New to the TapRooT® VI software? Don’t fear, Webinar Wednesdays are here! Yes, it’s Thursday BUT it’s always a good practice to plan ahead!
Webinar Wednesday occurs the fourth Wednesday of every month! If you have been trained in TapRooT®, and want to optimize your investigations, join us. Every month we will be offering a software-specific webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software.
- When: Webinar Wednesdays occur the fourth Wednesday of every month
- Time: 2:00-3:30pm Eastern Time
- Length: 90 minutes
- Price: $195 per seat
- Prerequisite: This webinar is intended for TapRooT® users only. Registration is subject to validation that you have had formal TapRooT® training.
Technically Speaking is a weekly series that highlights various aspects of the TapRooT® VI software and occasionally includes a little Help Desk humor.
Remember, just because it’s technical, doesn’t mean it has to be complicated!
From Book1: TapRooT® Root Cause Analysis Leadership Lessons, Copyright 2017. Used by permission.
The diagram below was given to me by a VP at a utility. He thought it was funny. In reality, it was what the workers at that utility thought of the system they lived under.
They were trapped in the Blame Vision.
The Blame Vision seems to be imbedded in human nature. Perhaps it started with the legal system’s adversarial insistence on finding the guilty party. However, when this vision is used on innocent participants trying to get a job done, it often just blames those that are handy or unlucky.
The best thing about the Blame Vision is that identifying the person to blame is fairly easy. Just figure out who touched the item last. Unfortunately when a site is caught up in the Blame Vision, there are many “mystery” incidents (when hidden problems are finally discovered). When asked what happened, employees know to act like Bart Simpson. They emphatically deny any knowledge of the problem with the following standard answer:
I didn’t do it!
Nobody saw me do it!
You can’t prove I did it!
But management with the Blame Vision won’t let this get in their way. If you can’t find the guilty party, an acceptable solution is to arbitrarily punish a random victim. Or you can punish everyone! (That way you are sure to get the guilty party.) We had a saying for this in the Navy:
Why be fair when you can be arbitrary?
A refinery manager told a story that illustrated the effect of the Blame Vision. Early in his career he had been an engineer and was on a team that designed and started up a new process that had eventually gone on to make the company a lot of money. It had been a hard working, close-knit team. Someone decided to organize a twenty-year reunion of all the designers, engineers, supervisors, operators, and mechanics who had worked on the project. At the reunion everyone told stories of their part in the process start-up.
One electrician told an especially interesting story. It seems that during the first plant start-up, electricity to a vital part of the process was briefly lost. This caused a process upset that damaged equipment and cost big bucks. Valuable time was spent trying to track down the cause of the mysterious power failure. Every possible theory was tracked down. Nothing seemed to explain it. The only explanation was that the breaker had opened and then closed itself.
The retired electrician told the rest of the story to all those present at the reunion. It seems that on that day he had been working on a problem on another part of the process. To troubleshoot the problem he needed to open a breaker and de-energize the system. He went to the breaker box that he thought powered the system he was troubleshooting and opened what he thought was the appropriate breaker (the breakers weren’t labeled, but he thought he knew which one to open because he had wired most of the panel). That’s when everything went wrong. He could hear alarms from the control room. He thought that something he had done had caused the problem, so he quickly shut the breaker and left the area to cover up his involvement.
Later, when he was asked if he knew what could cause that breaker to open and shut on its own, he thought about telling the supervisor what had happened. But he knew that if he did, he’d probably be fired. So he said he didn’t know what would cause a breaker to open and shut on its own (technically not a lie). But, since the incident was now long past and he was retired, he thought that the statute of limitations had run out. He admitted his mistake because it was too late to punish him.
If you are trapped at a company or site with the Blame Vision? Don’t give up hope. There are ways to change management’s vision and adopt the Opportunity to Improve Vision. Read more about it in Book 1: TapRooT® Root Cause Analysis Leadership Lessons.
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!
What is your company’s vision? Does your company have a:
- Blame Vision
- Crisis Management Vision
- Opportunity to Improve Vision
The only vision that leads to good root cause analysis is the opportunity to improve vision.
We’ve been helping people “adjust” their vision since Mark Paradies gave a talk about the opportunity to improve vision at the 1990 Winter American Nuclear Society Meeting.
How do you change your vision?
That takes more than the few paragraphs of a blog article to describe. But we did write about it in our newest book:
What’s in the new book?
- A Tale of Two Plants
- What is a Root Cause and How Was TapRooT® Developed to Help You Find Them?
