Category: Root Cause Analysis Tips

Root Cause Analysis Tip: Fixing Generic Causes

April 15th, 2015 by

One of the final steps in performing a TapRooT® Root Caquse Analysis is finding Generic Causes. 

What is a Generic Cause? It is the reason that a root cause is widespread.

For example, a root cause for an error made while using a procedure might be that the procedure have more than one action per step. 


EXAMPLE:

4. Remove the drum lid and the polyethylene liner lid, place liner in prepared drum and place in loading position at the final packaging hut. Insert plastic bag in drum liner. Seal the plastic bag with tape to the inside of the drum loading insert. 


The fix for this specific root cause might look something like this:

 

4.  Remove the drum lid and the polyethylene liner lid.     .     .     .     .     . ___

5.  Place liner in prepared drum.    .     .     .     .     .    .    .    .    .    .    .    . ___

6.  Place prepared drum in loading position at the final packaging hut.    . ___

7.  Insert plastic bag in drum liner.    .     .     .     .     .    .    .    .    .    .    .   ___

8.  Seal the plastic bag with tape to the inside of the drum loading insert.  ___

 

If the team then went to check other procedures and found that this problem was widespread, they would then have a generic problem. The question then becomes: “Why is the problem of ‘more than one action per step’ so widespread? What is the generic Cause that allows us to produce poor procedures?

The root cause analysis team may find that the people writing procedures have no guidance for writing procedures and no training on how to write procedures.

This should cause the team to look for other generic procedure problems.They might also find that procedure formats are confusing, the level of detail is inconsistent, there are excessive references,and the graphics need improvement.

The Corrective Action Helper® Guide provides guidance to fix these kinds of Generic Causes. But the widespread generic procedure problems probably indicate that the company or site doesn’t really know how to produce good procedures. Therefore, the Corrective Action Helper® Book recommendation to fix specific Generic Causes might not be enough guidance.

For example, the Corrective Action Helper® Guide says that for generic “greater than one action per step” problems, the investigators should consider:

“…a general procedure improvement program to remove multiple actions per step from the rest of the facilities procedures.”

However, if the procedures are in really bad shape, more must be done.

Of course, the Corrective Action Helper® Guide provides even more information – references. And if the investigators read the suggested reference, they may look for the additional problems and develop a plan to improve their procedures that is more comprehensive.

That would be great. But how many team read the references? My guess is … not that many. After all, in today’s downsized, super-efficient workplace, people just don’t have time.

That why System Improvements is here to provide assistance.

If you run into generic problems that you think may be important to fix, we can help.

At a minimum, we can coach your team on the development of generic corrective actions.

Beyond that, we can put an evaluation team together to evaluate the scope of the Generic Cause and develop a plan to improve performance by eliminating the Generic Cause and upgrading current systems.

Finally, if you really need help, we can put together a team to help implement the fix. In this cause, a team of experienced procedure writers to help your company fix their current procedures and coach your procedure writers how to write better procedures in the future.

We can even make rerun visits to audit the status of the corrective actions and the work of your procedure writers.

So when you find a Generic Cause that you know your company isn’t good at fixing (or doesn’t have the time to explore and fix), remember that System Improvements can help. 

Don’t let problems repeat because Generic Causes are left un-fixed. Get help. Call us at 865-539-2139 or CLICK HERE to end us a message. We can help you improve!

Process Improvement: Stopping Process Downtime

March 24th, 2015 by

Eliminating waste is at the core of Lean Manufacturing. But even without a lean program, any manufacturing manager knows that process downtime can be costly.

Process downtime can cause:

  • delayed orders, 
  • missed schedules, 
  • missed earning projections, and
  • increased costs, 

Improving process reliability is the same as improving safety, quality, and equipment reliability. When a process reliability problem happens, it needs to be investigated and the root causes need to be found and fixed.

How do you find and fix the causes of process downtime? You can use the same tools that experts use to find the root causes of other  to find the root causes causes of safety incidents, equipment failures, and quality issues. The TapRooT® Root Cause Analysis System.

An example of a process reliability improvement success story is share at:

http://www.taproot.com/archives/18976

And they used TapRooT® to go from losing money to a profitable operation. How did TapRooT® help? Watch the video and read about how to use TapRooT® to find root causes at:

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

Root Cause Analysis Tip: Protecting Your Root Cause Analysis from Discovery – Work Product and Motivation

March 10th, 2015 by

Saw an interesting short piece on McGuireWoods web site. It describe a case between Chevron Midstream Pipelines and Sutton Towing LLC. 

It seems the court decided that a “legally chartered” root cause analysis that was performed at the direction of in-house Chevron attorneys was not different from normal root cause analysis that the company performed after any incident.

Why? Because of the motivation to perform this root cause analysis was the same as any other RCA. The judge relied on several pieces of evidence:

  • A Chevron engineer “who agreed in her deposition that the ‘primary purpose of a root cause analysis’ is to ‘prevent a similar accident from happening again in the future,'” and “that it is ‘part of the Chevron ordinary course of business to conduct a root cause analysis’ after an incident.” 
  • “Chevron Pipeline’s President’s statement in an employee newsletter that ‘[w]e are conducting root cause analyses of both incidents and will apply lessons learned. Our ultimate goal remains the same – an incident and injury-free workplace.’”
  • “Chevron’s failure to provide the court examples of Chevron’s ordinary root cause analyses — noting that Chevron’s argument that its ordinary ‘incident reviews’ were different from its ‘legally chartered’ investigation ‘would be more convincing if there was actually another root cause analysis from which to distinguish the legally chartered one.'”

As Thomas Spahn, attorney from McGuireWoods wrote:

“To satisfy the work product motivation element, companies must demonstrate that they did something different or special because they anticipated litigation — beyond what they ordinarily would do, or which they were compelled to do by external or internal requirements.”

Of course, we always recommend that the statements in an incident report be carefully written and accurate. The words used can make a huge difference if your report is introduced as evidence in court.

Remember, what you write may not be interpreted or used as you intended it after the fact. An even if you think your investigation is protected as part of an attorney’s work product, the court may not agree.

Why is Performance Improvement (and Root Cause Analysis) Essential?

February 11th, 2015 by

Sometimes I get the impression that some managers think that performance improvement is an optional activity that can be cut to meet budget goals. That view surprises me because I think that performance improvement is an essential activity that can’t be cut because it supports activities that:

  1. Stop Fatalities
  2. Reduces Regulatory Conflict
  3. Avoids Major Financial Losses
  4. Keeps Clients Happy
  5. Eliminates Bad Press
  6. Improves Operational Efficiency and Equipment Reliability

After all, can you really afford deaths, regulatory initiatives, major losses, unhappy clients, bad press, and broken, inefficient operations?

If your performance improvement program isn’t world class, you are inviting disaster. And disaster is expensive. Every cent you save by reducing effective performance improvement efforts will come back to you in expensive accidents, incidents, plant upsets, equipment downtime, and regulatory headaches.

So, the next time management has a great idea to cut the performance improvement budget, remind them what the budget does for them. Remind them of the losses avoided and the good nights of sleep they get and how bad it will be when things go haywire.

Root Cause Analysis Video Tips: Best Practices in Process Quality

February 5th, 2015 by

Tune in to this week’s TapRooT® Instructor Root Cause Analysis Tip with Chris Vallee. He shares a great process quality tip and news about his upcoming Process Quality & Corrective Action Track at the 2015 Global TapRooT® Summit, June 3-5, 2015 in Las Vegas, Nevada!

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Was this tip helpful?

Check out more short videos in our series:

Equifactor® – Are You Using it to Prevent Equipment Failures? (Click here to view tip.)

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

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

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

Can Being Cheap Cost Your Company Big Bucks? … Let Me Count the Ways!

January 29th, 2015 by

I was thinking about the ways that trying to be cheap when doing root cause analysis could cost companies millions of dollars, when a discussion with a legal counsel gave me an additional idea. Then I thought,

I need to share these ideas to keep people from making these mistakes.”

 1. CHEAP INVESTIGATIONS

I’ve seen many companies assign supervisors to investigate accidents “in their spare time.” This is definitely a cheap investigation. But the problem is that the results could cost the company millions of dollars.

For example, let’s say that a near-miss doesn’t cost anything and no one is seriously injured. Therefore, a supervisor does a quick investigation without looking into the problem in too much detail. He recommends re-training those involved and the training is conducted days later. Case closed!

However, the root causes and failed safeguards for a bigger accident are never fixed. Nearly a year later, a major accident occurs that could have been prevented IF the root causes of the previous near-miss had been found and fixed. However, because a “cheap” investigation was performed, the causes were never identified and 10 people died needlessly. The company spent $1 million on an OSHA fine and almost $100 million more on legal and settlement costs.

What do you think? Was the savings of a cheap investigation worthwhile?

One key to a world-class incident investigation and root cause analysis program is to spend time identifying which “small incidents” are worthy of a good investigation because they have the potential to prevent major accidents. These near-misses (of a big accident) should be treated as seriously as the big accident itself with a thorough investigation , management review, and implementation of effective corrective actions to prevent recurrence of the causes (and, thus, the big accident that’s waiting to happen).

2. CHEAP CORRECTIVE ACTIONS

I’ve seen companies try to perform a thorough root cause analysis only to try to take the cheap way out when it comes to corrective actions.

You have probably all seen “cheap” corrective actions. Try these:

  • Caution workers to be more careful when …
  • Re-train employees to follow the procedure.
  • Re-emphasize to employees the importance of following the rules.

These seem cheap. (Cautioning employees is almost free.) But the change very little and will be forgotten in days or at least in several months. Plus, new folks who join the organization after the caution, re-train, or re-emphaize occurs, won’t get the repeated emphasis.

What happens? The incident tends to repeat after a period of time. And repeat incidents can be expensive. Thus by saving on corrective actions, you may be costing your company big bucks.

Instead, for investigations that could prevent major accidents, investigators should propose (and management should insist upon) corrective actions that remove the hazard, remove the target, or significantly improve the human factors of the safeguards that are used to prevent a repeat of the accident. These may not be cheap but they will be infinitely more effective.

What if one of these three choices can’t be implemented? Then one or more additional safeguards that are effective should be developed.

3. CHEAP TRAINING

The legal counsel that I was talking to told me that MOST “TapRooT® Users” he ran into during their preparation for trails had never been formally trained in TapRooT®. The attorney had attended one of our public TapRooT® Courses. He was amazed that management at fairly major companies would assign people who had never been to ANY formal root cause analysis training to investigate serious incidents that had potential for expensive legal outcomes.

In one instance, the person using TapRooT® had obtained one of our old TapRooT® Books from a friend. He then “used” the technique after reading “some” of the book. He didn’t have a Root Cause Tree® Dictionary or a Corrective Action Helper®. However, his reading didn’t provide him with the knowledge he needed to use TapRooT® correctly when investigating serious incidents (or not serious ones for that matter).

Don’t get me wrong, the TapRooT® Book is a great read. But I would never recommend it as the only source of training for someone who will be investigating serious accidents (fatalities and major environmental releases). What would I recommend? The 5-Day TapRooT® Advanaced Root Cause Analysis Team Leader Training.

The attorney also mentioned that he frequently meets TapRooT® Users who are out of practice using TapRooT® and really need a refresher because they don’t have many serious accidents to investigate and don’t get any feedback even when they do an investigation. My answer to that was ….

  1. They should be using TapRooT® proactively to get practice using the techniques.
  2. They should set up a company peer review process to help users get better at applying the techniques.
  3. They should attend the Incident Investigation and Root Cause Analysis Track at the Global TapRooT® Summit at least every two years to keep up with the latest improvements in the TapRooT® Techniques.

By the way, what had the “cheap training” cost the company? Over $50 million dollars in settlement costs.

HIGHLY QUALIFIED, COMPETENT, PRACTICED TapRooT® INVESTIGATORS ARE IMPORTANT INVESTMENTS

The first thing management needs to understand is that they need to invest in their incident investigators. Saving on training on root cause analysis is a stupid idea.

THOROUGH ROOT CAUSE ANALYSIS OF INCIDENTS THAT COULD HAVE BEEN MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS

Once you have excellent investigators, make sure they have the time and resources needed to investigate all incidents/near-misses that have a potential to become major accidents. Saving money on investigations is a fool’s mission.

CORRECTIVE ACTIONS THAT COULD PREVENT MAJOR ACCIDENTS ARE IMPORTANT INVESTMENTS

Management should insist upon effective corrective actions that go beyond training. Saving money by implementing “cheap” corrective actions is a false savings that will come back to haunt the company.

DON’T MAKE THESE MISTAKES! Invest in effective root cause analysis and prevent major accidents from occurring.

Can TapRooT® Help You Stop Quality Issues?

December 16th, 2014 by

Many people know how successful TapRooT® is at stopping safety incidents. But I had a potential TapRooT® User call me to ask:

“Can TapRooT® be used to solve quality issues?”

I was surprised by the question. Of course, the answer is YES!

We’ve had people using TapRooT® to solve quality problems ever since we invented it. In our first consulting job back in 1989, we used TapRooT® to solve engineering and construction quality issues.

Why didn’t this potential TapRooT® User know that TapRooT® could be applied to quality issues?

The only answer was … We had not told him!

Quality issues, just like safety issues, are mainly caused by human errors. And TapRooT® is excellent at helping people find the correctable root causes of human errors. 

Why does TapRooT® work on all kinds of problems (including ones that cause quality issues)? Because TapRooT® doesn’t care what the outcome of an error is. TapRooT® is looking for the correctable cause (or causes) of the error.

For example, an operator working in a factory may open the wrong breaker and stop the wrong piece of equipment. When he makes this mistake, he doesn’t know if the outcome will be a safety incident, a maintenance headache, an operations problem, or a quality issue. He wan’t planning on making the mistake and he certainly wasn’t deciding what kind of outcome his mistake would result in. And fixing the reason for his mistake will stop the problem no matter what outcome occurred after the error.

That’s why the examples in our standard 2-Day and 5-Day TapRooT® Courses apply not only to safety, but also to quality, maintenance, operations, and even hospital patient safety issues.

So if you are wondering if TapRooT® would work for the type of issues that your company faces, the answer is YES!

Attend one of our public 2-Day, 3-Day, or 5-Day TapRooT® Courses and find out how well TapRooT® can help you solve your toughest issues.

TapRooT® Terms and Definitions

December 5th, 2014 by

When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.

Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.

Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.

SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.

Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.

Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.

Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.

Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).

Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.

Generic Cause: A systemic problem that allows a root cause to exist.

Root Cause Analysis Tip: What is a corrective action worth? – A Gambler’s View of Corrective Actions (A Best of Article from the Root Cause Network™ Newsletter)

December 3rd, 2014 by

Adapted from the January 1995 Root Cause Network™ Newsletter, Copyright © 1995. Reprinted by permission. Some modifications have been made to update the article.

A GAMBLER’S VIEW OF CORRECTIVE ACTIONS

WHEN TO BET/WHEN TO FOLD

A winning gambler knows the odds. He knows that in the long run, he can beat the odds. Therefore, he looks for opportunities to bet more when the odds are in his favor. And when the odds are against him, he folds and waits for a better hand.

Preventing accidents is a numbers game. The pyramid blow provides a typical example of the ratio of accidents to incidents to near-misses to unsafe conditions.

Screen Shot 2014 10 06 at 1 48 46 PM

In this pyramid, every incident must have the potential under slightly different circumstances to become the major accident at the top of the pyramid. Also, every near miss must have the potential to become an incident that could have become the top level accident. Finally, every unsafe condition could have caused a near-miss that could have become an incident that could have become the top level accident.

Thus, every unsafe act included at the bottom level of the pyramid must have the potential with the right set of circumstances to “cause” the top level accident. 

The ratio above might not be exact. Your facility might be different. But we will use the ration of 1000 unsafe acts for every major accident as a starting point for out calculation of odds that we describe below.

The point is that every corrective action that fixes an unsafe condition has some odds of being the corrective action that could be preventing a major accident. Thus, we should try to understand the value NOT ONLY of the benefits that the corrective action immediately brings, BUT ALSO the reduction in the odds of a major accident that this corrective action provides.

THE COST OF A MAJOR ACCIDENT

To calculate the value of preventing a major accident, we need to calculate the potential cost of a major accident at your facility.

Of course, we don’t know the exact cost of the biggest accident (or even a typical major accident) that you face at your company. After all, they still don’t know what the cost of the Deepwater Horizon accident will be even after years of litigation. So, we have to make an educated guess that can be scaled to show how the cost could change.

For example, we might say that the cost a typical major accident would be $1,000,000,000. 

Then, if you think your accident might be ten times worse (or ten times less), you can multiple or divide the results we calculate by 10.

ASSESSING THE ODDS

Why do we have to use “odds” to perform this calculation? Because you can’t tell exactly which unsafe condition will be related to your next major accident. We don’t know what corrective action that we implement today will prevent the next Deepwater Horizon, Three Mile Island, or Exxon Valdez type accident that costs billions of dollars. No one is that prescient. That’s why preventing major accidents is a numbers game. To prevent the next major accident you must reduce thousands of unsafe conditions.

Because the exact odds of any one unsafe act being a key factor in the next accident is unknowable, we assign equal potential to every unsafe condition that has potential to cause a major accident.

If the pyramid above represents your accident pyramid, then for every major accident, there are 1000 unsafe conditions that could contribute to it. Or another way to think about it is that we can’t predict the exact combination of factors that will cause the next major accident but if we do 1000 things to fix problems that could be involved in a major accident, we will stop one major accident.

Thus the odds that any one corrective action will stop a major accident is 1000 to 1.

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CALCULATING THE VALUE OF A CORRECTIVE ACTION

I’ve seen people value corrective actions by using the value of the incident they would prevent.

For example, if the failure of a machine caused a delay that lost the company $100,000, the value of the corrective actions to prevent future failures would be $100,000. It’s never clear to me if this value should be divided between all of the corrective actions (for example, if there are 10 corrective actions, each would be worth, $10,000) or if each corrective action is worth $100,000. But the idea is that the corrective actions can be valued by the costs that will be saved from future similar incidents prevented. 

What this equation leaves out is the value of an even worse accident that could also be prevented by the corrective actions. 

Thus to calculate the value of a corrective action, you not only need to calculate the direct benefit, but also the amount that that corrective action contributed to the prevention of a major accident (if, indeed the corrective actions could help prevent a major accident).

But let’s stop here to correct misconceptions. A corrective action meant to stop paper cuts probably have very little value in preventing major accidents. Thus, we are not assigning severe accident risk to every corrective action. We would only assign the value to corrective actions that could help prevent major accidents.

The, the value of a corrective action is the direct cost that the corrective action saves us PLUS the value of the unknown major accident that it could prevent divided by the odds.

For example, if a corrective action saved us $10,000 in direct costs for a similar incident and if the value of a major accident at your facility is $1,000,000,000 and if we estimate that it will take correcting 1,000 unsafe acts to prevent the next accident, the value of our corrective action is…

VALUE = $10,000 + ($1,000,000,000/1000)

VALUE = $10,000 + $1,000,000

VALUE = $1,010,000

Thus valuing corrective action at their benefit for preventing a similar incident is UNDERVALUING the corrective actions.

And I believe we frequently undervaluing corrective actions.

Why?

Because we aren’t considering the value that a gambler sees. We are folding when we should be betting!

We should be investing much more in effective corrective actions thereby win by preventing the next major accident.

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YOU CAN IMPROVE THE ODDS

There is even better news that can help you make the corrective actions you implement even more valuable (effective).

The TapRooT® Root Cause Analysis System can help you do a better job of analyzing potential problems and developing even more effective corrective actions for the root causes you uncover. 

Think of TapRooT® as a luck rabbit’s foot that increases your odds of winning. 

Of course, TapRooT® is much better than a lucky rabbit’s foot because instead of being built upon superstition, it is built upon proven human performance and equipment reliability technology that makes your investigators much more effective.

So don’t wait. Stop undervaluing your corrective actions and if you haven’t already started using TapRooT®, see our upcoming courses list, click on your continent, and get signed up for a course near you (or in a spot that you would like to visit).

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

November 26th, 2014 by

AUDIT YOUR INVESTIGATION SYSTEM

AUDIT TO IMPROVE

We have all heard the saying:

Screen Shot 2014 10 01 at 1 03 35 PM

Tom Peters changed that saying to:

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

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

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

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

AREAS TO AUDIT

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

What should we audit?

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

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

08TapRooTBook Cover

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

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

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

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

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

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

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

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

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

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

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

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AUDIT TECHNIQUES (PROTOCOL)

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

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

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

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

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

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

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

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

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

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

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WHO SHOULD AUDIT & WHEN?

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

Who should perform these audits?

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

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

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

GET STARTED NOW

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

(This post is based on the October 1994 Root Cause Network™ Newsletter, Copyright © 1994. Reprinted/adapted by permission. Some modifications have been made to update the article.)

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

November 19th, 2014 by

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

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

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

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

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

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

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

 

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

November 12th, 2014 by

Gatlinburg Sunrise 1

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

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

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

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

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

November 5th, 2014 by

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

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

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

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

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

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

 

8 Reasons to Ask for Help with an Investigation

October 28th, 2014 by

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

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

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

1. LEGAL ISSUES

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

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

2. CUSTOMER DISPUTE

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

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

3. UNION ISSUE

Ever had an investigation that gets contentious with a union?

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

4. COMPLEX ACCIDENTS

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

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

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

5. INDEPENDENT INVESTIGATION / NEW SET OF EYES

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

6. CONTROVERSIAL INVESTIGATION

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

7. COACHING

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

8. OVERWHELMED

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

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

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

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

October 15th, 2014 by

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

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

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

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

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

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

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

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

October 6th, 2014 by

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

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

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

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

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

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

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

September 24th, 2014 by

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

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

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

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

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

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

September 10th, 2014 by

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

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

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

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

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

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

September 3rd, 2014 by

GoodBadUgly

Over a decade ago, I developed a rating sheet for root cause analysis implementation. We had several sessions at the TapRooT® Summit about it and it was posted on our web site (and then our blog). But in the last web site crash, it was lost. Therefore, I’m reposting it here for those who would like to download it. (Just click on the link below.)

GoodBadUgly.xls

Instructions for using the sheet are on the sheet.

I’m working on a new rating system for evaluation of individual incident investigations and corrective actions. Anyone have any ideas they would like to share?

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

August 27th, 2014 by

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

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

We teach several evidence collection techniques in our courses….

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

Interviewing (TapRooT® book, Chapter 3)

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

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

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

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

Click here to view Part 1 of this video.

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

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

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

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

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

August 20th, 2014 by

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

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

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

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

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

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

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

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

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

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

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

August 13th, 2014 by

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

Untitled

Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.

Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……

Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:

The hazard referenced in Inspection Number [insert 9-digit #]

for violation identified as:

 Citation [insert #] and item [insert #] was corrected on [insert

date] by:

 

Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..

….are the findings correct?

….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?

….is the finding a generic/systemic issue?

As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:

 

o   SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.

o   Root Cause Tree®: an easy-to-use resource to determine root causes of problems.

o   Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.

First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.

In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.

Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments

Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review

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

If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:

BENCHMARKING ROOT CAUSE ANALYSIS

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

 

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

August 13th, 2014 by

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

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

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

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

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

Root Cause Tip: What Should We Improve Next?

August 13th, 2014 by

Every company I’ve worked with has an existing improvement program.

Some companies have made great strides to achieve operating, safety, environmental, and quality excellence. Some  still have a long ways to go, but have started their improvement process.

No matter where you are, one question that always seems to come up is …

What should we improve next?

The interesting answer to this question is that your plant is telling you if you are listening.

But before I talk about that, let’s look at several other ways to decide what to improve…

1. The Regulator Is Emphasizing This

Anyone from a highly regulated industry knows what I’m talking about. In the USA wether it is the NRC, FAA, FDA, EPA, or other regulatory body, if the regulator decides to emphasize some particular aspect of operations, safety, or quality, it probably goes toward the top of your improvement effort list.

2. Management Hot Topic

Management gets a bee in their bonnet and the priority for improvements changes. Why do they get excited? It could be…

  • A recent accident (at your facility or someone else’s).
  • A recent talk they heard at a conference, a magazine article, or a consultant suggestion.
  • That the CEO has a new initiative.

You can’t ignore your boss’s ideas for long, so once again, improvement priorities change.

3. Industry Initiative

Sometimes an industry standard setting group or professional society will form a committee to set goals or publish a standard in an area of interest for that industry. Once that standard is released, you will eventually be encouraged to comply with their guidance. This will probably create a change/improvement initiative that will fall toward the top of your improvement agenda.

All of these sources of improvement initiatives may … or may not … be important to the future performance at your plant/company. For example, the regulatory emphasis may be on a problem area that you have already addressed. Yet, you will have to follow the regulatory guidance even if it may not cause improvement (and may even cause problems) at your plant.

So how should you decide what to improve next?

By listening to your plant/facility.

What does “listening to you plant” mean?

To “listen” you must be aware of the signals that you facility sends. The signals are part of “operating experience” and you need a systematic process to collect the signals both reactively and proactively.

Reactively collecting signals comes from your accident, incident, near-miss investigation programs.

It starts with good incident investigations and root cause analysis. If you don’t have good investigations and root cause analysis for everything in your database, your statistics will be misleading.

I’ve seen people running performance improvement programs use statistics that come from poor root cause analysis. Their theory is that somehow quantity of statistics makes up for poor quality of statistics. But more misleading data does NOT make a good guide for improvement.

Therefore, the first thing you need to do to make sure you are effectively listening to your plant is to improve the quality of your incident investigation and root cause analysis. Want to know how to do this? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training courses. After you’ve done that, attend the Incident Investigation and Root Cause Analysis Track at the TapRooT® Summit.

Next, you should become proactive. You should wait for the not so subtle signals from accidents. Instead, you should have a proactive improvement programs that is constantly listening for signals by using audits, observations, and peer evaluations. If you need more information about setting up a proactive improvement program, read Chapter for of the TapRooT® Book (© 2008 by System Improvements).

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Once you have good reactive and proactive statistics, the next question is, how do you interpret them. You need to “speak the language” of advanced trending. For many years I thought I knew how to trend root cause statistics. After all, I had taken an engineering statistics course in college. But I was wrong. I didn’t understand the special knowledge that is required to trend infrequently occurring events.

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Luckily, a very smart client guided me to a trending guru (Dr. Donald Wheeler – see his LinkedIn Profile HERE) and I attended three weeks of his statistical process control training. I took the advanced statistical information in that training and developed a special course just for people who needed to trend safety (and other infrequently occurring problems) statistics – the 2-Day Advanced Trending Techniques Course. If you are wondering what your statistics are telling you, this is the course to attend (I simply can’t condense it into a short article – although it is covered in Chapter 5 of the TapRooT® Book.)

Once you have good root cause analysis, a proactive improvement program, and good statistical analysis techniques, you are ready to start deciding what to improve next.

Of course, you will consider regulatory emphasis programs, management hot buttons, and industry initiatives, but you will also have the secret messages that your plant is sending to help guide your selection of what to improve next.

 

 

 

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