Category: Performance Improvement

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 mind 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 what 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. COUNSELLING (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’ 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 action 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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Six Sigma: Better Root Cause Analysis and Corrective Actions

June 22nd, 2017 by

I remember first learning about root cause analysis during Six Sigma training. The main methods we used were 5 Whys and Fishbone diagrams, but somehow we had a hard time arriving at good corrective actions. It took time and testing to get there, and still the fixes were not always robust.

Since then, I have learned a lot more about RCA. Unguided deductive reasoning tools like 5 Whys or Fishbones rely heavily on the knowledge and experience of the investigator. Since nobody can be an expert in every contributing field, this leads to investigator bias. Or, as the old adage goes: “If a hammer is your only tool, all your problems will start looking like nails”.

Other issues with deductive reasoning are investigations identifying only single causes (when in reality there are several), or ignorance of generic root causes that have broader quality impacts. Results will also be inconsistent; if several teams analyze the same issue, results can be wildly divergent. Which one is correct? All of them? None?

This is where the TapRooT® methodology has benefits over other tools. It is an expert system that guides investigators to look at a range of potential causal factors, like human engineering, management systems and procedures. There are no iterations of hypotheses to prove or disprove so investigator bias is not a problem.

The process is repeatable, identifies all specific and generic causes and guides the formulation of strong corrective actions. It is centered on humans, systems and processes, and the decisions they make every day.

The supporting TapRooT® Software is designed to enable investigators to keep efforts focused and organized:

  1. define the problem in a SnapCharT®
  2. identify Causal Factors and Root Causes with the Root Cause Tree®, and
  3. formulate sustainable corrective actions using the Corrective Action Helper® module

The TapRooT® process avoids blame, is easy to learn and quickly improves root cause analysis outcomes.

In Six Sigma parlance, the SnapCharT® is used for problem definition (Define), the Root Cause Tree® and trending for root cause identification (Measure and Analyze), and the corrective action process to define effective fixes (Improve).

#TapRooT_RCA

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.

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!)

Monday Motivation: Modify your dreams or magnify your skills!

June 5th, 2017 by

  You must either modify your dreams or magnify your skills. – Jim Rohn

“Dream big,”” they say.

“If you can dream it, you can become it,” they say.

It’s the season of high school and college graduations, and success clichés are in the air.  And, to be fair, there is a certain amount of vision that can be gleaned from inspirational quotes.  But there is more to reaching success in your career than simply having a dream.  Don’t settle and modify your dreams.  You can bridge the gap of where you are now to where you want to be by magnifying your skills.

We can help you do just that!

If you want to magnify your leadership skills, read the TapRooT® Root Cause Analysis Leadership Lessons book.

If you want to magnify your skills of conducting fast simple investigations, read the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book or attend our 2-day TapRooT® Root Cause Analysis Training.  We have made major strides in making TapRooT® easy to use. We even have a new five step process for doing a low-to-medium risk incident investigation.

If you want to magnify your skills of conducting major investigations, learn the whole TapRooT® process and tools for investigating high potential and high risk incidents by reading the TapRooT® Root Cause Analysis for Major Investigations book or attending our 5-day TapRooT® Advanced Root Cause Analysis Team Leader Training.  The book and course explain the entire 7-step TapRooT® System and all the TapRooT® Tools.

If you want to get ahead of accidents, incidents, and quality issues, then magnify your proactive/audit skills by reading the TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book.

Don’t settle for less than what you want to do with your career.  Magnify your skills!

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

May 31st, 2017 by

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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?

Simple 5-Whys becomes complex 5-Whys – Why not use TapRooT® Root Cause Analysis?

May 31st, 2017 by

This video doesn’t really address the problems with 5-Whys but it sure does make it more complex.

They suggest that you can brainstorm root causes. You can’t brainstorm what you don’t understand.

For a more complete discussion of why people have problems with 5-Whys, see:

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

And for a better way to find root causes see:

About TapRooT®

To get a book that will help you understand how to really find the root causes of low-to-medium risk problems, see:

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

Root Cause Tip: “Enforcement Needs Improvement” – You Can’t Train Obedience/Compliance/Positive Behavior

May 26th, 2017 by

This is a quick clarification to stop a definite no-no in poorly developed corrective actions.

You find evidence during your root cause analysis to support the root cause “Enforcement NI” based on the following statements from your Root Cause Tree® Dictionary for a particular causal factor:

  • Was enforcement of the SPAC (Standards, Policies, Administrative Controls) seen as inconsistent by the employees?
  • Has failure to follow SPAC in the past gone uncorrected or unpunished?
  • Did management fail to provide positive incentives for people to follow the SPAC?
  • Was there a reward for NOT following the SPAC (for example: saving time, avoiding discomfort).
  • When supervisors or management noticed problems with worker behavior, did they fail to coach workers and thereby leave problems similar to this causal factor uncorrected?

But then if you create a corrective action to retrain, remind, and reemphasize the rules, directed at the employee or in rare occasions the immediate supervisor, your investigation started on track and jumped tracks at the end.

Now, I am okay with an alert going out to the field for critical to safety or operation issues as a key care about reminder, but that does not fix the issues identified with the evidence above. If you use Train/Re-Train as a corrective action, then you imply that the person must not have known how to perform the job in the first place. If that were the case, root causes under the Basic Cause Category of “Training” should have been selected.

Training covers the person’s knowledge, skills and abilities to perform a specific task safely and successfully. Training does not ensure sustainment of proper actions to perform the task; supervision acknowledgement, reward and discipline from supervision, senior leadership and peers ensure acceptance and sustainment for correct task behaviors.

Don’t forget, it is just as easy for supervision to ignore unsafe behavior as it is for an employee to deviate from a task (assuming the task was doable in the first place). Reward and discipline applies to changing supervision’s behavior as well.

Something else to evaluate. If the root cause of Enforcement NI shows up frequently, make sure that you are not closing the door prematurely on the Root Cause Tree® Dictionary Near Root Causes of:

  • Oversight/Employee Relations (Audits should be catching this and the company culture should be evaluated).
  • Corrective Actions (If you tried to fix this issue before, why did it fail?).

Remember, you can’t train obedience/compliance/positive behavior. Finally, if you get stuck on developing a corrective active for Enforcement NI or any of our root causes, stop and read your Corrective Action Helper®.  

Learn more by attending one of our upcoming TapRooT® Courses or just call 865.539.2139 and ask a question if you get stuck after being trained.

Building a Safety Culture

May 26th, 2017 by

A Safety Culture can be defined as “the sum of what an organization is and does in the pursuit of safety”. Managing company culture is a task of the corner office; top management needs to embrace the safety mindset -that every employee and customer is free from harm.

In the health care field The Joint Commission (an accreditation organization for hospitals) takes patient safety very seriously. Their document, “11 Tenets of a Safety Culture” (https://www.jointcommission.org/assets/1/6/SEA_57_infographic_11_tenets_safety_culture.pdf) contains a lot of wisdom that can be applied in continuous safety improvement everywhere:

  1. Apply a transparent, nonpunitive approach to reporting and learning from adverse events, close calls and unsafe conditions.
  2. Use clear, just, and transparent risk-based processes for recognizing and distinguishing human errors and system errors from unsafe, blameworthy actions.
  3. CEOs and all leaders adopt and model appropriate behaviors and champion efforts to eradicate intimidating behaviors.
  4. Policies support safety culture and the reporting of adverse events, close calls and unsafe conditions. These policies are enforced and communicated to all team members.
  5. Recognize care team members who report adverse events and close calls, who identify unsafe conditions, or who have good suggestions for safety improvements. Share these “free lessons” with all team members (i.e., feedback loop).
  6. Determine an organizational baseline measure on safety culture performance using a validated tool.
  7. Analyze safety culture survey results from across the organization to find opportunities for quality and safety improvement.
  8. Use information from safety assessments and/or surveys to develop and implement unit-based quality and safety improvement initiatives designed to improve the culture of safety.
  9. Embed safety culture team training into quality improvement projects and organizational processes to strengthen safety systems.
  10. Proactively assess system strengths and vulnerabilities, and prioritize them for enhancement or improvement.
  11. Repeat organizational assessment of safety culture every 18 to 24 months to review progress and sustain improvement.

A formal safety culture statement like this is a good start. To avoid it becoming a “flavor of the day” initiative, it is important to put in place a robust root cause analysis method like TapRooT®. This lends immediate support to Tenets 1. and 2. above.  It is also important to empower employees at every level to stop risky behavior.

Every organization benefits from an objective and impersonal way of investigating or auditing safety incidents, that gets to the root causes. Instead of blaming, re-training or firing individuals more effective corrective actions can be implemented, and safety issues dealt with once and for all.

#TapRooT_RCA

Is there an easier way to investigate simple problems?

May 24th, 2017 by

People often ask me:

“Is there an easier way to investigate simple problems?”

The answer is “YES!”

The simplest method is:

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Of course, some methods may be too simple.

That’s why we wrote a book about the simplest, but reliable method to find the root causes of simple incidents. The title? Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Want to learn more? See an outline at: http://www.taproot.com/products-services/taproot-book

Or just order a copy by CLICKING HERE.

Ready for an On-Line Risk Assessment?

May 9th, 2017 by

Have you ever watch NAPO videos? Here is one about an on-line risk assessment tool …

Get more information at:

https://oiraproject.eu/en

Opportunity to Improve Vision

May 9th, 2017 by

(Taken from Book 1: TapRooT® Root Cause Analysis Leadership Lessons, used by permission of System Improvements)

The Opportunity to Improve Vision

What does the Opportunity to Improve vision look like?

If there is a problem, the people, either individually or in teams, work to solve the problem. Everyone views this as an opportunity to improve. The team doing the investigation knows better than to just address the symptoms. They are NOT looking for someone to blame. They ARE looking for the root causes. They know that if they find and fix root causes they will prevent the problem’s recurrence.

As W. Edwards Deming said:

“Management’s job is to improve the system.”

This is the Opportunity to Improve Vision. Improving the “system” is the key to improving performance.

But what is the system? The system is equipment, procedures, tools, communication techniques, training, human factors design, supervisory techniques, resources (time), policies, and rules that all impact the ability to achieve the intended goal. These are all things that management can change to improve performance.

The Opportunity to Improve Vision sees each incident as an opportunity. Not an opportunity to find a scapegoat (someone to blame). Not an opportunity to survive yet another crisis. The Opportunity to Improve Vision sees each incident as an opportunity to improve performance by changing the system.

If you are living in the Blame Vision or the Crisis Management Vision, this may seem like a fairy tale. But the Opportunity to Improve Vision exists at many sites using TapRooT® Root Cause Analysis. And TapRooT® helped them achieve the vision when they started finding the real root causes of problems rather than placing blame and using “quick fixes” that really didn’t work.

Would you like to learn more about TapRooT® Root Cause Analysis? Attend one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. See:

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

Senior Management: Can Your Investigators Tell You that Your BABY is UGLY?

May 3rd, 2017 by

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This article is for senior corporate management

Can your investigators tell you that your baby is UGLY?

What do I mean by this?

Can your investigators point out management system flaws that ONLY YOU can fix?

If you say yes … I want to know the last time they did it!

Why am I bringing this up?

Recently I was talking to several “senior investigators” from a major company. We were discussing some serious incidents (SIFs). I recognized that there had been a series of management system failures over a period of over a decade that had not been fixed. SEVERAL generation of senior management had contributed to the problem by creating a culture of expediency … a “just get it done” culture that put cost containment and keeping the plant operating over process safety. 

I asked them if they had pointed this out to senior management. They looked at me if I was nuts. 

That’s when I realized … THEY couldn’t tell management that their BABY was UGLY.

I also realized that management didn’t want to hear that their BABY was UGLY.

They just wanted problems to go away with the least muss and fuss. They didn’t want to confront the investments required to face the facts and put process safety first.

TapRooT® Root Cause Analysis will point out the problems in management systems. But investigators must be willing to confront senior management with the facts (tactfully) and show them clearly that their BABY is UGLY.

Senior management should be DEMANDING that investigators point out management system flaws and asking WHY management system flaws ARE NOT being presented if a serious incident happens.

I remember pointing out a serious management system flaw that had caused a multi-multi-million dollar accident (no one had been killed but someone easily could have been killed). The Senior VP said:

“If anyone would have pointed out the problems this decision caused, we wouldn’t have made it!”

Don’t let poor management system decisions go unchallenged and unreported. When unreasonable budgets, deferred maintenance, short staffing, unreasonable overtime, or standard violations become an issue – SAY SOMETHING! Let senior management know they have an UGLY BABY.

SENIOR MANAGEMENT – Occasionally you need an outside opinion of how your baby looks … Especially if you continue to have Significant Incidents. Maybe you need to face the facts that your BABY is UGLY.

Remember … Unlike real ugly babies, management CAN DO SOMETHING about management system problems. Effective corrective actions can make the UGLY BABY beautiful.

Crisis, Crisis Everywhere…

May 1st, 2017 by

The Crisis Management Vision

Has your management ever said:

 “If we investigated every incident we had, we’d do nothing but investigate incidents!”

Then there is a good chance that you are living in a crisis management vision.

What are your three most common corrective actions for any problem?

  • Counsel the operator to be more careful
  • Require more training.
  • Write (or rewrite) the procedure.

Unfortunately, this type of corrective action usually doesn’t work (even though sometimes it may appear to work). The problem happens again. The vicious cycle of crisis and crisis management repeats itself. And everyone complains about having to work too hard because they are always in “crisis mode.” 

Are you tired of crisis management?

Would you like to finally solve problems once and for all?

Then it is time you tried TapRooT® Root Cause Analysis. Attend one of our publics courses listed here…

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

This article was derived from Book 1: TapRooT® Root Cause Analysis Leadership Lessons. Copyright 2017 by System Improvements, Inc. Used by permission.

 

Trapped in the Blame Vision

April 20th, 2017 by

From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.

The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.

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They were trapped in the Blame Vision.

The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.

The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:

I didn’t do it! 
Nobody saw me do it! 
You can’t prove I did it!

But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:

Why be fair when you can be arbitrary?

A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up. 

One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself. 

The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement. 

Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him. 

If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.

What Would You Do If You Saw a Bad 5-Why Example?

April 19th, 2017 by

It seems that I’m continually confronted by folks that think 5-Whys is an acceptable root cause analysis tool. 

The reason they bring up the subject to me is that I have frequently published articles pointing out the drawbacks of 5-Whys. Here are some examples…

Article in Quality Progress: Under Scrutiny (page 32)

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

That got me thinking … Have I EVER seen a good example of a 5-Why root cause analysis that I thought was a good example of a root cause analysis? And the answer was “NO.”

So here is my question … 

What do you do when you see someone presenting a bad root cause analysis where they are missing the point?

Leave a comment below and let me know the tack that you take … What do you think?

Should We Continue to Fund the CSB?

April 17th, 2017 by

The Trump Administration has cut funding for several independent agencies in their 2017 budget request. One is the US Chemical Safety Board.

The CSB has produced this video and a report to justify their continued funding.

REPORT LINK

The question taxpayers need to ask and answer is, what are the returns on the investment in the CSB?

The CSB produces investigation reports, videos, and a wish list of improvements.  In 2016 the agency published seven reports and two videos  (it has six investigations that are currently open). That makes it a cost of $1.2 million per report/video produced when you divide their $11 million 2016 budget by their key products.

The 2017 budget request from the CSB was $12,436,000 (a 13% increase from their 2016 budget).

Should the government spend about $12 million per year on this independent agency? Or are these types of improvements better developed by industry, other regulatory agencies (EPA and OSHA), and not-for-profit organizations (like the Center for Chemical Process Safety)?

Leave your comments here (click on the comments link below) to share your ideas. I’d be interested in what you think. Or write your representatives to provide your thoughts.

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. 

Root Cause Analysis Tip: Does Your Company Vision PREVENT Good Root Cause Analysis?

