Category: Root Cause Analysis Tips

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.

Crisis, Crisis Everywhere…

May 1st, 2017 by

The Crisis Management Vision

Has your management ever said:

 “If we investigated every incident we had, we’d do nothing but investigate incidents!”

Then there is a good chance that you are living in a crisis management vision.

What are your three most common corrective actions for any problem?

  • Counsel the operator to be more careful
  • Require more training.
  • Write (or rewrite) the procedure.

Unfortunately, this type of corrective action usually doesn’t work (even though sometimes it may appear to work). The problem happens again. The vicious cycle of crisis and crisis management repeats itself. And everyone complains about having to work too hard because they are always in “crisis mode.” 

Are you tired of crisis management?

Would you like to finally solve problems once and for all?

Then it is time you tried TapRooT® Root Cause Analysis. Attend one of our publics courses listed here…

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

This article was derived from Book 1: TapRooT® Root Cause Analysis Leadership Lessons. Copyright 2017 by System Improvements, Inc. Used by permission.

 

Trapped in the Blame Vision

April 20th, 2017 by

From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.

The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.

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They were trapped in the Blame Vision.

The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.

The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:

I didn’t do it! 
Nobody saw me do it! 
You can’t prove I did it!

But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:

Why be fair when you can be arbitrary?

A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up. 

One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself. 

The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement. 

Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him. 

If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.

What Would You Do If You Saw a Bad 5-Why Example?

April 19th, 2017 by

It seems that I’m continually confronted by folks that think 5-Whys is an acceptable root cause analysis tool. 

The reason they bring up the subject to me is that I have frequently published articles pointing out the drawbacks of 5-Whys. Here are some examples…

Article in Quality Progress: Under Scrutiny (page 32)

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

That got me thinking … Have I EVER seen a good example of a 5-Why root cause analysis that I thought was a good example of a root cause analysis? And the answer was “NO.”

So here is my question … 

What do you do when you see someone presenting a bad root cause analysis where they are missing the point?

Leave a comment below and let me know the tack that you take … What do you think?

Are You Writing the Same Corrective Actions?

April 17th, 2017 by

Repeating the same corrective actions over and over again defeats the purpose of a quality root cause analysis investigation. If you spend the time investigating and digging deeper to find the REAL root cause, you should write the most effective corrective actions you can to ensure it was all worth the resources put into it. Instructor & Equifactor® and TapRooT® Expert, Ken Reed, talks about corrective actions and how to make them new and effective for each root cause.

 

Take a TapRooT® Root Cause Analysis course today to learn our effective and efficient RCA methodology. 

Root Cause Analysis Tip: Does Your Company Vision PREVENT Good Root Cause Analysis?

April 11th, 2017 by

What is your company’s vision? Does your company have a:

  • Blame Vision
  • Crisis Management Vision
  • Opportunity to Improve Vision

The only vision that leads to good root cause analysis is the opportunity to improve vision. 

We’ve been helping people “adjust” their vision since Mark Paradies gave a talk about the opportunity to improve vision at the 1990 Winter American Nuclear Society Meeting. 

How do you change your vision?

That takes more than the few paragraphs of a blog article to describe. But we did write about it in our newest book:

TapRooT® Root Cause Analysis Leadership Lessons

 

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What’s in the new book?

  • A Tale of Two Plants
  • Vision
  • What is a Root Cause and How Was TapRooT® Developed to Help You Find Them?
  • How Leaders Can Apply TapRooT® to Improve Performance
  • What Can TapRooT® Do for You?
  • What TapRooT® Books Do You Need to Read?

The new book is designed for senior managers and leaders of improvement programs to help them understand effective root cause analysis and how it fits into a performance improvement program.

Order your copy of the new book by clicking HERE and make sure your vision supports improved performance!

 

How to Interpret Body Language In Your Incident Investigation Interviews

April 10th, 2017 by

TapRooT® Instructor and Non-Verbal Communication Expert, Barb Phillips, explains how to interpret common body language cues with an example investigative interview. Watch here for some investigative interviewing tips!

Want to know more? Take a TapRooT® Effective Interviewing and Evidence Collection course.

When do you need a root cause analysis?

April 5th, 2017 by

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I heard one industry guru say that EVERY loss deserves an investigation and corrective action.

Is it possible?

Is it desirable? 

I would say no.

Not every loss needs an investigation and certainly not every loss deserves a root cause analysis.

Why?

Because every investigation should have at least a chance of a positive return on the investigation investment. Many losses are too small to get much benefit from an investigation. (This is true even if you take into account the potential for even bigger problems down the road.) Let’s face it, sometimes there just isn’t much to learn from a paper cut!

Why should we avoid wasting our improvement energy on unimportant minor problems?

Because every organization has resource limitations and we should spend our resources wisely. We need to put our effort where it will do the most good.

Therefore, we must target our resources where they will get the most improvement bang for the buck.

The targeting of improvement resources should match management’s goals. This targeting of resources should guide the improvement effort by assigning resources for safety, quality, reliability, productivity, and product improvement. Of course, the division of resources is guided by the company’s risk assessment and market analysis. 

Let’s look at an interesting hypothetical example.

At a large chemical company, a budget and level of emphasis has been assigned for safety improvement. How should the company spend this budget? Where should the safety team direct their resources?

The first place to look would be the company’s real accident data. Of course, if the company has poor root cause analysis, the data will not be meaningful. If that is true, the first place to apply resources is to achieving outstanding root cause analysis of significant accidents.

What if this company has been applying advanced root cause analysis for several years and has fairly good accident data. Then they can use that data to determine where their biggest risks are and what type of root causes contribute the most to that risk. That knowledge can help them target their resources. 

If a company’s safety improvement programs are fairly ineffective (measured by the fatality count), the majority of the emphasis should be put on the investigation of significant incidents and precursors to significant incidents. These are incidents that cause fatalities and serious injuries and incidents that could have caused a fatality or serious injury if one more Safeguard had failed.

The remaining improvement effort (say 33%) would be applied to proactive improvement. This includes local safety audits, peer observations, management field observations, and outside audits.

As the company improves, their safety performance and the time between significant incidents will improve significantly (do you trend this?). As this happens, effort is shifted from reactive investigations (because there are less of them) to targeted proactive improvement. This tends to cause an excelleration in the improvement progress. 

What happens if you don’t have good root cause analysis of significant incidents?

If a company does NOT do a good job investigating and fixing their serious incidents, the proactive improvement efforts tend to be miss-directed. The lessons learned from significant injuries and potential significant injuries are inaccurate. The data produced misdirects the proactive improvement efforts. The significant injuries continue even though the minor incidents targeted by the misdirected proactive improvement efforts tend to improve.

This misdirection of proactive improvement efforts has been written about extensively. Proactive behavior based safety improvement efforts produced good trends in lost time injury data with little improvement in fatality and significant injury data. This should not be a surprise. It is the reason that many companies hit a plateau of improvement for major accidents while having world-class lost time injury rates. 

I believe an excellent example of this misdirection of improvement efforts could be seen in the BP Texas City Refinery explosion. Management thought their improvement efforts were working because of a decrease in the LTI rate but the fatality rate (that included contractors) was unchanged (or maybe slightly worse). 

Where are you????

Are you trending the time between serious injuries and fatalities?

Is that time increasing significantly?

Do you know how to tell if the time between incidents is increasing significantly?

We can help you learn how to mathematically prove that improvement is occurring (or that things have taken a turn for the worse). 

Are your less significant incidents improving without making much impact on your significant injury rate? This is a sign of a misdirected improvement effort and a need to improve your root cause analysis of significant injuries.

We can review your program, point out potential improvements, and  teach your folks how to apply the best root cause analysis techniques reactively and proactively to make improvement happen.

We can also help your management understand their impact on improvement. How they directly influence the quality of the root cause analysis. (You can’t have excellent root cause analysis without management understanding and involvement.) Even the best root cause analysis systems can’t succeed unless management asks for the appropriate investigations and provides the resources needed to implement effective performance improvement fixes.

Once all of this is on track, we can help you see how to effectively apply your resources to get the most bang for your improvement buck. This includes targeting of improvement efforts and deciding when a root cause analysis is needed and when the effort should be applied elsewhere.

Call Per Ohstrom or Mark Paradies at 865-539-2139 (or CLICK HERE to contact us) to discuss your improvement efforts and see how we could help focus your program to get the best return on your improvement investment.

Investigate Near Misses with TapRooT® Root Cause Analysis

April 2nd, 2017 by

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I think that TapRooT® Root Cause Analysis might be one of best way to investigate near misses, right?

I received this question from one my students who has continued to stay engaged to keep his company running safe and efficient by applying his TapRooT® Root Cause Analysis Training every day.

As you know, we are able to prevent real incidents by investigating near misses.

 I think that TapRooT® RCA might be one of best ways to investigate near misses, right? Would you advise me how to use TapRooT RCA to investigate near misses and give me some examples of near miss investigations done with TapRooT® RCA?

 Any comments or advice would be highly appreciated.

Think about it, in most near misses, you are just One Causal Factor from your next major Incident. The Causal Factors found during the investigation are usually not a surprise or the first time that they have occurred at that site or in the company.

The only difference between an incident and a near miss incident root cause analysis is what goes in the circle on the SnapCharT® (sequence of events chart).  For example,

Picture.2

Vital to ensure success with a new near miss program implementation, is not to try to investigate all audit findings or catches. You do not have enough resources. Instead start with the high potentials for incidents only.

Wait, why did I just include audit findings? Simple, audits are more than looks for compliance. Processes are put in place to reduce or eliminate hazards (energy), isolate targets from hazards or to ensure responses to hazard and target contact do not make the incident worse. An audit is often the first documented point in time to identify a high potential near miss. Check out our new audit course with root cause analysis to improve your audit capability.

Just like I stated above concerning near misses, all audit findings may not need a root cause analysis, but audit findings with high potentials do.

If your company does not have a High Potential for Injury/Incident/Process Shutdown Program in place today, you will need to do some homework. Here are some simple steps to get started.

  1. Identify Tasks performed by your employees, contractors, vendors or suppliers, that if done incorrectly could cause Injury/Incident/Process Shutdown. For a jump start, review the following videos for Serious Injuries & Fatalities. For quality defects and process failures take a look at hierarchy of controls for defects.
  2. Once the potential tasks are identified, develop a triggering process that alerts the need for a root cause analysis.

Second homework item, if not trained in TapRooT® Root Cause Analysis, go to course close to you now.

If in Europe, check out our 5-Day TapRooT® Root Cause Analysis Course in Aberdeen, Scotland – May 22.

If in North America, checkout our 2-Day TapRooT® for Audits Charlotte, NC May 4, 2017 or our 5-Day TapRooT® Galveston, TX May 15, 2017.

Our complete course schedule can be found here.

Why do Audits fail and why do I have so many repeat findings? Take a detour!!!

March 27th, 2017 by

Have you ever performed an audit and got frustrated when you found the same issues as the last audit? I feel your pain….we all have. Why does this happen so much? Because most companies audit programs look a little like this:

Screen Shot 2017-03-27 at 4.00.54 PM

Q: What is missing from this picture?

A: Root Cause Analysis, of course!!

Many companies actually have good programs for FINDING problems without having a good program for FIXING problems. If you want problems fixed, root cause analysis has to be part of it. So on the road to improvement, take a DETOUR to Root Cause Land!

Screen Shot 2017-03-27 at 4.13.20 PM

For your program to be effective, it should look more like this:

Screen Shot 2017-03-27 at 4.04.23 PM

The best way to do root cause analysis on audits? TapRooT®.

We have a new course, TapRooT® for Audits, that we will be holding in Charlotte, NC on May 4-5. Why not join us? For more information and to register, click HERE

Root Cause Tip: What is the minimum investigation for a simple incident?

March 20th, 2017 by

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What is the minimum investigation for a simple incident?

Before you can answer this question, you need to decide the outcome you are looking for. For example:

  • Do you just want to document the facts?
  • Would you be happy with a simple corrective action that may (or may not) be effective?
  • Do you need effective corrective actions to prevent repeats of this specific incident?
  • Do you want to prevent similar types of incidents?

The answers to these questions depend on two factors that determine risk:

  1. What were the consequences of this incident and could things have happened slightly differently and had much worse consequences?
  2. What is the likelihood that this type of incident will happen again?

Of course, before you start an investigation, answering these two questions may be difficult. Before you start an investigation, you don’t really know what happened! But in spite of this lack of knowledge, someone must decide if an incident is worth investigating and the resources to dedicate to the investigation.

I’ve seen simple incidents that, when investigated, revealed complex problems that could have caused a serious accident. Therefore, if a thorough investigation is not performed, the investigator may never know what they could have discovered. That’s why I caution management that something that seems simple may not be simple.

However, some incidents ARE simple. I’ve seen many incidents that people were investigating that were similar to this one:

An employee stumbles, falls, and sprains
his wrist while walking down a flat sidewalk.
He had on simple shoes with adequate tread.
He was not particularly preoccupied
nor was he entirely paying attention to each step
(just normal walking).

How much can be learned by investigating this incident? Probably not much. I would suggest that even though the person sprained his wrist, this incident should not be investigated beyond a simple recording of the facts so that the incident could be recorded for safety records (OSHA logs in the USA) and included in future incident trending.

You might ask:

“But what if the employee had stumbled and fell in front of an oncoming car and the employee killed?”

In that case, because of the consequences, a detailed major investigation would be required.

In either case, the TapRooT® Root Cause Analysis System could be used to complete the investigation.

The TapRooT® Root Cause Analysis System is a robust, flexible system for analyzing and fixing problems. The complete system can be used to analyze and fix complex accidents, quality problems, hospital sentinel events, and other issues that require a complete understanding of what happened and effective corrective actions.

Learn more about when to investigate a simple incident by attending our 2-Day TapRooT® Root Cause Analysis training.  Click here to view the upcoming schedule.

 

Root Cause Analysis Tip: 3 Tips for Drawing a Better SnapCharT®

March 15th, 2017 by

 

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Visualize each step of an incident with a SnapCharT®.

It’s nearly impossible to conduct a useful root cause analysis unless you actually have some data to analyze. Many systems seem to think that you can dive right into an analysis before you have a full understanding of what actually happened. During the development of the TapRooT® System, one of the first items of business was to develop an easy way to visualize the problem and document the gathered facts. Thus, SnapCharT® was born.

SnapCharT®s are pretty easy to build. With just three shapes to worry about, and a few simple rules, the SnapCharT® gets you moving in the right direction right from the get-go.

Here are a few tips to help make the SnapCharT® even easier and more useful.

1. Avoid the word “and” in your Events. Events are meant to show a single action that occurred in the course of the incident investigation. Some people have an aversion to having a bunch of Events, and therefore put several actions in each one.  For example, if I wanted to document that the driver stopped at the stop sign, looked both ways, and then pulled out into the intersection, I would not want to write this as a single Event.  This should be 3 separate (short) Events, one after the other.

The reason this is important is because we want to see if any mistakes are made during each step in the sequence of events.  If we put several actions into a single Event, we find it is easy to miss one of these mistakes.  On the other hand, with 3 separate Events, I can ask, “Did the driver make a mistake while stopping?  Did she make a mistake while looking both ways?  Did she make a mistake by pulling forward?”  Having separate Events makes it much easier to catch individual problems.

Keep in mind that, later in the investigation, you may find that there were no mistakes made in any of these Events.  When you complete your SnapCharT®, it might then make sense to combine some Events to make the final SnapCharT® easier to read.  It is OK to combine Events later on; just leave them separate during your initial data-gathering phase.

2. Leave lots of space.  Many people tend to cram all their Events close together, I suppose to conserve real estate.  Don’t worry about it; leave lots of room between your individual Events.  Spread everything out.  You’ll be adding Conditions underneath each of these Events, and you’ll almost certainly end up moving everything to make room for these Conditions anyway.  Give yourself plenty of room to work at the beginning.  If using the software, I usually only put 2 or 3 Events on each page to start out.  Later on, once you have all of your Conditions documented and grouped, you can compress everything down a bit and get rid of extra spaces.  But even then, don’t try to squeeze everything tightly together.  It can make it hard to read, even after everything is set.  And you might also find new Conditions that need to be added once you start the root cause analysis.

3. Draw your lines at the very end.  It is tempting to start drawing lines early in the process.  You want to see those arrows showing your progression from one Event to the next.  And you want to arrange your Conditions into neat groups right from the start.  Unfortunately, this can cause problems later on.  There is a good chance you’ll be adding new Events, changing the order of the Events you have, or regrouping your Conditions into Causal Factor groups.  If you have already drawn your lines, you’ll just have to delete them, make your changes, and then draw them back in.  And then probably do it again later on.

I normally don’t draw any lines between Events or Conditions until after I’ve identified my Causal Factor groups.  My SnapCharT® is probably pretty close to being complete by that point, so I’m reasonably confident that I won’t be making a lot of changes.  This can be a tough lesson for those that are REALLY detail oriented (you know who you are!), and just have to have those lines drawn in early in the process.  Resist the temptation; it’ll save you some time (and frustration!) later on.

Let me know what you think about these tips.  If you have other tips that you’ve found that make it easier and quicker to produce your SnapCharT®s, share the best practices you’ve learned in the comments below.

We hope that you will also consider coming to the 2016 Global TapRooT® Summit, San Antonio, Texas, August 1-5 to share best practices.  Click here to learn more about the Summit.

 

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