Category: Root Cause Analysis Tips

Root Cause Tip: Audit Your Investigation System (A Best of The Root Cause Network™ Newsletter Reprint)

November 26th, 2014 by

Based on the October 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted/adapted by permission. Some modifications have been made to update the article.

AUDIT YOUR INVESTIGATION SYSTEM

AUDIT TO IMPROVE

We have all heard the saying:

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Tom Peters changed that saying to:

“If it aint broke, you aren’t looking hard enough.”

 We can’t improve if we don’t do something different. In the “Just Do It” society of the 1990’s, if you weren’t improving, you were falling behind. And the pace of improvement has continued to leap forward in the new millennium. 

Sometimes we overlook the need to improve in places that we need to improve the most. One example is our improvement systems. When was the last time you made a comprehensive effort to improve your incident investigations and root cause analysis? 

Improvement usually starts by having a clear understanding of where you are. That means you must assess (inspect) your current implementation of your incident investigation system. The audit needs to establish where you are and what areas are in need of improvement.

AREAS TO AUDIT

If we agree that auditing is important to establish where we are before we start to improve, the question then is:

What should we audit?

To answer that question, you need to know what makes an incident investigation system work and then decide how you will audit the important factors. 

The first research I would suggest is Chapter 6 of the TapRooT® Book (© 2008). This will give you plenty of ideas of what makes an incident investigation system successful.

08TapRooTBook Cover

Next, I would suggest reviewing Appendix A of the TapRooT® Book. Pay special attention to the sample investigation policy and use it as a reference to compare to your company’s policy.

Next, review Appendix C. It provides 16 topics (33 suggestions) to improve your incident investigation and root cause analysis system. The final suggestion is The Good, The Bad, and The Ugly rating sheet to rate your investigation and root cause analysis system. You can download a copy of an Excel spreadsheet of this rating system at:

http://www.taproot.com/archives/46359

Next, review the requirements of your regulator in your country. These will often be “minimum” requirements (for example, the requirements of OSHA’s Process Safety Management regulation. But you obviously should be meeting the government required minimums.

Also, you may have access to your regulators audit guidance. For example, OSHA provides the following guidance for Process Safety Management incident investigations:

12. Investigation of Incidents. Incident investigation is the process of identifying the underlying causes of incidents and implementing steps to prevent similar events from occurring. The intent of an incident investigation is for employers to learn from past experiences and thus avoid repeating past mistakes. The incidents for which OSHA expects employers to become aware and to investigate are the types of events which result in or could reasonably have resulted in a catastrophic release. Some of the events are sometimes referred to as “near misses,” meaning that a serious consequence did not occur, but could have.

Employers need to develop in-house capability to investigate incidents that occur in their facilities. A team needs to be assembled by the employer and trained in the techniques of investigation including how to conduct interviews of witnesses, needed documentation and report writing. A multi-disciplinary team is better able to gather the facts of the event and to analyze them and develop plausible scenarios as to what happened, and why. Team members should be selected on the basis of their training, knowledge and ability to contribute to a team effort to fully investigate the incident. Employees in the process area where the incident occurred should be consulted, interviewed or made a member of the team. Their knowledge of the events form a significant set of facts about the incident which occurred. The report, its findings and recommendations are to be shared with those who can benefit from the information. The cooperation of employees is essential to an effective incident investigation. The focus of the investigation should be to obtain facts, and not to place blame. The team and the investigation process should clearly deal with all involved individuals in a fair, open and consistent manner.

Also, OSHA provides more minimum guidance on page 23 of this document:

https://www.osha.gov/Publications/osha3132.pdf

Finally, another place to network and learn best practices to benchmark against your investigation practices is the TapRooT® Summit. Participants praise the new ideas they pick up by networking with some of the “best and brightest” TapRooT® Users from around the world.

Those sources should provide a pretty good checklist for developing your audit protocol.

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AUDIT TECHNIQUES (PROTOCOL)

How do you audit the factors that are important to making your incident investigation system work? For each factor you need to develop and audit strategy and audit protocol.  