April 11th, 2017 by

What is your company’s vision? Does your company have a:

  • Blame Vision
  • Crisis Management Vision
  • Opportunity to Improve Vision

The only vision that leads to good root cause analysis is the opportunity to improve vision. 

We’ve been helping people “adjust” their vision since Mark Paradies gave a talk about the opportunity to improve vision at the 1990 Winter American Nuclear Society Meeting. 

How do you change your vision?

That takes more than the few paragraphs of a blog article to describe. But we did write about it in our newest book:

TapRooT® Root Cause Analysis Leadership Lessons

 

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What’s in the new book?

  • A Tale of Two Plants
  • Vision
  • What is a Root Cause and How Was TapRooT® Developed to Help You Find Them?
  • How Leaders Can Apply TapRooT® to Improve Performance
  • What Can TapRooT® Do for You?
  • What TapRooT® Books Do You Need to Read?

The new book is designed for senior managers and leaders of improvement programs to help them understand effective root cause analysis and how it fits into a performance improvement program.

Order your copy of the new book by clicking HERE and make sure your vision supports improved performance!

 

When do you need a root cause analysis?

April 5th, 2017 by

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I heard one industry guru say that EVERY loss deserves an investigation and corrective action.

Is it possible?

Is it desirable? 

I would say no.

Not every loss needs an investigation and certainly not every loss deserves a root cause analysis.

Why?

Because every investigation should have at least a chance of a positive return on the investigation investment. Many losses are too small to get much benefit from an investigation. (This is true even if you take into account the potential for even bigger problems down the road.) Let’s face it, sometimes there just isn’t much to learn from a paper cut!

Why should we avoid wasting our improvement energy on unimportant minor problems?

Because every organization has resource limitations and we should spend our resources wisely. We need to put our effort where it will do the most good.

Therefore, we must target our resources where they will get the most improvement bang for the buck.

The targeting of improvement resources should match management’s goals. This targeting of resources should guide the improvement effort by assigning resources for safety, quality, reliability, productivity, and product improvement. Of course, the division of resources is guided by the company’s risk assessment and market analysis. 

Let’s look at an interesting hypothetical example.

At a large chemical company, a budget and level of emphasis has been assigned for safety improvement. How should the company spend this budget? Where should the safety team direct their resources?

The first place to look would be the company’s real accident data. Of course, if the company has poor root cause analysis, the data will not be meaningful. If that is true, the first place to apply resources is to achieving outstanding root cause analysis of significant accidents.

What if this company has been applying advanced root cause analysis for several years and has fairly good accident data. Then they can use that data to determine where their biggest risks are and what type of root causes contribute the most to that risk. That knowledge can help them target their resources. 

If a company’s safety improvement programs are fairly ineffective (measured by the fatality count), the majority of the emphasis should be put on the investigation of significant incidents and precursors to significant incidents. These are incidents that cause fatalities and serious injuries and incidents that could have caused a fatality or serious injury if one more Safeguard had failed.

The remaining improvement effort (say 33%) would be applied to proactive improvement. This includes local safety audits, peer observations, management field observations, and outside audits.

As the company improves, their safety performance and the time between significant incidents will improve significantly (do you trend this?). As this happens, effort is shifted from reactive investigations (because there are less of them) to targeted proactive improvement. This tends to cause an excelleration in the improvement progress. 

What happens if you don’t have good root cause analysis of significant incidents?

If a company does NOT do a good job investigating and fixing their serious incidents, the proactive improvement efforts tend to be miss-directed. The lessons learned from significant injuries and potential significant injuries are inaccurate. The data produced misdirects the proactive improvement efforts. The significant injuries continue even though the minor incidents targeted by the misdirected proactive improvement efforts tend to improve.

This misdirection of proactive improvement efforts has been written about extensively. Proactive behavior based safety improvement efforts produced good trends in lost time injury data with little improvement in fatality and significant injury data. This should not be a surprise. It is the reason that many companies hit a plateau of improvement for major accidents while having world-class lost time injury rates. 

I believe an excellent example of this misdirection of improvement efforts could be seen in the BP Texas City Refinery explosion. Management thought their improvement efforts were working because of a decrease in the LTI rate but the fatality rate (that included contractors) was unchanged (or maybe slightly worse). 

Where are you????

Are you trending the time between serious injuries and fatalities?

Is that time increasing significantly?

Do you know how to tell if the time between incidents is increasing significantly?

We can help you learn how to mathematically prove that improvement is occurring (or that things have taken a turn for the worse). 

Are your less significant incidents improving without making much impact on your significant injury rate? This is a sign of a misdirected improvement effort and a need to improve your root cause analysis of significant injuries.

We can review your program, point out potential improvements, and  teach your folks how to apply the best root cause analysis techniques reactively and proactively to make improvement happen.

We can also help your management understand their impact on improvement. How they directly influence the quality of the root cause analysis. (You can’t have excellent root cause analysis without management understanding and involvement.) Even the best root cause analysis systems can’t succeed unless management asks for the appropriate investigations and provides the resources needed to implement effective performance improvement fixes.

Once all of this is on track, we can help you see how to effectively apply your resources to get the most bang for your improvement buck. This includes targeting of improvement efforts and deciding when a root cause analysis is needed and when the effort should be applied elsewhere.

Call Per Ohstrom or Mark Paradies at 865-539-2139 (or CLICK HERE to contact us) to discuss your improvement efforts and see how we could help focus your program to get the best return on your improvement investment.

REVIEWING STATISTICS: How Much Did Safety Really Improve?

March 30th, 2017 by

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I was reading an article that congratulated the safety profession for improving industry safety statistics in the USA. These statistics were provided from the US Bureau of Labor Statistics:

Year          # of Fatalities          Fatality Rate          Number of Workers (in millions)

1971              13,700                         17                               81

1981              12,500                         13                               96

1991                9,800                           8                              123

2001                5,900                          4.3                            137

2009                4,551                          3.5                            130

2013               4,585                          3.3                            139

What’s missing from the stats above?

The TYPE of work being performed.

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Between 1971 and 2013 there was a major change in the type of work performed in the USA. We changed from a production economy to a service economy. Plus, we implemented extensive automation. Therefore, the risk per hour worked decreased as higher risk work was replaced by office jobs and other service related work. (Yes … the picture above is well before 1971, but you get the point.)

How much did the risk change? I don’t think anyone knows for sure.

Did it account for 10% of the improvement? 25% of the improvement? 50% of the improvement? 90% of the improvement? Picking a number would be guessing.

Here is another question …

If President Trump brings back manufacturing jobs to the USA, will the number of fatalities increase with the return of higher risk work? Or will factory automation reduce the risk and keep the numbers permanently lower?

Again, this question is difficult to answer.

What can we say for sure?

There is always room for improvement and advanced root cause analysis can help you make that improvement happen.

Why Does TapRooT® Exist?

March 28th, 2017 by

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

http://www.taproot.com/archives/category/success-stories

What’s Wrong with this Data?

March 20th, 2017 by

Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):

Summary Event Data

 Reviewing this data, one might ask … 

What can we learn?

I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…

  • Does a tic up or down in a particular category mean something? 
  • Why are suicides so high and infections so low? 
  • Why is there no category for misdiagnosis while being treated?

Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.

Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.  

If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.

That makes me ask some serious questions.

1. Are the other events being hidden? Ignored? Or investigated and not reported?

Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?

2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?

To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database. 

If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data. 

This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.

This isn’t happening.

What can you do to get things started?

1. Push for full reporting of sentinel events AND near-misses at your hospital.

2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.

3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.

That’s a start. After twelve years of reporting, shouldn’t every hospital get started?

If you are at a healthcare facility that is

  • reporting ALL sentinel events,
  • investigating most of your near-misses, 
  • doing good root cause analysis, 
  • implementing effective corrective actions that 
  • stop repeat sentinel events, 

I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.

If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.

The Joint Commission Issues Sentinel Event Alert #57

March 6th, 2017 by

Here’s a link to the announcement:

https://www.jointcommission.org/sea_issue_57/

Here are the 11 tenants they suggest:

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To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:

http://www.taproot.com/archives/54027

And then healthcare executives could also insist on advanced root cause analysis.

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