Category: Root Cause Analysis Tips

“People are SO Stupid”: Horrible Comments on LinkedIn

May 23rd, 2018 by

 

 

How many people have seen those videos on LinkedIn and Facebook that show people doing really dumb things at work? It seems recently LinkedIn is just full of those types of videos. I’m sure it has something to do with their search algorithms that target those types of safety posts toward me. Still, there are a lot of them.

The videos themselves don’t bother me. They are showing real people doing unsafe things or accidents, which are happening every day in real life. What REALLY bothers me are the comments that people post under each video. Again concentrating on LinkedIn, people are commenting on how dumb people are, or how they wouldn’t put up with that, or “stupid is as stupid does!”

Here are a couple examples I pulled up in about 5 minutes of scrolling through my LinkedIn feed.  Click on the pictures to see the comments that were made with the entries:

 

 

 

 

 

 

 

 

 

 

 

Click on picture to watch Video

 

 

 

 

 

 

 

These comments often fall under several categories.  We can take a look at these comments as groups

“Those people are not following safety guideline xxxx.  I blame operator “A” for  this issue!”

Obviously, someone is not following a good practice.  If they were, we wouldn’t have had the issue, right?  It isn’t particularly helpful to just point out the obvious problem.  We should be asking ourselves, “Why did this person decide that it was OK to do this?”  Humans perform split-second risk assessments all the time, in every task they perform.  What we need to understand is the basis of a person’s risk assessment.  Just pointing out that they performed a poor assessment is too easy.  Getting to the root cause is much more important and useful when developing corrective actions.

“Operators were not paying attention / being careful.”

No kidding.  Humans are NEVER careful for extended periods of time.  People are only careful when reminded, until they’re not.  Watch your partner drive the car.  They are careful much of the time, and then we need to change the radio station, or the cell phone buzzes, etc.

Instead of just noting that people in the video are not being careful, we should note what safeguards were in place (or should have been in place) to account for the human not paying attention.  We should ask what else we could have done in order to help the human do a better job.  Finding the answers to these questions is much more helpful than just blaming the person.

These videos are showing up more and more frequently, and the comments on the videos are showing how easy it is to just blame people instead of doing a human performance-based root cause analysis of the issue.  In almost all cases, we don’t even have enough information in the video to make a sound analysis.  I challenge you to watch these videos and avoid blaming the individual, making the following assumptions:

  1.  The people in the video are not trying to get hurt / break the equipment / make a mistake
  2.  They are NOT stupid.  They are human.
  3.  There are systems that we could put in place that make it harder for the human to make a mistake (or at least make it easier to do it right).

When viewing these videos in this light, it is much more likely that we can learn something constructive from these mistakes, instead of just assigning blame.

Root Cause Tip: Repeat-Back Strengthens Positive Communication

May 17th, 2018 by

Misunderstood verbal communication can lead to a serious incident.

Risk Engineer and HSE expert, Jim Whiting, shared this report with us recently highlighting four incidents where breakdowns in positive communications were factors. In each circumstance, an operator proceeded into shared areas without making positive communication with another operator.

Read: Positive communication failures result in collisions.

Repeat-back (sometimes referred to as 3-way communication) can reinforce positive communication. This technique may be required by policy or procedure and reinforced during training on a task for better compliance.

Repeat-back is used to ensure the information shared during a work process is clear and complete. In the repeat back process, the sender initiates the communication using the receiver’s name, the receiver repeats the information back, and the sender acknowledges the accuracy of the repeat back or repeats the communication if it is not accurate.

There are many reasons why communications are misunderstood. Workers make assumptions about an unclear message based on their experiences or expectations. A sender may choose poor words for communication or deliver messages that are too long to remember. The message may not be delivered by the sender in the receiver’s primary language. A message delivered in the same language but by a worker from a different geographical region may be confusing because the words do not sound the same across regions.

Can you think of other reasons a repeat-back technique can be helpful? Please comment below.

Avoid Big Problems By Paying Attention to the Small Stuff

May 16th, 2018 by

Almost every manager has been told not to micro-manage their direct reports. So the advice above:

Avoid Big Problems By Paying Attention to the Small Stuff

may sound counter-intuitive.

Perhaps this quote from Admiral Rickover, leader of the most successful organization to implement process safety and organizational excellence, might make the concept clearer:

The Devil is in the details, but so is salvation.

When you talk to senior managers who existed through a major accident (the type that gets bad national press and results in a management shakeup), they never saw it coming.

A Senior VP at a utility told me:

It was like I was walking along on a bright sunny day and
the next thing I knew, I was at the bottom of a deep dark hole.

They never saw the accident coming. But they should have. And they should have prevented it. But HOW?

I have never seen a major accident that wasn’t preceded by precursor incidents.

What is a precursor incident?

A precursor incident is an incident that has low to moderate consequences but could have been much worse if …

  • One of more Safeguards had failed
  • It was a bad day (you were unlucky)
  • You decided to cut costs just one more time and eliminated the hero that kept things from getting worse
  • The sequence had changed just a little (the problem occurred on night shift or other timing changed)

These type of incidents happen more often than people like to admit. Thus, they give management the opportunity to learn.

What is the response by most managers? Do they learn? NO. Why? Because the consequences of the little incidents are insignificant. Why waste valuable time, money, and resources investigating small consequence incidents. As one Plant Manager said:

If we investigated  every incident, we would do nothing but investigate incidents.

Therefore, a quick and dirty root cause analysis is performed (think 5-Whys) and some easy corrective actions that really don’t change things that are implemented.

The result? It looks like the problem goes away. Why? Because big accidents usually have multiple Safeguards and they seldom fail all at once. It’s sort of like James Reason’s Swiss Cheese Model…

SwissCheese copy

The holes move around and change size, but they don’t line up all the time. So, if you are lucky, you won’t be there when the accident happens. So, maybe the small incidents repeat but a big accident hasn’t happened (yet).

To prevent the accident, you need to learn from the small precursor incidents and fix the holes in the cheese or add additional Safeguards to prevent the major accidents. The way you do this is by applying advanced root cause analysis to precursor incidents. Learn from the small stuff to avoid the big stuff. To avoid:

  • Fatalities
  • Serious injuries
  • Major environmental releases
  • Serious customer quality complaints
  • Major process upsets and equipment failures
  • Major project cost overruns

Admiral Rickover’s seventh rule (of seven) was:

The organization and members thereof must have the ability
and willingness to learn from mistakes of the past.

And the mistakes he referred to were both major accidents (which didn’t occur in the Nuclear Navy when it came to reactor safety) and precursor incidents.

Are you ready to learn from precursor incidents to avoid major accidents? Then stop trying to take shortcuts to save time and effort when investigating minor incidents (low actual consequences) that could have been worse. Start applying advanced root cause analysis to precursor incidents.

The first thing you will learn is that identifying the correct answer once is a whole lot easier that finding the wrong answer many times.

The second thing you will learn is that when people start finding the real root causes of problems and do real root cause analysis frequently, they get much better at problem solving and performance improves quickly. The effort required is less than doing many poor investigations.

Overall you will learn that the process pay for itself when advanced root cause analysis is applied consistently. Why? Because the “little stuff” that isn’t being fixed is much more costly than you think.

How do you get started?

The fastest way is by sending some folks to the 2-Day TapRooT® Root Cause Analysis Course to learn to investigate precursor incidents.

The 2-Day Course is a great start. But some of your best problem solvers need to learn more. They need the skills necessary to coach others and to investigate significant incidents and major accidents. They need to attend the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

Once you have the process started, you can develop a plan to continually improve your improvement efforts. You organization will become willing to learn. You will prove how valuable these tools are and be willing to become best in class.

Rome wasn’t built in a day but you have to get started to see the progress you need to achieve. Start now and build on success.

Would you like to talk to one of our TapRooT® Experts to get even more ideas for improving your root cause analysis? Contact us by CLICKING HERE.

Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results)

May 9th, 2018 by

Find the Root Cause

I hear people say that 5-Whys is a good root cause analysis system for “simple” incidents. So, I thought I would show a simple incident that was provided as an example by a very experienced 5-Why user and compare it to the analysis that would be performed using TapRooT®.

Taiichi Ohno, the father of the Toyota Production System and the creator of the 5-Why method of root cause analysis, is the source of the example – a robot failure. He used the example to teach employees the 5-Why technique while he was at Toyota. Here is the example as he described it…

1.    Why did the robot stop?

–    The circuit has overloaded, causing a blown fuse.

2.    Why did the circuit overload?

–    There was insufficient lubrication on the bearings, so they locked up.

3.    Why was there insufficient lubrication on the bearings?

–    The oil pump on the robot is not circulating sufficient oil.

4.    Why is the pump not circulating sufficient oil?

–    The pump intake is clogged with metal shavings.

5.    Why is the intake clogged with metal shavings?

–    Because there is no filter on the pump.

For Mr. Ohno, that was the end of the root cause process: Install a filter and get back to work. But this isn’t even the start of the root cause analysis process in TapRooT®.

Let’s look at this incident using TapRooT® and see how 5-Whys compares to the advanced TapRooT® Root Cause Analysis System.

TapRooT® Root Cause Analysis

TapRooT® is more than a tool. It is a systematic process with embedded tools to help an investigator find and fix the root causes of a problem. It starts with either the TapRooT® 5-Step Process for low-to-medium risk incidents or the the TapRooT® 7-Step Process for major investigations. The 5-Step Process is shown below…

To start investigating the problem, one gathers evidence and draws a SnapCharT® (shown below being drawn by a team in a TapRooT® 2-Day Root Cause Analysis Course).

Notice that the 5-Whys that Mr. Ohno asked in the example above turned out to be mainly the sequence of events leading up to the failure in the  SnapCharT® (shown below).

The SnapCharT® makes the example event easier to understand than the 5-Why example above. Plus, the SnapCharT® goes beyond the 5-Whys by indicating that there was no low oil pressure alarm.

In TapRooT®, if the investigator decides that there is more to learn, the investigator continues to collect evidence (grows the SnapCharT®) to expand his/her understanding of what happened. A good TapRooT® Investigator would have several areas to look at.

First, what happened to the filter? Was it forgotten during maintenance or was it never designed into the system?

Next, where did the metal shavings come from? Metal shavings in a lube oil system are unusual. What was the source?

The new information provides a fairly complete understanding of what happened and is shown on the SnapCharT® below.

Notice that in TapRooT®, we complete the collection of evidence about what caused the metal filings and what caused the filter to be missing. These were significant issues that were left out of the 5-Why analysis. This type of omission is common in 5-Why analyses – even when experts apply 5-Whys. Thus the problem isn’t with the investigator or their training – it is embedded in the 5-Why system.

Causal Factors

Once one understands what happened, the third step is to identify the Causal Factors that, if eliminated, would have stopped the accident from occurring or reduced the seriousness of the incident. A simple technique called Safeguard Analysis is used to do this. The four Causal Factors for the Robot Stops incident were identified as:

  1. Mechanic A uses cloth to cover openings in system.
  2. Mechanic A does not report metal shaving contamination.
  3. Mechanic B does not install oil filter.
  4. Operator does not know oil pressure is low.

Where Mr. Ohno only had one root cause, TapRooT® has already identified four Causal Factors. Each of these Causal Factors could have multiple root causes so TapRooT® is already highlighting one of the weaknesses of 5-Whys: that it usually focuses on a single cause and misses additional causes (and the needed corrective actions for those root causes that aren’t identified).

TapRooT® Root Causes

In fourth step of the TapRooT® 5-Step Process, each Causal Factor is analyzed using the Root Cause Tree® to guide the investigator to the Causal Factor’s root causes. The tree is described in detail in the TapRooT® Book (CLICK HERE for info).

For this example, we won’t show the entire analysis of all four Causal Factors using the Root Cause Tree® and Dictionary. For people who would like to know more about the 15-question Human Performance Troubleshooting Guide and the way the tree is used to help investigators find causes beyond their current knowledge, we recommend  attending a 2-Day or 5-Day TapRooT® Course.

However, we will describe the analysis of the Causal Factor “Operator doesn’t know oil pressure is low.”

This starts out on the tree as a Human Performance Difficulty that leads us to the Human Performance Troubleshooting Guide. When asking the 15 Questions, two questions get a “yes” for this Causal Factor and guide us to the Human Engineering, Procedures, and Training Basic Cause Categories on the back side of the Root Cause Tree®.

Copyright © 2015 by System Improvements, Inc.
Used by permission. Duplication prohibited.

In analyzing these categories, no causes are found in the Procedures or Training Basic Cause Categories. However, two root causes are found to be applicable in the Human Engineering Basic Cause Category (above).

Thus, it was determined that if the operator needed an oil pressure display/alarm (displays NI root cause) to make the detection of a problem possible (errors not detectable root cause). If the display/alarm had been present, then the robot could have been stopped and fixed before damage to the bearings had occurred. Thus, the incident would have been made significantly less severe.

The corrective action for these two root causes would be to install a bearing lube oil pressure indicator and a low bearing lube oil pressure alarm to notify the operator of impending equipment problems before the bearing would lock up.

After analyzing just one Causal Factor using the TapRooT® Root Cause Tree® we have found that even an expert like Taiichi Ohno could miss important root causes when using 5-Whys. But there is more. There are still three more Causal Factors to analyze (and then Generic Causes – an optional technique in the 5-Step Process).

Why would you use a root cause tool with known, proven weaknesses? Why would you risk lives, your corporate reputation, and large sums of money on an inferior approach to problem solving? If something is worth fixing, it is worth fixing it right! Learn and apply TapRooT® Advanced Root Cause Analysis to find the real root causes of problems and effectively fix them. Attend an upcoming course to learn more.

A tip for ensuring accuracy of your investigation findings

May 4th, 2018 by

Gary Gardner shares an idea at the 2018 Global TapRooT Summit.

 

Cyber Attack Root Cause Analysis

May 4th, 2018 by

(if you can’t see the video, here’s a link)

Yes .. It happened right here in Knoxville! A cyber attack on the county computer system on election night!

What is the root cause? The county is having an outside contractor look into it.

Can you use the TapRooT® Root Cause Analysis System to do a root cause analysis of a cyber security attack. Yes! People have been doing it for decades.

How to Keep Your Investigators Proficient

April 26th, 2018 by

Why work harder when you can work smarter? Ken and Benna discuss great ideas about keeping your investigation team sharp. It’s easier than you think with a few simple guidelines.

How many precursor incidents did your site investigate last month? How many accidents did you prevent?

April 25th, 2018 by

A precursor incident is an incident that could have been worse. If another Safeguard had failed, if the sequence had been slightly different, or if your luck had been worse, the incident could have been a major accident, a fatality, or a significant injury. These incidents are sometimes called “hipos” (High Potential Incidents) or “potential SIFs” (Significant Injury or Fatality).

I’ve never talked to a senior manager that thought a major accident was acceptable. Most claim they are doing EVERYTHING possible to prevent them. But many senior managers don’t require advanced root cause analysis for precursor incidents. Incidents that didn’t have major consequences get classified as a low consequence event. People ask “Why?” five times and implement ineffective corrective actions. Sometimes these minor consequence (but high potential consequence incidents) don’t even get reported. Management is letting precursor incidents continue to occur until a major accident happens.

Perhaps this is why I have never seen a major accident that didn’t have precursor incidents. That’s right! There were multiple chances to identify what was wrong and fix it BEFORE a major accident.

That’s why I ask the question …

“How many precursor incidents did your site investigate last month?”

If you are doing a good job identifying, investigating, and fixing precursor incidents, you should prevent major accidents.

Sometimes it is hard to tell how many major accidents you prevented. But the lack of major accidents will keep your management out of jail, off the hot seat, and sleeping well at night.

Screen Shot 2018 04 18 at 2 08 58 PMKeep Your Managers Out of These Pictures

That’s why it’s important to make sure that senior management knows about the importance of advanced root cause analysis (TapRooT®) and how it should be applied to precursor incidents to save lives, improve quality, and keep management out of trouble. You will find that the effort required to do a great investigation with effective corrective actions isn’t all that much more work than the poor investigation that doesn’t stop a future major accident.

Want to learn more about using TapRooT® to investigate precursor incidents? Attend one of our 2-Day TapRooT® Root Cause Analysis Courses. Or attend a 5-Day TapRooT® Root Cause Analysis Course Team Leader Course and learn to investigate precursor incidents and major accidents. Also consider training a group of people to investigate precursor incidents at a course at your site. Call us at 865-539-2139 or CLICK HERE to send us a message.

Are you ready for quality root cause analysis of a precursor incident?

April 17th, 2018 by

Many companies use TapRooT® to investigate major accidents. But investigating a major accident is like closing the barn door after the horse has bolted.

What should you be doing? Quality investigations of incidents that could have been major accidents. We call these precursor incidents. They could have been major accidents if something else had gone wrong, another safeguard had failed, or you were “unlucky” that day.

How do you do a quality investigation of a precursor incident? TapRooT® of course! See the Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents book.

NewImage

Or attend one of our TapRooT® Root Cause Analysis Courses.

Evidence Collection: Two things every investigator should know about scene management

April 17th, 2018 by

You may not be part of scene management when an incident occurs at your facility but there are two things every investigator should know:

  1. Hazards that are present in the work area and how to handle them. It’s impossible to anticipate every accident that could happen but we can evaluate hazards that are present at our facilities that could affect employees and the community at large to structure a scene management plan.
  2. Priorities for evidence collection. The opportunity to collect evidence decreases over time. Here are a few things to keep in mind during, and immediately following, scene management.
    • Fragile evidence goes away.
    • Witnesses forget what they saw.
    • Environmental conditions change making it hard to understand why an incident occurred.
    • Clean-up and restart begins; thus, changing the scene from its original state.

Learn more by holding our 1-Day Effective Interviewing & Evidence Collection Training at your facility. It is a standalone course but also fits well with our 2-Day TapRooT® Root Cause Analysis Training. Contact me for details: carr@taproot.com.

 

You’re invited to Facebook Live for Wednesday lunch

April 16th, 2018 by

We invite you to tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a contemporary, workplace-relevant topic. Put a reminder on your calendar, in your phone, or stick a post-it on your forehead to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s how to connect with us for Wednesday’s Facebook Live:

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

When? Wednesday, April 18, 2018

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

If you missed last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation, you can catch up on the discussion via the Vimeo below. You may want to peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

NOTE: Be sure to save the date for the 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

The Scientific Method In Relation To Root Cause Analysis

April 13th, 2018 by

Did you miss last week’s Facebook Live session with TapRooT® co-founder Mark Paradies and Barb Carr, editorial director at TapRooT®, as they discussed methodologies for root cause analysis in incident investigation? Here’s an opportunity to catch up on the discussion, as Mark and Barb distill the disciplines and factors that historically have been involved in solving complex problems. Also, peruse Mark’s article, Scientific Method and Root Cause Analysis, to supplement this significant learning experience. Feel free to comment or ask questions on our Facebook page.

The Scientific Method In Relation To Root Cause Analysis from TapRooT® Root Cause Analysis on Vimeo

Tune into TapRooT®’s Facebook Live every Wednesday. You’ll be joining TapRooT® professionals as we bring you a workplace-relevant topic. Put a reminder on your calendar or in your phone to watch TapRooT®’s Facebook Live this week for another terrific discussion and for news you can use. We look forward to being with you on Wednesdays!

Here’s the info you need to connect with us for our next Facebook Live:

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

When? Wednesday, April 18, 2018

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

NOTE: Save the date for 2019 Global TapRooT® Summit: March 11-15, in the Houston, TX area (La Torretta Lake Resort)!

Where to Start When Finding Root Causes

April 11th, 2018 by

I had someone ask me the other day …

”Where do I start when finding root causes?”

To me, the answer was obvious. You need to understand what happened BEFORE you can understand why it happened.

That’s why the TapRooT® System starts by developing a SnapCharT® of what happened.

Here is a simple example.

Someone sprains their ankle while walking to their car in the parking lot.

What is the root cause.

You might think the obvious answer is …

“They didn’t have their eyes on path!”

But you are jumping to conclusions! You don’t know what happened. So start here…

NewImage

You are starting to develop the story of what happened. You keep working on the story until you have clearly defined Causal Factors …

SprainSnapwCF

That’s a lot more information! It isn’t as simple as “eyes on path.”

Now you are ready to start identifying the root causes of each of the four Causal Factors.

So, that’s where you need to start to find root causes!

Scientific Method and Root Cause Analysis

April 4th, 2018 by

Screen Shot 2018 03 26 at 2 15 18 PM

I had someone tell me that the ONLY way to do root cause analysis was to use the scientific method. After all, this is the way that all real science is performed.

Being an engineer (rather than a scientist), I had a problem with this statement. After all, I had done or reviewed hundreds (maybe thousands?) of root cause analyses and I had never used the scientific method. Was I wrong? Is the scientific method really the only or best answer?

First, to answer this question, you have to define the scientific method. And that’s the first problem. Some say the scientific method was invented in the 17th century and was the reason that we progressed beyond the dark ages. Others claim that the terminology “scientific method” is a 20th-century invention. But, no matter when you think the scientific method was invented, there are a great variety of methods that call themselves “the scientific method.” (Google “scientific method” and see how many different models you can find. The one presented above is an example.)

So let’s just say the scientific method that the person was insisting was the ONLY way to perform a root cause analysis required the investigator to develop a hypothesis and then gather evidence to either prove or disprove the hypothesis. That’s commonly part of most methods that call themselves the scientific method.

What’s the problem with this hypothesis testing model? People don’t do it very well. There’s even a scientific term the problem that people have disproving their hypothesis. It’s called CONFIRMATION BIAS. You can Google the term and read for hours. But the short description of the problem is that when people develop a hypothesis that they believe in, they tend to gather evidence to prove what they believe and disregard evidence that is contrary to their hypothesis. This is a natural human tendency – think of it like breathing. You can tell someone not to breath, but they will breath anyway.

What did my friend say about this problem with the scientific method? That it could be overcome by teaching people that they had to disprove all other theories and also look for evidence to disproves their theory.

The second part of this answer is like telling people not to breath. But what about the first part of the solution? Could people develop competing theories and then disprove them to prove that there was only one way the accident could have occurred? Probably not.

The problem with developing all possible theories is that your knowledge is limited. And, of course, how long would it take if you did have unlimited knowledge to develop all possible theories and prove or disprove them?

The biggest problem that accident investigators face is limited knowledge.

We used to take a poll at the start of each root cause analysis class that we taught. We asked:

“How many of you have had any type of formal training
in human factors or why people make human errors?”

The answer was always less than 5%.

Then we asked:

“How many of you have been asked to investigate
incidents that included human errors?”

The answer was always close to 100%.

So how many of these investigators could hypothesize all the potential causes for a human error and how would they prove or disprove them?

That’s one simple reason why the scientific method is not the only way, or even a good way, to investigate incidents and accidents.

Need more persuading? Read these articles on the problems with the scientific method:

The End of Theory: The Data Deluge Makes The Scientific Method Obsolete

The Scientific Method is a Myth

What Flaws Exist Within the Scientific Method?

Is the Scientific Method Seriously Flawed?

What’s Wrong with the Scientific Method?

Problems with “The Scientific Method”

That’s just a small handful of the articles out there.

Let me assume that you didn’t read any of the articles. Therefore, I will provide one convincing example of what’s wrong with the scientific method.

Isaac Newton, one of the world’s greatest mathematicians, developed the universal law of gravity. Supposedly he did this using the scientific method. And it worked on apples and planets. The problem is, when atomic and subatomic matter was discovered, the “law” of gravity didn’t work. There were other forces that governed subatomic interactions.

Enter Albert Einstein and quantum physics. A whole new set of laws (or maybe you called them “theories”) that ruled the universe. These theories were proven by the scientific method. But what are we discovering now? Those theories aren’t “right” either. There are things in the universe that don’t behave the way that quantum physics would predict. Einstein was wrong!

So, if two of the smartest people around – Newton and Einstein – used the scientific method to develop answers that were wrong but that most everyone believed … what chance do you and I have to develop the right answer during our next incident investigation?

Now for the good news.

Being an engineer, I didn’t start with the scientific method when developing the TapRooT® Root Cause Analysis System. Instead, I took an engineering approach. But you don’t have to be an engineer (or a human factors expert) to use it to understand what caused an accident and what you can do to stop a future similar accident from happening.

Being an engineer, I had my fair share of classes in science. Physics, math, and chemistry are all part of an engineer’s basic training. But engineers learn to go beyond science to solve problems (and design things) using models that have limitations. A useful model can be properly applied by an engineer to design a building, an electrical transmission network, a smartphone, or a 747 without understanding the limitations of quantum mechanics.

Also, being an engineer I found that the best college course I ever had that helped me understand accidents wasn’t an engineering course. It was a course on basic human factors. A course that very few engineers take.

By combining the knowledge of high reliability systems that I gained in the Nuclear Navy with my knowledge of engineering and human factors, I developed a model that could be used by people without engineering and human factors training to understand what happened during an incident, how it happened, why it happened, and how it could be prevented from happening again. We have been refining this model (the TapRooT® System) for about thirty years – making it better and more usable – using the feedback from tens of thousands of users around the world. We have seen it applied in a wide variety of industries to effectively solve equipment and human performance issues to improve safety, quality, production, and equipment reliability. These are real world tests with real world success (see the Success Stories at this link).

So, the next time someone tells you that the ONLY way to investigate an incident is the scientific method, just smile and know that they may have been right in the 17th century, but there is a better way to do it today.

If you don’t know how to use the TapRooT® System to solve problems, perhaps you should attend one of our courses. There is a basic 2-Day Course and an advanced 5-Day Course. See the schedule for public courses HERE. Or CONTACT US about having a course at your site.

Active Listening Inventory

March 28th, 2018 by

Are you a good listener? No one is born that way. Listening is a learned skill and practice makes perfect. Read through the following inventory statements and check for areas where you can improve your skills.

1. I listen without interrupting or finishing another’s sentences.
2. I am comfortable with long pauses in conversation.
3. I don’t “tune-out.”
4. I avoid distractions when listening.
5. I respond appropriately when someone is talking to let them know I am listening.
6. I am patient.
7. When someone is speaking, I am listening and not thinking of my next question or comment.
8. I am aware of my non-verbal messages as well as those displayed by others.

Root Cause Analysis Audit Idea

March 22nd, 2018 by

Screen Shot 2018 03 22 at 3 02 19 PM

In the past couple of years has your company had a major accident?

If they did, did you check to see if there were previous smaller incidents that should have been learned from and if the corrective actions should have prevented the major accident?

I don’t think I have ever seen a major accident that didn’t have precursors that could have been learned from to improve performance. The failure to learn and improve is a problem that needs a solution.

In the TapRooT® root cause analysis of a major accident, the failure to fix pervious precursor incidents should get you to the root cause of “corrective action NI” if you failed to implement effective corrective actions from the previous investigations.

If this idea seems like a new idea at your facility, here is something that you might try. Go back to your last major accident. Review your database to look for similar precursor incidents. If there aren’t any, you have identified a problem. You aren’t getting good reporting of minor incidents with potential serious consequences.

If you find previous incidents, it’s time for an audit. Review the investigations to determine why the previous corrective actions weren’t effective. This should produce improvements to your root cause analysis processes, training, reviews, …

Don’t wait for the next big accident to improve your processes. You have all the data that you need to start improvements today!

Root Cause Tip: Luck Versus Being Consistent, Success and Failure Can Come From Both

March 14th, 2018 by

Every best practice can be a strength or a weakness. Even one phrase like “I will ____” can be self-defeating or uplifting. “I will succeed” versus “I will fail.” Both phrases set your compass for success or failure. Okay, so what does philosophy have to do with root cause analysis? Simple….

Practice safe behaviors, build and sustain safe and sustainable processes with good best practices, and success is measured by less injuries, less near-misses, and more efficient processes.

Practice unsafe behaviors, build unsafe but sustainable processes with poor best practices, and success is measured by more injuries, more near-misses, and wasteful business processes. Safety only happens by luck!

Guess what? In many cases, you can still be in compliance during audits but still meet the criteria of “unsafe but sustainable processes with poor best practices . . . measured by more injuries, more near-misses, and wasteful business processes.”

This is why Question Number 14 on the TapRooT® Root Cause Tree® is so important.

Not every Causal Factor/Significant Issue that occurred during an incident or was found during an audit is due to a person just breaking a rule or taking shortcuts. In many cases, the employee was following the rules to the “T” when the action that the employee performed, got him/her hurt or got someone else hurt.

Take time to use the TapRooT® Root Cause Tree®, Root Cause Tree® Dictionary, and Corrective Action Helper® as designed to perform consistently with a successful purpose.

Want to learn more? Attend one of our public TapRooT® Courses or contact us to schedule an onsite course.

What does bad root cause analysis cost?

March 7th, 2018 by

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Have you ever thought about this question?

An obvious answer is $$$BILLIONS.

Let’s look at one example.

The BP Texas City refinery explosion was extensively investigated and the root cause analysis of BP was found to be wanting. But BP didn’t learn. They didn’t implement advanced root cause analysis and apply it across all their business units. They didn’t learn from smaller incidents in the offshore exploration organization. They didn’t prevent the BP Deepwater Horizon accident. What did the Deepwater Horizon accident cost BP? The last estimate I saw was $22 billion. The costs have probably grown since then.

I would argue that ALL major accidents are at least partially caused by bad root cause analysis and not learning from past experience.

EVERY industrial fatality could be prevented if we learned from smaller precursor incidents.

EVERY hospital sentinel event could be prevented (and that’s estimated at 200,000 fatalities per year in the US alone) if hospitals applied advanced root cause analysis and learned from patient safety incidents.

Why don’t companies and managers do better root cause analysis and develop effective fixes? A false sense of saving time and effort. They don’t want to invest in improvement until something really bad happens. They kid themselves that really bad things won’t happen because they haven’t happened yet. They can’t see that investing in the best root cause analysis training is something that leads to excellent performance and saving money.

Yet that is what we’ve proven time and again when clients have adopted advanced root cause analysis and paid attention to their performance improvement efforts.

The cost of the best root cause analysis training and performance improvement efforts are a drop in the bucket compared to any major accident. They are even cheap compared to repeat minor and medium risk incidents.

I’m not promising something for nothing. Excellent performance isn’t free. It takes work to learn from incidents, implement effective fixes, and stop major accidents. Then, when you stop having major accidents, you can be lulled into a false sense of security that causes you to cut back your efforts to achieve excellence.

If you want to learn advanced root cause analysis with a guaranteed training, attend of our upcoming public TapRooT® Root Cause Analysis Training courses.

Here is the course guarantee:

Attend the course. Go back to work and use what you have learned to analyze accidents,
incidents, near-misses, equipment failures, operating issues, or quality problems.
If you don’t find root causes that you previously would have overlooked
and if you and your management don’t agree that the corrective actions that you
recommend are much more effective, just return your course materials/software
and we will refund the entire course fee.

Don’t be “penny wise and pound foolish.” Learn about advanced root cause analysis and apply it to save lives, prevent environmental damage, improve equipment reliability, and achieve operating excellence.

Top 3 Reasons Corrective Actions Fail & What to Do About It

February 15th, 2018 by

Ken Reed and Benna Dortch discuss the three top reasons corrective actions fail and how to overcome them. Don’t miss this informative video! It is a 15 minute investment of time that will change the way you think about implementing fixes and improve performance at your facility.

Stop Assumptions in Their Tracks!

February 13th, 2018 by

Assumptions can cause investigators to reach unproven conclusions.

But investigators often make assumptions without even knowing that they were assuming.

So how do you stop assumptions in their tracks?

When you are drawing your SnapCharT®, you need to ask yourself …

How do I know that?

If you have two ways to verify an Event or a Condition, you probably have a FACT.

But if you have no ways to prove something … you have an assumption.

What if you only have one source of information? You have to evaluate the quality of the source.

What if one eye witness told you the information? Probably you should still consider it an assumption. Can you find physical evidence that provides a second source?

What if you just have one piece of physical evidence? You need to ask how certain you are that this piece of physical evidence can only have one meaning or one cause.

Dashed Boxes

Everything that can’t be proven to be a fact should be in a dashed box or dashed oval on your SnapCharT®. And on the boxes or ovals that you are certain about? List your evidence that proves they are facts.

Now you have stopped assumptions in their tracks!

Why You Should Use the TapRooT® Process for Smaller Investigations

February 7th, 2018 by

“If the hammer is your only tool, all of your problems will start looking like nails.”

Per Ohstrom shares how TapRooT® is used to investigate smaller incidents by demonstrating the methodology. Are you using the 5-Whys to investigate these types of incidents? The 5-Whys won’t take you beyond your own knowledge. Find out how TapRooT® will!

How to Make Incident Investigations Easier

January 31st, 2018 by

Ken Reed talks about the differences between an investigation for a low-to-moderate incident and a major incident. Find out how TapRooT® makes both types of investigation easier to manage.

Want to learn how to investigate a major/minor incident with all of the advanced tools? Sign up for an upcoming 5-day training!

Want to start with just the essential skills for performing a root cause analysis on a minor or major investigation? It’s a great place to start with a minor investment of time. Sign up for an upcoming 2-day training!

Root Cause Analysis Tip: Do you perform an incident investigation like you watch the news?

January 31st, 2018 by

If you are like me, you flip channels to see how each news station or news website reports the same issue of interest. Heck, I even look at how different countries discuss the same issue of interest. Take the “Deep Water Horizon Spill of 2010” or was it the “BP Oil Spill of 2010” or was it the “Gulf of Mexico Oil Spill of 2010”? It depends on where you were or what you watched when it was reported. At the end of the day we all often develop Bias Criteria of Trust… often without any true ability to determine which perspective is closer to the truth.

Now there are fancier terms of bias from confirmation bias to hindsight bias, but let’s take a look at some of our news source Bias Criteria of Trust.


So here is the question to stop and ask….. do you do the same thing when you start an investigation, perform root cause analysis or troubleshoot equipment? It is very easy to say YES! We tend to trust interviews and reports using the same criteria above before we actually have the evidence. We also tend to not trust interviews and reports purely because of who and where they came from, without evidence as well!

Knowing this…..

Stop the urge to not trust or to overly trust. Go Out And Look (GOAL) and collect the evidence.

Got your interest? Want to learn more? Feel free to contact me or any of our TapRooT® Instructors at info@taproot.com or call 865.539.2139.

Where Do You Get Ideas To Improve Root Cause Analysis?

4 Signs You Need to Improve Your Investigations

Where Do You Get Ideas To Improve Root Cause Analysis?

January 31st, 2018 by

When I was assigned the job of figuring out how to improve investigations and root cause analysis … I knew that we were NOT finding the causes of human errors. But where would I get ideas to help make things better? The year was 1985 and there wasn’t an easy place to start …

  • no internet
  • no e-mails with upcoming courses
  • no conferences on the topic (maybe one talk at a nuclear industry conference’s breakout session)

I knew that the Institute for Nuclear Power Operations was working on a system because they had tried to hire me to help create it.

So what did I do?

  • Started looking at the human factors research.
  • Networked with the folks I knew at our corporate headquarters, INPO, the University of Illinois, INEL, EPRI, and several utilities where I knew people.
  • Started trying to create a list of causes that encompassed the human factors research that I was familiar with.

This lead to a beginning system to find root causes that, eventually, led to the development of TapRooT® Root Cause Analysis System.

It was a long road with many lessons learned.

In 1988, we started System Improvements to help people improve their root cause analysis systems. In 1990, we won a contract to help the US Nuclear Regulator Commission improve their analysis of human errors. In 1991 we started working with our first oil and chemical company (Chevron) to improve their root cause analysis as part of their efforts to improve process safety. From there our growth into all types of industries with incidents – incidents that need fixes to prevent recurrence based on the real root causes – has been … pretty dramatic.

In 1994 we held the first TapRooT® Summit (not named the Summit until sometime later). It had great speakers and 35 attendees. I cooked steaks for everyone as our closing session.

Mark Ed 2

 1996 Summit Keynote Speaker with Mark Paradies (left)

Why did we decide to have a summit to focus on root cause analysis and performance improvement? Because I thought that our clients needed it. They needed:

  • a place to learn the latest ways to improve human performance.
  • to network and share best practices they were testing and perfecting.
  • to hear about what we were doing to improve the TapRooT® System.
  • motivation to keep them at the “performance improvement grindstone.”

L M Astronaut

Linda Under and Mark Paradies with 1997 Astronaut Keynote Speaker

Little did I know that this first conference would turn into an annual event that had hundreds of attendees who are some of the smartest people improving industrial safety, quality, patient safety, process safety, asset optimization, and operational excellence from around the world.

Linda1988

Linda Unger with Summit attendee from South Korea in 1998

I would never have guessed that I would draw people from Australia, Indonesia, Malaysia, UK, Saudi Arabia, Tanzania, New Zealand, Colombia, Brazil, Canada, Mexico, South Africa, Russia, Denmark, France, and many other countries (even the USA!) to hear what we thought others needed to learn to make their performance great.

Bestpractice

People sharing best practices at the 2016 Global TapRooT® Summit

But it happened. And now, if someone asks:

“Where Do You Get Ideas To Improve Root Cause Analysis?”

The answer is … The Global TapRooT® Summit.

The next Summit is rapidly approaching. Where is it? It is being held in Knoxville, Tennessee, (our hometown) on February 26 – March 2.

Want to find out more about the 10 pre-Summit courses being held on February 26-27? CLICK HERE.

Want to find out more about the blockbuster talks being delivered by the Keynote Speakers? CLICK HERE.

Want to see a list of the Best Practice Presenters? CLICK HERE.

Want to see the schedules for all nine Summit Tracks? CLICK HERE.

But don’t spend too much time clicking. You need to REGISTER ASAP and get your hotel and travel plans finalized because you need to attend this Summit.

Watch this video to see what past Summit attendees have to say…

Why do people try to make root cause analysis so difficult?

January 17th, 2018 by

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I read a comment string on LinkedIn about root cause analysis. People made the concepts and techniques so hard to understand.

First, there was an argument over what is a root cause. One person argued that there was no such thing because EVERY cause had another deeper cause. Someone else argued that there wasn’t a root cause because most incidents had multiple causes. Someone else introduced the idea of root causes, contributing causes, causal factors, and initiating events. Someone else brought up the concept of latent causes and Swiss cheese.

If that wasn’t enough disagreement, another side argument started over what was an incident, and accident, a near-miss, and a significant incident. This lead to a discussion of what needed investigation and how good an investigation was good enough.

At SI, we too had discussions about these topics 30 years ago. However, in the TapRooT® System, these arguments are settled and the terminology is either settled or irrelevant.

Perhaps it is my engineering and Nuclear Navy training that lead me away from philosophical discussions and turned me toward practical solutions to problems.

Perhaps it was my human factors training that made it easy to see why people made mistakes and what we could do to prevent them.

Perhaps it is my ability to take complex subjects and make them understandable that lead to the development of a systematic, practical, repeatable system to find the root causes of problems – the TapRooT® System.

So, if you are tired of debate and just want a system that has been proven around the world to find and fix the root causes of safety, quality, equipment, and production issues, learn about TapRooT® and save lot’s of time by avoiding needless arguments.

CLICK HERE to find out more about our 2-Day and 5-Day TapRooT® Training.

CLICK HERE to see where our upcoming public TapRooT® Training is being held.

Or CLICK HERE to contact us about having a course at your site.

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