Another great TapRooT® root cause analysis course in Bogota a couple of weeks ago!
Another successful TapRooT® training course in the books!
Here’s a link to the announcement:
Here are the 11 tenants they suggest:
To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:
And then healthcare executives could also insist on advanced root cause analysis.
Ignorance is Bliss
From many people’s actions, you might believe that they think “ignorance is bliss” is true. We need to ignore the real root causes of problems and just attack the symptoms.
Even the cartoon, Calvin and Hobbs, commented on it. See the cartoon on my Facebook page …
Is this the way you treat your root cause analysis?
Would you rather have a simple BUT WRONG answer?
For over a decade, I’ve explained the shortcomings of 5-Whys for root cause analysis but some still believe that easy is better than right.
What if you could find and fix the real root causes of what you think are “simple incidents” with a robust, advanced system (TapRooT®) and not make a career of the investigation? You would put in only the effort required. Your investigation would be as simple as possible without going overboard. And your corrective actions would be effective and stop repeat incidents.
That’s what the new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about.
Have you read the new book yet?
Once you read the book you will want to start implementing TapRooT® for all the “simple” investigations that are worth being done.
Get the book today and find out what you should be doing. Order the book at:
Today we had a bittersweet celebration for our Admin Team All-Stars, Nicki and LJ! They have dedicated many years to System Improvements (TapRooT®), and we will miss them greatly. If either of them have ever helped you with anything from general inquiries to product sales, you know what wonderful team members they are. Thank you for everything, Nicki and LJ. We wish you all the best!
I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.
Blame is the number one reason for bad root cause analysis.
Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.
As Bart Simpson says:
“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”
Blame is so common that people take it for granted.
Somebody makes a mistake and what do we do? Discipline them.
If they are a contractor, we fire them. No questions asked.
And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.
Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?
But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.
Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution.
How do you stop blame and get people to cooperate with investigations? Here are two best practices.
A. Start Small …
If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous.
Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.
B. Use a SnapCharT® to facilitate your investigation and report to management.
We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.
Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame.
What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:
2. FIRST ASK WHAT NOT WHY
Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.
Because they should have started by asking what before they asked why.
Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem.
How do you get people to ask what instead of why?
Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.
3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE
Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.
What happens when an investigator starts an investigation by jumping to conclusions?
They ignore evidence that is counter to their hypothesis. This problem is called a:
It has been proven in many scientific studies.
But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.
What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?
Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.
How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.
The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.
If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.
If your organization faces:
- Quality Issues
- Safety Incidents
- Repeat Equipment Failures
- Sentinel Events
- Environmental Incidents
- Cost Overruns
- Missed Schedules
- Plant Downtime
You need to be apply the best root cause analysis system: TapRooT®.
Learn more at:
And find the dates and locations for our public TapRooT® Training at:
Are you sending people to our Public TapRooT® Training?
Or are you having a TapRooT® Course at your site?
And arranging TapRooT® Training at one or more of your facilities around the world?
If you want to choose your dates, now is the time to get your onsite courses scheduled.
And if you want to choose a particular public course, now is the time to get your folks registered!
A great 2-Day TapRooT® course in Ecuador at AGUIP!
A Report from the UK Rail Accident Investigation Branch:
Structural failure caused by scour at Lamington viaduct, South Lanarkshire, 31 December 2015
At 08:40 hrs on Thursday 31 December 2015, subsidence of Lamington viaduct resulted in serious deformation of the track as the 05:57 hrs Crewe to Glasgow passenger service passed over at a speed of about 110 mph (177 km/h). The viaduct spans the River Clyde between Lockerbie and Carstairs. Subsequent investigation showed that the viaduct’s central river pier had been partially undermined by scour following high river flow velocity the previous day. The line was closed for over seven weeks until Monday 22 February 2016 while emergency stabilisation works were completed.
The driver of an earlier train had reported a track defect on the viaduct at 07:28 hrs on the same morning, and following trains crossed the viaduct at low speed while a Network Rail track maintenance team was deployed to the site. The team found no significant track defects and normal running was resumed with the 05:57 hrs service being the first train to pass on the down line. Immediately after this occurred at 08:40 hrs, large track movements were noticed by the team, who immediately imposed an emergency speed restriction before closing the line after finding that the central pier was damaged.
The viaduct spans a river bend which causes water to wash against the sides of the piers. It was also known to have shallow foundations. These were among the factors that resulted in it being identified as being at high risk of scour in 2005. A scheme to provide permanent scour protection to the piers and abutments was due to be constructed during 2015, but this project was deferred until mid-2016 because a necessary environmental approval had not been obtained.
To mitigate the risk of scour, the viaduct was included on a list of vulnerable bridges for which special precautions were required during flood conditions. These precautions included monitoring of river levels and closing the line if a pre determined water level was exceeded. However, this process was no longer in use and there was no effective scour risk mitigation for over 100 of the most vulnerable structures across Scotland. This had occurred, in part, because organisational changes within Network Rail had led to the loss of knowledge and ownership of some structures issues.
Although unrelated to the incident, the RAIB found that defects in the central river pier had not been fully addressed by planned maintenance work. There was also no datum level marked on the structure which meant that survey information from different sources could not easily be compared to identify change.
As a result of this investigation, RAIB has made three recommendations to Network Rail relating to:
- the management of scour risk
- the response to defect reports affecting structures over water
- the management of control centre procedures.
Five learning points are also noted relating to effective management of scour risk.
For more information, see: