Category: Performance Improvement
Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:
“Can TapRooT® be used to solve quality issues?”
I was surprised by the question. Of course, the answer is YES!
We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.
Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?
The only answer was … We had not told him!
Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors.
Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.
For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.
That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.
So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!
Risk Assessments are necessary in all safety processes, particularly to move programs beyond Behavior Based Safety (BBS).
At least qualitative Risk Assessments (RA) need to be included during any safety-related discussions or interactions, conversations, and meetings. RA are needed every time any safety-related decision needs to be made; and therefore, to move safety programs beyond traditional BBS principles and practices.
RA in safety processes, including BBS – type programs, improve decision-making by making them less subjective, emotional and biased. Safety decision-making needs to be based on the comparative risk levels of the options under consideration. Any chosen safety decision needs to be the option for which the likelihood and quantum of benefit and gain outweighs the likelihood and quantum of loss and harm more than for any other option.
Which option provides the best chance of gain and benefit at both personal and corporate levels?
One such illustrative example is related to un-demonizing the term “shortcut”.
The original, best definition of a shortcut is very simple, positive and with no emotive undertones:
“a smarter, better way of doing a job”
“the method, procedure that best reduces the time / $ / energy needed to achieve business objectives.”
Can a shortcut ever be an appropriate, lower risk and authorized job method? And how?
In any safety discussions between managers, supervisors and workers, this definition can help clarify the troublesome distinction between “finding a shortcut,” and “taking a shortcut without an authorized risk assessment.” Finding is undeniably “smart.” Taking without RA is patently “dumb.”
Issues of workplace complexity and relationships between managers, supervisors and workers need to be addressed to be able to move safety programs and cultures beyond BBS principles and practices. Workplace relationships are based on trust, respect, credibility, encouragement, and valued appreciation of jointly-found solutions of challenges and issues. RA provides processes needed in relationship-based safety RBS.
Positive relationships include establishing and holding common beliefs that we want everyone to come to work with their brains as well as their brawn, (and hopefully their hearts), because we all recognize that it is in everyone’s interest for everyone to be always challenged to find smarter better ways of doing our jobs. That is what business is about! It is the never-ending goal of finding smarter, more efficient, more effective, more productive and safer (lower risk) ways of doing our work.
However, too often we tell our people we need and want their “shortcut” ideas for more efficiency and productivity, but as soon as they do give them we jump on them and label their suggestions with negative emotive labels such as “violations” or “breaches” of existing rules and describe them in meaningless, undefined terms such as “unsafe acts” or “at-risk behaviors”. Use of these negative, emotion-loaded terms actually discourages searching for the deep underlying root causes of an apparently stupid, careless, and lazy “violation.”
It is more appropriate to use non-emotive descriptors such as “variations,” “adaptations,” “departures,” or very simply “work-arounds.”
All day-to-day safety meetings, discussions, and personal risk taking behavioral choices involve BBS questions such as:
- Which procedure or method is safer (lower risk) than another?
- Which is the safer tool, plant, equipment for this job?
- Which risk control option is better than the others?
- Which route should be taken?
- Which control panel design is less error-provoking than the other?
- Which roster is best for managing fatigue?
- What is the appropriate time that we need to allocate to this incident investigation?
- What to say and how to interact / converse with my peers, supervisors and managers?
These real examples of safety optioneering processes make a compelling argument for doing at least a qualitative (but preferably a Semi – Quantitative) Risk Assessment.
In fact, Risk Assessments will be recognized as definitely needed every time any safety-related decision needs to be made and therefore can move safety programs beyond traditional BBS principles and practices often confused and undermined by subjective beliefs, biases and perceptions.
How can you improve your confidence in the accuracy, reliability, consistency of Risk Assessments?
Learn Best Practices in the training courses being offered as below.
May 20-21, (Weds-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505HOUS20.html
May 27-28, (Wed-Thurs)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1505CALG27.html
Las Vegas, Nevada
June 1-2 (Mon-Tues before the TapRooT® Summit)
To register: http://www.taproot.com/store/2-Day-Risk-Management-Training-1506LASV01-RISKMGMT.html
IN-HOUSE Courses are also available. Contact us for a quote.
Jim Whiting, an international expert in risk management and root cause analysis will be conducting the courses detailed above. The courses are the updated versions of a highly successful course that he has been offering for a number of years to over 200 attendees at Pre-Summit courses at past TapRooT® Summits. Due to increasing requests for more offerings of the course, the TapRooT® folks and Jim have decided to offer three RAMBP PUBLIC Courses in North America in 2015.
Jim was on Committees developing the Risk Management Standard AS/ISO 31000 which has been adopted word for word by US standard bodies as ANSI Z690.2 and Canadian bodies as CAN/CSA/ISO 31000. He has developed Risk Assessment unique tools and processes for maximizing the confidence of the results of assessments need to make all safety-related decision-making such as – what is a tolerable risk ?
One of the students in a 5-Day TapRooT® Advanced Root Cause Team Leader Course came up to me on day 3 of the course and told me that the course had already paid for itself many times over.
I asked him what he meant. He said while we were teaching that morning, he identified a problem in some engineering work they were doing, and the savings he had avoided, (he had immediately called back to the office), totaled over $1 million dollars.
That’s a great return on investment. A $2500 course and a $1,000,000 payback. That’s a 40000% instant ROI.
That made me think … do TapRooT® Users think about how much they are saving their company?
Do they track the savings?
Do they know how much problems are costing their company and have a goal for cost saving?
Let me know if you have saved money for your company by leaving a note below as a comment…
If a fatality happens at a business, OSHA descends to investigate. The company must come up with corrective actions that will make sure the accident never happens again.
When a traffic accident happens, police investigate. A ticket is given to the party at fault. And a lawsuit is probably filed. But nobody ever talks about making sure the accident never happens again. Root causes aren’t mentioned unless it is excessive speed, drunk driving, or distracted driving … and are those really root causes?
What is the difference?
Why are fatal traffic accidents seemingly acceptable?
Could we learn from fatal car accidents and make sure they never happen again?
What would have to change to make this learning possible?
Could we save 10,000, 20,000, or 30,000 lives per year here in the US?
Root Cause Analysis Tip: What is a corrective action worth? – A Gambler’s View of Corrective Actions (A Best of Article from the Root Cause Network™ Newsletter)December 3rd, 2014 by Mark Paradies
Adapted from the January 1995 Root Cause Network™ Newsletter, Copyright © 1995. Reprinted by permission. Some modifications have been made to update the article.
A GAMBLER’S VIEW OF CORRECTIVE ACTIONS
WHEN TO BET/WHEN TO FOLD
A winning gambler knows the odds. He knows that in the long run, he can beat the odds. Therefore, he looks for opportunities to bet more when the odds are in his favor. And when the odds are against him, he folds and waits for a better hand.
