Category: Root Cause Analysis Tips

Interviewing and Evidence Collection Tip: 3 Goals for Packaging Physical Evidence

July 13th, 2017 by

 

When it comes to packaging physical evidence during evidence collection, there are three distinct goals.

  1.  Protect employees from hazardous evidence.  There may be biohazards associated with the evidence being packaged or the evidence may have sharp edges that could harm an employee who tries to handle it.  Protecting employees from hazardous evidence is a consideration when packaging it.  Label the evidence to clearly warn anyone who handles it of the hazard.
  2. Protect the evidence.  Protect the evidence from loss, contamination or deterioration when packaging it.  This may include packing the evidence in a container that is not too large or small, drying the evidence before packing it if it is wet or storing it in proper temperature.
  3. Label the evidence properly. Labeling the evidence properly includes: a) a description of what is contained in the packaging; b) where it was when it was collected; c) chain of custody; d) a unique identifier, such as a number, so that it not confused with other evidence.

Packaging physical evidence is important to preserving it for the duration of the investigation.  With these three goals in mind, you’ll be off to a good start.

To learn more about evidence collection, join me in Houston, Texas in November for a 3-day root cause analysis and evidence collection course, or just 1 day of evidence collection training.

Thanks for joining me for this week’s tip!  See you next week!

 

Can bad advice make improvements more likely?

July 12th, 2017 by

Here is what a consultant recently wrote in a blog article that was republished on LinkedIn:

“The 5 WHY analysis is a simple and very effective technique.”

What do I think about 5 Whys? It is simple but it is NOT effective. Proof of the lack of effectiveness is all over the place. See these articles to find out just some of what I’ve written about the effectiveness of 5 Whys in the past:

 An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

What’s Fundamentally Wrong with 5-Whys?

Teruyuki Minoura (Toyota Exec) Talks About Problems with 5-Whys

Under Scrutiny (page 32)

If your root cause analysis is having problems, don’t double down on 5 whys by asking more whys. The problem is the root cause analysis system (5 Whys) and not your ability to ask why effectively.

The problem is that the techniques wasn’t designed with human capabilities and limitations in mind.

What system was developed with a human factors perspective? The TapRooT® Root Cause Analysis System. Read more about how TapRooT® was designed here:

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

Or get the book that explains how TapRooT® can help your leadership improve performance:

TapRooT® Root Cause Analysis Leadership Lessons

Are you a member of the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends?

July 11th, 2017 by

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Sometimes people ask me what TapRooT® Users are doing about a particular issue. I recommend they ask the question on the LinkedIn Group: TapRooT® Root Cause Analysis Users and Friends.

There are over 3000 group members and it’ a great place to post a question or your opinions.

To join the group, see: https://www.linkedin.com/groups/2164007

 

Interviewing and Evidence Collection Tip: Interviews are Valuable People Evidence

July 6th, 2017 by

Evidence collected from interviews is an important component of evidence collection.

Evidence collected from interviews is an important component of evidence collection.

In TapRooT®, we use a mnemonic to quickly remember what types of evidence we may want to collect after an incident occurs: 3 Ps & an R. This stands for:

People evidence
Paper evidence
Physical evidence and
Recording evidence.

When people think about evidence collection, sometimes they focus on paper evidence (such as collecting policies, procedures, permits, HR records), physical evidence (such as collecting broken equipment and fluid samples), or recording evidence (such as taking or collecting photographs and videos).  They don’t always think of interviewing as evidence, and in spite of the fact that this weekly column is called “Interviewing and Evidence Collection,” interviewing is evidence collection.

Most of the time in a workplace incident investigation, the majority of the evidence will come from people evidence, especially interviews. Often, evidence collection will start there and guide the investigator to collect other types of evidence.

People evidence includes information about those involved with the incident as well as information from those who may not have been there but may have knowledge to provide (example: an expert witness).

We’ve spent a lot of time developing the TapRooT™ 12-Step Interview Process which is a very effective method of getting both quality and quantity of information from an interviewee. This technique is taught in both our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and our 1-Day Effective Interviewing and Evidence Collection Techniques Course.

Today, we want to offer you some free resources to help you collect valuable people evidence through interviews:

Video:  The Cognitive Interview

Video: How to Interpret Body Language

Top 3 Worst Practices in Root Cause Analysis Interviewing

Thanks for joining me for this evidence collection tip.  See you next week!

Causal Factors and remembering one of the worst incidents in American history

July 5th, 2017 by

We just returned from enjoying our Independence Day Holiday here in the US.

There were many good shows over the weekend about American History and during one I watched I was reminded of one of the worst events in our history (from a workplace safety standpoint); the Triangle Shirtwaist Fire in 1911.

Most safety professionals know of this incident as the Life Safety Code was partially born from the tragedy. I started to think about the incident in terms of TapRooT®, Causal Factors in particular. In our courses, we teach the concept of initiating errors, and chances to stop/catch/mitigate. There were many failures that day and many lost opportunities to stop and mitigate the event.

Possible causal factors that would be identified if TapRooT® would have been used:

CF – fire started (initiating error)

CF – egress blocked/not sufficient for the number of people to escape

CF – exit doors locked

CF – fire escapes collapsed

CF – fire hoses did not work

CF – ladders from fire department did not reach higher floors

I am sure there are more, but these are the ones that jumped out at me while watching the show.

It is a real shame that so many had to die for better conditions to become the norm.

Triangle Shirtwaist Factory fire escape collapsed during the March 15, 1911 fire. 146 died, either from fire, jumping or falling to the pavement.

For more on Causal Factors and stop/catch/mitigate, see this earlier POST

What happens when root cause analysis becomes too simple? Six problems I’ve observed.

July 5th, 2017 by

I’ve had many people explain to me that they understand that for serious incidents, they need robust root cause analysis (TapRooT®) because … finding effective fixes is essential. But for simple incidents, they just can’t invest the same effort that they use for major investigations.

I get it. And I agree. You can’t put the same level of effort into a simple incident that you put into a major accident. But what happens when the effort you put into a simple incident is too little. What happens when your simple investigation becomes too simple?

Here are the results that I’ve observed when people perform “too simple” investigations.

1. The first story heard is analyzed as fact.

People doing simple investigations often take the first “story” they hear about a simple incident and start looking for “causes”. The shortcut – not verifying what you hear – means that simple investigations are sometimes based on fairy tales. The real facts are never discovered. The real root causes are unknown. And the corrective actions? They are just ideas based on a fantasy world.

The result? The real problems never get fixed and they are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb.

2. Assumptions become facts.

This is somewhat similar to the first issue. However, in this case the investigator fills in holes in the story they heard with assumptions. Because the investigator doesn’t have time to collect much info, these assumptions become facts and become the basis for the root cause analysis and corrective actions.

The result? Just like the first issue, real problems never get fixed. The real, undiscovered problems are left in place to cause future incidents. If the problems have the potential to cause more serious accidents … you have a ticking time bomb #2.

3. Skip root cause analysis and go straight to the fixes.

When you don’t have time for the investigation, why not just skip straight to the fixes? After all … we already know what caused the incident … right?

This is a frequent conclusion when people THINK they already know the answers and don’t need to bother with a troublesome investigation and root cause analysis to fix a “simple” problem.

The problems is that without adequate investigation and root cause analysis … you don’t really know if you are addressing the real issues. Do you feel lucky? Well do ya punk? (A little Clint Eastwood imitation.)

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The result? You are depending on your luck. And the problem you may not solve may be more powerful than a .44 magnum … the most powerful handgun in the world.

OK … if you want to watch the scene, here it is …

4. The illusion of progress.

Management often thinks that even though they don’t give people time to do a good investigation, simple investigations are better than nothing … right?

Management is buying into the illusion of progress. They see some action. People scurry around. Fixes are being recommended and maybe even being implemented (more training). So things must be getting better … right?

NO!

As Alfred A. Montapert said:

Do not confuse motion and progress.
A rocking horse keeps moving but does not make any progress
.”

The result? If people aren’t finding the real root causes, you are mistaking the mistake of assuming that motion is progress. Progress isn’t happening and the motion is wasted effort. How much effort does your company have to waste?

5. Complacency – Just another investigation.

When people in the field see investigators make up facts and fixes, they know the real problems aren’t getting fixed. They see problems happening over and over again. They, too, may think they know the answers. Or they may not. But they are sure that nobody really cares about fixing the problems or management would do a better job of investigating them.

The result? Complacency.

If management isn’t worried about the problems … why should I (the worker) be worried?

This contributes to “the normalization of deviation.” See this LINK is you are interested.

6. Bad habits become established practice.

Do people do more simple investigations or major investigations?

If your company is like most, there are tons of simple investigations and very few major investigations. What happens because of this? The practices used in simple investigations become the practices used in major investigations.

Assumptions, shortcuts, made up fixes and more become the standard practice for investigators. The things they learned in a root cause analysis class aren’t what they practice. What gets practiced (the bad practices) becomes the standard way that business is done.

The result? The same poor standards that apply to simple investigations infect major investigations. Major investigation have the same poor root cause analysis and corrective actions seen in the simple investigations.

DON’T LET BAD PRACTICES INFECT YOUR CULTURE.

Would you like to see good practices for performing simple investigations? Here are two options:

1. Attend a TapRooT® 2-Day Root Cause Analysis Course. See the the dates and location of upcoming public courses here:

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

2. Read the new book: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

7 Traits of a Great Root Cause Analysis Facilitator

June 27th, 2017 by

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After decades of teaching TapRooT® and being consulted about many investigations, I’ve met lots of root cause analysis facilitators. Some were good. Some were not so good. Some were really superior. Some were horrible. Therefore, I thought it might be interesting to relate what I see that separates the best from the rest. Here are the seven traits of the BEST.

1. They don’t jump to conclusions. The worst investigators I’ve seen think they know it all. They already have their minds made up BEFORE the first interview. They START the investigation to prove their point. They already know the corrective action they are going to apply … so all they have to do is affirm that the causes they already have assumed ARE the cause they find.

What do the best investigators do? They start by seeing where the evidence leads them. The evidence includes:

  • Physical evidence,
  • Paper evidence (documentations),
  • People evidence (interviews), and
  • Recordings (videos/pictures/tapes/computer records).

They are great at collecting evidence without prejudice. They perform “cognitive interviews” to help the interviewee remember as much as possible. (See the new book TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills to learn more about cognitive interviews. The book should be released in August. Get the book with the course being held in November in Houston.)

The best investigators may have some technical knowledge, but they know when they need help to understand what the evidence is telling them. Therefore, they get technical experts when they need them.

2. They understand What before Why. The worst investigators start by asking WHY? Why did someone make a mistake? Why did the part fail? Why didn’t the guilty party use the procedure? These “why” questions tend to put people on the defensive. People start justifying what they did rather than sharing what they know.

The best investigators start with what and how. They want to understand what happened and how those involved reacted. What did they see as the problem? What were the indications they were observing? Who did they talk to and what did they say? What was happening and in what order did it happen?

People don’t get defensive about what and how questions. They are much more likely to share information and tell the truth. And these questions help develop an excellent SnapCharT® that helps the root cause analysis facilitator develop a “picture” of what happened.

3. They are not looking for the single root cause. The worst investigators are always looking for THE root cause. The smoking gun. The one thing that caused the problem that can be corrected by a simple corrective action. THE root cause that they are looking for.

The best investigators know that most accidents have multiple things that went wrong. They facilitate their team to understand all the causal factors and how these causal factors came together to cause that particular incident.

These root cause facilitators use their SnapCharT® and Safeguard Analysis to show how the problems came together to cause the incident. This can help show management how latent condition are hidden traps waiting to produce an accident that previously seemed impossible.

4. They dig deeper to find root causes. The worst investigator stop when they identify simple problems. For the worst investigators, HUMAN ERROR is a root cause.

The best investigators know that human error is just a starting point for a root cause analysis. They go beyond equipment failure and beyond human error by using effective investigative techniques that help them go beyond their own knowledge.

For example, if there is an equipment failure they consult the Equifactor® Troubleshooting Tables to find out more about the failure. This helps them get to the bottom of equipment problems. They often find that equipment failures are caused by human error.

For human performance related causal factors they use the Human Performance Troubleshooting Guide of the Root Cause Tree® to help them determine where they need to dig deeper into the causes of human error.

The best investigators don’t accept false stories. They have a good BS detector because false stories seldom make a sensible SnapCharT®.

5. They find root causes that are fixable. The worst investigators find root causes that management really can’t do anything to prevent. For example, telling people to “try harder” not to make a mistake IS NOT an effective corrective action to stop human errors.

The best investigators know that their are many ways to improve human performance. They understand that trying harder is important but that it is not a long-term solution. They look for human factors related fixes that come from human performance best practices. They know that the Root Cause Tree® can help them find problems with:

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

And that by implementing best practices related to the root causes they identify, they can reduce the probability of future human errors.

6. They recommend effective corrective actions. The worst investigators recommend the three standard corrective actions for almost every problem:

  1. MORE TRAINING
  2. COUNSELING (tell them to be more careful and fire them if they get caught making the mistake again)
  3. If you are desperate, WRITE A PROCEDURE

That’s about it.

The best investigators start by understanding the risk represented by the incident. Higher risk incidents deserve higher order corrective actions. The highest order is to remove the Hazard. Other corrective actions may be related to strengthening the Safeguards by implementing human performance best practices. Sometimes these corrective actions may include training and procedures but that is seldom the only corrective actions recommended.

7. They know what they are doing. The worst investigators don’t really know what they are doing. They haven’t been trained to find root causes or the training they had was superficial at best. (Can you ask “Why?” five times?)

The best investigators are accomplished professionals. They’ve been in advanced root cause analysis training and have practiced what they have learned by performing many simple investigations before they were asked to jump into a major investigation. Even if they have several major investigations under their belt, they continue to practice their root cause analysis skills on simple investigations and on proactive audits and assessments.

Beyond practicing their skills, they attend the only worldwide summit focused on root cause analysis and investigation facilitation – The Global TapRooT® Summit. At the Summit they benchmark their skills with other facilitators from around the world and share best practices. Think of this as steel sharpening steel.

GOOD NEWS. The knowledge and skills that make the best investigators the best … CAN BE LEARNED.

Where? Have a look at these courses:

http://www.taproot.com/courses

And then plan to attend the 2018 Global TapRooT® Summit in Knoxville, Tennessee, on February 26 – March 2 to sharpen your skills (or have those who work for you sharpen their skills).

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Root Cause Tip: Accountability NI

June 23rd, 2017 by

Growing up as a child, it was common to hear and sometimes say, “You’re not the boss of me!”

There always seemed to be some challenges to parents, teachers and friends, as we started to develop our independence. Somewhere through this journey of life however, we soon started to hear our peers and some cases out of our own mouths…

In other words, “I’m not in charge” and “I’m not the boss.”
Many people started wanting to give up responsibility as they get more responsibility.

  • I’m not the boss
  • I don’t get paid enough to make the decision
  • It’s their equipment, they should know how to operate it safely
  • That’s outside my job description

The issue of not really knowing who is in charge is commonplace in many of the incidents that I have reviewed. In TapRooT® Root Cause Analysis, we define accountability as ensuring that the person who is in charge of the working being done knows he/she is in charge and coworkers/management know that person is in charge. When many different companies with different functional roles work together, the more susceptible the work being performed is to the root cause of Accountability Needs Improvement.

Take the following work environments and think about what issues have or could arise…

Operation Room: Company A Surgeon, Company B Anesthesiologist, Local Hospital RN Nurses, Company C X-Ray Technician…

Deepwater Ocean Rig: Company A Operator, Company B Owner, Company C System Vendor Technician…

Construction Site: Company A Crane Operator, Company B Crane Rental Mechanic, Company C Labor, Property Owner, Company D Project Planner…

Here are a few best practices to help when performing the actual work:

1. At the beginning of each job, people introduce themselves and their role during the work to be performed that day. This gives each person a voice and role.

2. Client supervisors that must perform Tailboard and JSA meetings at the beginning of each job should familiarize themselves with the energy and line of fire danger areas for all equipment on site. Even if it is equipment used by contractors. The contractor also has a role to educate the client and other contractors in the area.

3. All people performing the task should discuss possible issues that may occur and what would require work stop and actions to follow when possible. Learn more about this concept of Crew Resource Management in our 5-Day Team Leader Course.

Remember, we all have a role to perform during a task. If roles are not defined and there is no clear sign of true accountability, that task may not get done, get done incorrectly and there will be no one with the right knowledge to stop the work when issues occur.

Six Sigma: Better Root Cause Analysis and Corrective Actions

June 22nd, 2017 by

I remember first learning about root cause analysis during Six Sigma training. The main methods we used were 5 Whys and Fishbone diagrams, but somehow we had a hard time arriving at good corrective actions. It took time and testing to get there, and still the fixes were not always robust.

Since then, I have learned a lot more about RCA. Unguided deductive reasoning tools like 5 Whys or Fishbones rely heavily on the knowledge and experience of the investigator. Since nobody can be an expert in every contributing field, this leads to investigator bias. Or, as the old adage goes: “If a hammer is your only tool, all your problems will start looking like nails”.

Other issues with deductive reasoning are investigations identifying only single causes (when in reality there are several), or ignorance of generic root causes that have broader quality impacts. Results will also be inconsistent; if several teams analyze the same issue, results can be wildly divergent. Which one is correct? All of them? None?

This is where the TapRooT® methodology has benefits over other tools. It is an expert system that guides investigators to look at a range of potential causal factors, like human engineering, management systems and procedures. There are no iterations of hypotheses to prove or disprove so investigator bias is not a problem.

The process is repeatable, identifies all specific and generic causes and guides the formulation of strong corrective actions. It is centered on humans, systems and processes, and the decisions they make every day.

The supporting TapRooT® Software is designed to enable investigators to keep efforts focused and organized:

  1. define the problem in a SnapCharT®
  2. identify Causal Factors and Root Causes with the Root Cause Tree®, and
  3. formulate sustainable corrective actions using the Corrective Action Helper® module

The TapRooT® process avoids blame, is easy to learn and quickly improves root cause analysis outcomes.

In Six Sigma parlance, the SnapCharT® is used for problem definition (Define), the Root Cause Tree® and trending for root cause identification (Measure and Analyze), and the corrective action process to define effective fixes (Improve).

#TapRooT_RCA

Interviewing and Evidence Collection Tip: How to Package Physical Evidence

June 21st, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  We refer to four basic categories of evidence in our Interviewing & Evidence Techniques training:

  1. People
  2. Paper
  3. Physical
  4. Recordings

Some investigations only require evidence that does not need special packaging such as training records, policies and procedures (paper evidence) and/or interviews of the people who were there (people evidence). While a workplace investigation is not the same as a criminal investigation where physical evidence often requires forensic examination, there are definitely situations where collecting physical evidence is helpful to the root cause investigation.  Here are a few basic tips:

Packaging: Most physical evidence can be stored in paper containers, like envelopes and boxes. There is a plethora of websites that sell packaging material designed specifically for evidence. Wet evidence (such as fabric) should be air dried before packaging because moisture causes rapid deterioration and risks environmental contamination, like mold.   Allow wet evidence to dry thoroughly and then package it. Then store the evidence at room temperature. If the item is not wet and does not need to “breathe” (for example, the evidence is a collection of bolts), you can also use plastic containers for storage.

Sharp objects:  Package sharp objects in a way to ensure the safety of those handling it.  Packaging may include metal cans, plastic or hard cardboard boxes so long as the object will not protrude.

Size: Ensure the packaging is of adequate size. If the packaging is too small for the item, it may fail over time.  If it’s too large, it could become damaged when it moves around the container.

Avoid using staples to seal evidence envelopes:  Staples can damage the evidence.  Tape across the entire flap of an envelope to seal it.

Don’t forget to tag and mark evidence containers so that you will be able to easily identify what is stored in each container at a later date.

If you’re interested in learning more about Interviewing & Evidence Collection, I hope you will join me in Houston, Texas in November for a 3-day root cause analysis + interviewing and evidence collection course or 1-day  interviewing and evidence collection training.

How do you plan your root cause analysis?

June 20th, 2017 by

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General George Patton said:

“A good plan today is better than a perfect plan tomorrow.”

But for many investigations, I might ask … Do you have any plan at all?

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Copyright © 2016 by System Improvements, Inc. Duplication prohibited. Used by permission.

Planning is the first step in the TapRooT® 7-Step Major Investigation Process. We even recommend a simple plan for simple investigations.

You may have read the earlier article about using a SnapCharT® to plan your investigation (see: http://www.taproot.com/archives/58488)

What else can help you plan your investigation? Here’s a list:

  • Have an investigation policy that specifies team make up and other factors that can be predefined.
  • Make sure that people on the scene are trained to preserve evidence and to obtain witness statements.
  • Consider PPE requirements for team members visiting the scene.
  • Collect any recorded evidence (cell phone recordings).
  • Maintain a chain of custody for evidence.
  • Do you need legal or PR assistance for your team?

That’s just a few ideas. There is a whole chapter about planning in the new book: TapRooT® Root Cause Analysis for Major Investigations.

When you order the new book you will also get the latest copies of theRoot Cause Tree®, the Root Cause Tree® Dictionary, and the Corrective Action Helper® Guide – all of which were recently updated.

Order your copy by CLICKING HERE.

TapRooT® Optional Root Cause Analysis Tools

June 14th, 2017 by

All TapRooT® Users are familiar with the SnapCharT®, Safeguard Analysis, the Root Cause Tree® and Dictionary, and the Corrective Action Helper® Guide. But do you know about the optional TapRooT® Tools:

  • Equifactor®
  • CHAP
  • Change Analysis

These optional techniques are usually applied in more complex investigations.

Equifactor® is used to troubleshoot equipment problems. We found that many people try to understand the root causes of equipment failures BEFORE they really understand the basic reasons for the failure. That’s why we partnered with Heinz Bloch to develop the Equifactor Troubleshooting Tables and Software. 

CHAP is used for a deep dive on human performance issues. Once again we found that people tended to jump into asking “why” before they understood all the details about a human error. That’s why we developed CHAP to help people collect information about the human action before they start asking why things went wrong.

Change Analysis is an older technique that was derived from the work of Charles Kepner and Benjamin Tregoe. The technique helps identify changes that could have contributed to the equipment failure or human error. 

How can you learn to apply these optional techniques to improve your root cause analysis? Attend one off our 5-Day TapRooT® Root Cause Analysis Team Leader Courses. To see the locations and dates of our public TapRooT® 5-Day Courses being held around the world, CLICK HERE.

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Don’t have time to travel to a course but you do have time for some reading? Then order the TapRooT® Root Cause Analysis for Major Investigations book by CLICKING HERE.

Interviewing and Evidence Collection Tip: What Evidence Should You Collect First?

June 14th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Today, let’s talk about what evidence to focus on first during the flurry of activity that occurs after an accident.

Always begin with a SnapCharT®

Begin your investigation with a planning SnapCharT® – it takes just a few minutes to create an incident and add a few events that lead up to it into the TapRooT® software or into a paper-based version of SnapCharT®.  The SnapCharT® is a tool that will help you visually organize and prioritize evidence collection.

Pre-collection

So, what evidence should be collected first? Ideally, an investigator can photograph the scene at various angles and distances before carefully collecting the most fragile evidence and before disturbing the scene by removing larger, heavier, or less fragile evidence.  Once things start getting moved, it gets really tricky to remember the initial scene or understand the scene.

Locard’s exchange principle holds that every time a person enters an environment, something is added to and removed. This is sometimes stated as “every contact leaves a trace.” So, depending on the incident, the evidence may have already been altered in some way by first responders, employees or bystanders. It may also be disturbed by an investigator’s attempt to photograph it.  This is why it is so critical to cordon off a path for first responders and employees to minimize contamination (and this also helps first response and others avoid injury).

Take photographs or a video recording of the overall scene first.

After photography, collect fragile evidence

Fragile evidence is evidence that loses its value either because of its particular nature and characteristics, or because of the conditions at the accident scene. For example, blood in rain. Fragile evidence should be collected before it is further contaminated or before it disappears.

When the fragile evidence is removed, an investigator should begin by systematically collecting the “top” layer of evidence.  This may be photographing or collecting what he finds beneath that fragile evidence.  Collecting fragile evidence includes memorializing first impressions and observations in writing, including measurements of the scene that photographs cannot capture or record, including smells, temperature, and humidity.

Every accident and incident is different; however, this is a general guideline of how to get started with evidence collection.  Next week, we’ll discuss the best way to package evidence.

If you’re interested in learning more about Interviewing & Evidence Collection, I hope you will join me in Houston, Texas in November for a 3-day root cause analysis + interviewing and evidence collection course or 1-day  interviewing and evidence collection training.

Root Cause Tip: Anyone Can Do The Job! Or Can They?

June 9th, 2017 by

Caution

Training Corrective Actions will not fix everything but when it does make sure you do it right.

When we analyze an action or inaction that caused a problem, failed to catch/stop the problem that was occurring or caused the problem to get worse after it occurred, the TapRooT® Root Cause Process has us ask questions focusing “on the knowledge, skills, and abilities of the person performing the task?” If we say “yes” to any of the questions, the process then asks, “Should the person have had better training to understand the task, develop the skill needed, or maintain the knowledge and skills needed to successfully complete the task?”

Warning

Please don’t cheat the TapRooT® Root Cause Process by answering the above questions without full understanding of the person or task.

The key to fully understanding the issue of training is to identify the task first. Next you must identify the knowledge, skills and abilities needed to perform the task. Easier said than done if you have never truly looked at a task in this manner.

Task – A task can be one action or a sequence of actions that a person must successfully complete in order to produce a required output.

Knowledge is the theoretical or practical understanding of a subject. You can read a book on how to drive a car, but that in itself doesn’t equate to having the skill or ability to drive a car. You need to have the knowledge, however, to build your skills on. Sometimes you have to perform a new task with no experience and just basic knowledge. You are taught to turn into a skid while driving but have you ever done it?

Skills are the proficiencies developed through training or experience. Skills must be learned, by experience or through formal training. You practice driving a car under supervision, get licensed and then continue improving your skills over time. When you hire someone to drive a car, how do you know he/she can? Do you test them or just depend on a license requirement? 

Abilities are the qualities of being able to do something. There is a fine line between skills and abilities. Skills require certain physical abilities or mental abilities. For example, depth perception is a must to drive safely in certain situations. You need the ability to add, divide and multiply to properly calculate how much gas is needed for a cross country trip. Do you assess for physical and mental task capabilities for particular positions for certain critical tasks?

Here is a challenge to our TapRooT® Root Cause Blog Readers….

  1. Identify one task that you perform daily and list the steps.
  1. Identify and write down the Knowledge, Skills and Abilities that you must have and use to perform the task.

For a great example of core tasks and skills needed, go to this CFETP link for my old aircraft job.

It takes a little more work to assess the true need for training than most people imagine. Remember this blog challenge when you do your next problem analysis.

This article gave the blog reader a little knowledge for the task of analyzing a task and a possible training issues tied to training. To get hands on training and application to build your skills, attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course to learn more about ADDIE, CHAP (Critical Human Action Profile) and errors made due to knowledge, skill or ability deficiencies. Plus learn how to correct and prevent these type of issues.

Abilities Required to attend the course: reading, writing and a passion to make the world around you better and safer.

Interviewing and Evidence Collection Tip: Organize your information with TapRooT® Software

June 7th, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents. We’ve talked about the value of a planning SnapCharT® as well as how important it is to uncover facts through evidence collection.

Today, let’s talk about how to keep all of this information organized using TapRooT® Software. Our software is designed to help you track investigations, manage evidence and report on results with ease.

Create a Sequence of Event

The SnapCharT® is a simple method for drawing a sequence of events and is always where an investigator begins evidence collection. Here, you decide many things, including:

  • What information is available
  • What needs to be collected
  • What order the evidence will be collected
  • Who will be interviewed
  • What conflicts exist in the sequence of events and what evidence could help clear them up

Building the SnapCharT® in the TapRooT® software allows you to add all of these notes quickly and efficiently, save them, and edit them as you progress through evidence collection.

Organize digital documents and photos

It doesn’t take long for paper evidence to feel out of control.  Standard operating procedures, work orders, maintenance procedures, company policies and so much more are all collected as you begin uncovering the important facts that will support your conclusions.  Digital photos can easily get lost if they are not stored somewhere immediately.  Storing the digital files in your TapRooT® software catalogs them and keeps them secure.  This also keeps all of these digital items available to pull into the management report feature of the software.  You can easily upload images and documents and add them to your attachment files for each investigation.  Here is a short video to show you how to do just that:  View video.

Use TapRooT® software to create new investigations, manage tasks and analyze the results all in one place.  If you have been trained in TapRooT® and are ready to optimize your investigations, join us for our June 28 webinar!

Are you using the latest TapRooT® Tools and do you have the latest TapRooT® Books?

June 6th, 2017 by

Over the past three years, we’ve been working hard to take everything we have learned about using TapRooT® in almost 30 years of experience and use that knowledge (and the feedback from thousands of users) to make TapRooT® even better.

So here is the question …

Do you have the latest TapRooT® Materials?

How can you tell? Look at the copyright dates in your books.

If you don’t have materials that are from 2016 or later, they aren’t the most up to date.

Where can you get the most recent materials?

First, if you have not yet attended a 5-Day TapRooT® Root Cause Analysis Course, I’d recommend going. You will get:

Or, you can order all of these by CLICKING HERE.

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I think you will find that we’ve made the TapRooT® System even easier to use PLUS made it even more effective.

We recently published two other new books:

The TapRooT® Root Cause Analysis Leadership Lessons book helps management understand how to apply TapRooT® to achieve operational excellence, high quality, and outstanding safety performance.

The TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement book explains how to use the TapRooT® Tools proactively for audits and assessments.

To order the books, just click on the links above.

And watch for the releases of the other new books we have coming out. Shortly, you will see the new books on:

  • Interviewing and information collection
  • Implementing TapRooT®
  • Troubleshooting and finding the root causes of equipment problems

That’s a lot of new information.

We have plans for even more but you will here about that at the 2018 Global TapRooT® Summit that is being held in Knoxville, Tennessee, on February 26 – March 2. The Summit agenda will be posted shortly. (Watch for that announcement too!)

Simple 5-Whys becomes complex 5-Whys – Why not use TapRooT® Root Cause Analysis?

May 31st, 2017 by

This video doesn’t really address the problems with 5-Whys but it sure does make it more complex.

They suggest that you can brainstorm root causes. You can’t brainstorm what you don’t understand.

For a more complete discussion of why people have problems with 5-Whys, see:

An Example of 5 Whys – Is this Root Cause Analysis? Let Me Know Your Thoughts…

And for a better way to find root causes see:

About TapRooT®

To get a book that will help you understand how to really find the root causes of low-to-medium risk problems, see:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html 

Interviewing & Evidence Collection Tip: You can’t know the “why” before the “what”

May 31st, 2017 by

Hello and welcome to this week’s column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.  Last week we talked about the value of a planning SnapCharT®.  I’d like to take a moment to expand on that thought.

Grasping at the “why” before the “what” is a common mistake that even experienced investigators make.  But you have to understand “what” happened before you can understand why it happened.  The goal of interviewing and evidence collection is to provide facts for the “what” so you can continue with the “why” (identifying causal factors and root causes).

When I worked in the legal field, I felt that most investigations were hypothesis-based.  It seemed that more often than not, we started with several hypotheses and then began a process of elimination until we were left with one we liked.  Instead of collecting evidence before we determined “why” an incident happened, we came up with our guesses and then looked for evidence that supported the guesses.

When an investigator reaches for the “why” before the “what,” this is what occurs:

  1. Tunnel vision.  The investigator only focuses on the hypotheses presented, and none of them may be correct.
  2. Abuse of evidence. The investigator may force the evidence to “fit” the hypothesis he/she feels most strongly about.  Further, any evidence collected that does not fit the hypothesis is ignored or discarded.
  3. Confirmation bias. The investigator only seeks evidence that supports his/her hypothesis.

It is a tenet of psychology that the human brain immediately desires a simple pattern that makes sense of a complex situation. So, there is really nothing that the investigator is intentionally doing wrong when he or she falls into that trap. Not to mention, humans simply do not like changing their minds when they become emotionally attached to an idea. And then there is social pressure… when a strong personality on the investigation team thinks he/she knows the “why” – and the rest of the team goes along with it.

TapRooT® helps investigative teams avoid reaching for the “why” before the “what.”  The 7-Step Major Investigation Process taught during our 5-Day training offers a systematic way to move through the investigation and takes the investigator beyond his/her knowledge to determine the “what” first so that the causal factors and root causes identified are accurate. Learn how to collect the evidence you need to understand the “what” in our 1-day Interviewing and Evidence Collection Techniques course on November 8 in Houston, Texas.

Have you fallen into the trap of trying to decide the “why” before the “what”? Do you have something additional to share about this common problem? How has TapRooT® helped you avoid it? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

Root Cause Tip: “Enforcement Needs Improvement” – You Can’t Train Obedience/Compliance/Positive Behavior

May 26th, 2017 by

This is a quick clarification to stop a definite no-no in poorly developed corrective actions.

You find evidence during your root cause analysis to support the root cause “Enforcement NI” based on the following statements from your Root Cause Tree® Dictionary for a particular causal factor:

  • Was enforcement of the SPAC (Standards, Policies, Administrative Controls) seen as inconsistent by the employees?
  • Has failure to follow SPAC in the past gone uncorrected or unpunished?
  • Did management fail to provide positive incentives for people to follow the SPAC?
  • Was there a reward for NOT following the SPAC (for example: saving time, avoiding discomfort).
  • When supervisors or management noticed problems with worker behavior, did they fail to coach workers and thereby leave problems similar to this causal factor uncorrected?

But then if you create a corrective action to retrain, remind, and reemphasize the rules, directed at the employee or in rare occasions the immediate supervisor, your investigation started on track and jumped tracks at the end.

Now, I am okay with an alert going out to the field for critical to safety or operation issues as a key care about reminder, but that does not fix the issues identified with the evidence above. If you use Train/Re-Train as a corrective action, then you imply that the person must not have known how to perform the job in the first place. If that were the case, root causes under the Basic Cause Category of “Training” should have been selected.

Training covers the person’s knowledge, skills and abilities to perform a specific task safely and successfully. Training does not ensure sustainment of proper actions to perform the task; supervision acknowledgement, reward and discipline from supervision, senior leadership and peers ensure acceptance and sustainment for correct task behaviors.

Don’t forget, it is just as easy for supervision to ignore unsafe behavior as it is for an employee to deviate from a task (assuming the task was doable in the first place). Reward and discipline applies to changing supervision’s behavior as well.

Something else to evaluate. If the root cause of Enforcement NI shows up frequently, make sure that you are not closing the door prematurely on the Root Cause Tree® Dictionary Near Root Causes of:

  • Oversight/Employee Relations (Audits should be catching this and the company culture should be evaluated).
  • Corrective Actions (If you tried to fix this issue before, why did it fail?).

Remember, you can’t train obedience/compliance/positive behavior. Finally, if you get stuck on developing a corrective active for Enforcement NI or any of our root causes, stop and read your Corrective Action Helper®.  

Learn more by attending one of our upcoming TapRooT® Courses or just call 865.539.2139 and ask a question if you get stuck after being trained.

Is there an easier way to investigate simple problems?

May 24th, 2017 by

People often ask me:

“Is there an easier way to investigate simple problems?”

The answer is “YES!”

The simplest method is:

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Of course, some methods may be too simple.

That’s why we wrote a book about the simplest, but reliable method to find the root causes of simple incidents. The title? Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents.

Want to learn more? See an outline at: http://www.taproot.com/products-services/taproot-book

Or just order a copy by CLICKING HERE.

Interviewing & Evidence Collection Tip: The Value of a Planning SnapCharT®

May 24th, 2017 by

Hello and welcome to our new weekly column focused on interviewing and evidence collection for root cause analysis of workplace incidents and accidents.

If you are a TapRooT® user, you know that the SnapCharT® is the first step in conducting a root cause investigation.  It doesn’t matter if you’re investigating a simple incident or major accident – SnapCharT® is always the starting line.

A SnapCharT® is a simple method for drawing a sequence of events.  It can be drawn on sticky notes or in the TapRooT® software.  Sometimes we refer to the SnapCharT® in it’s initial stages as a “planning” SnapCharT®. So why is a SnapCharT® essential for evidence collection and interviewing?

When you begin an investigation, you are working with suppositions, assumptions and second hand information. The planning SnapCharT® will guide you to who you need to interview and what evidence you need to collect to develop a factual sequence of events and appropriate conditions that explain what happen during the incident. Remember, a fact is not a fact until it is supported by evidence.  

The planning SnapCharT® is used to:

  • develop an initial picture of what happened.
  • decide what information is readily available and what needs to be collected immediately.
  • establish a list of potential witnesses to interview.
  • highlight conflicts that exist in the preliminary information.
  • plan the next steps of interviewing and evidence collection.

The SnapCharT® provides the foundation for solid evidence collection.  Learn how to create a SnapCharT® by reading, “Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents or register for our 1-day Interviewing and Evidence Collection Course in Houston, Texas on November 8, 2017.  We also offer this course as a one or two-day onsite course that can be customized for your investigators.

How has SnapCharT® helped you plan your investigative interviews and evidence collection?  If you’ve never used a SnapCharT®, how do you think a planning SnapCharT® would be helpful to you? Comment below and be entered into our August drawing to win a copy of our new “Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills” book!

See you next week!

To Hypothesize or NOT to Hypothesize … that is the Question!

May 16th, 2017 by

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

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

Interviewing & Evidence Collection: The Cognitive Interview

May 15th, 2017 by

In this video, we highlight Step 6 of the TapRooT® 12-Step Process: the cognitive interviewing technique.

Healthcare Professionals! Please come visit the TapRooT® Booth at the NPSF Conference

May 10th, 2017 by

If you are coming to the conference (May 17 – 19), please stop by and see us at Booth 300; Per Ohstrom and I will both be there.

Of course TapRooT® can help you with patient safety and reducing Sentinal Events. But there are many more ways to use TapRoot® in your hospital:

Improve Employee Safety and reduce injuries

Improve Quality, reduce human error, and make your processes more efficient

We hope to see you there. We have a free gift for the first 500 people, so don’t miss out!

Senior Management: Can Your Investigators Tell You that Your BABY is UGLY?

May 3rd, 2017 by

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This article is for senior corporate management

Can your investigators tell you that your baby is UGLY?

What do I mean by this?

Can your investigators point out management system flaws that ONLY YOU can fix?

If you say yes … I want to know the last time they did it!

Why am I bringing this up?

Recently I was talking to several “senior investigators” from a major company. We were discussing some serious incidents (SIFs). I recognized that there had been a series of management system failures over a period of over a decade that had not been fixed. SEVERAL generation of senior management had contributed to the problem by creating a culture of expediency … a “just get it done” culture that put cost containment and keeping the plant operating over process safety. 

I asked them if they had pointed this out to senior management. They looked at me if I was nuts. 

That’s when I realized … THEY couldn’t tell management that their BABY was UGLY.

I also realized that management didn’t want to hear that their BABY was UGLY.

They just wanted problems to go away with the least muss and fuss. They didn’t want to confront the investments required to face the facts and put process safety first.

TapRooT® Root Cause Analysis will point out the problems in management systems. But investigators must be willing to confront senior management with the facts (tactfully) and show them clearly that their BABY is UGLY.

Senior management should be DEMANDING that investigators point out management system flaws and asking WHY management system flaws ARE NOT being presented if a serious incident happens.

I remember pointing out a serious management system flaw that had caused a multi-multi-million dollar accident (no one had been killed but someone easily could have been killed). The Senior VP said:

“If anyone would have pointed out the problems this decision caused, we wouldn’t have made it!”

Don’t let poor management system decisions go unchallenged and unreported. When unreasonable budgets, deferred maintenance, short staffing, unreasonable overtime, or standard violations become an issue – SAY SOMETHING! Let senior management know they have an UGLY BABY.

SENIOR MANAGEMENT – Occasionally you need an outside opinion of how your baby looks … Especially if you continue to have Significant Incidents. Maybe you need to face the facts that your BABY is UGLY.

Remember … Unlike real ugly babies, management CAN DO SOMETHING about management system problems. Effective corrective actions can make the UGLY BABY beautiful.

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