Category: Root Causes

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

August 30th, 2017 by

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Here is an e-mail I received in response to my recent articles about the Navy’s collision root cause analysis:

As a former naval officer (and one who has navigated the infamous Strait of Malacca as Officer of the Deck on a warship bridge twice), I read your post with interest and wanted to respond.  You understandably criticize the Navy for taking disciplinary action early on in the investigation process, but you fail to understand the full scope of the military’s response to such incidents.  Yes, punishment was swift – right or wrong from a civilian perspective, that’s how the military holds its leaders accountable.  And make no mistake: The leadership of USS Fitzgerald is ultimately responsible and accountable for this tragedy.  (Same goes for the most recent collision involving USS John S. McCain, which also led to the ‘firing’ of the Commander of the 7th Fleet – a Vice Admiral nonetheless.)  That’s just how the military is, was, and always will be, because its disciplinary system is rooted in (and necessary for) war fighting.  

But don’t confuse accountability with cause.  No one in the Navy believes that relieving these sailors is the solution to the problem of at-sea collisions and therefore the ONLY cause.  I won’t speculate on causal factors, but I’m confident they will delve into training, seamanship, communications, over-reliance on technology and many other factors that could’ve been at work in these incidents.  It’s inaccurate and premature for anyone outside the investigation team to charge that the Navy’s root cause analysis began and ended with disciplinary actions.  How effective the final corrective actions are in preventing similar tragedies at-sea in the future will be the real measure of how effective their investigation and root cause analysis are, whether they use TapRooT, Apollo (my company uses both) or any other methodology.

I appreciate his feedback but I believe that many may be misunderstanding what I wrote and why I wrote it. Therefore, here is my response to his e-mail:

Thanks for your response. What I am going to say in response may seem pretty harsh but I’m not mad at you. I’m mad at those responsible for not taking action a decade ago to prevent these accidents today.

 

I’m also a previously qualified SWO who has been an OOD in some pretty tight quarters. The real question is … Why haven’t they solved this problem with prior accidents. The root causes of these collisions have existed for years (some might say over a decade or maybe two). Yet the fixes to prior accidents were superficial and DISCIPLINE was the main corrective action. This proves the Navy’s root cause analysis is inadequate in the past and, I fear, just as inadequate today.

 
These two ships weren’t at war and, even if they were, blaming the CO and the OOD almost never causes the real root causes of the issues to get fixed. 
 
I seem pretty worked up about this because I don’t want to see more young sailors needlessly killed so that top brass can make their deployment schedules work while cutting the number of ships (and the manning for the ships) and the budget for training and maintenance. Someone high up has to stand up and say to Congress and the President – enough is enough. This really is the CNO’s job. Making that stand is really supporting our troops. They deserve leadership that will make reasonable deployment and watch schedules and will demand the budget, staffing, and ships to meet our operational requirements.
 
By the way, long ago (and even more recently) I’ve seen the Navy punishment system work. Luckily, I was never on the receiving end (but I could have been if I hadn’t transferred off the ship just months before). And in another case, I know the CO who was punished. In each case, the CO who was there for the collision or the ship damage was punished for things that really weren’t his fault. Why? To protect those above him for poor operational, maintenance, budget, and training issues. Blaming the CO is a convenient way to stop blame from rising to Admirals or Congress and the President.
 
That’s why I doubt there will be a real root cause analysis of these accidents. If there is, it will require immediate reductions in operation tempo until new training programs are implemented, new ships can be built, and manning can be increased to support the new ships (and our current ships). How long will this take? Five to 10 years at best. Of course it has taken over 20 years for the problem to get this bad (it started slowly in the late 80s). President Trump says he wants to rebuild the military – this is his chance to do something about that.
 
Here are some previous blog articles that go back about a decade (when the blog started) about mainly submarine accidents and discipline just to prove this really isn’t a recent phenomenon. It has been coming for a while…. 
 
USS Hartford collision:
 
 
 
 
USS Greeneville collision:
 
 
USS San Francisco hits undersea mountain:
 
 
USS Hampton ORSE Board chemistry cheating scandal:
 
 
I don’t write about every accident or people would think I was writing for the Navy Times, but you get the idea. Note, some links in the posts are missing because of the age of these posts, but it will give you an idea that the problems we face today aren’t new (even if they are worse) and the Navy’s top secret root cause system – discipline those involved – hasn’t worked.
 
Are these problems getting worse because of a lack of previous thorough root cause analysis and corrective actions? Unfortunately, we don’t have the data to see a trend. How many more young men and women need to die before we take effective action – I hope none but a fear it will be many.
 
Thanks again for your comment and Best Regards,
 
Mark Paradies
President, System Improvements, Inc.
The TapRooT® Folks

I’m not against the Navy or the military. I support our troops. I am against the needless loss of life. We need to fix this problem before we have a real naval battle (warfare at sea) and suffer unnecessary losses because of our lack of preparedness. If we can’t sail our ships we will have real problems fighting with them.

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Interesting Story – Was Quarry Employee Responsible for His Own Death?

August 24th, 2017 by

Jim Whiting, one of our TapRooT® Instructors in Australia, set me this article:

MCG Quarries blames Sean Scovell, 21, for his own death in 2012

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Read the article. What do you think? Where does self responsibility end and management responsibility start? What would your root cause analysis say?

Is There Just One Root Cause for a Major Accident?

July 26th, 2017 by

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Some people might say that the Officer of The Deck on the USS Fitzgerald goofed up. He turned in front of a containership and caused an accident.

Wait a second. Major accidents are NEVER that simple. There are almost always multiple things that went wrong. Multiple “Causal Factors” that could be eliminated and … if they were … would have prevented the accident or significantly reduced the accident’s consequences.

The “One Root Cause” assumption gets many investigators in trouble when performing a root cause analysis. They think they can ask “why” five times and find THE ROOT CAUSE.

TapRooT® Investigators never make this “single root cause” mistake. They start by developing a complete sequence of events that led to the accident. They do this by drawing a SnapCharT® (either using yellow stickies or using the TapRooT® Software).

They then use one of several methods to make sure they identify ALL the Causal Factors.

When they have identified the Causal Factors, they aren’t done. They are just getting started.

EACH of the Causal Factors are taken through the TapRooT® Root Cause Tree®, using the Root Cause Tree® Dictionary,  and all the root causes for each Causal Factor are identified.

That’s right. There may be more than one root cause for each Causal Factor. Think of it as there may be more than one best practice to implement to prevent that Causal Factor from happening again.

TapRooT® Investigators go even one step further. They look for Generic Causes.

What is a Generic Cause? The system problem that allowed the root cause to exist.

Here’s a simple example. Let’s say that you find a simple typo in a procedure. That typo cause an error.

Of course, you would fix the typo. But you would also ask …

Why was the typo allowed to exist?

Wasn’t there a proofing process? Why didn’t operators who used the procedure in the past report the problem they spotted (assuming that this is the first time there was an error and the procedure had been used before)?

You might find that there is an ineffective proofing process or that the proofing process isn’t being performed. You might find that operators had previously reported the problem but it had never been fixed.

If you find there is a Generic Cause, you then have to think about all the other procedures that might have similar problems and how to fix the system problem (or problems). Of course, ideas to help you do this are included in the TapRooT® Corrective Action Helper® Guide.

So, in a major accident like the wreck of the USS Fitzgerald, there are probably multiple mistakes that were made (multiple Causal Factors), multiple root causes, some Generic Causes, and lots of corrective actions that could improve performance and stop future collisions.

To learn advanced root cause analysis, attend a public TapRooT® Courses. See the dates and locations here:

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

Or schedule a course at your facility for 10 or more of people. CLICK HERE to get a quote for a course at your site.

Where did you eat last weekend? (or, why do companies continue to not learn from their mistakes?)

July 24th, 2017 by

Happy Monday. I hope everyone had a good weekend and got recharged for the week ahead.

Every few weeks, I get a craving for Mexican food. Maybe a sit-down meal with a combo plate and a Margarita, maybe Tex-Mex or maybe traditional. It’s all good.