Preventing accidents is a numbers game. The pyramid blow provides a typical example of the ratio of accidents to incidents to near-misses to unsafe conditions.
In this pyramid, every incident must have the potential under slightly different circumstances to become the major accident at the top of the pyramid. Also, every near miss must have the potential to become an incident that could have become the top level accident. Finally, every unsafe condition could have caused a near-miss that could have become an incident that could have become the top level accident.
Thus, every unsafe act included at the bottom level of the pyramid must have the potential with the right set of circumstances to “cause” the top level accident.
The ratio above might not be exact. Your facility might be different. But we will use the ration of 1000 unsafe acts for every major accident as a starting point for out calculation of odds that we describe below.
The point is that every corrective action that fixes an unsafe condition has some odds of being the corrective action that could be preventing a major accident. Thus, we should try to understand the value NOT ONLY of the benefits that the corrective action immediately brings, BUT ALSO the reduction in the odds of a major accident that this corrective action provides.
THE COST OF A MAJOR ACCIDENT
To calculate the value of preventing a major accident, we need to calculate the potential cost of a major accident at your facility.
Of course, we don’t know the exact cost of the biggest accident (or even a typical major accident) that you face at your company. After all, they still don’t know what the cost of the Deepwater Horizon accident will be even after years of litigation. So, we have to make an educated guess that can be scaled to show how the cost could change.
For example, we might say that the cost a typical major accident would be $1,000,000,000.
Then, if you think your accident might be ten times worse (or ten times less), you can multiple or divide the results we calculate by 10.
ASSESSING THE ODDS
Why do we have to use “odds” to perform this calculation? Because you can’t tell exactly which unsafe condition will be related to your next major accident. We don’t know what corrective action that we implement today will prevent the next Deepwater Horizon, Three Mile Island, or Exxon Valdez type accident that costs billions of dollars. No one is that prescient. That’s why preventing major accidents is a numbers game. To prevent the next major accident you must reduce thousands of unsafe conditions.
Because the exact odds of any one unsafe act being a key factor in the next accident is unknowable, we assign equal potential to every unsafe condition that has potential to cause a major accident.
If the pyramid above represents your accident pyramid, then for every major accident, there are 1000 unsafe conditions that could contribute to it. Or another way to think about it is that we can’t predict the exact combination of factors that will cause the next major accident but if we do 1000 things to fix problems that could be involved in a major accident, we will stop one major accident.
Thus the odds that any one corrective action will stop a major accident is 1000 to 1.
CALCULATING THE VALUE OF A CORRECTIVE ACTION
I’ve seen people value corrective actions by using the value of the incident they would prevent.
For example, if the failure of a machine caused a delay that lost the company $100,000, the value of the corrective actions to prevent future failures would be $100,000. It’s never clear to me if this value should be divided between all of the corrective actions (for example, if there are 10 corrective actions, each would be worth, $10,000) or if each corrective action is worth $100,000. But the idea is that the corrective actions can be valued by the costs that will be saved from future similar incidents prevented.
What this equation leaves out is the value of an even worse accident that could also be prevented by the corrective actions.
Thus to calculate the value of a corrective action, you not only need to calculate the direct benefit, but also the amount that that corrective action contributed to the prevention of a major accident (if, indeed the corrective actions could help prevent a major accident).
But let’s stop here to correct misconceptions. A corrective action meant to stop paper cuts probably have very little value in preventing major accidents. Thus, we are not assigning severe accident risk to every corrective action. We would only assign the value to corrective actions that could help prevent major accidents.
The, the value of a corrective action is the direct cost that the corrective action saves us PLUS the value of the unknown major accident that it could prevent divided by the odds.
For example, if a corrective action saved us $10,000 in direct costs for a similar incident and if the value of a major accident at your facility is $1,000,000,000 and if we estimate that it will take correcting 1,000 unsafe acts to prevent the next accident, the value of our corrective action is…
VALUE = $10,000 + ($1,000,000,000/1000)
VALUE = $10,000 + $1,000,000
VALUE = $1,010,000
Thus valuing corrective action at their benefit for preventing a similar incident is UNDERVALUING the corrective actions.
And I believe we frequently undervaluing corrective actions.
Because we aren’t considering the value that a gambler sees. We are folding when we should be betting!
We should be investing much more in effective corrective actions thereby win by preventing the next major accident.
YOU CAN IMPROVE THE ODDS
There is even better news that can help you make the corrective actions you implement even more valuable (effective).
The TapRooT® Root Cause Analysis System can help you do a better job of analyzing potential problems and developing even more effective corrective actions for the root causes you uncover.
Think of TapRooT® as a luck rabbit’s foot that increases your odds of winning.
Of course, TapRooT® is much better than a lucky rabbit’s foot because instead of being built upon superstition, it is built upon proven human performance and equipment reliability technology that makes your investigators much more effective.
So don’t wait. Stop undervaluing your corrective actions and if you haven’t already started using TapRooT®, see our upcoming courses list, click on your continent, and get signed up for a course near you (or in a spot that you would like to visit).
Root Cause Tip: Audit Your Investigation System (A Best of The Root Cause Network™ Newsletter Reprint)November 26th, 2014 by Mark Paradies
AUDIT YOUR INVESTIGATION SYSTEM
AUDIT TO IMPROVE
We have all heard the saying:
Tom Peters changed that saying to:
“If it ain’t broke, you aren’t looking hard enough.”
We can’t improve if we don’t do something different. In the “Just Do It” society of the 1990’s, if you weren’t improving, you were falling behind. And the pace of improvement has continued to leap forward in the new millennium.
Sometimes we overlook the need to improve in places that we need to improve the most. One example is our improvement systems. When was the last time you made a comprehensive effort to improve your incident investigations and root cause analysis?
Improvement usually starts by having a clear understanding of where you are. That means you must assess (inspect) your current implementation of your incident investigation system. The audit needs to establish where you are and what areas are in need of improvement.
AREAS TO AUDIT
If we agree that auditing is important to establish where we are before we start to improve, the question then is:
What should we audit?
To answer that question, you need to know what makes an incident investigation system work and then decide how you will audit the important factors.
The first research I would suggest is Chapter 6 of the TapRooT® Book (© 2008). This will give you plenty of ideas of what makes an incident investigation system successful.
Next, I would suggest reviewing Appendix A of the TapRooT® Book. Pay special attention to the sample investigation policy and use it as a reference to compare to your company’s policy.
Next, review Appendix C. It provides 16 topics (33 suggestions) to improve your incident investigation and root cause analysis system. The final suggestion is The Good, The Bad, and The Ugly rating sheet to rate your investigation and root cause analysis system. You can download a copy of an Excel spreadsheet of this rating system at:
Next, review the requirements of your regulator in your country. These will often be “minimum” requirements (for example, the requirements of OSHA’s Process Safety Management regulation. But you obviously should be meeting the government required minimums.
Also, you may have access to your regulators audit guidance. For example, OSHA provides the following guidance for Process Safety Management incident investigations:
“12. Investigation of Incidents. Incident investigation is the process of identifying the underlying causes of incidents and implementing steps to prevent similar events from occurring. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. The incidents for which OSHA expects employers to become aware and to investigate are the types of events which result in or could reasonably have resulted in a catastrophic release. Some of the events are sometimes referred to as “near misses,” meaning that a serious consequence did not occur, but could have.“
“Employers need to develop in-house capability to investigate incidents that occur in their facilities. A team needs to be assembled by the employer and trained in the techniques of investigation including how to conduct interviews of witnesses, needed documentation and report writing. A multi-disciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened, and why. Team members should be selected on the basis of their training, knowledge and ability to contribute to a team effort to fully investigate the incident. Employees in the process area where the incident occurred should be consulted, interviewed or made a member of the team. Their knowledge of the events form a significant set of facts about the incident which occurred. The report, its findings and recommendations are to be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigation process should clearly deal with all involved individuals in a fair, open and consistent manner.“
Also, OSHA provides more minimum guidance on page 23 of this document:
Finally, another place to network and learn best practices to benchmark against your investigation practices is the TapRooT® Summit. Participants praise the new ideas they pick up by networking with some of the “best and brightest” TapRooT® Users from around the world.
Those sources should provide a pretty good checklist for developing your audit protocol.
AUDIT TECHNIQUES (PROTOCOL)
How do you audit the factors that are important to making your incident investigation system work? For each factor you need to develop and audit strategy and audit protocol.
For example, you might decide that sharing of lessons learned with employs and contractors is a vital part of the investigation process. The first step in developing an audit strategy/protocol would be to answer these questions:
- Are there any regulatory requirements for sharing information?
- What is required by our company policy?
- What good practices should we be considering?
Next, you would have to develop a protocol to verify what is actually happening right now at your company. For example, you might:
- Do a paper audit of the practices to see if they meet the requirements.
- Go to the field to verify workers knowledge of past best practices that were shared.
Each factor may have different techniques as part of the audit protocol. These techniques include:
- paperwork reviews
- field observations
- field interviews
- worker tests
- management/supervision interviews
- training and training records reviews
- statistical reviews of investigation results
To have a thorough audit, the auditor needs to go beyond paperwork reviews. For example, reading incident investigation reports and trying to judge their quality can only go so far in assessing the real effectiveness of the incident investigation system. This type of assessment is a part of a broader audit, but should not provide the only basis by which the quality of the system is judged.
For example, a statistical review was performed on the root cause data from over 200 incident investigations at a facility. The reviewer found that there were only two Communication Basic Cause Category root causes in all 200 investigations. This seemed too low. In further review it was found that investigators at this facility were not allowed to interview employees. Instead, they provided their questions to the employee’s supervisor who would then provide the answers at a later date. Is it any surprise that the supervisor never reported a miscommunication between the supervisor and the employee? This problem could not be discovered by an investigation paperwork review.
Don’t forget, you can use TapRooT® to help develop your audit protocol and find the root causes of audit findings. For example, you can flow chart your investigation process as a Spring SnapCharT® to start developing your audit protocol (see Chapter 5 of the 2008 TapRooT® Book for more ideas).
WHO SHOULD AUDIT & WHEN?
We recommend yearly audits of your improvement system. You shouldn’t expect dramatic improvements every year. Rather, if you have been working on improvement for quite some time, you should expect gradual changes that are more obvious after two or three years. This more like measuring a glacier moving than measuring a dragsters movement.
Who should perform these audits?
First, the system’s owner should be doing annual self-assessments. Of course, auditing your own work is difficult. But self-assessments are the foundation of most improvement programs.
Next, at least every three years you should get an outside set of eyes to review your program. This could be a corporate auditor, someone from another site, or an independent (hired) auditor.
System Improvements (the TapRooT® Folks) provides this type of hired audit service (contact us by calling 865-539-2139 or by CLICKING HERE). We bring expertise in TapRooT® and an independent set of eyes. We’ve seen incident investigation systems from around the world in all sorts of industries and have access to the TapRooT® Advisory Board (a committee of industry expert users) that can provide us with unparalleled benchmarking of practices.
GET STARTED NOW
Audits should be an important part of you continuous improvement program. If you aren’t already doing annual audits, the best time to start is NOW! Don’t wait for poor results (when compared to your peers) that make your efforts look bad. Those who are the best are already auditing their system and making improvements. You will have to run hard just to keep up!
(This post is based on the October 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted/adapted by permission. Some modifications have been made to update the article.)
Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.
For more information regarding our Public and Onsite TapRooT® Courses, click here.
Want to join us at the Global TapRooT® Summit? Click here for more information and registration.
Was this tip helpful? Check out more short videos in our series:
Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)
What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)
TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)
At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:
- Management revises the facts. (Or management says “You can’t say that.”)
- Assumptions become facts.
- Untrained team of investigators. (We assign good people/engineers to find causes.)
- Started investigation too late.
- Stopped investigation too soon.
- No systematic investigation process.
- Management can’t be the root cause.
- Supervisor performs investigation in their spare time.
- Fit the facts to the scenario. (Management tells the investigation team what to find.)
- Hidden agendas.
What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.
What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.
Perhaps they should have said “process safety” record, but I won’t quibble. Here’s the quote:
“America’s Nuclear Navy is one of the oldest and largest nuclear organizations in the world and has the best safety record of any industry.
And no one ever discusses it.”
See the article at:
The article mentions the potential impact of budget cuts … a topic that worries many of us who know what it costs to maintain a flawless record – especially in the current environment of a shortage of ships and increased operating tempos.
Admiral Rickover was famous for telling a Congressman at a hearing that his question was “stupid.” What do you think he would say about saving a few million dollars but allowing process safety to degrade because of a shortage of funds with the ultimate result of an expensive nuclear accident that costs billion?
IT DIDN’T HAVE TO HAPPEN
An anesthesia machine cuts off oxygen to a patient causing extensive brain damage. The investigation team finds a mechanical defect that was undetectable without complex testing. They also find that the sentinel event almost happened before.
The baggage door on a 747 opens after takeoff, tearing off part of the plane. Four people are swept out the hole to their death. The investigation uncovers poor, less catastrophic accidents of a similar nature and a history of problems with the door on this particular aircraft.
A plant upset occurs due to corrective maintenance. A relief lifts but fails to shut when pressure decreases. Operators, initially preoccupied with other alarms, misdiagnose the problem and shut off critical safety equipment. The “impossible” accident – a core meltdown – happens at Three Mile Island. The investigation uncovers similar, precursor incidents and a history of relief valve failure at TMI.
These accidents didn’t have to happen. They are typical of hundreds of “missed opportunities” that happen every year. The cost?
