Category: Root Cause Analysis Tips

5 Cognitive Biases that Influence Incident Investigations

September 20th, 2018 by

Whether we admit it or not, we are constantly under the influence of cognitive biases that distort our thinking, influence our beliefs, and sway the judgments we make as investigators.

Most of us are familiar with confirmation bias (looking for evidence to support a hypothesis, and rejecting any evidence that does not). However, did you know there are over 250 cognitive biases?

Here are five that may be affecting your investigations:

  1. Overconfidence. Yes, overconfidence is a bias even though it doesn’t sound like a fancy psychological term. This can really be a problem with experienced investigators because they know more, and may be more convinced that they are right.
  2. Stereotyping. Expecting a group or person to have certain qualities without having real information about the person. Again, a term that we are familiar with but may not realize we are doing to those involved in incidents. I’m not just referring to gender or racial stereotypes. You can stereotype a person many different ways. Here are some other examples: “She has an MBA. She must be smart.” “He has 20 years in the industry, he must be experienced.”
  3. Choice-supportive bias. When you decide something you tend to feel more attached to your decision, even if the decision has flaws.
  4. Bandwagon effect. Not sure of what to think of an investigation? Take the easy road . . . jump on the bandwagon. The probability of one investigator adopting a belief increases based on the number of team members who hold the same belief.
  5. Blind-spot bias. This simply means that we don’t accept that we could possibly be biased! We tend to notice biases in other people and not within us. We all fall into biases and need to be aware of that.

How do you avoid biases in an investigation? Use a system that doesn’t start with a hypothesis, TapRooT® Root Cause Analysis. Using the guided system, an investigator does not:

  • rely on his/her limited knowledge (no one can possibly know everything!).
  • fit workers into stereotypes that align with our hypothesis.
  • become married to his/her ideas.
  • become easily influenced by others.
  • have to fight his or her biases!

You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions. Once you understand what happened and identify the mistakes, errors or equipment failures, you will then be ready to analyze why the safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary. This system gets you to think beyond your current knowledge, and decreases investigator bias.

Learn the entire TapRooT® System in just two days. View the upcoming schedule here.

 

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

September 19th, 2018 by

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Chris Vallee discussing, Do you perform incident investigations like you watch the news?

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort. You don’t want to miss a minute of the TapRooT® Summit!

Join the Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

September 18th, 2018 by

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 19

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Investigative Interviewing Webinar: Tips for collecting better quality and quantity of evidence

September 14th, 2018 by

TapRooT® Instructor, Barb Carr, was a recent guest expert for Intelex, a global leader in EHSQ software. View the recorded webinar to learn how to become a more effective interviewer, and collect better quality and quantity of evidence.


Is It Better To Be Fast or Good?

September 12th, 2018 by

Imagine the old west. Two gunslingers standing 20 yards apart. It’s time to draw.

NewImage

Would it be better to be fast or good? As Wyatt Earp said:

Fast is fine. Accurate is final.

What does this have to do with root cause analysis?

I had someone ask me the other day:

How long should a simple root cause analysis take?

If you use Spin-A-Cause™, the answer is about 5 seconds.

Spin A Cause

But you have to answer the question …

Do you want FAST or GOOD?

But what if you could have BOTH?

That’s what the 2-Day TapRooT® Root Cause Analysis Training and the book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about. Fast and Good simple investigations.

We selected the minimum number of powerful root cause analysis tools and built a simple process to perform simple investigations fast and accurately.

How long does it take to apply these techniques? Maybe 30 minutes to an hour once you have the information you need to answer the questions. Maybe slightly longer. Maybe longer yet if the incident turns out not to be “simple.”

The biggest variable is collecting the information (evidence). The second biggest variable is the requirements of your investigation system (presentations to management and approval red tape).

So if you are ready to be fast and good, sign up for one of our public 2-Day TapRooT® Root Cause Analysis Courses today. Here are the upcoming dates and locations:

http://www.taproot.com/store/2-Day-Courses/

Or have a course at your site. Contact us for a quote by clicking HERE.

The UK General Medical Council Shows a Lack of Understanding of Root Cause Analysis

September 11th, 2018 by

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Here is a quote from an article in gponline.com:

“The GMC says human factors refers to the ‘environmental, organisational and job factors –
and human and individual characteristics – which influence behaviour at work in a way
that can affect health and safety,’ while root cause analysis is a systematic process for identifying
‘root causes’ of problems or events and an approach for responding to them.

Responding to the review, the GMC said: ‘Focusing on root cause analysis may not always be
the best way of dealing with all investigations and we understand that exploration of a
human factors approach is underway at several NHS Trusts in England.'”

To use an “English” term …

“What rubbish!”

Who gave this team of senior managers the idea that human factors is not a part of a root cause analysis?

If they aren’t including human factors, behavior, organizational factors (Management Systems), procedures, training, communications, work direction, and quality processes in their root cause analysis … THEY AREN’T DOING ROOT CAUSE ANALYSIS THE RIGHT WAY.

Instead of trying “human factors,” they should try a root cause analysis system that automatically includes “human factors,” the TapRooT® Root Cause Analysis System.

Find out more about how TapRooT® includes human factors at:

http://www.taproot.com/products-services/about-taproot

Why did they decide they needed to change? Because their system exhibits a blame culture and abysmal root cause analysis. A particle case involving Dr. Bawa-Garba finally got senior leadership to admit that they need to improve. But instead of finding out what is wrong with their practices, they decided they needed a new buzz-word … human factors.

We have written several articles about root cause analysis practices in the UK and the need for improvement (see Dr. Death, Healthcare Scandal, Bias & Blame, House of Commons Calls for RCA Training, Highest Number of Serious Incidents. and Not Preventable), but even though a decade has passed, little improvement has occurred.

Will a new focus on human factors solve the problems of the UK National Health System? Doubtful. Good root cause analysis (that includes human factors among other things), and implementation of appropriate corrective actions could have solved these problems years ago. I would guess that:

  • poor root cause analysis,
  • unwillingness to change,
  • understaffing and budgeting,
  • poor Management Systems, and
  • bureaucracy,

will continue to haunt NHS patients no matter how many human factors courses are given to hospital staff members.

NHS senior leadership must understand what is wrong (through advanced root cause analysis) and be willing to make change happen BEFORE real improvement will occur.

Contact us (CLICK HERE) if you are committed to making root cause analysis (that includes human factors) work at your facility or company.

The #1 Skill for Accident Investigation Interviewing (It’s Not What You Think!)

September 10th, 2018 by

I’m excited to be a guest writer for Intelex, a technology leader in environmental, safety and quality management and a TapRooT® partner.

Read my article “The #1 Skill for Accident Investigation Interviewing (It’s Not What You Think!)” HERE.

Learn about how you can do TapRooT® investigations through this technology below.

Monday Accidents & Lessons Learned: Ensure Safety Behind the Wheel

September 10th, 2018 by

In June 2018, a Queensland owner/operator truck driver was reversing his single-deck truck up to a ramp to load cattle used in a rodeo. It appears he placed the truck in reverse and began to idle backwards. The gearing of the truck in reverse was sufficiently low that it did not require the driver to have his foot on the accelerator. He then opened the door and stood on the running board of the truck holding onto the steering wheel to maneuver the truck while looking backward to where he was going. He fell from the running board of the truck and was fatally crushed under the front wheel as the truck continued to reverse itself.

Also, in June 2018, a courier van driver sustained serious fractures when he was dragged under his vehicle. He had returned to the parked van to retrieve an item through the front window when it rolled backward. It appears he was dragged under the vehicle while trying to stop it.

Both investigations are continuing.

Contributing factors
Some contributing factors to these incidents include:

  • Workers being under a heavy vehicle or trailer, or in its path
  • Unsafe systems of work being applied, such as poor separation of traffic from pedestrian areas
  • Failing to immobilize:
    -the handbrake of the vehicle not applied
    -the wheels of the heavy vehicle or trailer not immobilized
    -components of the heavy vehicle or trailer not restrained or adequately supported
    -brakes malfunctioning
  • Not conducting a risk assessment before working on the vehicle

Action required in immobilizing heavy vehicles
If an employee needs to work near a heavy vehicle, or between a heavy vehicle and another object, first make sure the vehicle is immobilized by:

  • Switching off the motor and removing the key from the ignition to render it inoperable
  • Applying the handbrake
  • Using wheel chocks, if warranted and required

Establish a safe operating procedure and ensure workers follow it to eliminate the risk of anyone failing to immobilize their vehicle.

Consider installing a handbrake warning system to alert drivers when the handbrake has not been applied (these can be easily retrofitted).

Working under heavy vehicles and trailers
For work under heavy vehicles and trailers, ensure an appropriate load support is used (e.g. stands or lifting devices).

Risk assessments before commencing work
Before commencing work, identify hazards and assess risks associated with working under and around heavy vehicles or trailers. Where appropriate:

  1. Establish an exclusion zone that is clearly marked and enforced.
  2. Use safe work procedures for maintenance and repair tasks, and ensure that workers are trained in these procedures.
  3. Ensure worker training, experience, and competency is consistent with the nature and complexity of the task.

Similar risks exist for light and smaller vehicles, and a risk assessment should be conducted before commencing work.

Preventing similar incidents
There have been incidents where vehicle drivers and others have been killed or seriously injured after being hit, pinned, or crushed by the uncontrolled movement of vehicles. The risk of a vehicle moving in an uncontrolled or unexpected manner must be managed by ensuring appropriate control measures are in place. Controls may include, but are not limited to, the following:

  • Before leaving a vehicle, ensure it is stationary and out of gear with the emergency brake applied.
  • Do not climb into a moving vehicle.
  • Do not allow any movement of the truck or vehicle unless there is someone in the driver’s seat who is able to receive oral or visual warnings and can immediately act to prevent harm (e.g. apply brakes or steer the truck).
  • When reversing, ensure the area around the vehicle is clear.
  • Always employ reverse with the aid of mirrors or a spotter.

The person conducting a business or undertaking should conduct a risk assessment of work practices, develop appropriate safe work systems, conduct appropriate training, and ensure the system is enforced at the workplace.

Statistics
Since 2012, there have been 47 incidents involving workers or others being crushed, struck or run over by a truck moving in an uncontrolled method. Eleven were fatal, and 27 involved a serious injury. In the same period, 49 improvement notices and 25 prohibition notices were issued for uncontrolled movement or rolling of trucks, semitrailers, and more.

Since 2012, there have been 10 work-related deaths involving a person being run over by a vehicle or some other type of machinery. In the same period, 10 prohibition notices and eight improvement notices have been issued in relation to a person being run over by a vehicle or other type of machinery.

Each year, there are around 130 accepted worker compensation claims involving a worker being struck or crushed by a truck. Of these claims, more than a third involve a serious injury, and two are fatal.

Annually, there are around 600 accepted workers compensation claims involving a worker injured by mobile plant*. Of these claims, about 40 percent involve a serious injury requiring five or more days off work, and two are fatal.

Prosecutions and compliance
In May 2017, a company was fined $60,000 and an individual $3,000 following the death of a worker who was run over by a truck and trailer. The worker was lying under the back of the trailer to check on bouncing that had occurred while driving. Moments later, the truck and trailer began moving backward. The trailer wheels rolled over the worker, followed by the truck wheels.

In February 2017, a regional council was fined $170,000 following the death of a worker. The worker was killed after he was struck and run over by a reversing truck on a civil construction site.

In December 2016, a road freight transport company was fined $60,000 and a court ordered undertaking for two years with recognizance of $60,000 following the death of a worker who was run over by a trailer. The prime mover and trailer appeared to have trouble releasing its trailer brakes. The worker went to the rear of the trailer and attempted to release a trailer brake. When the vehicle began rolling backward, he tried to reengage the spring brake but was struck by the trailer wheels.

In June 2016, a company was fined $120,000, after a worker was killed operating a six-ton mobile yard crane to perform shifting the load of steel product. The worker was seen running alongside the crane which was traveling down a slope, uncontrolled, with no one in the operator’s seat. He was either struck by the crane, or it tipped, then run over and killed. The driver was not licensed to operate this type of crane.

*Powered mobile plant is defined by the Work Health and Safety Regulation 2011 (WHS Regulation) to mean any plant that is provided with some form of self-propulsion that is ordinarily under the direct control of an operator, and includes: earthmoving machinery (e.g. rollers, graders, scrapers, bobcats) excavators.

Thanks to WorkCover Queensland for this information highlighting the risks associated with workers being crushed or hit by heavy vehicles or trailers.

Circumstances can crop up anywhere at any time if proper and safe sequence and procedures are not planned and followed. We encourage you to learn and use the TapRooT® System to find and fix problems. Attend one of our courses. We offer a basic 2-Day Course and an advanced 5-Day Course. You may also contact us about having a course at your site.

What makes a great root cause system?

September 5th, 2018 by

What makes a great root cause system?

That’s a question that I started researching back in 1985. What would I say is the answer to that question 33 years later? Here are some of my best ideas…

1. Guides Investigators: The root cause system needs to guide investigators to the real, fixable root causes of human performance and equipment reliability problems. Most root cause system don’t do this. Cause-and-effect, 5-Whys, fishbone diagrams, Why Trees, and Fault Trees all require someone on the team to know the right answer. This is especially troublesome when it comes to human error because most investigators have not been trained in human factors. Thus they are guessing at the causes of human error.

2. No Blame: Blame is probably one of the biggest obstacles to finding the causes of incidents. If people think that the outcome of an investigation will be blame, you won’t get their full and free cooperation. You will start having mystery incidents where no one knows what caused the problem. In fact, you might get the Bart Sympson response:

Bart simpson I didnt

That doesn’t lead to a great root cause analysis.

Some root cause systems actually have “blame categories.” (See this LINK.) Other people think that blame makes sense. (See this LINK.) But in TapRooT®, you look for causes – not blame. And if someone did something on purpose (sabotage or horseplay), you find it using the system and rule out other causes.

3. What Happened: You have to understand what happened BEFORE you can understand why it happened. That’s why I see many people adding a “time line” to the use of 5-Whys. If you don’t understand the sequence of events, you can’t understand the causes of what went wrong. A thorough understanding of “What happened?” is a must for great root cause analysis.

4. Consistency: If two different teams performed the root cause analysis would they find the same root causes? many root causes systems fall short here. The analysis depends on who is on the team. And it often depends on the conclusions the investigators reach before the investigation starts. Sometimes people just set out to find their favorite causes. They are consistent … but a different team may have different favorite causes.

5. New Ideas: Does your root cause system stimulate new ideas to solve problems? It should. It should provide investigators with guidance to help people fix the root causes they find.

6. A System: You root cause analysis tool is not enough unless it is a system. A set of tools designed for a purpose. There should be a process with steps and tools to use to achieve those steps.

7. Flexibility: You should be able to use your root cause system for simple incidents or major accidents. That’s a test of the system’s flexibility. You can’t afford to train people on two systems (one for simple incidents and one for major accidents). And even if you can, you will have to get them practiced in multiple systems (which is difficult).

8. Promotes Trending: You should use the data from your root cause analysis system to understand performance and spot trends. Does your system have a built in categorization that is designed to promote accurate trending?

9. Management Understands: Your system has to be understood by your management. In fact, it should be designed so that the end result is a east-to-undertand management presentation. One that explains what happened, what cause the problems, and what we need to do to stop future incidents.

10. Great Training: What good is a great root cause analysis system if you don’t have great training to get people to understand and use the system? You may want to inquire about the number of trainers and their experience. Can they support you around the world?

11. Proven Effective: Has the system been proven to be effective by users around the world? Do the have success stories from around the globe? Reference that you can believe?

12. Software Support: Does the system have effective software that makes the system even easier to use? Can that software be tied to other systems (safety or quality software)?

13. Continuously Improved: Is the system being continuously improved? What are the plans for future improvements?

That’s a pretty thorough list. What system meets all those criteria? The TapRooT® Root Cause System. Talk to us about all of these advantages that the TapRooT® System can bring to your company.

CLICK HERE to contact us and get more information.

If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST!

September 5th, 2018 by

Tune in today for TapRooT®’s Facebook Live conversation. At noon EST, join TapRooT® professionals Benna Dortch and Mark Paradies who will offer insights and improvements to implement in your job and to include in situations throughout your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 5

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Join the Smart Conversation: TapRooT® & Facebook Live Tomorrow at Noon EST

September 4th, 2018 by

Join us tomorrow for TapRooT®’s Facebook Live conversation. We’ll begin at noon EST with TapRooT® professionals Benna Dortch and Mark Paradies presenting a workplace-relevant discussion full of insights and improvements to implement in your job and to include in other roles in your organization.

NOTE: Be sure to tap on the Follow button on our videos so you will get notifications the next time TapRooT® goes live.

We look forward to being with you on Wednesdays! Here’s how to connect with us for tomorrow’s Facebook Live session:

Where? https://www.facebook.com/RCATapRooT/

When? Wednesday, September 5

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

TapRooT® Around the World: Onsite at TransCanada in Mexico

August 31st, 2018 by

Here’s a glimpse into recent TapRooT® Root Cause Analysis Training courses, held onsite in Mexico at TransCanada. The courses were taught by TapRooT® Instructors Marco Flores, Jesus Alonso, and Piedad Colmenares. We appreciate Piedad passing along these great images of teamwork and the learning process!

Through TapRooT® Training with our exceptional instructors, these students learned to find and fix the root causes of incidents, accidents, quality problems, precursor events, operational errors, hospital sentinel events, and many other types of problems. Take a course taught by one of our expert TapRooT® instructors and you will understand how to troubleshoot and identify the root cause of any issue and/or incident.

Put yourself in the picture by becoming trained in troubleshooting and identifying root causes of issues and incidents. Register today for a TapRooT® course and gain advantage, experience, and expertise from our professional instructors. Here are some of our upcoming courses:

Newcastle, Australia, September 12, 2018: 2-Day TapRooT® Root Cause Analysis Training

Denver, Colorado, September 18, 2018: 2-Day TapRooT® Root Cause Analysis Training

Calgary, Canada, September 24, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Amsterdam, The Netherlands, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Atlanta, Georgia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 2-Day TapRooT® Root Cause Analysis Training

Bogota, Colombia, September 26, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

Manchester, United Kingdom, October 1, 2018: 2-Day TapRooT® Root Cause Analysis Training

Aberdeen, Scotland, October 08, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Knoxville, Tennessee, October 15, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Kuala Lumpur, Malaysia, October 17, 2018: 2-Day TapRooT® Root Cause Analysis Training

Edmonton, Alberta, Canada, October 18, 2018: Special 2-Day Equifactor® Equipment Troubleshooting and Root Cause Analysis Course

Bogota, Colombia, October 22, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Seattle, Washington, October 24, 2018: 2-Day TapRooT® Root Cause Analysis Training

Albuquerque, New Mexico, October 29, 2018: 2-Day TapRooT® Root Cause Analysis Training

Orlando, Florida, November 8, 2018: 2-Day TapRooT® Root Cause Analysis Training

Johannesburg, South Africa, November 19, 2018: 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course

Bogota, Colombia, November 21, 2018: 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Course

We are global to meet your needs. If you need other times or locations, please see our full selection of courses.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Analyzing Great Britain’s Workplace Fatality Statistics: Up or Down?

August 29th, 2018 by

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Good news! Workplace deaths in the UK are down. Or are they up? Here’s the stats from the UK HSE

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Note that the 2017-2018 are provisional.

These figures don’t include fatal diseases, fatal accidents on non-rail transport systems (for example, driving), and fatal errors in hospital care that kills patients. The items not included are consistent from year to year.

The total number of deaths in the statistic period covered for 2017-2018 were 144. That’s down from 233 deaths in the 2007-2008 year. But it is up from the 135 deaths in 2016-2017.

They also look at the statistics in several different ways.

KINDS

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INDUSTRY

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AGE

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LOCATION

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COMPARED TO OTHER EUROPEAN COUNTRIES

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HOW DO YOU EVALUATE STATISTICS?

These different graphs and comparisons should get you thinking about how you evaluate your incident/accident statistics. What kinds of stats should you be trending and how will they help you evaluate your performance improvement initiatives.

For example, in the statistics above, how much of the overall decrease in fatalities is due to less work being performed in the most dangerous industries? The fatality rate has been declining in all industries but if the amount of workers in the most hazardous industries has declined significantly, this might make the overall improvement in deaths across all industries look more significant.

Thus, a more significant trend evaluation is within an industry and within a specific work type.

Why look at work types? Let’s look at the deaths in the Communications, business services and finance sector (11 in the 2017-2018 stats). This sector includes building maintenance and landscaping included in renting and leasing activities (7 of the 11 deaths).

How you count and compare things makes a big difference.

STATISTICAL SIGNIFICANCE

Another question that management often asks is:

“Is that trend significant?”

Let’s look at the total death stats. Are the increases and decreases in the graph in the first figure significant? The UK HSE says:

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In the TapRooT® Advanced Trending Techniques Course, we teach a different method to judge a significant trend. We use Process Behavior Charts.

TRENDING THE GREAT BRITAIN STATS

I used the data I could derive from the graphs on the report (note that I am making estimates on the real numbers from the graphs they provide) to draw three new graphs of fatality data. One from the 1980s. One is from 1994 to 2008. And one is from 2009 to 2018. I think you will find the results interesting.

Let’s start with the 1980’s data…

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Note that in the early 1980’s the data was fairly stable. I used that data from 1981 to 1987 to set some limits. What we can see is that the average number of fatalities was 471. The upper limit (you would expect no more fatalities than this) was 528. The lower limit (you would expect no less fatalities than this) was 413.

In 1988 the fatalities exceeded the upper limit. There were about 605 fatalities. Exceeding the upper limit leads you to believe that something changed. What was it? The Piper Alpha accident. The 167 people who died in a single accident cased the total number of fatalities to be abnormally high that year.

Also, you may note that the fatalities dropped below the lower limit in 1991. To me, it looks as if there had been an improvement in the UK’s fatalities and the system was driving to a new lower average number of fatalities. Can anyone explain this? Was it really a safety improvement or just an new way to count fatalities? Or did the type of work change?

Next, let’s look at the 1994 to 2008 data…

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I used the 1994 to 2007 data to set a new set of limits. The new average number of fatalities was 247. The new upper limit was 322. The new lower limit was 172. The data was fairly flat for 15 years (no data points outside the limits). But in 2009, we had our first point outside the limits low. Again, something was changing. Leave a comment if you have an idea what caused the change.

Now let’s look at 2009 to 2018…

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I used the data from 2009 to 2018 to set a new average and limits. The new average number of fatalities is 154. The upper limit is 187. The new lower limit is 121. In 2010 we were one fatality over the limit. Since this was a new set of limits set on data from 2009-2018, we might just say that the system was not stable at the new set of limits yet. Since then the new fatality numbers have been fairly stable with no significant changes.

Trending using Process Behavior Charts is a very good way of understanding significant trends in safety data.

What I don’t like about this county wide data is that it is an average of data across a whole country. What looks like stable data in a large average may be covering up more detailed trends. For example, mining deaths may be declining while construction deaths are increasing and the one downward trend covers up the other upward trend.

Would you like to learn more about Process Behavior Charts and how to use them to understand your safety, quality, or process and equipment reliability? We teach a course once a year on these advanced trending techniques call Trending for Managing Performance. The next course is March 11-12, 2019 near Houston, TX (Montgomery, TX). It will be held just before the 2019 TapRooT® Summit. If you are interested in trending and performance improvement, you should plan to attend both.

Join TapRooT® Today at Noon EST on Facebook Live

August 29th, 2018 by

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements to implement in your job and to include in other roles in your organization.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, August 29

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Does Social Media Encourage Poor Root Cause Analysis?

August 29th, 2018 by

Who doesn’t love a good online video? Videos can encourage interaction and make you think, but are they leading us down poor thought paths or compelling us to jump to conclusions? Asking ourselves this question caused us to ponder, Does social media encourage poor root cause analysis?

Listen as TapRooT® professionals Benna Dortch and Ken Reed explore this topic. You will want to glean further insights from Ken’s article, Do LinkedIn Posts Encourage Poor Investigations? (For the Vimeo version of this video, click here.)

TapRooT® Root Cause Analysis training can transform your investigations, to clearly isolate systemic problems that can be fixed, and prevent (or greatly reduce) repeat accidents. Attend a TapRooT® Root Cause Analysis Course and find out how you can use TapRooT® to help you change your workplace into a culture of performance improvement.

If you would like for us to teach a course at your workplace, please reach out here to discuss what we can do for you, or call us at 865.539.2139.

Dunning-Kruger Effect – Another Reason You Need TapRooT® Root Cause Analysis

August 22nd, 2018 by

Watch this Ted-Ed talk about the Dunning-Kruger Effect.  The Dunning-Krger Effect is a cognitive bias whereby people who are incompetent at something are unable to recognize their own incompetence.  Not only do they fail to recognize it, they’re also likely to feel confident that they are competent.

Investigators can fall into this trap. Often when people use cause-and-effect (5-Whys, Fault Trees, Why Trees, …), they think they know the root cause of the problem. All they have to do is build the tree that proves their answers. How does cause and effect analysis fall short?

The #1 reason it falls short is because gaps in an investigator’s knowledge (that he/she underestimate) block the other possibilities, and the investigator doesn’t realize that he/she is jumping to conclusions.

“When you don’t know that you don’t know, it’s a lot different than when you do know that you don’t know.” – Bill Parcells

If you do know that you don’t know every possibility, how do you bridge that gap? The TapRooT® Root Cause Analysis System guides you. TapRooT® root cause analysis helps investigators “fill in the gaps” in their knowledge to keep them from making the mistake of thinking that they know more than they do. TapRooT® offers an investigation and improvement process that includes built-in human factors, root cause analysis and troubleshooting tools. It takes investigators far beyond their own knowledge. TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.

TapRooT® encourages investigators to identify all the mistakes, errors or equipment failures, and find the root cause of each one. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each mistake, error or equipment failure that contributed to an accident.

The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. This is how an investigator can know what he/she doesn’t know.

Attend a public TapRooT® Root Cause Analysis Course and find out how TapRoot® can help you improve your ability to find and fix the real root causes of incidents, accidents, quality problems, patient safety events, process safety incidents, quality problems, and equipment failures.  See our upcoming courses here:

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

Join the Smart Conversation: If It’s Wednesday, It’s TapRooT® on Facebook Live, Noon EST

August 22nd, 2018 by

It’s TapRooT® time! Join us today at noon EST when knowledgeable TapRooT® professionals will present a workplace-relevant Facebook Live discussion that brings you insights and improvements to implement in your job and to include in other roles in your organization.

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, August 22

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Tune in tomorrow for TapRooT®’s Facebook Live, noon EST

August 21st, 2018 by

Join our Facebook Live session tomorrow as TapRooT® professionals share insights designed to expand your knowledge base and sharpen your expertise and performance. We’ll be discussing Ken Reed’s recent post “Do LinkedIn Posts Encourage Poor Investigations?”

Connect with us tomorrow—and every Wednesday—for the TapRooT® discussion on Facebook Live. Make it a recurring event in your calendar—a good habit that will produce game-changing results. Put a reminder in your computer and smartphone to tune in on Wednesdays, noon EST. As always, feel free to comment on the discussion via our Facebook page.

Here’s how to join us tomorrow for the Facebook Live conversation:

Where? https://www.facebook.com/RCATapRooT/

When? Tomorrow, Wednesday, August 22, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

As you glean takeaways from the Facebook Live discussion, make plans to become immersed in best practices and learn state-of-the-art techniques at the 2019 Global TapRooT® Summit.

The Summit consistently earns the highest possible reviews from attendees. Using the TapRooT® System, attendees report documented constant improvement in workplace practices and reliability; dramatically improved statistics in problems, incidents and accidents, and losses; improvement efforts in process reliability that net significant financial savings, often hundreds of millions saved.

Save the date for the 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

Do your own investigation into our courses and discover what TapRooT® can do for you. Contact us or call us at 865.539.2139 to pinpoint how we can best meet your needs.

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

August 15th, 2018 by

Join our Facebook Live session today as TapRooT® professionals Ken Reed and Benna Dortch discuss human factors. As you listen and glean takeaways from this discussion, start making plans to learn even more from the Human Factor Track at the 2019 Global TapRooT® Summit, designed to share best practices and the latest state-of-the-art techniques to improve human performance. That’s only part of what you’ll get through attending the Human Factor Track at the 2019 Summit.

Plan ahead to tune in for next week’s Wednesday with FB Live. Put a reminder on your calendar, in your phone, or a post-it on your forehead to tune in for TapRooT®’s FB Live. Dig in with us as we explore a workplace-relevant topic with takeaways. And, as always, feel free to join the discussion via comments on our Facebook page.

Here’s the scoop for tuning in:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, August 15, 2018

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What’s Wrong with Pharmaceutical Root Cause Analysis?

August 8th, 2018 by

Pharma

I was forwarded a copy of an interesting letter about American and Canadian Standards Boards with certifying bodies rejecting pharmaceutical quality incident reports because of poor root cause analysis. It stated that 90% of the rejections of reports were due to three types of root causes that were unacceptable (and I quote):

  1. Employee Error / Human Error / Operator Error OR anyone else who made an error is not an acceptable root cause – Was the training ineffective?  Was the procedure too vague?
  2. Misunderstood the requirement / Did not know it was a requirement / Our consultant told us this was ok OR any other misunderstandings is not an acceptable root cause.  Was the training effective?
  3. We had a layoff / Mona was on maternity leave / we moved locations / we scaled back production / we are still closing out Wayne’s 40 deviations from the last audit OR most other employee or business conditions are not acceptable root causes  They are DIRECT CAUSES.

The letter proposed four rules to follow with all future submissions:

  1. RULE #1:  The root cause can not be a re-statement of the deviation.  Example:  Deviation – Company XYZ did not document Preventive Actions as required by procedure.  Root Cause – We did not document Preventive Actions as required by the procedure.
  2. RULE #2:  There can not be an obvious “Why” that can be easily answered to the provided root cause – in this case they have not gone deep enough.  Example: Root Cause – The purchasing coordinator made a mistake and did not check to see if the supplier was approved.  Obvious “WHY” Was the training effective?  Did the procedure provide enough detail in this area?
  3. RULE #3:  The root cause can not be a direct cause.  Example:  Deviation – There were a number of internal audits scheduled for 2008 that were not completed.  Root Cause – We had a layoff and we did not have enough Internal Auditors to conduct the audits.
  4. RULE #4:  The root cause is a brief description of the cause of the problem.  We do not want any long stories regarding direct causes or what they are doing well even though this happened or who said what.  This is un-necessary detail and only adds confusion.

Wow! I would have thought this guidance would not be necessary. Are responses to quality incidents really this poor? Or is this letter a fake?

No wonder TapRooT® Users have no problem getting approvals for their root cause analysis. None of these problems would happen with any investigation using TapRooT®.

Why would TapRooT® Users never stop at the three causes listed above? Because they would understand that some are Causal Factors (the start of the root cause analysis) and they would have guidance provided by the Root Cause Tree® Diagram to help them find the real, fixable root causes of human performance and equipment failure related problems. This includes analyzing things like “internal audits not completed”; “human error”; and “misunderstood requirements.”

In addition, the TapRooT® Software helps investigators develop concise custom reports that only includes the details needed to understand what happened, how it happened, the root causes, and the effective corrective actions needed to prevent recurrence.

If you are in the pharmaceutical industry and you want to stop having problems with root cause analysis and want to start having effective investigations, root cause analysis, and fixes for problems, attend our TapRooT® Training and learn how simple advanced root cause analysis is.

Investigating Even the Smallest Problems using TapRooT®

July 31st, 2018 by

 

Many companies think about using TapRooT® only when something really significant occurs. Things like major environmental releases, or serious injuries, or expensive quality control issues. These are considered Major Investigations in TapRooT®.

Some companies are also using TapRooT® on less complex, lower risk problems. Problems such as a dropped object, a small spill from a container, or a minor first aid case might be investigated using the Simple Investigation process in TapRooT®.

However, what about REALLY simple problems? Does it make sense to perform entire TapRooT® investigations for just a simple problem that you spot on the job site? Actually, TapRooT® is EXCELLENT at helping you quickly find root causes for even small issues, before they become incidents or near misses. Think about the benefits of finding, analyzing, and fixing these tiny problems:

  • They are pretty easy to find
  • They are pretty easy to fix
  • They are pretty inexpensive to fix
  • They have the opportunity to prevent major issues in the future

Chris Vallee and I talked a bit about this on our last TapRooT® Live session.  Take a look here and let us know what you think.

Why Does Blame “Make Sense”?

July 25th, 2018 by

Think about a recent accident …

  • a ship runs aground
  • a refinery has a major fire
  • an oil well has a blowout and explosion
  • a pharmaceutical plant makes a bad batch of drugs and it gets by the QA process and customers are harmed

One thing that you can be sure of in ALL of the accidents above is that:

someone screwed up!

You never have a major accident if all the Safeguards function as designed. And guess what … we depend on human actions, in many cases, as a significant or sometimes as the ONLY Safeguard.

Therefore, when an accident happens, there is usually at least one human action Safeguard that failed.

If you are in a blame oriented organization, the obvious answer is to BLAME the individual (or team) that failed to prevent the accident. If you can find who is to blame and punish them, you can get back to work.

It MAKES SENSE because “if only they had done their job …” the accident would not have happened. Punishing the individual will set an example for everyone else and they will try harder not to make mistakes.

Sure enough, when the same accident doesn’t happen again right away, management believes they fixed the problem with blame and punishment.

I was thinking of this the other day when someone was talking to me about an investigation they had done using TapRooT®. They had recently adopted TapRooT® and, in the past, had frequently blamed people for accidents.

In this case, a worker had made a mistake when starting up a process. The mistake cost the facility over $200,000. The operator thought that she probably was going to be fired. Her apprehension wasn’t reduced when someone told her she was going to be “taprooted.”

She participated in the investigation and was pleasantly surprised. The investigation identified a number of Causal Factors including her “screw up.” But, to her surprise, they didn’t just stop there and blame her. They looked at the reasons for her mistake. They found there were three “root causes” that could be fixed (improvements that could be made) that would stop the mistake from being made in the future.

She came away realizing that anybody doing the same job could have made the same mistake. She saw how the investigation had improved the process to prevent future similar mistakes. She became a true believer in the TapRooT® System.

When you discover the real fixable root causes of human performance related Causal Factors, BLAME DOES NOT MAKE SENSE. In fact, blame is counter productive.

If people see that the outcome of an investigation is usually blame and discipline, it won’t take long until most incidents, if at all possible, become mystery incidents.

What is a mystery incident?

A refinery plant manager told me this story:

Back early in his career, he had been an engineer involved in the construction and startup of a major facility. One day when they were doing testing, the electrical power to some vital equipment was lost and then came back on “by itself.” This caused damage to some of the equipment and a delay in the startup of the plant. An investigation was performed and no reason for the power failure or the reason for the power coming back on could be found. No one admitted to being in the vicinity of the breaker and the breaker was closed when it was checked after the incident.

Thirty years later they held an unofficial reunion of people who had worked on the project. At dinner, people shared funny stories about others and events that had happened. An electrician shared his story about accidentally opening the wrong breaker (they weren’t labeled) and then, when he heard alarms going off, re-shutting the breaker and leaving the area. He said “Well, I’m retired and they can’t punish me for it now.”

That electrician’s actions had been the cause of the incident. The refinery manager telling the story added that the electrician probably would have been fired if he had admitted what he had done at the time. The refinery manager then added that, “It is a good thing that we use TapRooT® and know better than to react to incidents that way. Now we look for and find root causes that improve our processes.”

Are you looking for the root causes of incidents and improving processes?

Or are you still back in the “bad old days” blaming people when a mistake happens?

If you haven’t been to a TapRooT® Course, maybe you should go now and see how to go beyond blame to find the real, fixable root causes of human error.

See our upcoming TapRooT® Courses by clicking on THIS LINK.

Or contact us to get a quote for a course at your site by CLICKING HERE.

And if your management still thinks that blame and punish is a good idea, maybe you should find a way to pass this article along (without being identified and blamed).

It’s Facebook Live Wednesday! Join TapRooT® at Noon EST

July 25th, 2018 by

Join our Facebook Live session today as TapRooT® professional Ken Reed discusses, How to Use TapRooT® to Analyze a Single, Small Problem. As Ken observes, “Sometimes, there is no need to perform an entire investigation on a tiny problem. You can just take a single Causal Factor through the Root Cause Tree®.”

There is a full spectrum of possible uses of TapRooT® in your improvement programs. Use TapRooT® for:

  • Really large, complex, high-risk incidents (Major Investigations)
  • Smaller, less complex problems (Low-to-Medium Risk Incidents)
  • A very simple problem found, for example, during an audit (single Causal Factor)

We look forward to being with you on Wednesdays! Here’s how to connect with us for today’s Facebook Live:

Where? https://www.facebook.com/RCATapRooT/

When? Today, Wednesday, July 25

What Time? Noon Eastern | 11:00 a.m. Central | 10:00 a.m. Mountain | 9:00 a.m. Pacific

Do your own investigation into our courses and discover what TapRooT® can do for you; contact us or call us: 865.539.2139.

Save the date for our upcoming 2019 Global TapRooT® Summit, March 11-15, 2019, in the Houston, Texas, area at La Torretta Lake Resort.

What Are SnapCharT®s and Why Are They Important?

July 23rd, 2018 by

TapRooT®’s systematic process for finding the root causes of problems is used around the world to investigate and fix all categories of mission-critical issues, problems, and potential incidents. The first steps of the TapRooT® process are planning the investigation, collecting information, and understanding what happened. The investigator draws a SnapCharT® to understand what happened and to organize the information about what happened. In this Facebook Live session, you will learn more about the value and vital importance of SnapCharT®s from TapRooT® professionals Benna Dortch and Dave Janney.

Watch the session here in Vimeo.

TapRooT® has special tools—such as the Root Cause Tree® and TapRooT® Root Cause Tree Dictionary—to help investigators find root causes of Causal Factors. Our books and training through our custom courses, software and webinars, and TapRooT® professionals will educate, facilitate, and guide you through investigations into the root causes of human performance problems. Let us know how we may help you. Contact or call us: 865.539.2139.

 

The Best Incident Investigation Performance Indicator

July 18th, 2018 by

NewImage

If an incident investigation and the corrective actions are effective, it will prevent, or significantly reduce the likelihood or consequences of, a repeat incident.

If we want to monitor the effectiveness of our incident investigation, root cause analysis, and corrective action processes, probably the best performance indicator is monitoring the rate of repeat incidents.

If an incident (or even a Causal Factor) is a repeat, it indicates that there was a problem with the previous investigation. For example:

  • Was the root cause analysis inadequate?
  • Were the corrective actions ineffective?
  • Why didn’t management or peer review catch the problem with the previous investigation?

Of course, the question that is tough to answer is … What is a repeat incident (or Causal Factor).

Judging repeat incidents takes some soul searching. The real question is, should have the previous incident investigation prevented the current incident.

Here are two examples:

  • Should the investigation and corrective actions for the Challenger Space Shuttle accident have prevented the Columbia Space Shuttle accident?
  • Should the BP Texas City fire and explosion accident investigation have prevented the BP Deepwater Horizon accident?

You be the judge.

What is the rate for your facility? Do you have 80% repeats? 10%? 0.1%?

Each repeat incident provides a learning opportunity to improve your incident investigation, root cause analysis, corrective action, and incident review processes. Are you using these opportunities to improve your system?

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