Sometimes, though, a simple California Style Burrito does the trick. This weekend was one of those weekends. Let’s see, what are my choices…? Moe’s, Willy’s, Qdoba, Chipotle?

Chipotle? What??!!!

Unfortunately, Chipotle is back in the news. More sick people. Rats falling from the ceiling. Not good.

It seems like we have been here before. I must admit I did not think they would survive last time, but they did. What about this time? In the current world of social media we shall see.

For those of us in safety or quality, the story is all too familiar. The same problem keeps happening. Over and Over…and Over

So why do companies continue to not learn from mistakes? A few possible reasons:

**They don’t care
**They are incompetent
**They don’t get to true root causes when investigating problems
**They write poor corrective actions
**They don’t have the systems in place for good performance or performance improvement

TapRooT® can help with the last three. Please join us at a future course; you can see the schedule and enroll HERE

So, what do you think? Why do companies not learn from their mistakes? Leave comments below.

By the way, my Burrito from Moe’s was great!

What is the Root Cause of the USS Fitzgerald Collision?

July 17th, 2017 by

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As a root cause analysis expert and former US Navy Officer who was qualified as a Surface Warfare Officer (SWO) and was qualified to stand underway steaming Officer of the Deck watches, I’ve had many friends ask me what was the root cause of the collision of the USS Fitzgerald.

Of course, the answer is that all the facts aren’t yet in. But that never keeps us from speculation…

But before I speculate, let’s honor the seven crew members who died as a result of this accident: Dakota Kyle Rigsby. Shingo Alexander Douglass. Ngoc T Truong Huynh. Noe Hernandez. Carlos Victor Ganzon Sibayan. Xavier Alec Martin. Gary Leo Rehm Jr.

Also, let’s note that the reason for good root cause analysis is to prevent fatalities and injuries by solving the problems discovered in an accident to keep a similar repeat accident from happening in the future.

Mia Culpa: It’s been a long time since I stood a bridge watch. I’m not familiar with the current state of naval readiness and training. However, my general opinion is that you should never turn in front of a containership. They are big. Even at night you can see them (commercial ships are often lit up). They are obvious on even a simple radar. So what could have gone wrong?

1. It was the middle of the night. I would bet that one thing that has not changed since I was in the Navy is FATIGUE. It would be interesting to see the Oficer of the Deck’s and the Conning Officer’s (if there was one) sleep schedule for the previous seven days. Fatigue was rampant when I was at sea in the navy. “Stupid” mistakes are often made by fatigued sailors. And who is to blame for the fatigue? It is built into the system. It is almost invisible. It is so rampant that no one even asks about it. You are suppose to be able to do your job with no sleep. Of course, this doesn’t work.

2. Where was the CO? I heard that the ship was in a shipping lane. Even though it was the middle of the night, I thought … where was the Commanding Officer? Our standing orders (rules for the Officer of the Deck) had us wake the CO if a contact (other ship) was getting close. If we had any doubt, we were to get him to the bridge (usually his sea cabin was only a couple of steps from the bridge). And the CO’s on the ships I was on were ALWAYS on the bridge when we were in a shipping lane. Why? Because in shipping lanes you are constantly having nearby contacts. Sometimes the CO even slept in their bridge chair, if nothing was going on, just so they would be handy if something happened. Commander Benson (the CO) had only been in his job for a month. He had previously been the Executive Officer. Did this have any impact on his relationship with bridge watchstanders?

3. Where was the CIC watch team?  On a Navy ship you have support. Besides the bridge watch team, you are supported by the Combat Information Center. They constantly monitor the radars for contacts (other ships or aircraft) and they should contact the Officer of the Deck if they see any problems. If the OOD doesn’t respond … they can contact the Commanding Officer (this would be rare – I never saw it done). Why didn’t they intervene?

4. Chicken of the Sea. Navy ships are notorious for staying away from other ships. Many Captains of commercial shipping referred to US Navy ships as “chickens of the sea” because they steered clear of any other traffic. Why was the Fitzgerald so close to commercial shipping?

