Category: Root Cause Analysis Tips

What’s the most important information in a root cause analysis?

July 29th, 2015 by

Welcome to this week’s root cause tips column. So what is the most important information or criteria in a good root cause analysis? (By the way, this is a trick question)

I started a list:

• A timeline of what happened
• Complete evidence
• Identification of causal factors
• Safeguards analysis (what failed)
• Safeguards Analysis (what worked)
• Root Causes substantiated by evidence
• Generic (system) Causes identified
• Corrective Actions that eliminate the root causes
• Corrective Actions that are implemented
• Corrective Actions that have been verified effective

So what do you think? Have I missed anything? Please comment below if you have any other ideas.

And which are the most important?

Yes, it is a trick question. They are ALL important.

For example, what if you did a really good job of collecting evidence and got good root causes but wrote weak corrective actions? Have you ever seen training as a corrective action for root causes that had nothing to do with training? Of course you have, that’s my point.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

TapRooT® is a systematic process, software, and training for finding the real root causes of problems.

What if you had great corrective actions but they were never implemented (or checked to see if they were effective)?

The fact of the matter is you have to have all these things for an effective investigation and root cause analysis. It is easy to miss things, we’re all human and we all have different experiences, knowledge, and biases. But the good news is that this is all built into how TapRooT® functions. Just follow the process and you will have a good root cause analysis.

You must know WHAT happened before you can determine why. This is why evidence collection is so important.

You must know WHY before you can write corrective actions. If you do not have good evidence you will miss causal factors and root causes. ALL root causes have to be substantiated with evidence.

You must FIX the root causes. Your corrective action has to specifically address the root causes, has to be implemented, and has to be verified.

Think of it as a chain link fence. If any part of the chain is broken, the fence is compromised, and in this case, so is your investigation.

If you are interested in learning the TapRooT® Root Cause Analysis, our 2-day course offers all the process essentials needed to conduct an investigation including:

  • SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
  • Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
  • Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.

Check out our schedule for a course near you:  http://www.taproot.com/courses#2-day-incident

I hope I’ve given you some food for thought. Thanks for visiting our blog and happy investigating.

Root Cause Analysis Tip: 6 Reasons to Look for Generic Root Causes

July 22nd, 2015 by

Derail

“Allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.”

You have established a good performance improvement program, supported by performing solid incident investigations.  Your teams are finding good root causes, and your corrective action program is tracking through to completion.  But you still seem to be seeing more repeat issues than you expect.  What could be the problem?

We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations.  But many companies are skipping over the Generic Cause Analysis portion of the investigation process.  While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.

6 Reasons to Look for Generic Root Causes

Here are 6 reasons to conduct a generic cause analysis on your investigation results:

1. The same incident occurs again at another facility.

2. Your annual review shows the same root cause from several incident investigations.

3.  Your audits show recurrence of the same behavior issues.

4. You apply the same corrective action over and over.

5. Similar incidents occur in different departments.

6. The same Causal Factor keeps showing up.

These indicators point to the need to look deeper for generic causes.  These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents.  When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present.  Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.

Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis.  There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.

Learn more about finding and fixing root causes in our 2-day or 5-day TapRooT® Root Cause Analysis courses!

Interviewing: Why Every Investigator Should Avoid These 3 Things

July 15th, 2015 by

When an employee is a witness to an incident that occurs in the workplace, what he or she witnessed becomes valuable information for evidence collection and finding and fixing the root causes.  Retrieval from memory is hard work, and when an interview is not set up properly, a witness will not remember important details.

The two short videos below are actors playing the role of interviewer and interviewee in a mock incident investigation interview for a General Motors incident investigation training module. They created one “good” interview, and one “bad” interview scenario.

Let’s take a quick look at the bad scenario, what not to do when interviewing.

Three mistakes to avoid:

  1. The interviewer did not communicate open, friendly body language during the greeting or try to “break the ice.” Notice that the interviewer appeared uninterested in the interviewee when she sat down, and he gestured with palms down which may convey to the interviewee that he already knows what happened. Soon thereafter, he actually says the words “I know what happened” and “I gotta ask you some questions so I can fill out this report.” At this point, the interviewee may feel like the interview is just a formality and he doesn’t need her information.  This mistake is a good way to completely shut the interviewee down right off the bat.
  2. The interviewer asked closed-ended, leading questions. “Was Larry wearing a seatbelt?”  “Was Larry speeding?” “Was Larry out partying again last night?” The interviewer put the interviewee on defense with this line of questioning.  Also, these questions are limited to a “yes” or “no” answer and will not elicit much information, and they are leading. The interviewer already told her “I know what happened” so she may have been afraid at this point to say “yes” or “no” because it may not be the same thing the interviewer “knows.”  Overall, interviewees want to provide good information so when interviewers lead them into thinking they already have “the right” information, the interviewees may doubt what they witnessed so they can also give “the right” answer.
  3. The interviewer does not set up the cognitive interview properly and interrupts constantly. Interrupting when an interviewee is delivering a narrative (i.e., telling the story as she remembers it) is the worst mistake an interviewer can make because it causes the interviewee to lose her train of thought and valuable information she may provide.  The interviewer has already made the mistake of assuming the principle role with his “I already know what happened” attitude so the interviewee will wait for him to ask specific questions without volunteering anything.  The interviewer also said “I only have a few questions here.” This makes the interviewee feel like he is in a hurry so she should keep her answers brief.

How the interview could be improved:

  1. Begin the interview with a friendly tone to develop rapport.  This includes open body language (smile, eye contact, open palms).  Tell the interviewee about the purpose of the interview (to find the root causes of the incident so they can be corrected and kept from occurring again).  If the interviewee was injured or witnessed a tragic accident, ask her how she is feeling or how she is doing since witnessing the accident.  Be human. Research proves that the amount of information an interviewee remembers changes based on the tone established during the first few minutes of the interview.
  2. Save closed-ended questions to follow-up something specific the interviewee said. When the interviewee is telling her story (the narrative) of the incident and a question pops into the interviewer’s mind about what she said, don’t interrupt.  After the witness gives her narrative, try open-ended questions before closing in on small details with closed-ended questions.  This will keep the interviewee in memory retrieval mode for a little longer.  The interviewer should write down questions and ask them after the interviewee has completely finished her narrative, and the questions should pertain to the narrative. For example, “You stated that you were on Workstation 3 when the incident occurred. Is that your normal workstation?”
  3. Set up the cognitive interview.  There are three steps to setting up a cognitive interview. The first step is to tell the interviewee explicitly to assume the principle role.  “I didn’t see the incident, so I’m relying on you to tell me what happened.”  The second step is to ask the interviewee for the narrative.  “Picture, in your mind’s eye, where you were right before the incident occurred.  Think about where you were standing, what you were thinking and feeling at the time. Get a clear picture of your surroundings.”  The third step is to ask the witness to report small details. “Tell me everything you remember about the incident no matter how trivial.”  Then don’t interrupt!

Let’s take a quick look at a “good” interview.

Keep in mind that these videos were recorded for training purposes.  A true cognitive interview would last longer than 3 minutes, but this is a good example of a few good techniques to use. Kudos to these two actors and their efforts to make our workplaces safer.

Comment below on the techniques the interviewer used that made this interview better than the first as well as any mistakes in the first video that were not discussed above.

For more information about how to conduct an investigative interview, attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.

What were the Safeguards?

July 9th, 2015 by

I love to use Safeguard Analysis to examine incidents and determine Causal Factors. 

What were the Safeguards keeping this officer safe and how did they fail? (A failed Safeguard is usually a Causal Factor.)

Watch and leave a comment about your ideas …

Investigating the Human Error Causes of Drug and Device Manufacturing Problems

July 8th, 2015 by

For the drug and medical device manufacturing industries, the US Code of Federal Regulations 211.22, Good Manufacturing Practices, states that if manufacturing errors occur, quality control should make sure that the errors “… are fully investigated.”

From past FDA actions it is clear that stopping the investigation at a “human error” cause is NOT fully investigating the error.

Here are three reasons people fail when they are investigating human error issues and when they develop fixes:

  1. They did not use a systematic process.  5-Whys is not a systematic process.
  2. The system they used did not guide them to the real, fixable causes of human errors (most quality professionals are not trained in human factors),
  3. The system did not suggest ways to fix human errors once the causes had been identified (the FDA expects effective corrective actions).

What tool provides a systematic process with guidance to find and fix the causes of human error? The TapRooT® System!

If you would like to read more about how TapRooT® can help you find the root causes of human error, see:

http://www.taproot.com/archives/44542

or

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

 To learn about how to use TapRooT® to improve your investigations of human error, We suggest attending the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. See the list of public course held around the world at:

http://www.taproot.com/store/5-Day-Courses/?coursefilter=Team+Leader+Training

With your hard work and effort and a system that will find and fix the root causes of human error you can succeed in fixing human error issues and in meeting the FDA’s expectations.

Root Cause Tip: What is the Root Cause of Memory Failure While Learning?

July 1st, 2015 by

pablo(9)

Ever take your laptop to training to take notes? According to psychological research, (The Pen is Mightier than the Keyboard), if you want to retain what you learn during training, using a laptop to take notes is not a good idea.

The research indicates that the act of taking notes on a laptop seems to interfere with our ability to remember the information. Mueller & Oppenheimer, psychologists for the research, believe that’s because learners on laptops are mindlessly typing everything the instructor is saying.  When tested, laptop users performed similar to pen notetakers on factual questions about the notes, but significantly worse on conceptual questions.

Since we can’t take notes as fast nor capture as much information with a pen, we are required to think and actively listen for what’s most important to write down.  Thus, we store information into memory as we think about it.

One of the root causes of memory failure during learning appears to be the way we take notes.  Will this research change the way you take notes in training?  Leave your comments below.

Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

Product Safety Recall…… one of the few times that I see Quality and Safety Merge

June 22nd, 2015 by

We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.

Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?

You received a defective tool or product….

  1. You issued a defective tool or product….
  2. A customer complained….
  3. A customer was hurt….
  4. ???….

Each of the occurrences above often triggers an owner for each type of problem:

  1. The supplier…
  2. The vendor…
  3. The contractor…
  4. The manufacturer….
  5. The end user….

Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?

This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:

  1. Customer Service (Quality)
  2. Manufacturing (Quality or Engineering)
  3. Supplier Management (Supply or Quality)
  4. EHS (Safety)
  5. Risk (Quality)
  6. Compliance (?)

The investigations then take the shape of the tools and experiences of those departments training and experiences.

Does anyone besides me see a problem or an opportunity here?

Incident Investigation & Root Cause Analysis Sessions Offered Exclusively June 3-5, 2015 in Las Vegas

April 29th, 2015 by

Benna interviews Ken Reed, track leader for the 3-day Incident Investigation & Root Cause Analysis track at the 2015 Global TapRooT® Summit.

Attend this track for a deeper understanding of investigation and root cause analysis.

REGISTER for the 2015 Global TapRooT® Summit.

How Did the TapRooT® Root Cause Analysis System Get So Far Ahead of the Rest?

April 28th, 2015 by

I was at a conference yesterday and one of the talks was about advanced root cause analysis. The presenter’s company had their own “home grown” root cause analysis system and they discovered that they were not getting consistent results. Improvement was needed!

They studied their system and discovered something that was missing – management system causes. In the TapRooT® System we have called these “Generic Causes” since we copyrighted the first TapRooT® manual in 1991. 

It made me think … Why did they wait 24 years to discover something we’ve known about since before 1991?

Next, I talked with an engineer who had been trained in a common cause and effect system. He wasn’t too pleased with the results he was getting. He wanted to know how TapRooT® could help. Was it different?

I shared how TapRooT® works (see this LINK for the explanation) and it took quite a bit of effort to get beyond the cause and effect model that he thoroughly understood so that he could understand why he was missing things. He was really smart. He asked very insightful questions. He latched onto the reasons that the less systematic cause and effect analysis led to inconsistent results. He saw how TapRooT® could help investigators go beyond their paradigm and get consistent results. 

By the end of this second conversation I started thinking … How did we get so far ahead of common root cause systems?

I think I know the answer.

It starts with the Human Factors training that I received at the University of Illinois. It really showed me how to think about human centered design – including designing a root cause analysis system that people could use consistently.

Second, I was fortunate enough to work in the Nuclear Navy where there was an excellent process safety culture and for Du Pont where there was an excellent industrial safety culture. This helped me see how management systems made a difference to performance. (My boss and I at Du Pont actually coined the phrase “Management System” that is now commonly used throughout industry.)

Third, I was well trained by my mentor at the University of Illinois, Dr. Charles O. Hopkins, how to do applied research. So the research I did studying root cause analysis in the mid-1980’s and early 1990’s really paid off when we created the TapRooT® System.

Fourth, we had a really good team that brought out the best in each other during the early development.

Next, we were lucky to have some excellent clients in the nuclear, oil, and aviation industries that were great early adopters and provided excellent feedback that we used to quickly improve TapRooT® root cause analysis in the early and mid-1990’s. 

Finally, I made friends with and/or listened to many industry gurus who were experts in safety, process safety, quality, and equipment reliability. Their influence was built into TapRooT® and helped it be a world-class system even in it’s early stages. These experts included:

  • Jerry Ledderer, aviation safety pioneer
  • Dr. Charles O. Hopkins, human factors pioneer
  • Smoke Price, human factors expert
  • Larry Minnick, nuclear safety expert
  • Rod Satterfield, nuclear safety expert
  • Dr. Alan Swain, human reliability expert
  • Heinz Bloch, equipment reliability expert
  • Admiral Hyman Rickover, father of the Nuclear Navy and process safety expert
  • Dr. Christopher Wickens, human factors expert
  • Dr. Jens Rassmussen, system reliability and human factors expert
  • W. Edwards Deming, quality management guru
  • Admiral Dennis Wilkerson, first CO of the Nautilus and first CEO of INPO

That’s quite a list and I was lucky to be influenced by each of these great men. Their influence made TapRooT® root cause analysis far ahead of any other root cause tool.

So that’s why I shouldn’t be surprised that others are finally catching on to things that we knew 25 years ago. Perhaps in a century, they will catch up with the improvements we are making to TapRooT® today (with the help of thousands of users from around the world). 

If you would like to learn the state-of-the-art of root cause analysis and not wait 25 to 100 years to catch up, perhaps you should attend a TapRooT® Course in the next month or two. See our course schedule for upcoming public courses at:

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

And get information about all the courses we offer at:

http://www.taproot.com/courses

And if you would like to learn about the state of the art of performance improvement, attend the 2015 TapRooT® Summit coming up on June 1-5 in Las Vegas. Get more information and download the brochure at:

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

 But don’t wait. Every day you wait you will be another day behind the state-of-the-art in root cause analysis and performance improvement. Don’t be left behind!

TapRooT® Root Cause Analysis
Changing the Way the World Solves Problems

 

 

Root Cause Analysis Tip: Fixing Generic Causes

April 15th, 2015 by

One of the final steps in performing a TapRooT® Root Cause 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 has 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 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’s 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 send 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
quality

Our 2-day, 3-day and 5-day root cause analysis courses can help you find the solution to quality issues.

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.)

 

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