- Suffering for survivors and surviving loved ones.
- Millions – no billions – of Dollars (Yen, Euros, and Pounds).
We could prevent ALL of them. Why don’t we? Don’t we know that:
An ounce of prevention is worth a pound of cure?
Maybe it is:
- Intellectual laziness?
- Just plain bad management?
- A bad system to identify problems?
- Bad investigation techniques?
- Something else?
What would it take to start learning?
STEP 1: MANAGEMENT UNDERSTANDING
Your management – from the CEO down – must understand the problem … People and machines are variable (you might call them unreliable) BY NATURE.
Our job is to reduce the variability and make systems reliable and safe.
In the long run a safe, reliable system will always out perform an unreliable, unsafe systems.
Therefore, improving reliability and safety provides your company with a competitive advantage.
The competitive advantage IS NOT FREE. It requires up front effort and investment in root cause analysis and improvements. It requires persistent attention to detail.
Thus, attaining reliability and safety is the challenge.
STEP 2: GET A PERFORMANCE IMPROVEMENT & ROOT CAUSE ANALYSIS SYSTEM THAT WORKS
Although Ben Franklin’s advice seems simple, consistently identifying the right “ounce of prevention” can be complex.
How dangerous is it to reason from insufficient data.
Improving safety and reliability requires a systematic approach and the use of sophisticated performance improvement techniques. You need a good performance monitoring system.
A good performance monitoring system includes:
- self-reporting of near misses
- reporting and instigation of accidents and incidents
- audits, observations, and self-assessments
- advanced root cause analysis (TapRooT®)
- advanced statistical analysis of trends
- understanding of how to fix human performance problems
- training for those who make the system work
Is putting together this kind of a system a tall order? You bet. Bit it is worth it.
If you need help putting this type of system together, we have the experience to help you and we can provide the training that people need. Call us at 865-539-2139 or drop us a note.
STEP 3: USE THE SYSTEM & FIX PROBLEMS
Get your facts first.
Then you can distort them as much as you please.
Preventing accidents is NOT a quick fix. Something you can do once and forget. Management needs to stay involved. You must be consistently persistent.
Find and fix the root causes of accidents, incidents, near-misses, and audit findings.
The first measure of the effective of the system IS NOT a reduced accident rate (although this will come along quickly enough). The first measure of success is an increased rate of finding and implementing effective corrective actions.
Management needs to demand that people properly using the system to investigate problems, find their root causes, identify effective fixes, and get them implements. If management doesn’t demand this, it won’t happen.
STEP 4: NEVER STOP IMPROVING
If you aren’t better today than you were yesterday, you are falling behind. As my boss once said:
If you’re not peddling, you are going downhill.
Captain William J. Rodriguez, United Staes Navy
Never stop looking for areas that need improvement. This should include improving your improvement system!
We can help. How? Several ways…
- Call us at 865-539-2139 and we can discuss your plans to improve. The call is FREE and we may be able to suggest ways to make your plan even better.
- We can conduct an independent review of your root cause analysis implementation, trending, and performance improvement systems. Although this isn’t free, we guarantee it will be worth the time and money. Just drop us a note to get things started.
- Attend the TapRooT® Summit. Each year we design the Summit to help people learn to solve the toughest problems facing industry. You will network with some of the world’s most knowledgeable performance improvement experts and peers who have faced the same types of problems that you face and found best practices to solve their problems.
Don’t wait for the next “missed opportunity”. Do something to make improvement happen before a major accident takes place.
Save lives – save money – save jobs – improve quality and reliability – that’s what TapRooT® is all about.
(Reprinted from the April 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.)
What do you have planned to keep walkways clear this winter?
Here are some tips for snow and ice removal from WeatherChannel.com: (Read tips.)
Root Cause Tip: Making Team Investigations Work (A Best of Article from the Root Cause Network™ Newsletter)October 9th, 2014 by Mark Paradies
Reprinted from the June 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted by permission. Some modifications have been made to update the article.
MAKING TEAM INVESTIGATIONS WORK
WHY USE A TEAM?
First, team investigations are now required for process safety related incidents at facilities covered by OSHA’s Process Safety Management regulation (1910.119, section m). But why require team investigations?
Quite simply because two heads are better than one! Why? Several reasons:
- A team’s resources can more quickly investigate an incident before the trail goes cold.
- For complex systems, more than one person is usually needed to understand the problem.
- Several organizations that were involved in the incident need to participate in the investigation.
- A properly selected team is more likely to consider all aspects of a problem rather than focusing on a single aspect that a single investigator may understand and therefore choose to investigate. (The favorite cause syndrom.)
MAKING THE TEAM WORK
Investigating an incident using a team is different than performing an individual investigation. To make the team work, you need to consider several factors:
- Who to include on the team.
- The training required for team members.
- Division of work between team members and coordinating the team’s activities.
- Record keeping of the team’s meetings.
- Software to facilitate the team’s work.
- Keeping team members updated on the progress of the investigation (especially interview results) and maintaining a team consensus on what happened, the causal factors, and the root causes.
WHO’S ON THE TEAM?
The OSHA 1910.119 regulation requires that the team include a member knowledgeable of the process and a contractor representative if contractor employees were involved in the incident. Other you may want on the team may include:
- Engineering/technical assistance for hardware expertise.
- Human engineering/ergonomics experts for human performance analysis.
- Operations/maintenance personnel who understand the work practices.
- An investigation coach/facilitator who is experienced in performing investigation.
- A recorder to help keep up with meeting minutes, evidence documentation, and report writing/editing.
- A union rep.
- A safety professional.
TRAINING THE TEAM
A common belief is that “good people” naturally know how to investigate incidents. All they need to do is ask some questions and use their judgement to decide what caused the incident. Then they can use their creative thinking (brainstorming) to develop corrective actions. Hopever, we’ve seen dramatic improvements in the ability of a team to effectively investigate an incident, find its root causes, and propose effective corrective actions when they are appropriately trained BEFORE they perform an investigation.
What kind of training do they need? Of course, more is better but here is a suggestion for the minimum training required…
- Team Leaders / Coaches – A course covering advanced root cause analysis, interviewing, and presentation skills. We suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. Also, the Team Leaders should be well versed in report writing and the company’s investigation policies. Coaches/facilitators should be familiar with facilitation skills/practices. Also, Team Leaders and Facilitations should continually upgrade their skills by attending the TapRooT® Summit.
- Team Members – A course covering advanced root cause analysis skills. We suggest the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
- People Involved in the Incident – It may seem strange to some that people involved in an incident need training to make the investigation more effective. However, we have observed that people are more cooperative if they understand the workings of the investigation (process and techniques) and that a TapRooT® investigation is not blame oriented. Therefore, we recommend that all line employees take a 4-hour TapRooT® Basics course. We have developed and provided this training for many licensed clients who have found that it helps their investigation effectiveness.
KEEPING ON TRACK
One real challenge for a team investigation is keeping a team consensus. Different team members will start the investigation with different points of view and different experiences. Turf wars or finger pointing can develop when these differences are considered. This can be exacerbated when different team members perform different interviews and get just a few pieces of the puzzle. Therefore, the Team Leader must have a plan to keep all the team members informed of the information collected and to build a team consensus as the investigation progresses. frequent team meetings using the SnapCharT® to help build consensus can be helpful. Using the Root Cause Tree® Dictionary to guide the root cause analysis process and requiring the recording of evidence that causes the team to select a root cause is an excellent practice.
MORE TO LEARN
This article is just a start. There is much more to learn. Experienced Team Leaders have many stories to tell about the knowledge they have learned “the hard way” in performing team incident investigations. But you can avoid having to learn many of these lessons the hard way if you attend the TapRooT® 5-Day Advanced Root Cause Analysis Team Leader Course. See the upcoming public courses by CLICKING HERE. Or contact us to schedule a course at your site.
We can help you stop bad things from happening.
Is your team trying to prevent fatalities?
Improve your root cause analysis?
Investigate a difficult incident?
Solve equipment reliability issues?
Reduce lost time accidents and workers comp costs?
Stop sentinel events?
Improve process safety?
Meet senior management improvement expectations?
We would be glad to help.
In helping companies all over the world implement TapRooT® and train their personnel to use advanced root cause analysis, we get involved in all types of performance improvement initiatives. We see what works. We see what doesn’t.
What are some common areas where we can help?
IMPROVE YOUR TapRooT® IMPLEMENTATION
We wrote the book on implementing TapRooT®. We know how it should be used and common ways to improve its use. We see best practices from around the world and we can help you catch up by applying best practices that you haven’t tried.
How do you get started? Call us at 865-539-2139. We’ll be glad to listen to the issues you face, what you’ve done so far to make improvement happen, and explain what you can do to take your program to the next level.
Our instructors are experts in applying TapRooT® to investigate problems. accidents, incidents, quality issues, sentinel events, equipment issues, production problems, and cost overruns. We don’t “do” investigations. But we can supply an an experienced TapRooT® facilitator to help your team with a tough investigation or to review an investigation that is nearing completion. Call us at 865-539-2139 or CLICK HERE to drop us a note to get the process started.
Using TapRooT® to investigate accidents and stop them from happening again is good. But is even better to use TapRooT® to stop accidents from ever occurring by being PROACTIVE.
We can show you how to apply TapRooT® proactively to stop accidents, incidents, quality issues, equipment reliability problems, production problems, or sentinel events. We actually have a specific course to teach the skills you will need to apply (Proactive Use of TapRooT® Course). You can attend the public course (next one is scheduled for June 1-2, 2015 in Las Vegas) which is offered just prior to the TapRooT® Summit. Or you can contact us to have a course at your site. And we would be glad to work with you before the course to get your proactive program set up to take advantage of the tools that TapRooT® offers.
Not only do we teach a course on Advanced Trending Techniques, we can help you apply those techniques to analyze your performance issues and help you present the findings to your management. We’ve found that many TapRooT® Users have never had experience in using trends to target improvement initiatives. So we can give you the training you need to understand trending and help you do your first trend analysis to understand how trending can be applied to prevent problems. Call us at 865-539-2139 or drop us a note to find out what we can do to help you look at your trends.
Many people use TapRooT® Software to analyze incidents. But to get the most from your software, you need to do up front business analysis to properly implement the software. Of course, we offer a course – Getting the Most from Your TapRooT® Software – to help TapRooT® Software Administrators and TapRooT® Software Super-Users learn what is needed to set up their software for best results. But we can also consult with TapRooT® Users and Software Administrators to help them develop a TapRooT® Software implementation plan. Call us at 865-539-2139 or drop us a note for more info about this service,
CREATE AN IMPROVEMENT INITIATIVE
If you are considering starting a new performance improvement initiative, why not get us involved from the ground up? We can use our knowledge of improvement programs from around the world to help you implement a world-class initiative. We can also bring in experts that we have worked with in equipment reliability, aviation safety, construction safety, nuclear safety, human factors, process safety, lean/six sigma, and patient safety to give your program a head start. Don’t try to reinvent the wheel. Let us help you get ahead of the game. Call us at 865-539-2139 to discuss your program and find out how we can help.
- – -
That’s just a few ideas. We have many more. But you will never know how we could have helped you unless you give as a call (865-539-2139) or drop us a note. Our initial advice is FREE and we’ll be happy to provide a quote for any services, training, or software needed to help your program become world-class.
Don’t procrastinate – call today.
Note: We have decided to republish articles from the Root Cause Network™ Newsletter that we find particularly interesting and still applicable today. These are used with the permission of the original publisher. In some cases, we have updated some parts of the text to keep them “current” but we have tried to present them in their original form as much as possible. If you enjoy these reprints, let us know. You should expect about two per month.
BEAT ‘EM OR LEAD ‘EM
A TALE OF TWO PLANTS
You’re the VP of a 1000 MW nuclear power plant. A senior reactor operator in the control room actuates the wrong valve.
The turbine trips.
The plant trips.
If the plant had just 30 more days of uninterrupted operation, your utility would have been eligible for a better rate structure based on the Public Service Commission’s (PUC) policy that rewards availability. Now you can kiss that hefty bonus check (that is tied to plant performance goals) good-bye.
To make matters worse, during the recovery, a technician takes a “shortcut” while performing a procedure and disables several redundant safety circuits. An inspector catches the mistake and now the Nuclear Regulatory Commission (the plant’s nuclear safety regulator – the NRC) is sending a special inspection team to look at the plant’s culture. That could mean days, weeks or even months of down time due to regulatory startup delays.
What do you do???
PLANT 1 – RAPID ACTION
He who hesitates is lost!
Corporate expects heads to roll!
You don’t want to be the first, so you:
- Give the operator a couple of days off without pay. Tell him to think about his mistake. He should have used STAR! If he isn’t more careful next time, he had better start looking for another job.
- Fire the technician. Make him an example. There is NO excuse for taking a shortcut and not following procedures. Put out another memo telling everyone that following procedure is a “condition of employment.”
- Expedite the root cause analysis. Get it done BEFORE the NRC shows up. There is no time for detailed analysis. Besides, everyone knows what’s wrong – the operator and technician just goofed up! (Human error is the cause.) Get the witch-hunt over fast to help morale.
- Write a quick report. Rapid action will look good to the regulator. We have a culture that does not accept deviation from strict rules and firing the technician proves that. Tell them that we are emphasizing the human performance technology of STAR. Maybe they won’t bother us any more.
- Get the startup preparation done. We want to be ready to go back on-line as soon as we can to get the NRC off our backs and a quick start-up will keep the PUC happy.
PLANT 2 – ALTERNATIVE ACTION
No one likes these types of situations, but you are prepared, so you:
- Start a detailed root cause analysis. You have highly trained operations and maintenance personnel, system and safety engineers, and human factors professionals to find correctable root causes. And your folks don’t just fly by the seat of their pants. They are trained in a formal investigation process that has been proven to work throughout a variety of industries – TapRooT®! It helps them be efficient in their root cause analysis efforts. And they have experts to help them if they have problems getting to the root causes of any causal factors they identify.
- Keep the NRC Regional Office updated on what your team is finding. You have nothing to hide. Your past efforts sharing your root cause analyses means that they have confidence that you will do a thorough investigation.
- “Keep the hounds at bay.” Finding the real root causes of problems takes time to perform a trough investigation. Resist the urge (based on real or perceived pressure) to give in to knee-jerk reactions. You don’t automatically punish those involved. Yoiu believe your people consistently try to do their best. You have avoided the negative progression that starts with a senseless witch-hunt, progresses to fault finding, and results in future lies and cover-ups.
- Check to see that the pre-staged corrective maintenance has started. Plant down time – even unscheduled forced outages – is too valuable to waste. You use every chance to fix small problems to avoid the big ones.
- Keep up to date on the root cause analysis team’s progress. Make sure you do everything in your power to remove any roadblocks that they face.
- Get ready to reward those involved in the investigation and in developing and implementing effective corrective actions. This is a rare opportunity to show off your team’s capabilities while in the heat of battle. Reward them while the sweat is still on their brow.
- Be critical of the investigation that is presented to you. Check that all possible root causes were looked into. Publicly ask: “What could I have done to prevent this incident?” Because of your past efforts, the team will be ready for good questions and will have answers.
Which culture is more common in your industry?
Which plant would you rather manage?
Where would you rather work?
What makes Plant 1 and Plant 2 so different? It is really quite simple…
- Management Attitude: A belief in your people means that you know they are trying to do their best. There is no higher management purpose that to help then succeed by giving them the tools they need to get the job done right.
- Trust: Everyone trusts everyone on this team. This starts with good face to face communications. It includes a fair application of praise and punishment after a thorough root cause analysis.
- Systematic Approach and Preparation: Preparation is the key to success and the cause of serendipity. Preparation requires planning and training. A systematic approach allows outstanding performance to be taught and repeated. That’s why a prepared plant uses TapRooT®.
Which plant exhibited these characteristics?
HOW TO CHANGE
Can you change from Plant 1 to Plant 2? YES! But how???
The first step has to be made by senior managers. The right attitude must be adopted before trust can be developed and a systematic approach can succeed.
Part of exhibiting the belief in your people is making sure that they have the tools they need. This includes:
- Choosing an advanced, systematic root cause analysis tool (TapRooT®).
- Adopting a written accident/incident investigation policy that shows managements commitment to thorough investigations and detailed root cause analysis.
- Creating a database to trend incident causes and track corrective actions to completion.
- Training people to use the root cause analysis tool and the databases that go with them.
- Making sure that people have time to do proper root cause analysis, help if things get difficult, and the budget to implement effective corrective actions.
- Providing a staff to assist with and review important incidents, to trend investigation results, and to track the implementation of corrective actions and report back to management on how the performance improvement system is performing.
Once the proper root cause analysis methods (that look for correctable root causes rather than placing blame) are implement and experienced by folks in the field, trust in management will become a forgone conclusion.
YOU CAN CHANGE
Have faith that your plant can change. If you are senior management, take the first step: Trust your people.
Next, implement TapRooT® to get to the real, fixable causes of accidents, incidents, and near-misses. See Chapter 6 of the © 2008 TapRooT® Book to get great ideas that will make your TapRooT® implementation world class.
_ _ _
Copyright 2014 by System Improvements, Inc. Adapted from an article in the March 1992 Root Cause Network™ Newsletter (© 1992 by System Improvements – used by permission) that was based on a talk given by Mark Paradies at the 1990 Winter American Nuclear Society Meeting.
Root Cause Analysis Tip: Rate Your Root Cause Analysis / Incident Investigation System – The Good, The Bad, and The UglySeptember 3rd, 2014 by Mark Paradies
Over a decade ago, I developed a rating sheet for root cause analysis implementation. We had several sessions at the TapRooT® Summit about it and it was posted on our web site (and then our blog). But in the last web site crash, it was lost. Therefore, I’m reposting it here for those who would like to download it. (Just click on the link below.)
Instructions for using the sheet are on the sheet.
I’m working on a new rating system for evaluation of individual incident investigations and corrective actions. Anyone have any ideas they would like to share?
Every company I’ve worked with has an existing improvement program.
Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some still have a long ways to go, but have started their improvement process.
No matter where you are, one question that always seems to come up is …
“What should we improve next?“
The interesting answer to this question is that your plant is telling you if you are listening.
But before I talk about that, let’s look at several other ways to decide what to improve…
1. The Regulator Is Emphasizing This
Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.
2. Management Hot Topic
Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…
- A recent accident (at your facility or someone else’s).
- A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
- That the CEO has a new initiative.
You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.
3. Industry Initiative
Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.
All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.
So how should you decide what to improve next?
By listening to your plant/facility.
What does “listening to you plant” mean?
To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.
Reactively collecting signals comes from your accident, incident, near-miss investigation programs.
It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.
I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.
Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.
Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).
Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.
Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler – see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)
Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.
Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.
BENCHMARKING ROOT CAUSE ANALYSIS
I’ve had many people ask me to comment on their use of root cause analysis. How are they doing? How do they compare to others? So I thought I’d make a simple comparison table that people could use to see how they were doing (in my opinion). I’ve chosen to rate the efforts as one of the following categories …
- Even Better
For each of these categories I’ve tried to answer the following questions about the efforts so that you could see which one most closely parallels your efforts. The questions are:
- To What Extent?
- Under What Conditions?
This is one step above no effort to find root causes.
Who performs the root cause analysis? The supervisor involved.
What do they use to perform the root cause analysis? 5-Why’s or no technique at all.
When do they perform the root cause analysis? In their spare time. (They must do their regular job and do the root cause analysis at the same time.)
Where do they perform the root cause analysis? Mainly in their office – they may do a few simple interviews with employees out in the plant but they don’t have a quiet, private room for interviewing.
To what extent do they pursue root causes? Usually as far as they think management will push them to go. If they can find a piece of equipment or a person to blame, that is far enough. The corrective actions can be to fix the equipment or to discipline the person and that is all that is needed.
Under what conditions do they perform the root cause analysis? They are in a hurry because management needs to know who to punish. Or the punishment may come before the root cause analysis is completed. They also know that if they can’t make a good case for someone else being blamed, they may get blamed for not having done a thorough pre-job risk assessment (call it a job safety analysis, pre-job brief, or pre-job planning if those terms fit better at your company). One more thing to worry about is that they certainly can’t point out any management system flaws or they may become a target of management’s wrath.
PROBLEMS WITH BAD
The problems with a BAD root cause analysis effort is that the solutions implemented seldom cause improvement. You frequently see very similar incidents happen over and over again due to uncorrected root causes.
Also, the root cause analysis tends to add to morale problems. People don’t like to be blamed and punished even if they may think that it was their fault. They especially don’t like it when they feel they are being made a scape goat.
Finally, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident that results in a fatality (or even worse, multiple fatalities). In almost every major accident, there were chances to learn from previous smaller issues. If these issues had been addressed effectively with a thorough root cause analysis and corrective actions, the major accident would have never occurred.
Better is better than bad, but still has problems.
Who performs the root cause analysis? The supervisor involved.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? In their spare time. (Similar to BAD.)
Where do they perform the root cause analysis? Mainly in their office. (Similar to BAD.)
To what extent do they pursue root causes? They use the Root Cause Tree® and find at least one root cause for at least a few of the Causal Factors.
Under what conditions do they perform the root cause analysis? They are trained in only the minimum knowledge to use TapRooT®. Sometimes they don’t even get the full 2-Day TapRooT® Course but instead are given a “short course” which should be “good enough” for supervisors. (Supervisors don’t have time to attend two days of root cause analysis training.) They often treat the Root Cause Tree® as a pick list and don’t use (or perhaps don’t have a copy of) the Root Cause Tree® Dictionary to use to guide their root cause analysis. Also, they may not understand the importance of having a complete SnapCharT® to understand what happened before they start trying to find out why it happened (using the Root Cause Tree®). And they probably don’t use the Corrective Action Helper® to develop effective corrective actions. Instead, rely on the well understood three standard corrective actions: Discipline, Training, and Procedures.
PROBLEMS WITH BETTER
The problems with a BETTER root cause analysis effort is that people claim to be doing a thorough TapRooT® root cause analysis and they aren’t. Thus they miss root causes that they should have identified and they implement ineffective fixes (or at best, the weakest corrective action – training). The results may be better than not using TapRooT® (they may have learned something in their training) but they aren’t getting the full benefit of the tools they are using. Their misuse of the system gives TapRooT® a bad name at their site.
Also, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident (just like the BAD example above).
Even better is the minimum that you should be shooting for. Don’t settle for less.
Who performs the root cause analysis? A well trained investigator. This investigator should have some independence from the actual incident.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? They either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.
Where do they perform the root cause analysis? They probably use a regular conference room to conduct interviews away from the “factory floor”.
To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest. This includes developing a thorough SnapCharT®, Safeguards Analysis to identify or confirm Causal Factors, the Root Cause Tree® and the Root Cause Tree® Dictionary to find root causes. And Safeguards Analysis and the Corrective Action Helper® to develop effective fixes.
Under what conditions do they perform the root cause analysis? They have support from management, who are also trained in what is required to find root causes using TapRooT®. They have experienced experts to consult with for difficult root cause analysis process questions. If it is a major investigation, they have the help of appropriate investigation team members and the root cause analysis effort is performed with a real time peer review process from another experienced TapRooT® facilitator.
PROBLEMS WITH EVEN BETTER
There aren’t too many problems here. There is room for improvement but the root cause analysis process and fixes are generally very effective. Smaller problems tend to be fixed effectively and help prevent major accidents from occurring.
The one issue tends to be that as performance improves, investigators get less and less experience using the TapRooT® techniques. New investigators don’t get the practice and feedback they need to develop their skills.
Read Chapter 6, section 6.3, of the TapRooT® Book for a complete description of what an excellent implementation of TapRooT® looks like. This kind of TapRooT® implementation should be your long term root cause analysis effort goal. The following is a brief description of what Chapter 6 covers.
Who performs the root cause analysis? For major investigations, a well trained facilitator with a trained team. For more minor investigations, a trained investigator. The site investigation policy should clearly identify the investigative effort needed based on the actual and potential consequences of the particular incident.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? Per the company’s pre-planning, the investigator and team either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.
Where do they perform the root cause analysis? For a major investigation an appropriate room is set aside for the team and they use a regular conference room to conduct interviews away from the “factory floor”.
To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest.
Under what conditions do they perform the root cause analysis? The management sponsor has pre-approved a performance improvement policy that covers the investigation process. managers, facilitators, and all employees involved are trained per the policy standards. A no blame or “just” culture has been established and the purpose of the investigation is understood to be performance improvement.
PROBLEMS WITH EXCELLENT
You can’t be excellent without a senior management sponsor and management support. And being excellent is a never ending improvement process.
Also, as performance improves, investigator get less experience with reactive investigations. Therefore, proactive use of TapRooT® must be an integral part of any EXCELLENT TapRooT® root cause analysis effort. Proactive use of TapRooT® is covered in Chapter 4 of the TapRooT® Book and an example of proactive use of TapRooT®, the after action review, is provided HERE.
How did your root cause analysis efforts compare? What do you need to improve? Even if you are EXCELLENT, you need to continuously improve your efforts. For even more improvement ideas and benchmarking, consider attending the 2015 Global TapRooT® Summit in Las Vegas on June 1-5. For more information, see:
Are you prepared for a tornado at your facility?
Watch what nuclear power plants (Watts Bar NPP – part of TVA) are doing …
Monday Accident & Lessons Learned: Human Error Leads to Near-Miss at Railroad Crossing in UK – Can We Learn Lessons From This?June 23rd, 2014 by Mark Paradies
Here’s the summary from the UK RAIB report:
At around 05:56 hrs on Thursday 6 June 2013, train 2M43, the 04:34 hrs passenger service from Swansea to Shrewsbury, was driven over Llandovery level crossing in the town of Llandovery in Carmarthenshire, Wales, while the crossing was open to road traffic. As the train approached the level crossing, a van drove over immediately in front of it. A witness working in a garage next to the level crossing saw what had happened and reported the incident to the police.
The level crossing is operated by the train’s conductor using a control panel located on the station platform. The level crossing was still open to road traffic because the conductor of train 2M43 had not operated the level crossing controls. The conductor did not operate the level crossing because he may have had a lapse in concentration, and may have become distracted by other events at Llandovery station.
The train driver did not notice that the level crossing had not been operated because he may have been distracted by events before and during the train’s stop at Llandovery, and the positioning of equipment provided at Llandovery station relating to the operation of trains over the level crossing was sub-optimal.
The RAIB identified that an opportunity to integrate the operation of Llandovery level crossing into the signalling arrangements (which would have prevented this incident) was missed when signalling works were planned and commissioned at Llandovery between 2007 and 2010. The RAIB also identified that there was no formalised method of work for train operations at Llandovery.
The RAIB has made six recommendations. Four are to the train operator, Arriva Trains Wales, and focus on improving the position of platform equipment, identifying locations where traincrew carry out operational tasks and issuing methods of work for those locations, improvements to its operational risk management arrangements and improving the guidance given to its duty control managers on handling serious operational irregularities such as the one that occurred at Llandovery.
Two recommendations are made to Network Rail. These relate to improvements to its processes for signalling projects, to require the wider consideration of reasonable opportunities to make improvements when defining the scope of these projects, and consideration of the practicability of providing a clear indication to train crew when Llandovery level crossing, and other crossings of a similar design, are still open to road traffic.
The full report has very interesting information about the possibility of fatigue playing a part in this near miss. See the whole report HERE.
This report is an excellent example of how much can be learned from a near-miss. People are more whilling to talk when a potential near-fatal accident happens than when a fatality happens. And all of this started because a bystander reported the near-miss (not the train crew or the driver).
How can you improve the reporting and investigation of potentially fatal near-miss accidents? Could your improvements in this area help stop fatalities?
Tide and Time Wait for No Man
(reprinted from the May 2014 Root Cause Network™ Newsletter by permission)
Some TapRooT® Users lament:
“I don’t get enough practice using TapRooT® to be good at finding root causes.”
Why do they say that? Because they only use TapRooT® to investigate major accidents. For most TapRooT® users, major accidents a re few and far between.
Not having major accidents is a good thing, so this complaint isn’t all bad. But why aren’t they getting practice using TapRooT® proactively to find root causes and improve performance? I think the answer to this question has to do with the effective use of TIME.
There’s never enough time to do it right, but there’s always enough time to do it over. – Jack Bergman
The first thing that I notice is that most people are reactive. They aren’t planning ahead. Rather, they respond as things go wrong. As W. Edwards Deming said:
Stamping out fires is fun, but it only puts things back the way they were.
To become excellent is to look ahead and avoid firefighting and being reactive.
But many complain that they just don’t have the time to be proactive and get ahead of the problems they face. They should remember:
The great dividing line between success and failure
can be expressed in five words: “I did not have time.” – Franklin Field
Lack of time is always an excuse. Here are two quotes to remember when someone complains about having too little time:
If you have time to whine and complain about something
then you have the time to do something about it. - Anthony J. D’Angelo
One always has enough time if one will apply it well. – Johann Wolfgang von Goethe
The first step in creating time for proactive analysis is to avoid wasting time on ineffective reactive efforts.
Start by being good when reactive improvement is called for. Get the training you need to apply TapRooT® effectively (we suggest the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course) and continue to learn by attending the TapRooT® Summit.
Next, make sure that your reactive investigations are as efficient as possible. Read Chapter 3 of the 2008 version of the TapRooT® Book to make sure that you are applying all the ways it recommends to save time during investigations. Also, review Appendix C, A Guide to Improving the Use of TapRooT®, in the TapRooT® Book to find even more ways to save time and effort.
Next, make sure that you aren’t wasting time investigating problems that aren’t important. Focus your reactive root cause analysis efforts on incidents that are truly significant or that could have caused a significant accident.
Finally, if you are a manager, be well trained in root cause analysis so that you ask good questions and know what to look for when you are reviewing investigators’ recommendations. That will keep you from wasting your investigators’ time.
SPEND TIME BEING PROACTIVE
Start small and start now using TapRooT® proactively to find and fix the root causes of problems before they happen.
Don’t wait. The time will never be just right. – Napoleon Hill
Learn how to use TapRooT® proactively by reading Chapter 4 of the TapRooT® Book. Also, read this LINK to get ideas about using TapRooT® root cause analysis proactively in after action reviews. What if you still can’t see how to find the time for proactive improvement?
In truth, people can generally make time for what they choose to do;
it is not really the time but the will that is lacking. – Sir John Lubbock
To develop more “will” to be proactive, picture success. Picture…
- Never having to investigate a major accident – EVER.
- No fatalities.
- Crisis management eliminated.
- Reliable equipment that doesn’t fail when you need it the most.
- No major cost overruns and no major schedule slippages.
- Happy clients that aren’t complaining about quality issues.
The only way to achieve this goal is by systematically, proactively improving using root cause analysis. Reactive root cause analysis will never get you to this picture of success.
Success is simple. Do what’s right, the right way, at the right time. – Arnold H. Glasgow
If you still need help after you’ve attended TapRooT® Training, read the TapRooT® Book, and tried becoming proactive, give us a call (865-539-2139) or drop us a note (click here) and ask us for more ideas to address your specific problems. We’ll be glad to help you apply TapRooT® root cause analysis proactively to achieve performance excellence.
Time is not measured by the passing of years,
but by what one does,
what one feels, and
what one achieves.
- Jawaharlal Nehru
Monday Accident & Lessons Learned: You Don’t Have to be in a High Risk Industry to be Killed on the JobJune 16th, 2014 by Mark Paradies
This fatal accident should remind all of us that you don’t have to be in a high risk occupation to be killed on the job. A forklift in the warehouse is all that is needed to provide the energy needed to start a fatal accident. See the press report here of a recent forklift fatality that is being investigated by OSHA:
Proactive use of root cause analysis is needed in all sorts of industries to improve safety and prevent fatal accidents. Are you doing all you can to keep your employees safe?
The US Bureau of Labor Statistics release some interesting information about workplace fatalities in a recent press release.
It would be interesting to see these statistics graphed on an XmR Chart … as we teach in our Advanced Trending Techniques Course. If you are interested in learning advanced trending techniques, you missed our 2014 course. But we are planning to offer the course again on June 1-2, 2015 prior to the 2015 TapRooT® Summit (June 3-5, Las Vegas, NV). I know that’s a long ways ahead to start planning but you probably can’t say that your schedule is already full.
One more note, if you have a bunch of folks at your company who need to learn advanced trending techniques, we can come to your site to present the course. If you are interested, CLICK HERE to contact us.
Do you want a World-Class Improvement Program? Then read “Tide and Time Wait for No Man” on page 1 of this month’s Root Cause Network™ Newsletter. Download your copy of the newsletter by clicking on this link:
- 5 Ways to Improve Your Interviews (Page 2)
- Best Practice from the 2014 Global TapRooT® Summit: The TapRooT® Expert Help Desk (Page 2)
- How things naturally go from “Excellence to Complacency” (Page 2)
- A new idea … “Budget for Your Next Accident” (Page 3)
- Dilbert Joke (Page 3)
- An answer to “Is Human Error a Root Cause?” (Page 3)
- A list of upcoming public TapRooT® Courses – Is one near you? (Page 4)
Mark Paradies, President, System Improvements, is building a network of people interested in root cause analysis and improving incident and accident investigations. Help him reach a milestone of 11,000 direct connections on LinkedIn. At the writing of this post, he only needs 22 more connections to reach this goal. To see his profile and send him an invitation to join his network, go to: