident.

Always begin with a SnapCharT®

Begin your investigation with a planning SnapCharT® – it takes just a few minutes to create an incident and add a few events that lead up to it into the TapRooT® software or into a paper-based version of SnapCharT®.  The SnapCharT® is a tool that will help you visually organize and prioritize evidence collection.

Pre-collection

So, what evidence should be collected first? Ideally, an investigator can photograph the scene at various angles and distances before carefully collecting the most fragile evidence and before disturbing the scene by removing larger, heavier, or less fragile evidence.  Once things start getting moved, it gets really tricky to remember the initial scene or understand the scene.

Locard’s exchange principle holds that every time a person enters an environment, something is added to and removed. This is sometimes stated as “every contact leaves a trace.” So, depending on the incident, the evidence may have already been altered in some way by first responders, employees or bystanders. It may also be disturbed by an investigator’s attempt to photograph it.  This is why it is so critical to cordon off a path for first responders and employees to minimize contamination (and this also helps first response and others avoid injury).

Take photographs or a video recording of the overall scene first.

After photography, collect fragile evidence

Fragile evidence is evidence that loses its value either because of its particular nature and characteristics, or because of the conditions at the accident scene. For example, blood in rain. Fragile evidence should be collected before it is further contaminated or before it disappears.

When the fragile evidence is removed, an investigator should begin by systematically collecting the “top” layer of evidence.  This may be photographing or collecting what he finds beneath that fragile evidence.  Collecting fragile evidence includes memorializing first impressions and observations in writing, including measurements of the scene that photographs cannot capture or record, including smells, temperature, and humidity.

Every accident and incident is different; however, this is a general guideline of how to get started with evidence collection.  Next week, we’ll discuss the best way to package evidence.

If you’re interested in learning more about Interviewing & Evidence Collection, I hope you will join me in Houston, Texas in November for a 3-day root cause analysis + interviewing and evidence collection course or 1-day  interviewing and evidence collection training.

Interviewing and Evidence Collection Tip: Organize your information with TapRooT® Software

June 7th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents. We’ve talked about the value of a planning SnapCharT® as well as how important it is to uncover facts through evidence collection.

Today, let’s talk about how to keep all of this information organized using TapRooT® Software. Our software is designed to help you track investigations, manage evidence and report on results with ease.

Create a Sequence of Event

The SnapCharT® is a simple method for drawing a sequence of events and is always where an investigator begins evidence collection. Here, you decide many things, including:

  • What information is available
  • What needs to be collected
  • What order the evidence will be collected
  • Who will be interviewed
  • What conflicts exist in the sequence of events and what evidence could help clear them up

Building the SnapCharT® in the TapRooT® software allows you to add all of these notes quickly and efficiently, save them, and edit them as you progress through evidence collection.

Organize digital documents and photos

It doesn’t take long for paper evidence to feel out of control.  Standard operating procedures, work orders, maintenance procedures, company policies and so much more are all collected as you begin uncovering the important facts that will support your conclusions.  Digital photos can easily get lost if they are not stored somewhere immediately.  Storing the digital files in your TapRooT® software catalogs them and keeps them secure.  This also keeps all of these digital items available to pull into the management report feature of the software.  You can easily upload images and documents and add them to your attachment files for each investigation.  Here is a short video to show you how to do just that:  View video.

Use TapRooT® software to create new investigations, manage tasks and analyze the results all in one place.  If you have been trained in TapRooT® and are ready to optimize your investigations, join us for our June 28 webinar!

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

Screen Shot 2017 05 31 at 1 20 19 PM

Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

Interviewing & Evidence Collection Tip: You can’t know the “why” before the “what”

May 31st, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Last week we talked about the value of a planning SnapCharT®.  I’d like to take a moment to expand on that thought.

Grasping at the “why” before the “what” is a common mistake that even experienced investigators make.  But you have to understand “what” happened before you can understand why it happened.  The goal of interviewing and evidence collection is to provide facts for the “what” so you can continue with the “why” (identifying causal factors and root causes).

When I worked in the legal field, I felt that most investigations were hypothesis-based.  It seemed that more often than not, we started with several hypotheses and then began a process of elimination until we were left with one we liked.  Instead of collecting evidence before we determined “why” an incident happened, we came up with our guesses and then looked for evidence that supported the guesses.

When an investigator reaches for the “why” before the “what,” this is what occurs:

  1. Tunnel vision.  The investigator only focuses on the hypotheses presented, and none of them may be correct.
  2. Abuse of evidence. The investigator may force the evidence to “fit” the hypothesis he/she feels most strongly about.  Further, any evidence collected that does not fit the hypothesis is ignored or discarded.
  3. Confirmation bias. The investigator only seeks evidence that supports his/her hypothesis.

It is a tenet of psychology that the human brain immediately desires a simple pattern that makes sense of a complex situation. So, there is really nothing that the investigator is intentionally doing wrong when he or she falls into that trap. Not to mention, humans simply do not like changing their minds when they become emotionally attached to an idea. And then there is social pressure… when a strong personality on the investigation team thinks he/she knows the “why” – and the rest of the team goes along with it.

TapRooT® helps investigative teams avoid reaching for the “why” before the “what.”  The 7-Step Major Investigation Process taught during our 5-Day training offers a systematic way to move through the investigation and takes the investigator beyond his/her knowledge to determine the “what” first so that the causal factors and root causes identified are accurate. Learn how to collect the evidence you need to understand the “what” in our 1-day Interviewing and Evidence Collection Techniques course on November 8 in Houston, Texas.

Have you fallen into the trap of trying to decide the “why” before the “what”? Do you have something additional to share about this common problem? How has TapRooT® helped you avoid it? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

Interviewing & Evidence Collection Tip: The Value of a Planning SnapCharT®

May 24th, 2017 by

Hello and welcome to our new weekly column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.

If you are a TapRooT® user, you know that the SnapCharT® is the first step in conducting a root cause investigation.  It doesn’t matter if you’re investigating a simple incident or major accident – SnapCharT® is always the starting line.

A SnapCharT® is a simple method for drawing a sequence of events.  It can be drawn on sticky notes or in the TapRooT® software.  Sometimes we refer to the SnapCharT® in it’s initial stages as a “planning” SnapCharT®. So why is a SnapCharT® essential for evidence collection and interviewing?

When you begin an investigation, you are working with suppositions, assumptions and second hand information. The planning SnapCharT® will guide you to who you need to interview and what evidence you need to collect to develop a factual sequence of events and appropriate conditions that explain what happen during the incident. Remember, a fact is not a fact until it is supported by evidence.  

The planning SnapCharT® is used to:

  • develop an initial picture of what happened.
  • decide what information is readily available and what needs to be collected immediately.
  • establish a list of potential witnesses to interview.
  • highlight conflicts that exist in the preliminary information.
  • plan the next steps of interviewing and evidence collection.

The SnapCharT® provides the foundation for solid evidence collection.  Learn how to create a SnapCharT® by reading, “Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents or register for our 1-day Interviewing and Evidence Collection Course in Houston, Texas on November 8, 2017.  We also offer this course as a one or two-day onsite course that can be customized for your investigators.

How has SnapCharT® helped you plan your investigative interviews and evidence collection?  If you’ve never used a SnapCharT®, how do you think a planning SnapCharT® would be helpful to you? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

See you next week!

CSB Video of Torrance Refinery Accident

May 3rd, 2017 by

CSB Releases Final Report into 2015 Explosion at ExxonMobil Refinery in Torrance, California

Press Release from the US CSB:

May 3, 2017, Torrance, CA, — Today, the U.S. Chemical Safety Board (CSB) released its final report into the February 18, 2015, explosion at the ExxonMobil refinery in Torrance, California. The blast caused serious property damage to the refinery and scattered catalyst dust up to a mile away from the facility into the nearby community. The incident caused the refinery to be run at limited capacity for over a year, raising gas prices in California and costing drivers in the state an estimated $2.4 billion.

The explosion occurred in the refinery’s fluid catalytic cracking (FCC) unit, where a variety of products, mainly gasoline, are produced. A reaction between hydrocarbons and catalyst takes place in what is known as the “hydrocarbon side” of the FCC unit. The remainder of the FCC unit is comprised of a portion of the reaction process and a series of pollution control equipment that uses air and is known as the “air side” of the unit.The CSB’s report emphasizes that it is critical that hydrocarbons do not flow into the air side of the FCC unit, as this can create an explosive atmosphere. The CSB determined that on the day of the incident a slide valve that acted as a barrier failed. That failure ultimately allowed hydrocarbons to flow into the air side of the FCC, where they ignited in a piece of equipment called the electrostatic precipitator, or ESP, causing an explosion of the ESP.

CSB Chairperson Vanessa Allen Sutherland said, “This explosion and near miss should not have happened, and likely would not have happened, had a more robust process safety management system been in place. The CSB’s report concludes that the unit was operating without proper procedures.”

In its final report, the CSB describes multiple gaps in the refinery’s process safety management system, allowing for the operation of the FCC unit without pre-established safe operating limits and criteria for a shut down.  The refinery relied on safeguards that could not be verified, and re-used a previous procedure deviation without a sufficient hazard analysis of the current process conditions.

Finally, the slide valve – a safety-critical safeguard within the system – was degraded significantly. The CSB notes that it is vital to ensure that safety critical equipment can successful carry out its intended function. As a result, when the valve was needed during an emergency, it did not work as intended, and hydrocarbons were able to reach an ignition source.

The CSB also found that in multiple instances leading up to the incident, the refinery directly violated ExxonMobil’s corporate safety standards. For instance, the CSB found that during work leading up to the incident, workers violated corporate lock out tag out requirements.

In July 2016, the Torrance refinery was sold by ExxonMobil to PBF Holdings Company, LLC, which now operates as the Torrance Refining Company. Since the February 2015 explosion, the refinery has experienced multiple incidents.

Chairperson Sutherland said, “There are valuable lessons to be learned and applied at this refinery, and to all refineries in the U.S.  Keeping our refineries operating safely is critical to the well-being of the employees and surrounding communities, as well as to the economy.

The CSB investigation also discovered that a large piece of debris from the explosion narrowly missed hitting a tank containing tens of thousands of pounds of modified hydrofluoric acid, or MHF. Had the tank ruptured, it would have caused a release of MHF, which is highly toxic.  Unfortunately, ExxonMobil, the owner-operator of the refinery at the time of the accident, did not respond to the CSB’s requests for information detailing safeguards to prevent or mitigate a release of MHF, and therefore the agency was unable to fully explore this topic in its final report.

Chairperson Sutherland said, “Adoption of and adherence to a robust safety management process would have prevented these other incidents.  In working with inherently dangerous products, it is critical to conduct a robust risk management analyses with the intent of continually safety improvement.”

The CSB is an independent, non-regulatory federal agency charged with investigating serious chemical incidents. The agency’s board members are appointed by the president and confirmed by the Senate. CSB investigations look into all aspects of chemical accidents, including physical causes such as equipment failure as well as inadequacies in regulations, industry standards, and safety management systems.

Visit our website, www.csb.gov, for more information or contact Communications Manager Hillary Cohen, cell 202-446-8094 or email public@csb.gov. 

 

Are You Writing the Same Corrective Actions?

April 17th, 2017 by

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

How to Interpret Body Language In Your Incident Investigation Interviews

April 10th, 2017 by

TapRooT® Instructor and Non-Verbal Communication Expert, Barb Phillips, explains how to interpret common body language cues with an example investigative interview. Watch here for some investigative interviewing tips!

Want to know more? Take a TapRooT® Effective Interviewing and Evidence Collection course.

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

March 20th, 2017 by

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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.

Learn more about when to investigate a simple incident by attending our 2-Day TapRooT® Root Cause Analysis training.  Click here to view the upcoming schedule.

 

Carnival Pride NTSB Allision Report – Causal Factor Challenge

March 7th, 2017 by

collision, allision, carnival

The NTSB released their report on the allision of the Carnival Pride cruise ship with the pier in Baltimore last may. It caused over $2 million in damages to the pier and the ship, and crushed several vehicles when the passenger access gangway collapsed onto them. Luckily, no one was under or on the walkway when it fell.  You can read the report here.

Pride

The report found that the second in command was conning the ship at the time.  He had too much speed and was at the wrong angle when he was approaching the pier.  The report states that the accident occurred because the captain misjudged the power available when shifting to an alternate method of control to stop the ship.  It states there may have been a problem with the controls, or maybe just human error.  It also concluded that the passenger gangway was extended into the path of the ship, and that it did not have to be extended until ready for passengers to debark.

collision, allision, carnival

Gangway collapse after allision

While I’m sure these findings are true, I wonder what the actual root causes would be?  If the findings are read as written, we are really only looking at Causal Factors, and only a few of those to boot.  Based on only this information, I’m not sure what corrective actions could be implemented that would really prevent this in the future.  As I’m reading through the report, I actually see quite a few additional potential Causal Factors that would need to be researched and analyzed in order to find real root causes.

YOUR CHALLENGES:

  1. Identify the Causal Factors you see in this report.  I know you only have this limited information, but try to find the mistakes, errors, or equipment failures that lead directly to this incident (assuming no other information is available)
  2. What additional information would you need to find root causes for the Causal Factors you have identified?
  3. What additional information would you like in order to identify additional Causal Factors?

Reading through this incident, it is apparent to me that there is a lot of missing information.  The problems identified are not related to human performance-based root causes; there are only a few Causal Factors identified.  Unfortunately, I’m also pretty sure that the corrective actions will probably be pretty basic (Train the officer, update procedure, etc.).

BONUS QUESTION:

For those that think I spelled “collision” wrong, what is the meaning of the word “allision”?  How many knew that without using Google?

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