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:
Happy Wednesday and welcome to this week’s root cause analysis tips.
Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.
Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.
While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.
PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.
As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.
Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.
Thanks for reading the blog, and best of luck with your improvement efforts.
Happy Wednesday, and welcome to this week’s root cause analysis column.
This week I wanted to share an excerpt from our new book which will be coming out on August 1st, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. I hope this small part of the book will help you start to think about being more proactive.
“An Ounce of Prevention is Worth a Pound of Cure.”
Around the world, professionals and companies have sought to find a better way to perform investigations on problems and losses. Many of the smartest people and leading companies use TapRooT®.
The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix simple or complex accidents, difficult quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and the development of effective corrective actions. However, wouldn’t it be better if you never had to do investigations in the first place?
Many companies do perform audits. Unfortunately, in some cases, this work does not yield improvements. Why? There are many reasons, but the primary reason is lack of good root cause analysis. A company can actually be very good at finding problems, but not be effective at FIXING problems.
Beyond auditing, proactive improvement can take many forms, and when effective, becomes an overall mindset and can put an organization on the path to excellence. If that is the case, why are more companies not proactive? Here are just a few reasons:
- Time (perceived at least)
- They don’t have a reason to (not enough pain)
- They do not have the buy-in (management and employee support)
- Procrastination (human nature!)
- They don’t know how (this is where TapRooT® comes in!)
TapRooT®, when used with auditing and proactive improvement programs, can help lead to organizational excellence and reduce the number of investigations required.
Would you like to be one of the first people to get the new book? If so, attend our new course, TapRooT® for Audits, at the Global TapRooT® Summit, August 1-2, in San Antonio. To register for the course (and the summit on August 3-5, click HERE
I had a couple of things I wanted to share with our clients who work in quality:
First, Chris Vallee and I will be at the ASQ World Conference on Quality and Improvement starting Sunday. We will be in Booth 507, so please come and see us!
Second, we will be launching our new course, TapRooT® for Audits, at our 2016 Global TapRooT® Summit. The course will be on August 1-2 in San Antonio. I hope you can join us, and don’t forget to stick around for the summit itself on August 3-5. To register, visit HERE
The course will include a copy of our new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.
By the way, the new course is not just for quality people, it is for anyone who wants to learn to use TapRooT® for audits. Safety, Quality, Food Safety, Operations, it does not matter. And you do not to be previously trained in TapRooT® to attend.
If you already know how to use TapRooT® for auditing, but work in Quality and want to learn more about process improvement, Chris will be teaching the TapRooT® Quality Process Improvement Facilitator Course at the summit as well.
We are pleased to announce the first TapRooT® course for auditors. We will debut this course as a pre-summit offering before the 2016 Global TapRooT® summit.
TapRooT® is the best method for performing investigations and doing root cause analysis. But wouldn’t it be better if you never had to do the investigations in the first place? Of course, and that is why auditing is so important.
Sadly, most companies take the time and resources to do audits but do not get the desired results. Why? Because corrective actions are developed without proper root cause analysis. That is where TapRooT® comes in.
TapRooT® can be used to perform root cause analysis on any problem, so why not find the problem and do root cause analysis before these problems manifest themselves into incidents? We decided to develop a course for auditors and audit participants to see how TapRooT® works, both reactively, and with audits. Regardless of your role in the audit process, you must understand the entire TapRooT® process to be effective, so this course is for anyone involved in auditing, from auditors themselves, to auditees, to management who is responsible for improvements. Here is the agenda:
TapRooT® Process Introduction and Initial Audit
SnapCharT® and Exercise
Causal Factors, Significant Issues and Exercise
Root Cause Tree® and Exercise
Corrective Actions and Exercise
The Root Cause Tree® and Preparing for Audits with Root Cause Exercise
Audit Programs, Trend and Process Root Cause Analysis
TapRooT® Software Introduction
Frequently Asked Questions about TapRooT®
Final Audit Observation Exercise
Participants in the course will receive a copy of the new book, “TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement.”
We hope to see you in the course! To register:
REGISTER for this course and the 2016 Global TapRooT® Summit (August 1 – 5, 2016).
REGISTER for this 2-day course only (August 1 – 2, 2016).
“Easier than making a mistake” … now that is good Human Engineering!
While listening to a radio commercial recently, I heard the announcer say, “Easier than making a mistake!” As a TapRooT® Root Cause Instructor with a quality and human engineering (Human Factors) background, all that I could think about is mistake-proofing, Poka-yoke.
The concept was formalized, and the term adopted, by Shigeo Shingo as part of the Toyota Production System. It was originally described as baka-yoke, but as this means “fool-proofing” (or “idiot-proofing”) the name was changed to the milder poka-yoke. (From Wikipdia)
Now, I did not learn about Dr. Shigeo Shingo during my Human Factors study, even though a large part of training dealt 100% with design and usability from products, to controls and to user graphic user interfaces. On the flip side, Human Factors and Usability was rarely discussed during my Lean Six Sigma certification either, even though Poka-yoke was covered.
Why are two major interactive topics such as Human Factors and Poka-yoke kept in isolation, very dependent on where and what you study? Simple, shared best practices and industry secrets are not always the norm.
Where can you learn about both topics? In San Antonio, Texas during our TapRooT® Summit Week August 1-5.
In the pre-summit 2-Day TapRooT® Quality Process Improvement Facilitator Course, we cover the error of making weak preventative or corrective action items that are not based on the actual root causes found and not optimizing and understanding mistake-proofing that will impact your success in continuous process improvements.
For those that need a deeper understanding of why mistake-proofing should be considered, you should look into signing up for the 2-Day Understanding and Stopping Human Error Course.
If it is written down, it must be followed. This means it must be correct… right?
Lack of compliance discussion triggers that I see often are:
- Defective products or services
- Audit findings
- Rework and scrap
So the next questions that I often ask when compliance is “apparent” are:
- Do these defects happen when standard, policies and administrative controls are in place and followed?
- What were the root causes for the audit findings?
- What were the root causes for the rework and scrap?
In a purely compliance driven company, I often here these answers:
- It was a complacency issue
- The employees were transferred…. Sometimes right out the door
- Employee was retrained and the other employees were reminded on why it is important to do the job as required.
So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.
Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.
What are some options to removing the blinders of pure compliance?
GOAL (Go Out And Look)
- Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
- Don’t just check off the audit checklist fro compliance’s sake, GOAL
- Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
- Learn how to evaluate your own process without the pure Compliance Glasses on.
If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.
There is no Normalization of Deviation. Deviation IS NORMAL!
If you don’t think that is true, read this previous article:
In 1946, Admiral Rickover was one of a small group of naval officers that visited the Manhattan Project in Oak Ridge, Tennessee, to learn about nuclear power and to see if there were ways to apply it in the US Navy. He had the foresight to see that it could be applied as a propulsion for submarines – freeing subs from the risky proposition of having to surface to recharge their batteries.
But even more amazing than his ability to see how nuclear power could be used, to form a team with exceptional technical skills, and to research and develop the complex technologies that made this possible … he saw that the normal ways that the Navy and industrial contractors did things (their management systems) were not robust enough to handle the risk of nuclear technology.
Rickover set out to develop the technology to power a ship with the atom and to develop the management systems that would assure excellence. In PhD research circles these new ways of managing are often called a “high performance organization.”
Rickover’s pursuit of excellence was not without cost. It made him the pariah in naval leadership. Despite his accomplishments, Rickover would have been forced out of the Navy if it had not been for strident support from key members of Congress.
Why was Rickover an outcast? Because he would not compromise over nuclear safety and his management philosophies were directly opposed to the standard techniques used throughout the Navy (and most industrial companies).
What is the proof that his high performance management systems work? Over 60 years of operating hundreds of naval nuclear reactors ashore and at sea without a single process safety accident (reactor meltdown). And his legacy continues even after he left as head of the Nuclear Navy. The culture he established is so strong that it has endured for 30 years!
Compare that record to the civilian nuclear power industry, refinery process safety incidents, or off shore drilling major accidents. You will see that Rickover developed a truly different high performance organization that many with PhD’s still don’t understand.
In his organization, deviation truly was abnormal.
What are the secrets that Rickover applied to achieve excellence? They aren’t secret. He testified to his methods in front of Congress and his testimony is available at this link:
What keeps other industries from adopting the Rickover’s management systems to achieve equally outstanding performance in their industries? The systems Rickover used to achieve excellence are outside the experience of most senior executives and applying the management systems REQUIRES focussed persistence from the highest levels of management.
To STOP the normalization of deviation, the CEO and Presidents of major corporations would have to insist and promote the Normalization of Excellence that is outlined in Rickover’s testimony to Congress.
Sometimes Rickover’s testimony to Congress may not be clear to someone who has not experience life in the Nuclear Navy. Therefore, I will explain (translate from Nuclear navy terminology) what Rickover meant and provide readers with examples from my Nuclear Navy career and from industry.
Read Part 3: Normalization of Excellence – The Rickover Legacy – Technical Competency
This week I would like to ask the question…what is the difference between a safety incident and a quality problem?
Before you answer that, let me tell you that this is a trick question.
The answer is……drum roll please: there is NO DIFFERENCE. The difference in a safety problem vs. a quality problem is the consequence; there is no difference in the approach you take in investigating.
In TapRooT®, the first thing we always do is to create a SnapCharT®. And the first thing we do when creating a SnapCharT® is to define the incident with a circle. This defines the scope of your investigation. Your circle could contain anything that creates pain for your company and that you would like to prevent from happening again. Examples of things that might go in your circle:
• Lost time injury
• Recordable injury
• Vehicle accident
• Facility damage
• etc. etc.
• Defective product (not sent to customer)
• Defective product (sent to customer)
• Customer complaint
• Delayed shipment
• etc. etc.
Once you have defined the incident, you map out what happened, define the causal factors, perform root cause analysis, and develop corrective actions.
So start thinking about different ways your company can use TapRooT®. I’ve mentioned Safety and Quality, but there are many more. equipment reliability, environment, security, project delays; the list is really endless.
The more ways you can use TapRooT®, the better ROI you will get from your training. I know from experience when different disciplines in an organization start speaking the same language, there are some great intangible benefits as well. So if you are a safety manager, drag your quality manager with you to training next time. You will be glad you did.
Thanks for visiting the blog and best wishes for your improvement efforts.
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The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.
A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.
Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
This article in the Houston Chronicle about and FDA audit and problems left unsolved at Blue Bell Ice Cream should convince people that thorough root cause analysis and implementation of effective corrective actions is needed to prevent business disasters.
Find out how TapRoot® can help you solve problems by reading this link:
I read an article in the Houston Chronicle about failed corrective actions at Blue Bell® Ice Cream.
It made me wonder:
“Did Blue Bell perform an adequate root cause analysis?”
Sometimes people jump tp conclusions and implement inadequate corrective actions because they don’t address the root causes of the problem.
Its hard to tell without more information, but better root cause analysis sure couldn’t have hurt.
Find out how TapRooT® Root Cause Analysis can help find and fix the root causes of problems by reading about TapRooT®’s history at:
Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Chris Vallee. He shares a great process quality tip and news about his upcoming Process Quality & Corrective Action Track at the 2015 Global TapRooT® Summit, June 3-5, 2015 in Las Vegas, Nevada!
Was this tip helpful?
Check out more short videos in our series:
Equifactor® – Are You Using it to Prevent Equipment Failures? (Click here to view tip.)
Be Proactive with Dave Janney (Click here to view tip.)
Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)
What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)
Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…
… your own actions.
… your understanding of other peoples actions.
… your past corrective or preventative actions.
Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.
To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.
To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit
If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw
Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:
“Can TapRooT® be used to solve quality issues?”
I was surprised by the question. Of course, the answer is YES!
We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.
Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?
The only answer was … We had not told him!
Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors.
Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.
For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.
That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.
So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS