Category: Root Causes
Throwing it a few years back to the wonderful course in Aberdeen, Scotland in 2010! What an awesome learning experience these instructors had working on the new SnapChart® Exercise to enhance their TapRooT® skills. What have been your experiences with this innovative exercise for incident investigations? Leave a comment below to share your story!
Aberdeen Fun Fact: Aberdeen Harbour Board is the oldest business in Britain. It was established in 1136 and now handles around four million tons of cargo every year serving approximately 40 countries worldwide!
Interested to learn more? Sign-up for a course near you! Just click here for more information about available courses.
OSHA General Duty Clause Citations: 2009-2012: Food Industry Related Activities
Doing a quick search of the OSHA Database for Food Industry related citations, it appears that Dust & Fumes along with Burns are the top driving hazard potentials.
Each citation fell under OSH Act of 1970 Section 5(a)(1): The employer did not furnish employment and a place of employment which were free from recognized hazards that were causing or likely to cause death or serious physical harm to employees in that employees were exposed……
Each company had to correct the potential hazard and respond using an Abatement Letter that includes words such as:
The hazard referenced in Inspection Number [insert 9-digit #]
for violation identified as:
Citation [insert #] and item [insert #] was corrected on [insert
Okay so you have a regulatory finding and listed above is one of the OSHA processes to correct it, sounds easy right? Not so fast…..
….are the findings correct?
….if a correct finding, are you correcting the finding or fixing the problems that allowed the issue?
….is the finding a generic/systemic issue?
As many of our TapRooT® Client’s have learned, if you want a finding to go away, you must perform a proper root cause analysis first. They use tools such as:
o SnapCharT®: a simple, visual technique for collecting and organizing information quickly and efficiently.
o Root Cause Tree®: an easy-to-use resource to determine root causes of problems.
o Corrective Action Helper®: helps people develop corrective actions by seeing outside the box.
First you must define the Incident or Scope of the analysis. Critical in analysis of a finding is that the scope of your investigation is not that you received a finding. The scope of the investigation should be that you have a potential uncontrolled hazard or access to a potential hazard.
In thinking this way, this should also trigger the need to perform a Safeguard Analysis during the evidence collection and during the corrective action development. Here are a few blog articles that discuss this tool we teach in our TapRooT® Courses.
Monday Accident & Lesson NOT Learned: Why Do We Use the Weakest Corrective Actions From the Hierarchy of Safeguards?http://www.taproot.com/archives/28919#comments
Root Cause Analysis Tip: Analyze Things That Go Right … The After-Action Review
If you have not been taking OSHA Finding to the right level of action, you may want to benchmark your current action plan and root cause analysis process, see below:
BENCHMARKING ROOT CAUSE ANALYSIS
BENCHMARKING ROOT CAUSE ANALYSIS
I’ve had many people ask me to comment on their use of root cause analysis. How are they doing? How do they compare to others? So I thought I’d make a simple comparison table that people could use to see how they were doing (in my opinion). I’ve chosen to rate the efforts as one of the following categories …
- Even Better
For each of these categories I’ve tried to answer the following questions about the efforts so that you could see which one most closely parallels your efforts. The questions are:
- To What Extent?
- Under What Conditions?
This is one step above no effort to find root causes.
Who performs the root cause analysis? The supervisor involved.
What do they use to perform the root cause analysis? 5-Why’s or no technique at all.
When do they perform the root cause analysis? In their spare time. (They must do their regular job and do the root cause analysis at the same time.)
Where do they perform the root cause analysis? Mainly in their office – they may do a few simple interviews with employees out in the plant but they don’t have a quiet, private room for interviewing.
To what extent do they pursue root causes? Usually as far as they think management will push them to go. If they can find a piece of equipment or a person to blame, that is far enough. The corrective actions can be to fix the equipment or to discipline the person and that is all that is needed.
Under what conditions do they perform the root cause analysis? They are in a hurry because management needs to know who to punish. Or the punishment may come before the root cause analysis is completed. They also know that if they can’t make a good case for someone else being blamed, they may get blamed for not having done a thorough pre-job risk assessment (call it a job safety analysis, pre-job brief, or pre-job planning if those terms fit better at your company). One more thing to worry about is that they certainly can’t point out any management system flaws or they may become a target of management’s wrath.
PROBLEMS WITH BAD
The problems with a BAD root cause analysis effort is that the solutions implemented seldom cause improvement. You frequently see very similar incidents happen over and over again due to uncorrected root causes.
Also, the root cause analysis tends to add to morale problems. People don’t like to be blamed and punished even if they may think that it was their fault. They especially don’t like it when they feel they are being made a scape goat.
Finally, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident that results in a fatality (or even worse, multiple fatalities). In almost every major accident, there were chances to learn from previous smaller issues. If these issues had been addressed effectively with a thorough root cause analysis and corrective actions, the major accident would have never occurred.
Better is better than bad, but still has problems.
Who performs the root cause analysis? The supervisor involved.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? In their spare time. (Similar to BAD.)
Where do they perform the root cause analysis? Mainly in their office. (Similar to BAD.)
To what extent do they pursue root causes? They use the Root Cause Tree® and find at least one root cause for at least a few of the Causal Factors.
Under what conditions do they perform the root cause analysis? They are trained in only the minimum knowledge to use TapRooT®. Sometimes they don’t even get the full 2-Day TapRooT® Course but instead are given a “short course” which should be “good enough” for supervisors. (Supervisors don’t have time to attend two days of root cause analysis training.) They often treat the Root Cause Tree® as a pick list and don’t use (or perhaps don’t have a copy of) the Root Cause Tree® Dictionary to use to guide their root cause analysis. Also, they may not understand the importance of having a complete SnapCharT® to understand what happened before they start trying to find out why it happened (using the Root Cause Tree®). And they probably don’t use the Corrective Action Helper® to develop effective corrective actions. Instead, rely on the well understood three standard corrective actions: Discipline, Training, and Procedures.
PROBLEMS WITH BETTER
The problems with a BETTER root cause analysis effort is that people claim to be doing a thorough TapRooT® root cause analysis and they aren’t. Thus they miss root causes that they should have identified and they implement ineffective fixes (or at best, the weakest corrective action – training). The results may be better than not using TapRooT® (they may have learned something in their training) but they aren’t getting the full benefit of the tools they are using. Their misuse of the system gives TapRooT® a bad name at their site.
Also, because near-misses and small problems aren’t solved effectively, there is a chance that the issues involved can cause a major accident (just like the BAD example above).
Even better is the minimum that you should be shooting for. Don’t settle for less.
Who performs the root cause analysis? A well trained investigator. This investigator should have some independence from the actual incident.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? They either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.
Where do they perform the root cause analysis? They probably use a regular conference room to conduct interviews away from the “factory floor”.
To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest. This includes developing a thorough SnapCharT®, Safeguards Analysis to identify or confirm Causal Factors, the Root Cause Tree® and the Root Cause Tree® Dictionary to find root causes. And Safeguards Analysis and the Corrective Action Helper® to develop effective fixes.
Under what conditions do they perform the root cause analysis? They have support from management, who are also trained in what is required to find root causes using TapRooT®. They have experienced experts to consult with for difficult root cause analysis process questions. If it is a major investigation, they have the help of appropriate investigation team members and the root cause analysis effort is performed with a real time peer review process from another experienced TapRooT® facilitator.
PROBLEMS WITH EVEN BETTER
There aren’t too many problems here. There is room for improvement but the root cause analysis process and fixes are generally very effective. Smaller problems tend to be fixed effectively and help prevent major accidents from occurring.
The one issue tends to be that as performance improves, investigators get less and less experience using the TapRooT® techniques. New investigators don’t get the practice and feedback they need to develop their skills.
Read Chapter 6, section 6.3, of the TapRooT® Book for a complete description of what an excellent implementation of TapRooT® looks like. This kind of TapRooT® implementation should be your long term root cause analysis effort goal. The following is a brief description of what Chapter 6 covers.
Who performs the root cause analysis? For major investigations, a well trained facilitator with a trained team. For more minor investigations, a trained investigator. The site investigation policy should clearly identify the investigative effort needed based on the actual and potential consequences of the particular incident.
What do they use to perform the root cause analysis? TapRooT®.
When do they perform the root cause analysis? Per the company’s pre-planning, the investigator and team either have time set aside in their normal schedules to perform investigations or they are relived of their regular duties to perform the investigation. They also have a reasonable time frame to complete the investigation.
Where do they perform the root cause analysis? For a major investigation an appropriate room is set aside for the team and they use a regular conference room to conduct interviews away from the “factory floor”.
To what extent do they pursue root causes? They use the tools in TapRooT® to their fullest.
Under what conditions do they perform the root cause analysis? The management sponsor has pre-approved a performance improvement policy that covers the investigation process. managers, facilitators, and all employees involved are trained per the policy standards. A no blame or “just” culture has been established and the purpose of the investigation is understood to be performance improvement.
PROBLEMS WITH EXCELLENT
You can’t be excellent without a senior management sponsor and management support. And being excellent is a never ending improvement process.
Also, as performance improves, investigator get less experience with reactive investigations. Therefore, proactive use of TapRooT® must be an integral part of any EXCELLENT TapRooT® root cause analysis effort. Proactive use of TapRooT® is covered in Chapter 4 of the TapRooT® Book and an example of proactive use of TapRooT®, the after action review, is provided HERE.
How did your root cause analysis efforts compare? What do you need to improve? Even if you are EXCELLENT, you need to continuously improve your efforts. For even more improvement ideas and benchmarking, consider attending the 2015 Global TapRooT® Summit in Las Vegas on June 1-5. For more information, see:
A frequent question that I see in various on-line chat forums is: “Is human error a root cause?” For TapRooT® Users, the answer is obvious. NO! But the amount of discussion that I see and the people who even try suggesting corrective actions for human error with no further analysis is amazing. Therefore, I thought I’d provide those who are NOT TapRooT® Users with some information about how TapRooT® can be used to find and fix the root causes of human error.
First, we define a root cause as:
“the absence of a best practice or the failure to apply knowledge that would have prevented a problem.”
But we went beyond this simple definition. We created a tool called the Root Cause Tree® to help investigators go beyond their current knowledge to discover human factors best practices/knowledge to improve human performance and stop/reduce human errors.
How does the Root Cause Tree® work?
First, if there is a human error, it gets the investigator to ask 15 questions to guide the investigator to the appropriate seven potential Basic Cause Categories to investigate further to find root causes.
The seven Basic Cause Categories are:
- Quality Control,
- Human Engineering,
- Work Direction, and
- Management Systems.
If a category is indicated by one of the 15 questions, the investigator uses evidence in a process of elimination and selection guided by the questions in the Root Cause Tree® Dictionary.
The investigator uses evidence to work their way down the tree until root causes are discovered under the indicated categories or until that category is eliminated. Here’s the Human Engineering Basic Cause Category with one root cause (Lights NI).
The process of using the Root Cause Tree® was tested by users in several different industries including a refinery, an oil exploration division of a major oil company, the Nuclear Regulatory Commission, and an airline. In each case, the tests proved that the Tree helped investigators find root causes that they previously would have overlooked and improved the company’s development of more effective corrective actions. You can see examples of the results of performance improvement by using the TapRooT® System by clicking here.
If you would like to learn to use TapRooT® and the Root Cause Tree® to find the real root causes of human error and to improve human performance, I suggest that you attend our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course and bring an incident that you are familiar with to the course to use as a final exercise.
Note that we stand behind our training with an ironclad guarantee. Attend the course. Go back to work and apply what you have learned. If you and your management don’t agree that you are finding root causes that you previously would have overlooked and that your management doesn’t find that the corrective actions you recommend are much more effective, just return your course materials and software and we will refund the entire course fee. No questions asked. It’s just that simple.
How can we make such a risk-free guarantee?
Because we’ve proven that TapRooT® works over and over again at industries around the world. We have no fear that you will see that TapRooT® improves your analysis of human errors, helps you develop more effective corrective actions, and helps your company achieve the next level better level of performance.
Could scheduling be a root cause of fatigue related errors? Navy OKs new watch schedule to reduce fatigue on submarines.April 22nd, 2014 by Mark Paradies
Finally an attempt to reduce fatigue on submarines. See the story here:
News & Current Events: In the Wake of Fukushima, The Natural Resources Defense Council’s Newest Report Condemns the NRC’s Hydrogen Generation SafetyMarch 12th, 2014 by Megan Craig
From the Natural Resources Defense Council’s Report Preventing Hydrogen Explosions In Severe Nuclear Accidents: Unresolved Safety Issues Involving Hydrogen Generation And Mitigation
“The Nuclear Regulatory Commission is failing to meet the statutory standard of “adequate protection” of the public against the hazard of hydrogen explosions in a severe reactor accident.
After Fukushima Daiichi’s three devastating hydrogen explosions, the NRC decided to relegate investigating severe accident hydrogen safety issues to the lowest-priority and least proactive stage of its post–Fukushima Daiichi accident response.
NRDC believes that the NRC should reconsider its approach and promptly address severe accident safety issues involving hydrogen.”
Click this link to read the full report: http://www.nrdc.org/nuclear/hydrogen-generation-safety.asp
A short synopsis of the findings:
NRDC Report: U.S. Nuclear Safety Regulators Ignore Severe Accident Hydrogen Explosion Risks Despite Fukushima Tragedy
An in-depth interpretation of the findings:
US Nuclear Safety Regulators Continue to Ignore Lessons of Fukushima for Severe Accident Hydrogen Explosion Risk at US Reactors
What do you think? Share your opinion in the comments.
Fukushima Photo courtesy of: http://www.globalresearch.ca/articlePictures/fukushimafire.bmp
If you’ve been following our blog lately, you’ve noticed we’ve been busy preparing for the 2014 Global TapRooT® Summit (Horseshoe Bay, Texas, April 7 – 11, 2013).
You may have even considered signing up. I mean, who wouldn’t want to stay at the AAA Four Diamond Horseshoe Bay Resort (maybe even bring your spouse and enjoy it as a couple).
And just how many chances in life do you get to meet and hear world-class speakers like Rocky Bleier?
But just when you were about to press the registration button, you thought:
Wait, I’m not sure I understand all there is to understand about TapRooT® Root Cause Analysis.
Since the TapRooT® folks are putting this together, shouldn’t I be TapRooT® trained before I attend?
First, if you are not TapRooT® trained, come to the 3-day Summit anyway. Multiple tracks designed to share best practices within and across industries and professions make this event valuable to all. There are plenty of best practice session to choose from and you can create your own schedule if you don’t want to select a specific learning track.
And second, you can actually be TapRooT® trained before the 3-day Summit begins! We’re offering our 2-Day TapRooT® Incident Investigation & Root Cause Analysis Pre-Summit Course on April 7-8, 2014 as a Pre-Summit Course!
TapRooT® Techniques are designed for everyone from beginner to expert. In just two days, learn the TapRooT® Essentials to find and fix the root causes of incidents, accidents, quality problems, near-misses, operational errors, hospital sentinel events and other types of problems.
The essential TapRooT® Techniques include:
- SnapCharT® – a simple, visual technique for collecting and organizing information to understand what happened.
- Root Cause Tree® – a systematic, repeatable way to find the root causes of human performance and equipment problems — the Root Cause Tree® helps investigators see beyond their current knowledge.
- Corrective Action Helper® – help lead investigators “outside the box” to develop effective corrective actions.
Using the TapRooT® System to find and fix the real root causes of problems keeps them from happening again and again.
So take our 2-Day course and then reinforce your new knowledge at the Summit by registering for the Incident Investigation and Root Cause Analysis Track. Make it a week of valuable learning that will contribute not only to your personal career development but also to saving lives and preventing injuries at your facility.
This is the same course we offer globally throughout the year, and what better time is there to join the global TapRooT® team than right before the Summit where all of our friends and experts meet?
Register for this Pre-Summit Course and the Summit today!
Or learn more about the 2014 Global TapRooT® Summit!
When many people first see the “enforcement NI” root cause on the TapRooT® Root Cause Tree®, they think that the obvious corrective action would be discipline. But those who read the TapRooT® Corrective Action Helper® know that there are reasons for people violating rules and that the only way to truly change behavior is to address the reasons why the rules are being broken.
The article, “The Five Pitfalls of Discipline in Safety,” clearly presents reasons why enforcement might need improvement. Click on the link and see if you agree.
Material found in a doughnut, see the initial indications from the KAKE media article below. A child is in a hospital bed at an Army Hospital after he took a bite of a glazed cake doughnut from a large retailer bakery. His mother says that the child said the doughnut tasted crunchy and then he chipped a tooth. “There were pieces of black metal, some of them looked like rings, like washers off of a little screw, some of them were black metal fragments, like real sharp pieces,” says the mother. The mother says that the child complained he had abdominal pains after swallowing the objects from the doughnut. Read the article here. The retailer spokesperson said the company’s food safety team is looking into the incident, reaching out to the doughnut supplier and trying to figure out what happened. Now what? Is this a safety or quality issue or both? If you were the retailer what would you do? Would you quarantine the doughnutt and ask for access to the material found in the stomach? Would you be allowed? If you were the doughnut supplier what would you do? Would you look for similar batches and quarantine them? Would you inspect the batches or turn them over to the supply? Would you be allowed? If you were the doughnut manufacturer what would you do? Would you inspect the equipment used for this batch? Would you look for facility work order reports already completed or reported? For all 3 parties, would you work together as one team to resolve the issue? What if you could not find any evidence on your side of missing parts? Everything just discussed would be part of the analysis/investigation planning stage. The first step of our TapRooT® 7 step investigation process. To learn more about what you would do following a problem, here are a few articles to learn more about are process and courses available. What is Root Cause Analysis? Root Cause Analysis Tip: Why Did The Robot Stop? (Comparing 5-Why Results with TapRooT® Root Cause Analysis Results) Our public course schedule
By Chris Vallee
I was an aircraft mechanic in USAF when this incident occurred. The aftermath of the F-15 Crash and Pilot Fatality continued with an Airman’s suicide was loss to many.
While, I knew the basics, I just recently found a follow up report and wanted to share it. The information is taken directly from the article as is without my paraphrase. Here is the website.
An Air Force review board has partly cleared the name of an F-15 mechanic who committed suicide in 1996 rather than face a court-martial for a fatal repair error.
Evidence showed that TSgt. XXXXXX did not perform the botched control rod maintenance at issue, although he did check the work and found nothing wrong.
In addition, several previous incidents in which other mechanics made the same mistakes should have alerted the Air Force to a potential problem, according to the board.
“We did not think XXXX was totally free of all responsibility,” said Lee Baseman, chairman of the correction board. “But it was our view that he was unduly carrying the burden for a series of missteps that went back at least 10 years.”
In May 1995, XXXX and TSgt. YYYYYY were carrying out maintenance on an F-15C based at Spangdahlem AB, Germany, when YYYYY accidentally crossed flight control rods while reinstalling them. XXXX did not catch the miscue, which made the airplane impossible to control in the air. It subsequently crashed, killing Maj. Donald G. Lowry Jr. (Great GUY!!)
Air Force authorities charged XXXX and YYYYY with dereliction of duty and negligent homicide. XXXXX shot himself in October 1996 during a break in court proceedings. Commanding officers then accepted YYYYY request for administrative separation, on grounds that the interests of the service would be best served by bringing the tragic case to a swift conclusion.
Similar crossed-rod cases occurred at least twice before the Spangdahlem crash, noted the review board-once in 1986 and again in 1991. But in both instances the problem was caught before takeoff.
In its conclusions, the board stated, “After the Black Hawk shootdown [in 1994], the demand for accountability for this accident may have been pursued with such zeal as to leave fairness and equity behind. The fatal crash was a tragedy waiting to happen, yet the decedent was singled out to pay for an accident that could have been prevented anywhere along the ‘chain of events’ had any of the numerous individuals involved made different decisions.
“Most disturbing was the way the Air Force leadership allowed this case to be handled. The Air Force’s representatives resisted the inclusion of potentially exculpatory evidence from the review and report and managed to have a good deal of it excluded from consideration in the pending trial.”
Following the death of Lowry, the Air Force took steps to prevent such a mix-up from happening again. The control rods are now color-coded to ensure proper installation, and the maintenance technical manual warns against the mistake. All flight control systems must now be checked any time the control rods undergo maintenance. ” “
Ref: Journal of the Air Force Association, June 1998 Vol. 81, No.5, Peter Grier
I know, it is too early for Friday’s Joke of the Day, but I could not help it. I saw this posted recently and had to share.
As you are laughing, look into your tool cabinet and tell me that you do not have these 2 items in it.
Now if you want to know how to troubleshoot equipment the right way to find the right what’s and why’s and want an Individual TapRooT® Software License (comes with the course), then join us at one of our Equifactor® courses.
Here is the current schedule: http://www.taproot.com/store/3-Day-Courses/
I’ll bring my WD-40 and Duct Tape for the classroom equipment.
What are the risks of setting a circuit breaker without knowing why it opened?
I just saw this local news article about a father teaching his daughter about the circuit breaker panel in their house after a ceiling fan stopped working. End result….. House on fire. Read more here.
With eighteen years in aviation and having worked on the C-141 Aircraft, this incident brought to mind the wrong pump replaced and reseting the circuit breaker during testing explosion. Read more here.
There are additional ways to gain equipment troubleshooting experience without starting a fire. The easiest way is to attend one of our upcoming Equifactor® Course coming up in your local area. See the schedule here: http://www.taproot.com/store/3-Day-Courses/
With community protests after losing school aged loved ones, the Indian Government is closing in on suspected causes to include suspects. But is this a sign of Systemic Food Quality Control or as TapRooT® calls them “Generic Causes”? Will the nature of the investigations detour looking for Generic Causes by looking for blame instead?
Read below and ask, how would this be investigated or analyzed if it were in your hometown? What would be the response of the lunch cafeterias and Food on Wheels programs for the elderly and sick?
In a months time…..
23 students in the southwestern coastal state of Goa were treated at a hospital after they got sick at lunch
23 students died and 25 people were hospitalized from food poisoning after a school lunch in northern India’s Bihar state
Schoolchildren falling sick after drinking contaminated water from hand pumps continued for the third consecutive day on Saturday with at least 35 more students taken ill in different parts of Bihar.
Arrests made in two of incidents with possible cause being insecticide poisoning; the water pump incident possibly criminal intent and the Bahir lunch room incident due to possible negligence. The Goa incident not so clear in details yet.
Due to fear, large lunch producers temporarily shut down their lunch kitchens resulting in children not getting their mandated free lunches during school.
See more at this link:
Whether in the medical device, pharmaceutical or the food manufacturing industry, a company usually has had many violation corrective action chances before they get a consent decree of permanent injunction. At this point a third party reviews current deviations and often identifies a weak or non-existent root cause analysis program.
Now don’t get me wrong, this is often when our TapRooT® Root Cause Process gets recommended as a possible option and we gain a new client. However, I would prefer working with an FDA regulated company to develop effective corrective actions before they get in trouble. Or at least when they get their first FDA Finding.
Often FDA findings are found by an external audit. To remain independent, the auditor turns over the findings through proper protocol and the company involved must provide proof that the causes were found and that the corrective action is effective. So if this protocol is followed, how did we get to a permanent injunction? Can the repeat findings be purely an Enforcement Needs Improvement Root Cause for policies not followed?
I suggest Enforcement needs improvement is not the only problem. To find out what your company might be missing in your RCA process. Find a course close to you and send one of your key quality or safety problem facilitators. Here is our upcoming courses link: http://www.taproot.com/store/Courses/
To get you thinking about possible gaps in your root cause analysis program, view this presentation given at our 2012 TapRooT® Summit. http://www.taproot.com/content/wp-content/uploads/2012/02/RileyandGorman.pdf
Then check out the quality track in the upcoming 2014 Summit in April. http://www.taproot.com/products-services/summit
The next time someone says they used 5-Whys to investigate an accident, just thing …
5-Whys = Root Cause Analysis Malpractice
Because 5-Whys is almost always root cause analysis malpractice. If you don’t believe it, assign someone who is good at 5-Whys to analyze a problem and someone who is good at using TapRooT® to analyze the same problem. Look at the results and you will see what I’m talking about.
That’s the lesson learned for today.
Everyone is interested in research statistics but the following infographic asserts that some scientists may make up the data, distort the data … even cook the data!
What would you guess is the root cause of bad science? The infographic suggests that one may be that the scientist changes results due to pressure from a funding source.
Monday Accident & Lessons Learned: Root Cause Analysis of San Onofre Nuclear Generating Station, Unit 2 & 3 Replacement Steam GeneratorsApril 1st, 2013 by Mark Paradies
This certainly sounds like an expensive incident and you would think they would use a state of the art root cause analysis system. Instead, they used cause-and-effect. See the report and see if you agree that the “root causes” of the incident are:
I think the lessons learned is to get a better root cause analysis tool!
Here’s the Meridian-Webster On-line Dictionary definition of “behavior”:
1. a : the manner of conducting oneself
b : anything that an organism does involving action and response to stimulation
c : the response of an individual, group, or species to its environment
2 : the way in which someone behaves; also : an instance of such behavior
3 : the way in which something functions or operates
Another definition that I think that management has in their heads is a “behavior” is:
“Any action or decision that an employee makes that management,
after the fact, decides was wrong.”
Why do I say that mangement uses this definition? Because I often hear about managers blaming the employee’s bad behavior for an accident.
For example, the employee was hurrying to get a job done and makes a mistake. That’s bad behavior!
What if an employee doesn’t hurry? Well, we yell at them to get going!
And what if they hurry and get the job done without an accident? We reward them for being efficient and a “go-getter.”
Management doesn’t usually see their role in making a “behavior” happen.
Behavior should NEVER be the end of a root cause analysis. Behavior is a fact. Just like a failed engine is a fact when a race car “blows it’s engine.”
Of course, a good root cause analysis should look into the causes for a behavior (a mistake) and uncover the reasons for the mistake and, if applicable, the controls that management has over behavior and how those controls failed when an accident occurred.
A bad decision or a human error that we call a “behavior” isn’t the end of the investigation … it is just the beginning!
TapRooT® helps investigator go beyond the symptoms (the behaviors) and find the root causes that management can fix. Some of the most difficult behaviors to fix are those so ingrained in the organization that people can’t see any other way to work.
For example, the culture of cost saving/cutting at BP was so ingrained, that even after the explosions and deaths at the Texas City Refinery, BP didn’t (couldn’t?) change it’s culture – at least not in the Gulf of Mexico exploration division – before they had the Deepwater Horizon accident. At least that is what I see in the reports and testimony that I’ve reviewed after the accident.
And with smaller incidents, it is even harder to get some managers’ attention and show them how they are shaping behavior. But at least in TapRooT® tries by providing guidance in analyzing human errors that leads to true root causes (not just symptoms).
Want to find out more about TapRooT® and behavior? Attend one of our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses. You’ll see how TapRooT® helps you analyze behavior issues in the exercises on the second day of the training. And you will learn much more. For a public 5-Day Course near you see:
Why Do People Have Problems Finding Root Causes? Read this Article – Under Scrutiny – from Quality Progress…February 25th, 2013 by Mark Paradies
Do you have problems finding the root causes of quality problems, safety incidents, or mechanical failures? It could be becuse of the root cause analysis tools you have chosen to use. Some tools have inherent weaknesses that are “built in.”
The article attached below (as first appeared in Quality Progress, the flagship magazine of the quality professional society ASQ), explains why some techniques commonly recommended for root cause analysis (like 5 Whys) will cause problems when applied by people in the field.
(click the link above to download the article)
Once you finished reading about the limitations of 5-Whys and Cause-and-Effect, sign up to learn about the advanced root cause analysis system that was intelligently designed to avoid those problems … TapRooT®.
The best way to keep your Valentine’s Day romantic and fun? Make food safety a priority!
A recent article on StateFoodSafety.com notes that the best restaurant to eat in on Valentine’s Day is a clean one. Here are a few of their food safety tips this Valentine’s Day:
- Take note of the dining area and restrooms. If they do not meet cleanliness standards, it’s probably a good sign that the kitchen is also in need of more than just a light dusting. You might consider eating elsewhere for your own safety.
- Only eat foods that are served to you hot. If the food is served to you at a lukewarm temperature, chances are that it was left sitting for too long and has allowed harmful bacteria to multiply.
- Make sure the staff does not touch your food or the tips of your silverware with their bare hands. It’s probably not a good idea to let them sample your drink either.
- Be wary of meat, eggs, oysters, or other raw foods that are undercooked.
- Wash your hands properly before and after eating.
Photo courtesy of NPR.
Based on client’s request, we have scheduled our ONLY Public India 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training for April 22 – April 26.
For those not familiar with the course, it includes the TapRooT® single user software (unless attendee’s company has a network software license), TapRoot® book, Corrective Action Helper®, Root Cause Dictionary & Laminated Root Cause Tree, Course Workbook.
Course Fee which includes a software individual license for each student is only $2,395 USD. Here is the registration link: Register
Please register 30 days prior to the course if you need a quote first to send to your billing department. Anything within 30 days or less must be paid for during registration. All course seats must be paid for prior to the course to hold the seat and attend the course.
We look forward to seeing our repeat clients and new clients in our only 5-Day public India course for 2013.
With many industries and natural resources located in Trinidad, System Improvements, Inc. teaches many onsite TapRooT® Root Cause Analysis Courses. In fact, I will be teaching a 3-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Failure Analysis this November with contract instructor, Mark Olson. I will be scheduling another 5 Day Course in Trinidad this the summer of 2013.
We get so busy sometimes in performing root cause analysis facilitations, courses and just plain business, that it is nice to see a reminder about why we want to make all industries safer. Pictured above is Safraz Ali, a student from the Trinidad Course, whom I had the opportunity to meet with his family.
Family, friends and the community are why we love what we do when we get it right!
Valerie Johnson is now certifed to teach the TapRooT® 2-Day Course to the ConocoPhillips Aviation Division. Valerie flew in from Alaska to Houston to get trained and upon return will be co-teaching with long time certified instructor Michael Rodriguez.
As a Senior Associate with System Improvements, Inc. with 18 years in aviation, it was a pleasure to teach the course in the Aviation Hangar offices. David Camille, also pictured above, was instrumental in coordinating this course and giving me the tour of one of their Gulfstreams.
R.R. Donnelley & Sons Co. prematurely filed Google Inc.’s earnings report with the Securities and Exchange Commission on Thursday. Google’s earnings were supposed to be released after the stock markets closed at 3 p.m. Instead, they showed up on the SEC’s Edgar website about 11:30 a.m. Google’s stock dropped as much as 11 percent, to $676 a share, before trading was halted about 20 minutes later at the company’s request.
About an hour after the earnings release, Google issued a statement blaming Chicago-based R.R. Donnelley for the blunder.
(“Glitch on Google Earnings Report under Investigation,” Chicago Tribune, October 19, 2012.)
Why do people think that blame will stop incidents? Haven’t we tried that already? Don’t the incidents just continue? Share your comments below.