5. Experience. One thing I always wonder about is the experience of the crew and especially the officers on a US Navy ship. Typically, junior officers stand Officer of the Deck watches at sea. They have from a two to three year tour of duty and standing bridge watches is one of many things they do. Often, they don’t have extensive experience as an Officer of the Deck. How much experience did this watch team have? Once again, the experience of the team is NOT the team’s fault. It is a product of the system to train naval officers. Did it play a factor?

6. Two crews. The US Navy is trying out a new way of manning ships with two crews. One crew is off while the other goes to sea. This keeps the ship on station longer than a crew could stand to be deployed. But the crew is less familiar with the ship as they are only on it about 1/2 the time. I read some articles about this and couldn’t tell if the USS Fitzgerald was in this program or not (the program is for forward deployed ships like the Fitzgerald). Was this another factor?

These six factors are some of the many factors that investigators should be looking into. Of course, with a TapRooT® investigation, we would start with a detailed SnapCharT® of what happened BEFORE we would collect facts about why the Causal Factors happened. Unfortunately, the US Navy doesn’t do TapRooT® investigations. Let’s hope this investigation gets beyond blame to find the real root causes of this fatal collision at sea.

“Human Error” by Maintenance Crew is “Cause” of NYC Subway Derailment. Two Supervisors Suspended Without Pay.

June 29th, 2017 by

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The New York Daily News says that a piece of track was left between the rails during repair of track on the NYC subway system. That loose track may have caused the derailment of an eight car train.

The rule is that any track less than 19.5 feet either be bolted down or removed. It seems that others say that the “practice” is somewhat different. This piece of track was only 13.5 feet long and was not bolted down.

But don’t worry. Two supervisors have been suspended without pay. And workers are riding the railed looking for other loose equipment between the rails. Problem solved. Human error root cause fixed…

Time for Advanced Root Cause Analysis of Special Operations Sky Diving Deaths?

May 31st, 2017 by

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Click on the image above for a Navy Times article about the accident at a recent deadly demonstration jump over the Hudson River.

Perhaps it’s time for a better root cause analysis of the problems causing these accidents?

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.

Root Cause Analysis Resource for Low-to-Medium Risk Incidents

May 11th, 2017 by

Our recent release, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is in it’s second printing! This popular book helps investigators develop a clear sequence of events, identify causal factors, find the real root causes and develop corrective actions that work.

Course attendees also receive this book in our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training and our 2-Day TapRooT® Root Cause Analysis training.  The book may also be purchased from the web store as part of a set (with our Major Investigation book):

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

It is the most practical tool any investigator can have on his/her desk to refresh his/her knowledge and is written in an easy-to reference format.  Do you have a copy of the new book?  Comment below with your thoughts.

 

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 attending the ASQ World Conference on Quality in Charlotte?

April 19th, 2017 by

If you are attending the conference, please stop by the TapRooT® Booth (#213) and say hello. Chris Vallee, Per Ohstrom, and I will be there.

The first 500 visitors will receive a special gift, the world’s fastest root cause analysis tool!

Bring a business card and enter the drawing for cool TapRooT® stuff during the Tuesday exhibit hall extravaganza.

Want to see the new TapRooT® VI 6.2.0 software? Come by on Tuesday from 09:00-1:30 and we’ll be happy to walk through a quality example for you.

See you then!

Why Does TapRooT® Exist?

March 28th, 2017 by

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to:

  • Save lives
  • Prevent injuries
  • Improve product/service quality
  • Improve equipment reliability
  • Make work easier and more productive
  • Stop sentinel events
  • Stop the cycle of blaming people for system caused errors

And we are accomplishing our mission around the world.

Of course, there is still a lot to do. If you would like to learn more about using TapRooT® Root Cause Analysis to help your company accomplish these things, get more information about TapRooT® HERE or attend one of our courses (get info HERE).

If you would like to learn how others have used TapRooT® to meet the objectives laid out above, see the Success Stories at:

http://www.taproot.com/archives/category/success-stories

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:

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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!

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

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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

How can TapRooT® help with your ISO programs (or other management system issues)?

January 25th, 2017 by

Happy Wednesday and welcome to this week’s root cause analysis tips.

Many companies are ISO certified and some of those that are not have some type of management system. There are too many different systems and standards out there to discuss individually, but one of the common themes is continuous improvement.

Whether you use a commonly known management system or developed your own, one of your goals should be to improve your system/business. When I think of a management system, I think of it as a framework for how you manage your business. Whether required or not, incorporating continuous improvement is a smart thing to do.

While ISO has hundreds of standards, some of the most commonly known are 9000 (Quality) and 14000 (Environmental); coming down the pike soon is 45001 (Safety). There are also numerous industry specific standards. Many of the ISO standards use a common framework that includes the PDCA (plan, do, check, act) cycle. This is where TapRooT® can help.

PDCA is a simple process that has been in use widely since the 1950’s. I do not know many processes that have endured that long. So why? Because it is easy and it works.

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As part of PDCA, you have to determine what to fix, how to fix it, and whether it works. Sounds a little like root cause analysis and corrective action, doesn’t it? So if you were going to use PDCA to help solve your problems, what would you use for root cause analysis? If I were you, I would use TapRooT®. Need help with corrective actions? Use the Corrective Action Helper®, SMARTER Matrix, and Safeguards hierarchy. You can incorporate TapRooT® tools into any improvement framework you use.

Also, don’t forget the importance of auditing. This should be part of your management system as well. We’ve taught auditing with TapRooT® for years, but we recently developed a new course specifically for Auditors, TapRooT® for Audits, and wrote a new book, TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement. The primary topic of the book is auditing, but we also have a short section on PDCA. We’ll be teaching this course in Charlotte, NC in May if you would like to join us. Or, if you are already TapRooT® trained, you can get the book on our store.

Audits Kit

Thanks for reading the blog, and best of luck with your improvement efforts.

You are just one Causal Factor from your next major Incident. Can you prevent it?

July 5th, 2016 by

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Words that I hate to hear when asked to help with an investigation: “I am surprised this incident did not happen earlier!” Rarely have I seen an incident where there is not a history of the same problems occurring.  Think of it like a math equation:

X + Y (A) = The Incident

A company’s issues are just waiting for the right math equation to occur at the right time. What are some of the common factors that populate the equation above?

  • Audit Findings (risk or compliance)
  • Near Misses (or some cases, Near Hits)
  • OSHA Non-Recordable(s)
  • Defects (caught before the defect reached the customer)
  • Project Delays
  • Procurement Issues
  • Behavior Based Safety Entries

This list of variables is infinite and dependent on the industry and service or product that your company provides. Should you be required to perform a full root cause analysis on each and every write-up or issue listed above to prevent an Incident? Not, necessarily.

Instead, I recommend that you start looking at what would be a risk to employees, customers, environment, product/service or future company success if you combined any of your issues in the same timeline or process of transactions (in TapRooT® our timeline is called a SnapCharT®). For example, take the 3 issues listed below that have a higher potential of incident occurrence when combined in the right equation.

Issue 1: Audit finding for outdated procedures found in a laboratory for testing blood samples.

Issue 2: Behavior Based Safety Write-up entered for cracked and faded face shields

Issue 3: Older Blood Analyzer has open equipment work orders for service issues.

Combining the 3 items above could cause a contaminated blood sample, exposure of contaminated blood to the lab worker or a failed test sample to the patient.

If the cautions about your future combination of known issues are not heeded then please do not acted surprised after the future Incident occurs.

Want to learn about causal factors? It’s not too late to sign up for our Advanced Causal Factor Development Course, August 1-2, 2016, San Antonio, Texas.

Need to Learn Root Cause Essentials Before the Global Summit? Here is the Solution!

June 3rd, 2016 by

We’re offering our 2-day course right before the Global TapRooT® Summit!  Take the course and then stay for the 3-day Summit.  LEARN MORE!

 

Root Cause Analysis on Trends

June 2nd, 2016 by

Welcome to this week’s root cause analysis tips. This week I would like to talk about root cause analysis on trends.

One of the most common discussions I have with people involves what to do with the things you do not have time to investigate. Many companies use some sort of ranking or risk matrix to determine at what point something is important enough to warrant an investigation. I have some thoughts on this…

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Sometimes people try to investigate everything and end up doing poor investigations.

First of all, sometimes people try to investigate everything and end up doing poor investigations on everything; that does not help anybody. One consideration on where to draw the line is related to your current numbers. For example, if you work in a plant that has a few incidents per year, if you have the resources to investigate, I say do it. But if you are looking at large numbers at a corporate level, you may not have the resources – and you have to decide where to draw the line.

So what about the minor incidents you have that don’t get investigated – what to do with them? Well, it goes beyond minor incidents, you have other things that can be trended, rootcaused (is that a word?), and corrected. It is actually quite easy to investigate a trend, the hard part is actually collecting the data. I call this getting things in the “right bucket.” Here are some examples of information you might collect (or should):

• Minor incidents
• Near Misses
• Audit Findings
• BBS Observations

If you do a good job of collecting data, you can then trend the information. Your trends should reveal what processes are causing you pain. You then investigate the PROCESS, rather than an incident. For example, let’s say you had some near misses, some audit findings, and some BBS observations related to your lockout/tagout process that revealed issues. You may have not had a major incident yet, but you have warning signs. You can’t (or don’t have time to) go back and do full blown investigations on each data point, so you map out the process with a SnapCharT®, adding everything you know about the process as conditions, and based on that information, you identify your known failures and potential failures as Significant Issues (the equivalent to Causal Factors) in TapRooT®. Then off to the Root Cause Tree® and corrective actions. You’ve done ONE investigation on potentially dozens (or hundreds) of issues. This is more effective and much easier than doing multiple bad investigations.

Investigation of trends is a very important consideration in Audit Programs. Again, do you have time to investigate every finding? Maybe not. Here is an example:

A corporate auditor for a big box store has 100 compliance questions on a checklist and 100 locations that were audited using this checklist in the past year. That is a fair amount of data. The auditor can use this data to develop a list of top findings and then analyze the biggest issues.

The data for the yearly compliance is presented on a Pareto Chart below.

Screen Shot 2016-05-10 at 4.02.03 PM

The top two categories are related to a similar topic: required signage. The audits have revealed both missing signs and outdated signs. Let’s look at these issues together on a SnapCharT®. Significant Issues are marked with a triangle:

Screen Shot 2016-05-10 at 4.02.24 PM

Next, you take the Significant Issues through the Root Cause Tree®, and apply corrective actions. One investigation on dozens of findings.

I hate to use clichés, but WORK SMARTER NOT HARDER!

If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on May 4-5.

Thanks for taking the time to read the blog, and happy auditing.

Root Cause Analysis Tip: Use the Dictionary!

May 19th, 2016 by

TapRooT® Users have more than a root cause analysis tool. They have an investigation and root cause analysis system.

The TapRooT® System does more than root cause analysis. It helps you investigate the problem, collect and organize the information about what happened. Identify all the Causal Factors and then find their root causes. Finally, it helps you develop effective fixes.

But even that isn’t all that the TapRooT® System does. It helps companies TREND their problem data to spot areas needing improvement and measure performance.

One key to all this “functionality” is the systematic processes built into the TapRooT® System. One of those systematic processes is the Root Cause Tree® and Dictionary.

2016Dictionary

The Root Cause Tree® Dictionary is a detailed set of questions that helps you consistently identify root causes using the evidence you collected and organized on your SnapCharT®.

For each node on the TapRooT® Root Cause Tree® Diagram, there is a set of questions that define that node. If you get a yes for any of those questions, it indicates that you should continue down that path to see if there is an applicable root cause. Atr the root cause level, you answer the questions to see if you have the evidence you need to identify a problem that needs fixing (needs improvement).

HotCold2

For example, to determine if the root cause “hot/cold” under the Work Environment Near Root Cause under the Human Engineering Basic Cause Category is a root cause, you would answer the questions (shown in the Dictionary above):

  1. Was an issue cause by excessive exposure of personnel to hot or cold environments (for example, heat exhaustion or numbness from the cold)?
  2. Did hurrying to get out of an excessively hot or cold environment contribute to the issue?
  3. Did workers have trouble feeling items because gloves were worn to protect them from cold or hot temperatures?

If you get a “Yes” then you have a problem to solve.

How do you solve it? You use Safeguards Analysis and the Corrective Action Helper® Guide. Attend one of our TapRooT® Root Cause Analysis Courses to learn all the secrets of the advanced TapRooT® Root Cause Analysis System.

The TapRooT® Root Cause Tree® Dictionary provides a common root cause analysis language for your investigators. The Dictionary helps the investigators consistently find root causes using their investigation evidence, This makes for consistent root cause analysis identification and the ability to trend the results.

The expert systems built into the Root Cause Tree® Diagram and Dictionary expand the number of root causes that investigators look for and helps investigators identify root causes that they previously would have overlooked. This helps companies more quickly improve performance by solving human performance issues that previously would NOT have been identified and, therefore, would not have been fixed.

Are you using a tool or a system?

If you need the most advanced root cause analysis system, attend one of our public TapRooT® Courses. Here are a few that are coming up in the next six months:

2-Day TapRooT® Root Cause Analysis Training

 Dublin, Ireland      June 8-9, 2016

Pittsburgh, PA   June 20-21, 2016

Hartford, CT       July 13-14, 2016

San Antonio, TX   August, 1-2, 2016

Copenhagen, Denmark September 22-23, 2016

 

2-Day TapRooT®/Equifactor® Equipment Troubleshooting & Root Cause Analysis Training

San Antonio, TX   August 1-2, 2016

 

5-Day TapRooT® Advanced Root Cause Analysis Training

Houston, TX           June 13-17, 2016

Gatlinburg, TN          June 20-24, 2016

Niagara Falls, Canada July 11-15, 2016

Monterrey, Mexico   August 22-26, 2016

Mumbai, India   August 29 – September 2, 2016

Aberdeen, Scotland  September 19-23, 2016

For the complete list of current courses held around the world, see: http://www.taproot.com/store/Courses/.

To hold a course at your site, contact us by CLICKING HERE.

(Note: Copyrighted material shown above is used by permission of System Improvements.)

When the Message does not Communicate the Message in Healthcare

May 16th, 2016 by

This week’s article is not so much based on RCA principles but on the decisions that senior leaders make and the consequences of those actions. I always highlight from an RCA perspective the impact of the messages and communications from senior leadership down through the organization and the possible negative consequences. But this takes the cake… or the donut, if you will.

Saw an article today about the University of North Carolina’s decision to remove the name of their newest (7-month-old) corporate sponsor off of their UNC Children’s Clinic. That corporate sponsor… wait for it…

“Krispy Kreme”

Now, I am surely no marketing genius (my strengths are more in the training and RCA world) but could anyone associated with the organization see past the $$$$ to know that this was not a good idea? In today’s money driven society there are reasons that sponsors are invited, and in most cases these are due to a lack of funding and a desire to continue doing good deeds and good work. But sometimes the word “NO” is very much underutilized.

What message was sent to all those Doctors and Nurses? To all the parents bringing their children for care to the clinic? Is it the health, care and safety of their young loved ones? Or is it something else? I certainly don’t want to be treated for a clogged artery in the “Beef it’s What’s For Dinner Cath lab”, or be treated for a peanut allergy in the “Peanut M & M’s Allergy Center.”

Now if you read the full article the name was tied to a fund-raising race and the Clinic and UNC’s dedication to it. But always remember that what you perceive the message to be may not be what is received. I have worked with investigations where too many times the Administration says one thing and a totally different message is received. From an RCA perspective in the diagram below you will see that the Administration/Management interview circle is dotted… in TapRooT® circles that means an assumption or unknown.  

whotointerview

From a data gathering perspective, this means that I need to compare what Administration/Management believes/says/communicates is what is understood by the masses. To understand if the true message has reached those who need it. And in the case of this article I believe that they totally missed the mark with all the right intentions. Let me know what you believe in the comments below.

If you would like to know more about TapRooT® or if you have any questions you can contact me at skompski@taproot.com or you can find out about our public course offerings at:

www.taproot.com/courses.

 

AFL-CIO releases “Death on the Job” Report

April 28th, 2016 by

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For the 25th year, the AFL-CIO has produced a report about the the state of safety and health for American workers. The report states that in 2014, 4,821 workers were killed on the job in the U.S., and approximately 50,000 died from occupational diseases. This indicates a loss of 150 workers each day from hazardous conditions.

READ the full report.

The EPA’s Revision to the Risk Management Plan Regulation is Open for Comments

March 30th, 2016 by

The modifications have been published in the Federal Register. See:

https://www.federalregister.gov/articles/2016/03/14/2016-05191/accidental-release-prevention-requirements-risk-management-programs-under-the-clean-air-act

To see the previous article about the modifications and their impact on root cause analysis, see:

http://www.taproot.com/archives/53634

Hurry if you want to submit comments. The register says:

“Comments: Comments and additional material must be received on or before May 13, 2016. Under the Paperwork Reduction Act (PRA), comments on the information collection provisions are best assured of consideration if the Office of Management and Budget (OMB) receives a copy of your comments on or before April 13, 2016.Public Hearing. The EPA will hold a public hearing on this proposed rule on March 29, 2016 in Washington, DC.”

April 13, 2016, isn’t far away!

For comment information, see:

https://www.regulations.gov/#!documentDetail;D=EPA-HQ-OEM-2015-0725-0001

To add your comment, see:

https://www.regulations.gov/#!submitComment;D=EPA-HQ-OEM-2015-0725-0001

Protection Through Prevention – A Study in Root Cause Analysis of Patient Safety Events

March 24th, 2016 by

As we on focus patient safety during this week, I thought it prudent to examine one of the more important aspects of providing a safe environment of care for our patients, the use of Root Cause Analysis (RCA) to prevent future events.  If we perform very thorough objective analysis, we can build corrective and preventative measures that will improve our systems and reduce or remove the chances for future similar events.

In the case study below, we’ll examine a medication error that affected one patient, could have affected two patients (due to swapped medications) but did not due to the quick response by the treatment team.  Learn to better analyze and create a safer environment for our patients, staff, and community.

DOWNLOAD this white paper.

 

Does A Good Quality Management System equate to Compliance?

March 8th, 2016 by

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If it is written down, it must be followed. This means it must be correct… right?

Lack of compliance discussion triggers that I see often are:

  • Defective products or services
  • Audit findings
  • Rework and scrap

So the next questions that I often ask when compliance is “apparent” are:

  • Do these defects happen when standard, policies and administrative controls are in place and followed?
  • What were the root causes for the audit findings?
  • What were the root causes for the rework and scrap?

In a purely compliance driven company, I often here these answers:

  • It was a complacency issue
  • The employees were transferred…. Sometimes right out the door
  • Employee was retrained and the other employees were reminded on why it is important to do the job as required.

So is compliance in itself a bad thing? No, but compliance to poor processes just means poor output always.

Should employees be able to question current standards, policies and administrative controls? Yes, at the proper time and in the right manner. Please note that in cases of emergencies and process work stop requests, that the time is mostly likely now.

What are some options to removing the blinders of pure compliance?

GOAL (Go Out And Look)

  • Evaluate your training and make sure it matches the workers’ and the task’s needs at hand. Many compliance issues start with forcing policies downward with out GOAL from the bottom up.
  • Don’t just check off the audit checklist fro compliance’s sake, GOAL
  • Immerse yourself with people that share your belief to Do the Right thing, not just the written thing.
  • Learn how to evaluate your own process without the pure Compliance Glasses on.

If you see yourself acting on the suggestions above, this would be a perfect Compliance Awareness Trigger to join us out our 2016 TapRooT® Summit week August 1-5 in San Antonio, Texas.

Go here to see the tracks and pre-summit sessions that combat the Compliance Barriers.

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