For example, you might decide that sharing of lessons learned with employs and contractors is a vital part of the investigation process. The first step in developing an audit strategy/protocol would be to answer these questions:

  1. Are there any regulatory requirements for sharing information?
  2. What is required by our company policy?
  3. What good practices should we be considering?

Next, you would have to develop a protocol to verify what is actually happening right now at your company. For example, you might:

  • Do a paper audit of the practices to see if they meet the requirements.
  • Go to the field to verify workers knowledge of past best practices that were shared.

Each factor may have different techniques as part of the audit protocol. These techniques include:

  • paperwork reviews
  • field observations
  • field interviews
  • worker tests
  • management/supervision interviews
  • training and training records reviews
  • statistical reviews of investigation results

To have a thorough audit, the auditor needs to go beyond paperwork reviews. For example, reading incident investigation reports and trying to judge their quality can only go so far in assessing the real effectiveness of the incident investigation system. This type of assessment is a part of a broader audit, but should not provide the only basis by which the quality of the system is judged.

For example, a statistical review was performed on the root cause data from over 200 incident investigations at a facility. The reviewer found that there were only two Communication Basic Cause Category root causes in all 200 investigations. This seemed too low. In further review it was found that investigators at this facility were not allowed to interview employees. Instead, they provided their questions to the employee’s supervisor who would then provide the answers at a later date. Is it any surprise that the supervisor never reported a miscommunication between the supervisor and the employee? This problem could not be discovered by an investigation paperwork review.

Don’t forget, you can use TapRooT® to help develop your audit protocol and find the root causes of audit findings. For example, you can flow chart your investigation process as a Spring SnapCharT® to start developing your audit protocol (see Chapter 5 of the 2008 TapRooT® Book for more ideas).

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WHO SHOULD AUDIT & WHEN?

We recommend yearly audits of your improvement system. You shouldn’t expect dramatic improvements every year. Rather, if you have been working on improvement for quite some time, you should expect gradual changes that are more obvious after two or three years. This more like measuring a glacier moving than measuring a dragsters movement. 

Who should perform these audits?

First, the system’s owner should be doing annual self-assessments. Of course, auditing your own work is difficult. But self-assessments are the foundation of most improvement programs.

Next, at least every three years you should get an outside set of eyes to review your program. This could be a corporate auditor, someone from another site, or an independent (hired) auditor.

System Improvements (the TapRooT® Folks) provides this type of hired audit service (contact us by calling 865-539-2139 or by CLICKING HERE). We bring expertise in TapRooT® and an independent set of eyes. We’ve seen incident investigation systems from around the world in all sorts of industries and have access to the TapRooT® Advisory Board (a committee of industry expert users) that can provide us with unparalleled benchmarking of practices.  

GET STARTED NOW

Audits should be an important part of you continuous improvement program. If you aren’t already doing annual audits, the best time to start is NOW! Don’t wait for poor results (when compared to your peers) makes your efforts look bad. Those who are the best are already auditing their system and making improvements. You will have to run hard just to keep up!

Root Cause Analysis Video Tip: TapRooT® Resources That Will Help You Be Proactive.

November 19th, 2014 by

Dave Janney, Senior Associate and instructor for TapRooT®, shares with us today the many TapRooT® resources that will help you be proactive in your company’s investigations. Dave also discusses the importance of being proactive; you might think that your company doesn’t have the resources (time, money, etc.) to spend to be proactive but it will cost you even more resources to let the incidents build up. Prevent them from happening using TapRooT® proactive resources such as the Root Cause Tree®, SnapCharT and Root Cause Tree Dictionary.

For more information regarding our Public and Onsite TapRooT® Courses, click here.

Want to join us at the Global TapRooT® Summit? Click here for more information and registration.

