Category: Performance Improvement
IT DIDN’T HAVE TO HAPPEN
An anesthesia machine cuts off oxygen to a patient causing extensive brian 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?
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.
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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:
I have no special talents. I am only passionately curious.
For those that have followed BP’s accidents (the explosion at Texas City and the blowout and explosion of the Macondo well to name the most prominent), the Baker Report is a famous independent review of the failure of process safety at BP.
I was reading a discussion about process safety and someone brought up the Baker Report as an excellent source for process safety knowledge. That got me thinking, “Was the Baker Report successful?”
The initial Panel Statement at the start of the report includes this quote:
“In the aftermath of the accident, BP followed the recommendation of the U. S. Chemical Safety and Hazard Investigation Board and formed this independent panel to conduct a thorough review of the company’s corporate safety culture, safety management systems, and corporate safety oversight at its U.S. refineries. We issue our findings and make specific and extensive recommendations. If implemented and sustained, these recommendations can significantly improve BP’s process safety performance.”
I believe the Deepwater Horizon/Macondo accident provides evidence that BP as a corporation either didn’t learn the lessons of the report or didn’t implement the fixes across the corporation, or that the report was not successful in highlighting areas to be changed and getting management’s attention.
What do you think?
Was the report successful? Did it cause change and help BP have an improved process safety culture?
Or did the report fail to cause change across the company?
And if it failed, why did it fail?
Let me know your ideas by leaving your comments by clicking on the comments link below.
You have to be burning with an idea, or a problem, or a wrong that you want to right. If you’re not passionate enough from the start, you’ll never stick it out.
What is a “thought leader”? I wasn’t sure what that meant when I heard the term recently because I wasn’t up-to-date with the latest lingo.
So, I read a Forbes article about thought leaders, (“What is a Thought Leader,” Russ Alan Prince and Bruce Rogers, March 16, 2012). Here’s how the article defined them:
Thought Leader Definition Part 1:
“A thought leader is an individual or firm that prospects, clients, referral sources, intermediaries and even competitors recognize as one of the foremost authorities in selected areas of specialization, resulting in its being the go-to individual or organization for said expertise.”
Thought Leader Definition Part 2:
“A thought leader is an individual or firm that significantly profits from being recognized as such.”
This made me curious, so I dug a little deeper and discovered five unmistakable qualities of a thought leader:
1. Thought leaders are driven by a higher purpose. The reward they seek is more than money; they find reward in a work that is a service to other human beings in some way.
2. Thought leaders implement positive change by first seeing things differently than the rest of the crowd. Their work helps people become unstuck and move forward.
3. Thought leaders are highly motivated and passionate about their missions. This inspires everyone they come into contact with to make a change for the better.
4. Thought leaders focus on their one big thing for decades. They are energized by expansiveness, but have always been driven toward solving one big problem.
5. Thought leaders are interested in creating positive change in the lives of others because they love people. They become students of human behavior, and are more interested in your story than their own.
That got me thinking. People at the Global TapRooT® Summit are thought leaders!
They are individuals and companies that are recognized as leaders in certain specialized areas or industry leaders AND they benefit from the knowledge they learn and take back and apply from the Summit.
Are you a thought leader? Do you want to be a thought leader?
Then you should register NOW for the 2014 Global TapRooT® Summit at Horseshoe Bay near Austin, Texas. The pre-Summit courses are on April 7-8. The Summit is next week – April 9-11.
For more information, see:
I often hear the complaint. “Our supervisors produce poor quality root cause analysis and incident investigations. Why can’t they do better?” Read on for several potential reasons and solutions…
Probably the most serious problem that prevents supervisors from performing good investigations is the blame game. Everyone has seen it. Management insists that someone must be punished for an error. Why does this cause problems? Because supervisors know that their people or even the supervisor is the most likely discipline target. They learn to blame the equipment to avoid useless discipline. And they know better than to blame management. That would surely result in retribution. Therefore, their investigations are light on facts and blame the equipment.
Obviously, to solve this problem, the whole management approach to human error and performance improvement must change. Good luck!
Supervisors are seldom given the proper training or time to do a good investigation. Training may be a four-hour course in five whys. What a joke! Then, they perform the investigations in their spare time.
What do they need? The same training in advanced root cause analysis that anyone else needs to solve serious problems. A minimum of a 2-Day TapRooT® Course. But a 3-Day TapRooT®/Equifactor® Course would be better for Maintenance Supervisors. Better yet, a 5-Day TapRooT® Course to teach them TapRooT® and additional skills about analyzing human performance and collecting information.
As for time to perform the investigation, it’s best to bring in a relief supervisor to give them time to focus on the investigation.
The last step is to motivate supervisors. They need to be rewarded for producing a good investigation with the unvarnished truth. If you don’t reward good investigations, you shouldn’t expect good investigations.
Learn more about TapRooT® Training at: http://www.taproot.com/courses
WHAT ARE HUMAN PERFORMANCE TOOLS?
Over the past decade, best practices and techniques have been developed “stop” or manage human error. They were developed mainly in the US nuclear industry and vary in content/name by the consultant/organization that offers them. Common tools include:
- Procedure Use*
- Place Keeping*
- Pre-Job Brief*
- Post-Job Brief
- Peer Checking*
- Time Out
- Rule of Three
- 3-Way Communication*
- Observation & Coaching*
- Questioning Attitude
- Attention to Detail
- Errors Traps/Precursors
Here are some links to learn more about the tools above:
Also, if you plan on attending the 2014 Global TapRooT® Summit, attend Mark Paradies’ talk on human performance tools to learn more about these tools.
The asterisk (*) techniques above have always been included on the Root Cause Tree® (part of the TapRooT® System) because they are supported by established human factors research. Post-Job Briefs are also a well-established best practice that isn’t included on the Root Cause Tree® because it would occur after an incident or as part of the normal performance improvement program.
WHAT’S WRONG WITH HUMAN PERFORMANCE TOOLS?
Some of the techniques seem like excellent best practices (paying attention, having a questioning attitude, STAR, and Time Out), but I haven’t been able to find scientific human factors research that supports their use. For example, the “Rule of Three” is supposedly supported by research in the aviation industry that three yellow lights (conditions that are worrisome but not enough to prevent a flight) are equal to one red light (a fight no-go indicator – for example weather that doesn’t meet the flight minimums).
Because they seem like good ideas, you may decide to adopt them, but they may not work as intended in all cases. After all, research hasn’t tested their limits.
The final technique, Error Traps/Precursors seems to violate a couple of human factors principles and therefore should only be used with caution.
ERROR TRAPS / PRECURSORS
The concept behind Error Traps/Precursors is that certain human conditions are indicators of impending human error. If a person can self-monitor to detect the “error likely” human condition, he/she can then apply an appro-priate human performance tool to avoid (stop) the impending error. For example, if you notice that you are rushing, you could apply STAR.
What are these human conditions? The selection varies depending on the consultant that presents the technique, but they commonly include:
- High Workload
- New Tasks
- First Time
- New Technique
A problem with this technique is that the person performing work must self-monitor to detect the human condition to self-trigger action. I’ve never seen research that people are particularly good at self-monitoring to detect any human condition. And even if they were, the list seems to indicate that people would be would be constantly self-triggering. By this list, people are always just about to make a mistake. (To err is human?)
Constantly monitoring points to another human factors limitation. The human brain automatically apportions a very limited resource – attention. Your brain continuously, subconsciously decides what to pay attention to and what to ignore. Your brain decides what sounds are important and which ones are noise. Your brain may decide that motion in the visual field deserves more attention than a stationary object. Or that a sharp pain is more important than a faint touch.
In times of crisis or when one is busy, your ability to pay attention is stressed. Imagine yourself driving on ice. You are so focused on the feel of the road and preventing sliding that you don’t have enough attention left over to even have a casual conversation.
Even when you are not stressed, if you self-monitor your state, you stealing attention from some other task. What faint signal might you miss?
All of the Human Performance Tools have a common limitation. They are weak corrective actions. They are 5’s or 6’s on the TapRooT® hierarchy of controls. Rules, procedures, training, are all attempts at improving human performance. And the human may be your weakest safeguard. If your human performance improvement program is based on the weakest safeguards, what should you expect?
This doesn’t mean that you should not try proven human performance tools. It means that you should try to adopt stronger safeguards and understand the limitations of human performance tools and, at a minimum, implement defense in depth to ensure adequate performance.
Maybe it’s time for you to join the 2330 members of the TapRooT® Root Cause Analysis Users & Friends Group on LinkedIn. It’s a great place to network with other TapRooT® Users, ask questions, anmd keep up with the latest TapRooT® Information.
You can set your group profile to receive an e-mail every time something is posted, daily, weekly, or never.
If you are a LinkedIn member, click on the link below to see the group:
One worker was killed and two were injured aboard a nuclear submarine under construction in India.
Was it some high tech nuclear accident? No. I was a simple pressure test of a hydraulic tank.
This accident once again shows that failure to control simple energy is often the cause of fatalities.
See the whole story here: http://www.dawn.com/news/1091836/accident-at-indian-nuclear-submarine-centre-kills-one-worker
Could this accident have been prevented? Yes. How? Find out at the Proactive Use of TapRooT® Course being held on April 7-8.
What if you missed a meeting that could have prevented someone’s death? Or what if you lost your job because you didn’t attend? Or your company lost millions of dollars simply because you didn’t attend a three-day meeting.
Would you make sure that you were there?
Sometimes that what I think about when someone says they just can’t attend this year’s Global TapRooT® Summit. Why? Because people have told me about the improvements in safety practices that they have learned about at the Summit that helped them save lives at their company. They told me how they applied best practices that they learned at the Summit to save their company millions of dollars. And they told me how the ideas they brought back from the Summit helped them looked good in front of their bosses and get promoted.
You might think that missing just one year isn’t that big of a deal … But that would be wrong. Every year the Summit is different. Every year there are different best practices discussed and leading edge practices presented. If you miss a year you might miss the best practice that could have helped you save a life in the following year. And even if that topic was repeated at a future Summit, that chance to save that life has been lost.
But how can you get your boss to approve attending (especially when the Summit is less than a month away)? They need to see the value and see that they too need the ideas that you will bring back. See the Summit brochure attached to the end of this newsletter and find the topics that will help you solve some of the toughest problems at your site. Then show your boss and explain that the company just can’t miss this valuable information. That should make the decision easy.
An intangible that you may not be considering is the motivation that you will get at the Global TapRooT® Summit. Have you thought about how much change you can make happen when you are motivated compared to being de-motivated? The Global TapRooT® Summit will help you revive your spirits and resume the battle to improve performance despite the obstacles. Register today! See: