Category: Root Causes
While reading Sentinel Event Alert 55 (SEA-55) from TJC issued September 28, 2015 on Fall Prevention, it occurred to me that TapRooT® can be used to aid in finding the root causes of the fall. Even more importantly, TapRooT® can be used to aid in maintaining your fall prevention program to ensure long-term success. The TJC lists the following common contributing factors (in TapRooT® these would be called “Causal Factors“):
- Inadequate assessments
- Communication Failures
- Lack of adherence to protocols and safety practices
- Inadequate staff orientation, supervision, staffing levels and skill mix
- Deficiencies in the physical environment
- Lack of Leadership
While these are good guidelines for what to look for and what data to gather, to us these do not represent root causes. These 6 items almost match up with most of the 7 Basic Categories on the back of our Root Cause Tree®. So as TapRooT® investigators, know you have to dig a bit deeper to find the true causes and define those at the Root Cause level not at the causal or contributing level.
All this being said, the more important reason I wanted to write this article is to highlight the use of your TapRooT® tools by using them for Proactive measures. How to examine and improve your fall management program and maintain continued success. Too many times we don’t think about the power of observation and the idea of raising awareness through communication. Each of these can be highlighted through the Proactive Process Flow below:
In SEA-55, two of the actions suggested by TJC were to 1) Lead an effort to raise awareness of the need to prevent falls resulting in injury and 2) Use a standardized, validated tool to identify risk factors for falls. These two items can benefit from the TapRooT® tools directly.
Starting with step 1 above in the Proactive Flow, use the SnapCharT® tool to outline the steps in patient assessment, highlight the steps that can or will affect the fall prevention portion of patient care, then use this flow as the basis for an observation program. By getting out and observing actual performance in the field you can do two things, show your concern for patient safety (and falls in this case) and gather actual performance data. These observations can be performed both in a scheduled and/or random fashion and can be done in any setting (ambulatory, non-ambulatory, clinic et cetera).
During the observation, document findings on the SnapCharT® and identify potential “Significant Issues” as they apply to fall prevention. This data can then be either evaluated using the Root Cause Tree® to define the areas of need for that single observation, or the data can be combined with other fall prevention observation data for use in an aggregate analysis or common cause analysis. With the aggregate analysis data from multiple observations can be combined, and “Significant Issues” can be identified based on multiple observations before an analysis using the Root Cause Tree® is performed. This could give you an overall bigger picture view of your processes.
Once the RCA is performed (in either situation), Steps 5-7 can be simply followed to produce some recommended actions to be implemented and measured using Corrective Action Helper® and SMARTER. And the beauty of this Proactive process is that you have not waited for a fall to learn. You and your organization are preventing future issues before they manifest thus showing your patients and staff that you truly care about their safety.
If you would like to learn more about using your TapRooT® tools proactively you can contact me at Skompski@taproot.com for more information or you can attend any of our public seminars, 2-day or 5-day to learn more on both the reactive and proactive use of the TapRooT® tools!
- Training. Retrain everyone, not just those involved.
- Policies/Procedures. Write new policies or procedures or make the current ones longer.
- Discipline. Send a message to everyone else that a behavior is unacceptable whether or not there is fault.
When these are the standard actions, many times we have recurrence of events. I am not saying these actions can’t work, but many times if they are default answers it is much like putting a round peg in a square hole.
In this article a hospital in Hong Kong presents an overview of their findings and recommended actions to a Sentinel Event at the hospital. Review the Corrective Actions and ask these two questions:
1. Do they meet the needs of the system based on the findings?
2. Do you see a correlation with our three standard corrective actions above?
Maybe there is a pattern… let us know your thoughts.
Here is a link to the significant incident report:
It seems from the report that the appropriate seat belt was present. Therefore the only applicable action in the “Action required” section is:
“Workers should be instructed, through training and inductions, regarding the importance of using the seatbelts provided in vehicles to reduce the impact of potential collisions.”
In my instant root cause analysis using the Root Cause Tree®, I wonder why there wasn’t a Standards, Policies, and Administrative Controls Not Used Near Root Cause. That would get me to dig more deeply into the Enforcement NI root cause.
What do you think? Was this a training root cause that needs a training corrective action?
Leave your comments below…
Once you’ve gathered all the information you need for a TapRooT® investigation, you’re ready to start with the actual root cause analysis. However, it would be cumbersome to analyze the whole incident at once (like most systems expect you to do). Therefore, we break our investigation information into logical groups of information, called Causal Factor groups. So the first step here is to find Causal Factors.
Remember, a Causal Factor is nothing more than a mistake or an equipment failure that, if corrected, could have prevented the incident from happening (or at least made it less severe). So we’re looking for these mistakes or failures on our SnapCharT®. They often pop right off the page at you, but sometimes you need to look a little harder. One way to make Causal Factor identification easier is to think of these mistakes as failed or inappropriately applied Safeguards. Therefore, we can use a Safeguard Analysis to identify our Causal Factors.
There are just a few steps required to do this:
First, identify your Hazards, your Targets, and any Safeguards that were there, or should have been there.
Now, look for:
- an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;
- an error that allowed a Safeguard to be missing;
- an error that allowed a Safeguard to fail;
- an error that allowed the Target to get too close to a Hazard; or
- an error that allowed the Incident to become worse after it occurred.
These errors are most likely your Causal Factors.
Let’s look at an example. It’s actually not a full Incident, but a VERY near miss. This video is a little scary!
Let’s say we’ve collected all of our evidence, and the following SnapCharT is what we’ve found. NOTE: THIS IS NOT A REAL INVESTIGATION! I’m sure there is a LOT more info that I would normally gather, but let’s use this as an example on how to find Causal Factors. We’ll assume this is all the information we need here.
Now, we can identify the Hazards, Targets, and Safeguards:
|Pedestrians (they could have stayed off the tracks)|
Using the error questions above, we can see that:
- An error allowed the Hazard to be too large (the train was speeding)
- An error allowed the Targets to get too close to the Hazard (the Pedestrians decided to go through the fence, putting them almost in contact with the Hazard)
These 2 errors are our Causal Factors, and would be identified like this:
We can now move on to our root cause analysis to understand the human performance factors that lead to this nearly tragic Incident.
Causal Factors are an important tool that allow TapRooT® to quickly and accurately identify root causes to Incidents. Using Safeguard Analysis can make finding Causal Factors much simpler.
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I know how this works. You get the notification that “something bad” happened, and you are assigned to perform a root cause analysis. Your initial reaction is, “There goes the rest of my week!”
However, there is no reason that a relatively simple analysis needs to take an inordinate amount of time. There are several things you can do to make sure that you can efficiently conduct the investigation, find solid root causes, and implement effective corrective actions. Here are a few ideas to help you make the process as smooth as possible.
1. The first thing that needs to be in place is a Detailed Investigation Policy for your company. When does a RCA need to be performed? What types of problems trigger an RCA? What is the decision-making chain of command? Who makes the notifications? Who is notified? Who will be on the team? All of these questions need to be easily answered in order to quickly get the process started. I have seen investigators receive notification of a problem over a week after the actual incident. By this time, evidence has been lost, key players are no longer available, and peoples’ memories have faded. All of this makes the investigation just that much harder. If you can streamline this initial decision-making and notification process so that the investigation can start within hours, you’ll find the actual investigation goes MUCH more smoothly.
2. Probably the biggest timesaver is to Be Proficient in the TapRooT® Process. We recommend you use TapRooT® at least once per month to maintain proficiency in the system. You can’t be good at anything if you only use it sparingly. I often hear people tell me, “Luckily, we don’t have enough incidents to use TapRooT® more than once per year.” Imagine if I asked you to put together an Excel spreadsheet using pivot tables, and you haven’t opened Excel since 2014! You’d have to relearn some key concepts, slowing you down. The same is true of an investigation process. If you only do an investigation once each year, you aren’t looking very hard for incidents. I’ll guarantee there are plenty of things that need to be analyzed. Each analysis makes you that much better at the process. Maybe go back to point #1 above and update your investigation trigger points.
3. When you actually get started on an investigation, the first thing you should do is Start A Spring SnapCharT®. This initial chart gets your investigator juices flowing. It helps you think about the timeline of the incident, identifying holes in your knowledge and questions you need to ask in order to fill those holes. It is the first step in the process. As soon as you get that initial phone call, start building your SnapCharT®!
4. Finally, although it is optional, The TapRooT® Software can really speed up your analysis. The SnapCharT® tool is extremely user friendly, and the Root Cause Dictionary is only a right-click away. It guides you through the investigation process so you don’t have to try to remember where you’re going.
You won’t perform an investigation in 5 minutes. However, by following these tips, you relatively quickly and efficiently move through the process, with terrific results.
To learn more about learning all of the essential techniques to perform a root cause investigation, read about our 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
People are often surprised when they learn the reasons they haven’t taken root cause analysis training are invalid. Here are the top three excuses people give that are wrong:
1. Most employers aren’t seeking that skill when hiring.
Root cause analysis is a top skill valued by employers because mistakes don’t “just happen” but can be traced to well-defined causal factors that can be corrected. A bonus to root cause analysis training is that root causes identified over time across multiple occurrences can be used for proactive improvement. For example, if a significant number of investigations point to confusing or incomplete SPAC (Standards, Policies, or Admin Controls), improvement of this management system can begin. Trending of root causes allows development of systematic improvements as well as evaluation of the impact of corrective actions. What boss doesn’t appreciate an employee who can prevent HUGE problems and losses from occurring? Promoting your root cause analysis skills is an impressive topic of conversation on any job interview.
2. It takes too long to learn enough to really use it on my job.
In just 2 days you can learn all of the essentials to conduct a root cause analysis and add this impressive skill to your resume. You will be equipped 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.
There are all kinds of training programs you can enroll in for your career development that take months, even years, to complete. A 2-day investment for this valuable training program will equip you with a powerful skill that will set you apart from the rest.
3. I don’t have enough technical knowledge to take training like that.
It doesn’t matter if you have a high school diploma or an MBA. It doesn’t matter if you do not know much about root cause analysis beyond the description provided below. Our attendees, at every level of education and technical skill, find that they can engage in the training and take away root cause analysis skills to implement immediately. It is not a “sit and listen” training – attendees do hands on exercises to develop their new knowledge in the course.
Root cause analysis is a systematic process used in investigating and fixing the causes of major accidents, everyday incidents, minor near-misses, quality issues, human errors, maintenance problems, medical mistakes, productivity issues, manufacturing mistakes and environmental releases.
Root cause analysis training provides:
- the knowledge to identify what, how and why something happened, and this knowledge is vital to preventing it from happening again.
- the understanding that root causes are identifiable and can be managed with corrective actions.
- an ease of data collection, root cause identification, and corrective action recommendations and implementation.
Still not convinced root cause analysis training is for you?
GUARANTEE for the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course: Attend this course, go back to work, and use what you have learned to analyze accidents, incidents, near-misses, equipment failures, operating issues, or quality problems. If you don’t find root causes that you previously would have overlooked and if you and your management don’t agree that the corrective actions that you recommend are much more effective, just return your course materials/software and we will refund the entire course fee.
CLICK HERE to register for the 2-Day TapRooT® Incident Investigation and Root Cause Analysis Course.
You have established a good performance improvement program, supported by performing solid incident investigations. Your teams are finding good root causes, and your corrective action program is tracking through to completion. But you still seem to be seeing more repeat issues than you expect. What could be the problem?
We find many companies are doing a great job using TapRooT® to find and correct the root causes discovered during their investigations. But many companies are skipping over the Generic Cause Analysis portion of the investigation process. While fixing the individual root causes are likely to prevent that particular issue from happening again, allowing generic causes to fester can sometimes cause similar problems to pop up in unexpected areas.
6 Reasons to Look for Generic Root Causes
Here are 6 reasons to conduct a generic cause analysis on your investigation results:
1. The same incident occurs again at another facility.
2. Your annual review shows the same root cause from several incident investigations.
3. Your audits show recurrence of the same behavior issues.
4. You apply the same corrective action over and over.
5. Similar incidents occur in different departments.
6. The same Causal Factor keeps showing up.
These indicators point to the need to look deeper for generic causes. These generic issues are allowing similar root causes and causal factors to show up in seemingly unrelated incidents. When management is reviewing incident reports and audit findings, one of your checklist items should be to verify that generic causes were considered and either addressed or verified not to be present. Take a look at how your incident review checklist and make sure you are conducting a generic cause analysis during the investigation.
Finding and correcting generic causes are basically a freebie; you’ve already performed the investigation and root cause analysis. There is no reason not to take a few extra minutes and verify that you are fully addressing any generic issues.
United grounds all of their flights for two hours due to “computer problems” (see the CNBC story).
The NYSE stops trading for over three hours due to an “internal technical issue” (see the CNBC story).
Computer issues can cost companies big bucks and cause public relations headaches. Do you think they should be applying state of the art root cause analysis tools both reactively and proactively to prevent and avoid future problems?
TapRooT® has been used to improve computer reliability and security by performing root cause analysis of computer/IT related events and developing effective corrective actions. The first TapRooT® uses for computer/high reliability network problems where banking and communication service providers that started using TapRooT® in the late 1990’s. The first computer security application of TapRooT® that we knew about was in the early 2000s.
Need to improve your root cause analysis of computer and IT issues? Attend one of our TapRooT® Root Cause Analysis Courses. See the upcoming course schedule at:
The 22-year-old man died in hospital after the accident at a plant in Baunatal, 100km north of Frankfurt. He was working as part of a team of contractors installing the robot when it grabbed him, according to the German car manufacturer. Volkswagen’s Heiko Hillwig said it seemed that human error was to blame.
A worker grabs the wrong thing and often gets asked, “what were you thinking?” A robot picks up the wrong thing and we start looking for root causes.
Read the article below to learn more about the fatality and ask why would we not always look for root causes once we identify the actions that occurred?
“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.
No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions. On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.
You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:
1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)
2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)
3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!
4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.
Simple… yes? Maybe? Feel free to post your examples and thoughts.
We can all remember some type of major product recall that affected us in the past (tires, brakes, medicine….) or recalls that may be impacting us today (air bags). These recalls all have a major theme, a company made something and somebody got hurt or worse. This is a theme of “them verses those” perception.
Now stop and ask, when is the last time quality and safety was discussed as one topic in your current company’s operations?
You received a defective tool or product….
- You issued a defective tool or product….
- A customer complained….
- A customer was hurt….
Each of the occurrences above often triggers an owner for each type of problem:
- The supplier…
- The vendor…
- The contractor…
- The manufacturer….
- The end user….
Now stop and ask, who would investigate each type of problem? What tools would each group use to investigate? What are their expertise and experiences in investigation, evidence collection, root cause analysis, corrective action development or corrective action implementation?
This is where we create our own internal silo’s for problem solving; each problem often has it’s own department as listed in the company’s organizational chart:
- Customer Service (Quality)
- Manufacturing (Quality or Engineering)
- Supplier Management (Supply or Quality)
- EHS (Safety)
- Risk (Quality)
- Compliance (?)
The investigations then take the shape of the tools and experiences of those departments training and experiences.
Does anyone besides me see a problem or an opportunity here?
On May 5, 1988, one of United States’ worst oil refinery explosions occurred in Norco, Louisiana. There were six employees that were killed and 42 local residents injured. The blast was said to have reached up to 3o miles away shattering windows, lifting roofs and sending a black fog over the entire town of Norco. Residents were forced to evacuate while officials died the fires down and gathered as much rubble as possible to recover any bodies. In order to discover the root cause of this disaster, the Federal Occupational Health and Safety Administration as well as the Environment Protection Agency came and investigated the scene to gather information. The only possible root cause they could find was the catalytic cracking unit, machine used to break down crude oil into gasoline, because it was at the center of the explosion, but there was no definite cause found. Overall, the amount of damage done cost Shell millions of dollars and set an incredible amount of fear into the residents.
I was at a conference yesterday and one of the talks was about advanced root cause analysis. The presenter’s company had their own “home grown” root cause analysis system and they discovered that they were not getting consistent results. Improvement was needed!
They studied their system and discovered something that was missing – management system causes. In the TapRooT® System we have called these “Generic Causes” since we copyrighted the first TapRooT® manual in 1991.
It made me think … Why did they wait 24 years to discover something we’ve known about since before 1991?
Next, I talked with an engineer who had been trained in a common cause and effect system. He wasn’t too pleased with the results he was getting. He wanted to know how TapRooT® could help. Was it different?
I shared how TapRooT® works (see this LINK for the explanation) and it took quite a bit of effort to get beyond the cause and effect model that he thoroughly understood so that he could understand why he was missing things. He was really smart. He asked very insightful questions. He latched onto the reasons that the less systematic cause and effect analysis led to inconsistent results. He saw how TapRooT® could help investigators go beyond their paradigm and get consistent results.
By the end of this second conversation I started thinking … How did we get so far ahead of common root cause systems?
I think I know the answer.
It starts with the Human Factors training that I received at the University of Illinois. It really showed me how to think about human centered design – including designing a root cause analysis system that people could use consistently.
Second, I was fortunate enough to work in the Nuclear Navy where there was an excellent process safety culture and for Du Pont where there was an excellent industrial safety culture. This helped me see how management systems made a difference to performance. (My boss and I at Du Pont actually coined the phrase “Management System” that is now commonly used throughout industry.)
Third, I was well trained by my mentor at the University of Illinois, Dr. Charles O. Hopkins, how to do applied research. So the research I did studying root cause analysis in the mid-1980’s and early 1990’s really paid off when we created the TapRooT® System.
Fourth, we had a really good team that brought out the best in each other during the early development.
Next, we were lucky to have some excellent clients in the nuclear, oil, and aviation industries that were great early adopters and provided excellent feedback that we used to quickly improve TapRooT® root cause analysis in the early and mid-1990’s.
Finally, I made friends with and/or listened to many industry gurus who were experts in safety, process safety, quality, and equipment reliability. Their influence was built into TapRooT® and helped it be a world-class system even in it’s early stages. These experts included:
- Jerry Ledderer, aviation safety pioneer
- Dr. Charles O. Hopkins, human factors pioneer
- Smoke Price, human factors expert
- Larry Minnick, nuclear safety expert
- Rod Satterfield, nuclear safety expert
- Dr. Alan Swain, human reliability expert
- Heinz Bloch, equipment reliability expert
- Admiral Hyman Rickover, father of the Nuclear Navy and process safety expert
- Dr. Christopher Wickens, human factors expert
- Dr. Jens Rassmussen, system reliability and human factors expert
- W. Edwards Deming, quality management guru
- Admiral Dennis Wilkerson, first CO of the Nautilus and first CEO of INPO
That’s quite a list and I was lucky to be influenced by each of these great men. Their influence made TapRooT® root cause analysis far ahead of any other root cause tool.
So that’s why I shouldn’t be surprised that others are finally catching on to things that we knew 25 years ago. Perhaps in a century, they will catch up with the improvements we are making to TapRooT® today (with the help of thousands of users from around the world).
If you would like to learn the state-of-the-art of root cause analysis and not wait 25 to 100 years to catch up, perhaps you should attend a TapRooT® Course in the next month or two. See our course schedule for upcoming public courses at:
And get information about all the courses we offer at:
And if you would like to learn about the state of the art of performance improvement, attend the 2015 TapRooT® Summit coming up on June 1-5 in Las Vegas. Get more information and download the brochure at:
But don’t wait. Every day you wait you will be another day behind the state-of-the-art in root cause analysis and performance improvement. Don’t be left behind!
TapRooT® Root Cause Analysis
Changing the Way the World Solves Problems
Caution: Watching this Video can and will make you laugh…… then you realize you might be laughing at…
… your own actions.
… your understanding of other peoples actions.
… your past corrective or preventative actions.
Whether your role or passion is in safety, operations, quality, or finance…. “quality is about people and not product.” Interestingly enough, many people have not heard Dr. Deming’s concepts or listened to Dr. Deming talk. Yet his thoughts may help you understand the difference between people not doing their best and the best the process and management will all to be produced.
To learn more about quality process thoughts and how TapRooT® can integrate with your frontline activities to sustain company performance excellence, join a panel of Best Practice Presenters in our TapRooT® Summit Track 2015 this June in Las Vegas. A Summit Week that reminds you that learning and people are your most vital variables to success and safety.
To learn more about our Summit Track please go to this link. https://www.taproot.com/taproot-summit
If you have trouble getting access to the video, you can also use this link http://youtu.be/mCkTy-RUNbw
There they go again. HUMAN ERROR as a root cause.
Haven’t they read my article at:
Human error is a symptom, not the root cause.
Attend a TapRooT® Course and find out how you can find and fix the real causes of human error.
When using TapRooT®, most of the terms are pretty self-explanatory. TapRooT® is pretty easy to understand and use. However, there are a few terms that we use that may be a little different than those you might be used to. I thought I’d give a few definitions to help make things just a little bit clearer.
Root Cause Tree®: This is the heart of the TapRooT® system. It is contains the guidance and the root causes needed by the investigator.
Root Cause Dictionary®: Contains a list of bulleted yes/no questions that guide your investigator through the Root Cause Tree®.
SnapCharT®: This is a visual representation of the investigation. It is used to document the evidence you find during your investigation, allows you to identify Causal Factors, and is used with the Root Cause Tree® during the analysis. It contains the Incident, Event, and Condition shapes.
Incident: This is the reason you are performing the investigation. It is the problem that lead you to start your TapRooT® process. It is a circle on your SnapCharT®.
Event: An action performed by someone or a piece of equipment. They are arranged in chronological order as rectangles on the SnapCharT®.
Condition: A piece of information that describes the Event that it is attached to. Represented by an oval on the SnapCharT®.
Root Cause: The absence of best practices or the failure to apply knowledge that would have prevented the problem (or significantly reduced the likelihood or consequences of the problem).
Causal Factor: Mistake or failure that, if corrected, could have prevented the Incident from occurring, or would have significantly mitigated its consequences.
Generic Cause: A systemic problem that allows a root cause to exist.
Airplane loses power during take off at a Kansas Airport and plane strikes building. Pilot of the King Air Aircraft that crashed and 3 people working in a flight simulator inside that building are dead. Read more here at KAKE News in Wichita, KS.
I post this because of the debates and blame that are going to ensue. Was it just one thing, the plane crashing, that caused this issue to occur? Was it the location of all the flight buildings in the vicinity of an airport. Was this just a “freak accident”. So much more to learn… I hope they get it right so it does not happen again.
But there can be times when an investigator needs to ask for help. When should you ask for help with an investigation?
Here are eight examples that could help you decide when to ask for help:
1. LEGAL ISSUES
Could this accident end up in court? If so, you need the help of your company’s attorney.
They may need to be involved BEFORE the investigation starts to establish “attorney/client privilege.” In these cases, the attorney may want to hire an outside expert to review the company’s investigation and help spot potential weaknesses before legal action starts.
2. CUSTOMER DISPUTE
It’s always tough when a customer has a problem and blames your product. What do you do if you think that the product was OK but, instead, the customer’s actions caused the problem? Root cause analysis could be a big help.
But will the customer believe the results of your employees’ investigation? This is a good time to get an outside facilitator to provide an independent perspective or lead a joint customer/supplier investigation.
3. UNION ISSUE
Ever had an investigation that gets contentious with a union?
This may be time to ask for help. An outside facilitator provides an independent perspective and can help both sides see how to achieve improvement. This can be a win-win investigation.
4. COMPLEX ACCIDENTS
TapRooT® Training is a great start for a new investigator. But, as we say in the course, get your feet wet when you go back to work by performing some easy investigations.
What if a complex accident happens when you are newly training? Ask for help! Get an experienced investigator to help you facilitate the investigation or to review your work and coach you.
What if you don’t have any experienced investigators at your site? Call SI at 865-539-2139. We have experienced investigators who can help.
5. INDEPENDENT INVESTIGATION / NEW SET OF EYES
Sometimes management may want a fresh set of eyes to look at a problem. An independent investigator may bring a different background, new knowledge, and the ability to see beyond “that’s the way we’ve always done it.” This can challenge “common knowledge” and go beyond groupthink.
6. CONTROVERSIAL INVESTIGATION
I’ve seen investigations that might result in someone in upper management losing their job. Nobody wanted to be on the investigation team because they didn’t want to be the one who got a senior manager fired. (Payback from friends of the one fired is a real problem.) So an independent investigator could step into this controversial situation without fear of retribution.
Even if your investigations aren’t too hard, you may want to hire our experienced investigators to provide feedback (coaching) on your “everyday” investigations so that your investigators constantly improve. If this sounds helpful, once again, give us a call.
Too many accidents to investigate? Augment your staff with facilitators to help investigate incidents and provide your investigators with valuable feedback.
Again, we can help. Our 40+ experienced TapRooT® Investigators from around-the-world provide help when you need it.
Still not sure? Contact us at: http://www.taproot.com/contact-us for more information.
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.
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