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Was this tip helpful? Check out more short videos in our series:

Conduct Real-Time Peer Reviews with Mark Paradies (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

 

Root Cause Analysis Tip: Top 10 Investigation Mistakes (in 1994)

November 12th, 2014 by

Gatlinburg Sunrise 1

At the first TapRooT® Summit in Gatlinburg, Tennessee, in 1994, attendees voted on the top investigation mistakes that they had observed. The list was published in the August 1994 Root Cause Network™ newsletter (© 1994). Here’s the top 10:

  1. Management revises the facts. (Or management says “You can’t say that.”)
  2. Assumptions become facts.
  3. Untrained team of investigators. (We assign good people/engineers to find causes.)
  4. Started investigation too late.
  5. Stopped investigation too soon.
  6. No systematic investigation process.
  7. Management can’t be the root cause.
  8. Supervisor performs investigation in their spare time.
  9. Fit the facts to the scenario. (Management tells the investigation team what to find.)
  10. Hidden agendas.

What do you think? Have things change much since 1994? If your management supports using TapRooT®, you should have eliminated these top 10 investigation mistakes.

What do you think is the biggest investigation mistake being made today? Is it on the list above? Leave your ideas as a comment.

Root Cause Analysis Video Tips: Equifactor®…Are you using it to prevent equipment failures?

November 5th, 2014 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Ken Reed. He briefly discusses the importance of using Equifactor® proactively in order to prevent equipment failures from ever happening.  Among the many uses of TapRooT®, using it proactively is one of the most important. Keep the investigations to a minimum if you can help it!

For more information on Equifactor® and the courses we offer for it, click here.

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Was this tip helpful? Check out more short videos in our series:

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.)

 

8 Reasons to Ask for Help with an Investigation

October 28th, 2014 by

ReportBinder
People who attend TapRooT® Training know that trainees are expected to go back to work as self-sufficient investigators. They should be able to perform an excellent root cause analysis without an outside facilitator.

But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?

Here are eight examples that could help you decide when to ask for help:

1. LEGAL ISSUES

Could this accident end up in court? If so, you need the help of your company’s attorney.

They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.

2. CUSTOMER DISPUTE

It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.

But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.

3. UNION ISSUE

Ever had an investigation that gets contentious with a union?

This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.

4. COMPLEX ACCIDENTS

TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.

What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.

What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.

5. INDEPENDENT INVESTIGATION / NEW SET OF EYES

Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.

6. CONTROVERSIAL INVESTIGATION

I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.

7. COACHING

Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.

8. OVERWHELMED

Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.

Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.

Still not sure? Contact us at: http://www.taproot.com/contact-us for more information.

Root Cause Analysis Video Tips: How TapRooT® Can Help with The Joint Commission Requirements

October 15th, 2014 by

This week for our Instructor Root Cause Tip we have Ed Skompski, partner with System Improvements, Inc. and TapRooT® Instructor with a specialty in the medical field. Listen closely as Ed talks about the Sentinel Event Matrix and Root Cause Analysis in the Healthcare industry and how TapRooT® is used to optimize their investigations.

Click here for more information regarding our TapRooT® courses around the world.

And connect with us on LinkedIn so that you can stay informed about the next tip video release: https://www.linkedin.com/company/system-improvements-inc.

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Was this tip helpful? Check out more short videos in our series:

Prevent Equipment Failures with Ken Reed (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.)

Root Cause Analysis Video Tips: What Makes a World Class Root Cause Analysis System?

October 6th, 2014 by

We hope you enjoy this new format of our Instructor Root Cause Tips. Today we have Ken Reed, TapRooT®/Equifactor® Instructor and Partner, discussing “What Makes a World Class Root Cause Analysis System?”. Be sure to pay attention to the 7 Strengths of TapRooT® that he discusses.

Click here to learn more about our courses where you can learn root cause analysis and implement in your own workplace.

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Was this tip helpful? Check out more short videos in our series:

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Be Proactive with Dave Janney (Click here to view tip.)

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Champion Technologies)

September 24th, 2014 by

Trevor Archibald of Champion Technologies shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he keeps his investigation teams’ skills fresh and up-to-date:

If you’re at work and don’t have time to watch the video, here’s his tip:

“My name’s Trevor Archibald. I work with Champion in Canada. It was written into my performance contract this year to improve the quality of our investigations. And one of my activities in meeting that goal is holding three workshops a year. We’ve got two dozen folks trained in TapRooT® – [we'll be] bringing them back in here three times a year, putting them through a smaller 1-day workshop, giving them some investigations, doing it all over again. In addition to that I’ve written about a dozen things you all have said here so I’ll be adding that in as well.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Marathon Petroleum)

September 10th, 2014 by

Pete Reynolds of Marathon Petroleum Company shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he uses peer groups to improve investigations:

If you’re at work and don’t have time to watch the video, here’s his tip:

We have a peer group that is kind of a silo buster. We all get together and talk about the TapRooT® Process and getting the investigation done.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tip: Rate Your Root Cause Analysis / Incident Investigation System – The Good, The Bad, and The Ugly

September 3rd, 2014 by

GoodBadUgly

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.)

GoodBadUgly.xls

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?

Root Cause Analysis Video Tips – Doing Better Investigations (Part 2)

August 27th, 2014 by

Last week we discussed how to improve your investigation by preparing well. This week we’ll dive into evidence collection.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart.

We teach several evidence collection techniques in our courses….

The 3 P’s and the R:
• People
• Plant
• Paper
• Recordings

Interviewing (TapRooT® book, Chapter 3)

Optional techniques:
• Equifactor® (for equipment problems) – TapRooT® book, Chapter 9
• Change Analysis (what has changed or what is different) TapRooT® book, Chapter 11
• CHAP (critical human action profile) TapRooT® book, Chapter 12

Trust me, if you have a good comprehensive SnapCharT® your analysis will be easy and you will find all the root causes. Without that, you will miss something, your corrective actions will be lacking, and your incidents will recur.

Once you have your chart complete, your causal factors identified, and have completed your root cause analysis, it is time for the output of your investigation – corrective actions. Don’t forget our SMARTER technique and use the Corrective Action Helper® for good ideas. Safeguards Analysis is also a great tool for developing corrective actions.

I could go on all day about this, but the key thing I want to bring out here is you MUST have a good SnapCharT®. If you focus on that the rest should fall into place nicely.

Click here to view Part 1 of this video.

or check out other short videos in our root cause tip series:

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Prevent Equipment Failures with Ken Reed (Click here to view tip.)

Root Cause Analysis Video Tips – Doing Better Investigations (Part 1)

August 20th, 2014 by

Hello and welcome to this week’s root cause analysis tip. This week the topic is doing better investigations.

The most important thing you can do for better investigations is to use TapRooT®! But assuming you already do that, here are some more tips that I hope will help.

The first thing to think about is preparation – does your company have an investigation policy and does everyone know their roles and responsibilities? In other words, do you have a plan? The time to develop your plan is not after you have had a major incident! You can refer to Appendix A of the TapRooT® book for a sample plan; however, I would imagine most of you already have a plan at your company, so your preparation is simple – read the plan and understand it.

Think about Notification – Who, and under what circumstances? Let senior management know someone’s working on the investigation.  You can share the preliminary information as well. Set expectation that it may take some time. They’ll often back off and let you do your job if you tell them these things.

Plan your investigation – what kind of photos, documents, equipment reliability data do you need? Plan what data to collect and how you’re going to collect that data.

So now you are ready to start your investigation. The best thing you can do to have a good investigation is to have a really good SnapCharT®. Most of the time you spend in an investigation is spent collecting evidence and putting it on your chart. Interviewing is an important part of evidence collection. Follow our 14-Step interview process, it’s in the book. The best way to interview is to let the person tell their story, they may answer your questions without you even needing to ask. If you only ask questions, you’ll only get the answers to your questions and nothing else.

View Part 2 of Dave’s tip on Performing Better Investigations!

or check out other short videos in our root cause tip series:

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Food Industry Related OSHA General Duty Clause Citations: Did you make the list? Now what?

August 13th, 2014 by

OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities

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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

date] by:

 

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

http://www.taproot.com/archives/43841

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

http://www.taproot.com/archives/45408

 

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Entergy Services)

August 13th, 2014 by

Darlene Normand of Entergy Services shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch her video below to learn how she got everyone engaged and having fun while teaching them TapRooT®:

If you’re at work and don’t have time to watch the video, here’s her tip:

“Hello my name is Darlene Normand. I’m with Entergy Services, fossil section. We’re building a new plant. We had a conference last year and I was tasked with teaching everyone a little bit about TapRooT®. We cover four states and they heard about TapRooT® because they were getting these corrective actions to put in place, but they didn’t know what it was. So how do you teach 1000 people about TapRooT® and make it fun? Well, I came up with a game, and called it the TapRooT® scramble. (I think I called Ken Reed and said “Hey, you got anything for me?”) I made a SnapCharT®. I used the pothole story from the 5-day class and I made puzzle pieces from the SnapCharT®. I had them all scrambled. I think I did 20 groups. I would give them the story, put them in teams, and their goal was to put the SnapCharT® in the sequence that it went. It went over well; the VPs and the directors got a little taste of it, and some people even took it back to their plants and started changed some of their ways with TapRooT®. It got the message across. It was fun.”

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Tip: What Should We Improve Next?

August 13th, 2014 by

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).

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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.

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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.

 

 

 

Root Cause Analysis Video Tip: Conduct Real-Time Peer Reviews

August 6th, 2014 by

Welcome to our first week of video root cause analysis tips. Today, TapRooT® Co-Creator Mark Paradies shares the some best practices for conducting peer reviews. Watch it above, and print out the notes below for future reference:

You don’t want to wait until you’ve finished your investigation to conduct a peer review. We’ve seen a lot of resistance to change at this point, since so much work has already gone into the investigation. Instead, conduct peer reviews at various stages of the investigation.

Here are four stages that are great times to evaluate investigators, and some guidelines on what to look for:

1. After Creating Summer SnapCharT® – Is the SnapCharT® thorough enough or do we need more interviews & data?

2. After Defining Causal Factors – Are they at the right end of the cause-and-effect chain? – Was a Safeguards Analysis conducted? – Were all the failed safeguards identified as causal factors?

3. After RCA and Generic Cause Analysis – Did they use their tools (Root Cause Tree®, Root Cause Tree® Dictionary, etc.)? – Did they find good root causes? – Did they find generic causes? – Did they have evidence for each root cause?

4. After Developing Corrective Actions – Use corrective action helper to determine effectiveness of corrective actions.

You may not want to conduct these peer reviews during every investigation, because it can become time-consuming. Ask these questions for new investigators and during major investigations. Another pro tip: Use your most experienced investigators to conduct peer reviews. In addition to improving the quality of your investigation step-by-step, you also gain the opportunity to sharpen the investigation skills of the investigators and the reviewers.

Join us in two weeks for another Root Cause Tip video, this time from TapRooT® Instructor Dave Janney.

Click here to learn more about the TapRooT® System.

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Was this tip helpful? Check out more short videos in our series:

Do Better Investigations with Dave Janney (Click here to view tip.)

What Makes a World-Class Root Cause Analysis System with Ken Reed (Click here to view tip.)

TapRooT® & Healthcare: Getting the Most from Your Sentinel Event Investigation with Ed Skompski (Click here to view tip.)

Benchmark Your Root Cause Analysis Efforts

July 30th, 2014 by

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 …

  • Bad
  • Better
  • Even Better
  • Excellent

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:

  • Who?
  • What?
  • When?
  • Where?
  • To What Extent?
  • Under What Conditions?

BAD

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

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

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.

 

NewImage

EXCELLENT

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.

 

BENCHMARK

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:

http://www.taproot.com/taproot-summit

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Arizona Public Service)

July 24th, 2014 by

Teresa Berry of Arizona Public Service shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch her video below to learn how she fixed her company’s poorly written reports by finding the root cause of the bad writing:

If you’re at work and don’t have time to watch the video, here’s her tip:

I’m Teresa Berry. I’m from Arizona Public Service and we’ve been using TapRooT® for probably three or three and a half years now on the process side of our industry and what we’ve found is that every now and then we’ll come up with a report that is not written very well. It doesn’t have facts to back up the root causes that were chosen. That is a symptom of a much bigger problem. The problem we found, that we had to go fix, is that people were not using all of the processes that we’re taught to use in TapRooT®; “the rules,” I call them when I teach. These are your rules. You must use the process as it’s laid out or it doesn’t work as well as you’d hoped. And along with that there are also assumptions. Make sure you turn those assumptions into questions so that you know you’ve got to go and answer that question. It’s not a fact until you prove that it’s a fact.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tip: How Are Managers Involved in a Root Cause Analysis?

July 23rd, 2014 by

I’m sure the answer to this question varies from company to company. But I also know that the best root cause analysis programs I’ve seen had the most involved managers.

Here are some suggestions to consider…

FIRST, management should be asking for (demanding) root cause analysis. They should insist on it when something bad happens. And they should make sure that there are sufficient trained investigators available and that they have the time they need to actually investigate the problem. But also, management should insist that root cause analysis be used proactively to stop problems before they happen.

SECOND, management needs to set the standard for what is an acceptable root cause analysis. If management accepts substandard reports, presentations, and corrective actions, it will be no wonder that the program fails. But to set the standard, they must know what can be accomplished and what they should look for when they review the results of a root cause analysis.

THIRD, management needs to be self-critical and encourage investigators to look for Management System problems. See the Root Cause Tree® if you don’t understand what a Management System problem is.

FOURTH, management needs to make sure that investigators go beyond specific root causes and look for generic root causes. This should be part of the questions that management asks for every serious incident review.

FIFTH, management should make a special effort to reward good root cause analysis. I didn’t say perfect root cause analysis. Rewards should be for every good root cause analysis. 

Do these five points give you any ideas?

Root Cause Analysis Tip: Is Human Error a Root Cause?

July 17th, 2014 by

A frequent question that I see in various on-line chat forums is: “Is human error a root cause?” For TapRooT® Users, the answer is obvious. NO! But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.

First, we define a root cause as:

the absence of a best practice or the failure to apply knowledge that would have prevented a problem.”

But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors. 

How does the Root Cause Tree® work?

First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.

The seven Basic Cause Categories are:

  • Procedures, 
  • Training, 
  • Quality Control, 
  • Communications, 
  • Human Engineering, 
  • Work Direction, and 
  • Management Systems.

If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.

The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).

Screen Shot 2014 07 08 at 10 35 20 AM

The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by clicking here.

If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise. 

Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.

How can we make such a risk-free guarantee?

Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance. 

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (Encana Oil & Gas)

July 17th, 2014 by

Devin Johnston of Encana Oil & Gas shared his TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during our Users Share Best Practices session. Watch his video below to learn how he streamlined the way his facility performed TapRooT® investigations to make each one more efficient than ever:

If you’re at work and don’t have time to watch the video, here’s his tip:

Hi I’m Devin Johnston, with Encana Oil & Gas, from Denver, Colorado. One of the issues with had with TapRooT® is when we would have an incident we would want everyone to be involved. … Everyone would come in the room, we’d lock the doors, we’d run through the whole TapRooT® process, and bang it all out. At the end of the day, everyone was so tired of going through the process and arguing on each little point, that the corrective action part of it at the end was just, they’d take whatever. You’d give them a corrective action and they’d take it, and they weren’t always quality corrective actions. So the thing we fixed at our company is that we made it a more iterate process where we would investigate it, have SnapCharT®s built out already before we went into that meeting, then we selected who actually attended that meeting. If it was contractors, we made sure it wasn’t the whole EHS team, just the guys that things happened to out there. We’d pick the people that were in the investigation at the end to make it simpler, to come to an agreement better, and to improve our process on how we did those TapRooT®s.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tip: 5 Ways to Improve Your Interviews

July 10th, 2014 by

1) Pick a Good Setting

What is a good setting? Someplace quiet where the interviewee can think without being disturbed. No visual or audible distractions. A place where the interviewee is comfortable and not threatened.

What is a bad setting? The plant manager’s office (threatening). The cafeteria at lunch (distracting). Out in the plant with work going on (distracting).

2) Be Prepared

Perform the interviews in the order to collect the facts first and then look into more complex issues (management system and generic causes). Data collection interviews come before management interviews.

Before any interview, make a list of the topics you hope to cover.

And, of course, be prepared to draw a SnapCharT® during the interview.

3) Don’t Ask Questions

People get the idea that interviews are all about asking questions. Actually, interviews should be about collecting information by getting the interviewee to tell you what they know: Explore his or her recollections (memory).

Often, asking questions hurts this process by interrupting the interviewee’s train of thought. Instead of asking questions, try the cognitive interviewing process taught in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course. We teach people how to combine cognitive interviewing techniques that help people remember what happened with the TapRooT® SnapCharT® technique.

4) Review What Was Collected

When the interview is nearly complete, review what you have learned with the interviewee.

An easy way to do this is to build an informal, draft SnapCharT® during the interview and then review it step by step with the interviewee once the interview is complete.

If you tell the interviewee that you will review what you learned from them at the end of the interview, this often helps the interviewee feel at ease. They can correct any mistakes they make later. Also, they can correct any misconceptions you might have had and fill in additional information that you didn’t pick up which they thought they told you about.

5) Remember to Say Thanks

At the end of an interview, it’s always good to thank the interviewees for their hard work.

But the “thank you” can serve an additional purpose. You can provide the interviewee with your business card and tell them if they remember any additional information after the interview, that they should write it down and then give you a call. Tell them that if they miss you when they call, they should leave a message with all the information they wrote down. 

Root Cause Analysis Tips: 2014 Global TapRooT® Summit Best Practices (US Army Medical Command)

July 10th, 2014 by

Dana Rocha of US Army Medical Command shared her TapRooT® best practice with us at the 2014 Global TapRooT® Summit, during out Users Share Best Practices session. Watch her video below to learn how she has tailored her TapRooT® investigations so that they are the absolute most thorough they can be:

If you’re at work and don’t have time to watch the video, here’s her tip:

Hello, my name is Dana Rocha, I work for US Army Medical Command. With the help of the navy and the air force we in the army have put together a couple of different documents for people who haven’t been through the training to prepare them for facilitating an RCA as well as sitting on a RCA team. And what we did is we put together a couple of documents for “just in time training” for TapRooT® to help them facilitate and what your roles and responsibilities are on the team. We also put together an RCA trifold and what this is, is a root cause analysis for what event you’re looking at whether its an adverse outcome or sentinel event, near misses or you’re looking at something proactively. It doesn’t matter what you’re looking at, so we use it in different realms. We also put together some checklists. When you do your SnapCharT®, have you considered this? Have you considered that? Check the dates, check the times. Talk to people, and things like that and we found this to be very helpful. And we have done checklists for certain types of events that we find occur more frequently than others. When I say this, don’t freak, but wrong site surgeries do occur, we have retained foreign objects, all kinds of things that do happen, unanticipated deaths, so certain types of events we put together the most common things and asking the questions to make sure that we do a real thorough job when we do the analysis and the investigation so we found that to be very helpful.

Want to learn more about our 2015 TapRooT® Summit in Las Vegas?

Click here: http://www.taproot.com/taproot-summit

Root Cause Analysis Tips: Ever heard of the Dvorak Keyboard?

July 9th, 2014 by

Have you ever heard of the Dvorak Keyboard?  If not, then you are like most people.

Over the last decade we have helped over 100 customers implement the TapRooT® Web Enterprise Software into their Information Technology networks, and business practices.One thing we’ve learned in that time is that every customer approaches implementation from a different perspective.

Some Companies have their Information Technology department drive the implementation from start to finish; While other Companies have their business users (the Safety people, most commonly) drive the implementation and task the Information Technology with certain objectives.

No matter what the plan of attack is, you need to have a plan (and a champion for that plan) or your implementation will die on the vine, like so many good ideas (including mass adaptation of the Dvorak keyboard) often do.

Below is a document I wrote a few years back to provide to our customers who are undertaking implementation. This document is based on my years of experience implementing software, not just TapRooT®.   What I’m implying is that software implementation has some universal truths that have nothing to do with TapRooT®, they have to do with gaining momentum in implementing a new innovation.

You might even learn a few things about that mysterious Dvorak Keyboard. Click Here To Review this Document.

Root Cause Analysis Tips – Building a Better SnapCharT®

June 25th, 2014 by

Welcome to this week’s root cause tips. This week I would like to talk about the SnapCharT®

SnapCHart_Popular_Posts

As you know, the SnapCharT® is the tool I use to plan my investigation, document my evidence, and present the incident to management. It’s a powerful yet easy tool to help in each of these areas.

First, let’s talk form. One of the common problems I see when people first start developing a SnapCharT® is trying to get too much information in a small space. I normally start the first page with no more than 4-5 events across the top of the page. As you continue to develop your timeline, you will soon know if you need to more pages, but the software also knows and will create the page for you. It is much easier to add your evidence if you leave plenty of room to work. If you try to put 10 events at the top of your page you will soon run out of space for your evidence. Your chart will be cluttered, hard to digest, and impossible to present with. I want to see a lot of evidence, but I want it to be organized and look good. This will make it much easier to read and understand it as I use the information later for my root cause analysis.

I’ve already said there should be a lot of evidence on the chart. Everything you know about the incident should be there. If you have been to a TapRooT® course before, you know that we always do a final exercise, and as part of the exercise the instructor will approve your causal factors. When I do this, sometimes the discussion begins with a student saying “let me tell you what happened” at which point I say STOP! – I should be table to tell what happened by reading your SnapCharT®! As I review it and start to ask questions, answers pour out of the team, but some of that information is not on the chart. Make sure everything is there. That way you will not forget anything when you do your analysis, and you will get fewer questions when presenting. And, make sure everything on the chart is factual.

Next, wording matters. Don’t be vague, be very specific. Don’t say it was hot; say it was 90 degrees. Use job titles or functions instead of names to reduce blame. Be very clear with your wording so someone who knows nothing about the incident can tell from your wording exactly what you mean. Get good at using the words ‘”did not” to describe things that were supposed to happen but did not; this will make causal factor identification much easier later in the process.

I try to assemble all my evidence directly below the event in a straight line so it is very easy to read and is arranged into nice groups of information. It is permissible to have two rows of information if it makes sense to do that, but I find that this is not always needed. When it is, make sure each row of information goes together in a logical group; for example, you might have a group with all the training information and another group with all the policy information. If you have been to a 5 day TapRooT® course, you might remember when we talk about procedures we say “the burden of written communication is on the writer, not the reader.” SnapCharT®s are no different!

Optionally, you might elect to put safeguards on your chart. Resist the temptation to only put failed safeguards. In fact, showing safeguards that worked on your chart for your management presentations is a great way of showing two things; what is working in the business, and that the incident could have been worse.

If you have been to a TapRooT® course, you have heard this before, but it is worth repeating – draw your lines last! If you draw your lines too early and you end up having to move things around, you will end up having to delete them. Don’t work any harder than you need to.

The last thing I want to address is the use of colors. It is fine to use colors if you want, but be careful and use light colors. If you use a dark color, it may look fine on your computer, but when you go to present people may not to be able to read it on the screen. I have seen people show causal factors in a different color in their presentations, and that is a great way to bring that information out. I say that you cannot go wrong with black and white. Then again, I am obsessed with simplicity, and I know not everyone is wired that way. Do what makes sense for you.

So that’s it for this week. I hope some of this information is helpful. Thanks for readying the blog, and happy investigating.

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Barb PhillipsBarb Phillips
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Chris ValleeChris Vallee
Human Factors & Six Sigma
Dan VerlindeDan Verlinde
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Dave JanneyDave Janney
Safety & Quality
Ed SkompskiEd Skompski
Medical Issues
Ken ReedKen Reed
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Linda UngerLinda Unger
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Mark ParadiesMark Paradies
Creator of TapRooT®
Megan CraigMegan Craig
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Steve RaycraftSteve Raycraft
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