- How Leaders Can Apply TapRooT® to Improve Performance
- What Can TapRooT® Do for You?
- What TapRooT® Books Do You Need to Read?
The new book is designed for senior managers and leaders of improvement programs to help them understand effective root cause analysis and how it fits into a performance improvement program.
Order your copy of the new book by clicking HERE and make sure your vision supports improved performance!
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:
Watch as Brian Tink discusses how his company used dye packs to help them isolate the location of a pipe leak.
Here’s a link to the announcement:
Here are the 11 tenants they suggest:
To broaden their thoughts, perhaps they should read about Admiral Rickover’s ideas about his nuclear safety culture. Start at this link:
And then healthcare executives could also insist on advanced root cause analysis.
Ignorance is Bliss
From many people’s actions, you might believe that they think “ignorance is bliss” is true. We need to ignore the real root causes of problems and just attack the symptoms.
Even the cartoon, Calvin and Hobbs, commented on it. See the cartoon on my Facebook page …
Is this the way you treat your root cause analysis?
Would you rather have a simple BUT WRONG answer?
For over a decade, I’ve explained the shortcomings of 5-Whys for root cause analysis but some still believe that easy is better than right.
What if you could find and fix the real root causes of what you think are “simple incidents” with a robust, advanced system (TapRooT®) and not make a career of the investigation? You would put in only the effort required. Your investigation would be as simple as possible without going overboard. And your corrective actions would be effective and stop repeat incidents.
That’s what the new book, Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents, is all about.
Have you read the new book yet?
Once you read the book you will want to start implementing TapRooT® for all the “simple” investigations that are worth being done.
Get the book today and find out what you should be doing. Order the book at:
How many companies are using TapRooT® for their “hard,” “high-risk” incident analyses and using something like 5-Whys for the “simple” stuff? Yep, I thought so. A lot of companies are doing this for various reasons. I’ll get into that more in a minute.
Now, another poll:
How many of you are performing effective root cause analyses on your “important,” “high-consequence” investigations, and performing nearly useless analyses on the “easy” stuff? Of course, you know this is really exactly the same question, but you’re not as comfortable raising your hand the second time, are you?
Those of you that follow this blog have already read why using inferior RCA methods don’t work well, but let me recap. I’m going to talk about 5-Whys specifically, but you can probably insert any of your other, less-robust analysis techniques here:
- It does not use an expert system. It relies on the investigator to know what questions to ask.
- Because of this, it allows for investigator bias. If you are a training person, you will (amazingly enough) end up with “training” root causes.
- The process does not rely on human performance expertise. Again, it relies on the skill of the investigator. Yes, I know, we’re all EXCELLENT investigators!
- It does not produce consistent results. If I give the same investigation to 3 different teams, I always get 3 different sets of answers.
- There is no assistance in developing effective corrective action. When 80% of your corrective actions fall into the “Training” “Procedures” and “Discipline” categories, you are not really expecting any new results, are you?
So, knowing this to be true, why are we doing this? Why are we allowing ourselves to knowingly get poor results?
- These are low risk problems, anyway. It doesn’t matter if we get good answers (Why bother, then?)
- It’s quick. (Of course, quickly getting poor results just doesn’t seem to be an effective use of your time.)
- It’s easy (to get poor results).
- TapRooT® takes too long. Finally, an answer that, while not true, at least makes sense.
So what you’re really telling me is that if TapRooT® were just easier to use, you would be able to ditch those other less robust methods, and use TapRooT® for the “easy” stuff, too.
Guess what? We’ve now made TapRooT® even easier to use! The 7-step TapRooT® process can now be shortened for those “easy” investigations, and still get the excellent results you’re used to getting.
We now teach the normal 7-Step method for major incidents, where you need the optional data-collection tools. However, we are now showing you how to use TapRooT® in low to medium-risk investigations. You are still using the tools that make TapRooT® a great root cause analysis tool. However, we show you how to shorten the time it takes to perform these less-complex analyses.
The 2-Day TapRooT® Incident Investigation Course concentrates on these low to medium-risk investigations. The 5-Day TapRooT® Advanced Team Leader Course teaches both the simple method, but also teaches the full suite of TapRooT® tools.
Don’t settle for poor investigations, knowing the results are not what you need. Take a look at the new TapRooT® courses and see how to use the system for all of your investigations. You can register for one of these courses here.
I’ve heard many high level managers complain that they see the same problems happen over and over again. They just can’t get people to find and fix the problems’ root causes. Why does this happen and what can management do to overcome these issues? Read on to find out.
Blame is the number one reason for bad root cause analysis.
Because people who are worried about blame don’t fully cooperate with an investigation. They don’t admit their involvement. They hold back critical information. Often this leads to mystery accidents. No one knows who was involved, what happened, or why it happened.
As Bart Simpson says:
“I didn’t do it.”
“Nobody saw me do it.”
“You can’t prove anything.”
Blame is so common that people take it for granted.
Somebody makes a mistake and what do we do? Discipline them.
If they are a contractor, we fire them. No questions asked.
And if the mistake was made by senior management? Sorry … that’s not how blame works. Blame always flows downhill. At a certain senior level management becomes blessed. Only truly horrific accidents like the Deepwater Horizon or Bhopal get senior managers fired or jailed. Then again, maybe those accidents aren’t bad enough for discipline for senior management.
Think about the biggest economic collapse in recent history – the housing collapse of 2008. What senior banker went to jail?
But be an operator and make a simple mistake like pushing the wrong button or a mechanic who doesn’t lock out a breaker while working on equipment? You may be fired or have the feds come after you to put you in jail.
Talk to Kurt Mix. He was a BP engineer who deleted a few text messages from his personal cell phone AFTER he had turned it over to the feds. He was the only person off the Deepwater Horizon who faced criminal charges. Or ask the two BP company men who represented BP on the Deepwater Horizon and faced years of criminal prosecution.
How do you stop blame and get people to cooperate with investigations? Here are two best practices.
A. Start Small …
If you are investigating near-misses that could have become major accidents and you don’t discipline people who spill the beans, people will learn to cooperate. This is especially true if you reward people for participating and develop effective fixes that make the work easier and their jobs less hazardous.
Small accidents just don’t have the same cloud of blame hanging over them so if you start small, you have a better chance of getting people to cooperate even if a blame culture has already been established.
B. Use a SnapCharT® to facilitate your investigation and report to management.
We’ve learned that using a SnapCharT® to facilitate an investigation and to show the results to management reduces the tendency to look for blame. The SnapCharT® focuses on what happened and “who did it” becomes less important.
Often, the SnapCharT® shows that there were several things that could have prevented the accident and that no one person was strictly to blame.
What is a SnapCharT®? Attend any TapRooT® Training and you will learn how to use them. See:
2. FIRST ASK WHAT NOT WHY
Ever see someone use 5-Whys to find root causes? They start with what they think is the problem and then ask “Why?” five times. Unfortunately this easy methods often leads investigators astray.
Because they should have started by asking what before they asked why.
Many investigators start asking why before they understand what happened. This causes them to jump to conclusions. They don’t gather critical evidence that may lead them to the real root causes of the problem. And they tend to focus on a single Causal Factor and miss several others that also contributed to the problem.
How do you get people to ask what instead of why?
Once again, the SnapCharT® is the best tool to get investigators focused on what happened, find the incidents details, identify all the Causal Factors and the information about each Causal Factor that the investigator needs to identify each problem’s root causes.
3. YOU MUST GO BEYOND YOUR CURRENT KNOWLEDGE
Many investigators start their investigation with a pretty good idea of the root causes they are looking for. They already know the answers. All they have to do is find the evidence that supports their hypothesis.
What happens when an investigator starts an investigation by jumping to conclusions?
They ignore evidence that is counter to their hypothesis. This problem is called a:
It has been proven in many scientific studies.
But there is an even bigger problem for investigators who think they know the answer. They often don’t have the training in human factors and equipment reliability to recognize the real root causes of each of the Causal Factors. Therefore, they only look for the root causes they know about and don’t get beyond their current knowledge.
What can you do to help investigators look beyond their current knowledge and avoid confirmation bias?
Have them use the SnapCharT® and the TapRooT® Root Cause Tree® Diagram when finding root causes. You will be amazed at the root causes your investigators discover that they previously would have overlooked.
How can your investigators learn to use the Root Cause Tree® Diagram? Once again, send them to TapRooT® Training.
The TapRooT® Root Cause Analysis System can help your investigators overcome the top 3 reasons for bad root cause analysis. And that’s not all. There are many other advantages for management and investigators (and employees) when people use TapRooT® to solve problems.
If you haven’t tried TapRooT® to solve problems, you don’t know what you are missing.
If your organization faces:
- Quality Issues
- Safety Incidents
- Repeat Equipment Failures
- Sentinel Events
- Environmental Incidents
- Cost Overruns
- Missed Schedules
- Plant Downtime
You need to be apply the best root cause analysis system: TapRooT®.
Learn more at:
And find the dates and locations for our public TapRooT® Training at:
Are you sending people to our Public TapRooT® Training?
Or are you having a TapRooT® Course at your site?
And arranging TapRooT® Training at one or more of your facilities around the world?
If you want to choose your dates, now is the time to get your onsite courses scheduled.
And if you want to choose a particular public course, now is the time to get your folks registered!
SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.
Are you using advanced root cause analysis to investigate near-misses and stop major accidents? Major accidents can be avoided. That’s a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:
TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.
For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.
Don’t wait! If you have attended TapRooT® Training, get signed up today!
When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:
The most basic cause (or causes)
that can reasonably be identified
that management has control to fix
and, when fixed, will prevent
(or significantly reduce the likelihood of)
the problem’s recurrence.
The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.
This modern definition of a root cause leads to this definition of root cause analysis:
Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring.
Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.
Even though a decade had passed since proposing this new definition, I still have people ask:
“Why did you change the definition? I liked it like it was!“
Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.
The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!
The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.
This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.
The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.
One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.
That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.
Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.
I’ve seen a strange phenomenon. People who say they want to improve performance but they don’t want to change the way they do work. I’ve heard people say:
“If people would just try harder, be more careful, or be more alert, the problems would go away.”
This implies bad people (careless, lazy, and/or dullards) are the issues.
Have you ever met one of these people? Do you work in an organization that thinks this way?
I once had a safety manager at a refinery tell me:
“At our refinery, 5% of the people account for 95% of the lost time injuries.”
He was implying that those 5% were bad people. My thought was, of course … you can’t injure everybody no matter how hard you try.
Are you ready to implement positive changes to improve human performance and equipment reliability? Then you should try the TapRooT® Root Cause Analysis System to find ways to improve that you may not have considered.
TapRooT® helps people go beyond their current knowledge and find human performance and equipment reliability best practices that can improve process reliability.
Attend either the 2-Day TapRooT® Root Cause Analysis Training or the 5-Day TapRooT® Root Cause Analysis Team Leader Training to learn a new way to effectively fix problems.
And don’t worry about trying something new. Our courses are guaranteed!
Attend our training, 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.
That’s a strong guarantee because we know that TapRooT® will work for your company.
For more information about TapRooT®, watch the video at:
In a short but interesting article in SEAPOWER, Vice Admiral Thomas J. Moore stated that Washing Navy Yard had just about completed the root cause analysis of the failure of the main turbine generators on the USS Ford (CVN 78). He said:
“The issues you see on Ford are unique to those particular machines
and are not systemic to the power plant or to the Navy as a whole.“
Additionally, he said:
“…it is absolutely imperative that, from an accountability standpoint, we work with Newport News
to find out where the responsibility lies. They are already working with their sub-vendors
who developed these components to go find where the responsibility and accountability lie.
When we figure that out, contractually we will take the necessary steps to make sure
the government is not paying for something we shouldn’t be paying for.”
That seems like a “Blame Vision” statement.
That Blame Vision statement was followed up by statement straight from the Crisis Mangement Vision playbook. Admiral Moore emphasized that would get a date set for commissioning of the ship that is behind schedule by saying:
“Right now, we want to get back into the test program and you’ll see us do that here shortly.
As the test program proceeds, and we start to development momentum, we’ll give you a date.
We decided, ‘Let’s fix this, let’s get to the root cause, let’s get back in the test program,’ and
when we do that, we’ll be sure to get a date out. I expect that before the end of the year
we will be able to set a date for delivery.”
Press statements are hard to interpret. Perhaps the Blame and Crisis Visions were just the way the reporters heard the statements or the way I interpreted them. An Opportunity to Improve Vision statement would have been more along the lines of:
We are working hard to discover the root causes of the failures of the main turbine generators
and we will be working with our suppliers to fix the problems discovered and apply the
lessons learned to improve the reliability of the USS Ford and subsequent carriers of this class,
as well as improving our contracting, design, and construction practices to reduce the
likelihood of future failures in the construction of new, cutting edge classes of warships.
Would you like to learn more about the Blame Vision, the Crisis Management Vision, and the Opportunity to Improve Vision and how they can shape your company’s performance improvement programs? The watch for the release of our new book:
The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
It should be published early next year and we will make all the e-Newsletter readers are notified when the book is released.
To subscribe to the newsletter, provide your contact information at:
Above is the start of an OSHA/EPA Fact Sheet titled: “The Importance of Root Cause Analysis During Incident Investigation.”
OSHA and EPA want companies to go beyond fixing immediate cause (which may eliminate a symptom of a problem) and instead, find and fix the root causes of the problems (the systemic/underlying causes). This is especially important for process safety incidents.
The fact Sheet explains some of the basic of root cause analysis and suggests several tools for root cause analysis.
UNFORTUNATELY, many of the tools suggested by the fact sheet are not really suited to finding and fixing the real root causes of process safety incidents. They don’t help the investigator (or the investigative team) go beyond their current knowledge. Thus, the suggested techniques produce the same ineffective investigations that we have all seen before.
Would you like to learn more about advanced root cause analysis that will help your investigators learn to go beyond their current investigative methods and beyond their current knowledge to discover the real root causes of equipment reliability and human performance related incidents? These are techniques that have been proven to be effective by leading companies around the world.
Yes? Then see: http://www.taproot.com/products-services/about-taproot
And choose one of our upcoming public TapRooT® Courses to learn more about the TapRooT® Root Cause Analysis System. See:
November is a month to be thankful and show your appreciation! Here at System Improvements (TapRooT®), we like to let our co workers know that we appreciate everything they do. Without each person in this office, none of what we do would be possible.
So, to keep the thankful spirit alive all November long, we are recognizing specific members of the SI team different weeks throughout the month. This week we are showing special thanks to the amazing TapRooT® Tech Support guys with Dunkin Donuts!
If you’ve ever had any technical issues, they’re always there to help. If you’ve used TapRooT® software, they put an incredible amount of work into development. If you work in our office and need any assistance whatsoever, they’re there!
Help us give a special shout out to the TapRooT® Tech Support guys!
Here are pictures from the 11 pre-Summit Courses ….
TapRooT® Incident Investigation & Root Cause Analysis Course
Equifactor® Equipment Troubleshooting and Root Cause Analysis
Advanced Causal Factor Development Course
Advanced Trending Techniques
TapRooT® Analyzing and Fixing Safety Culture Issues
Risk Assessment and Management Best Practices
TapRooT® Quality Process Improvement Facilitator Course
Getting the Most from Your TapRooT® VI Software
TapRooT® for Audits
Effective Interviewing & Evidence Collection Techniques
Understanding and Stopping Human Error
You’ve seen it hundreds of times. Something goes wrong and management starts the witch hunt. WHO is to BLAME?
Is this the best approach to preventing future problems? NO! Not by a long shot.
We’ve written about the knee-jerk reaction to discipline someone after an accident many times. Here are a few links to some of the better articles:
- Wacky Willie
- Will Discipline Fix the CTA’s Problems?
- USS Hartford / USS New Orleans Collision & Subsequent Discipline
- Should You Discipline BEFORE an Investigation is Complete?
- What Should Managers Know About Root Cause Analysis?
- Root Cause Analysis – Do it before even thinking about discipline!
Let me sum up what we know …
Always do a complete root cause analysis BEFORE you discipline someone for an incident. You will find that most accidents are NOT a result of bad people who lack discipline. Thus, disciplining innocent victims of the systems just leads to uncooperative employees and moral issues.
In the very few cases where discipline is called for after a root cause analysis, you will have the facts to justify the discipline.
For those who need to learn about effective advanced root cause analysis techniques that help you find the real causes of problems, attend out 5-Day TapRooT® Root Cause Analysis Training. See: http://www.taproot.com/courses
Here’s a partial list …
- New Zealand
- Saudi Arabia
- United Kingdom
That’s why we call the Summit a GLOBAL Summit. Every continent is represented.
Sing up for the 2016 Global TapRooT® Summit now and learn best practices from around the world. Register at:
And find out about all the great sessions and keynote speakers by visiting the Summit web site at:
Who would you like to network with if you were going to share best practices and learn how others have solved problems?
The TapRooT® Summit is a great place to meet industry leaders.
Here a partial list of companies that have signed people up for the 2016 Summit:
- Air Liquide
- Arizona Public Service
- Avangrid Renewables
- Balitmore Gas & Electric
- California Resources
- Duke Energy
- Formosa Plastics
- Lawrence Berkeley national Lab
- Liberty Carton Company
- Matrix Services
- Nalco Champion
- National Grid
- Northern Star Generation
- NRG Energy
- Nuclear Fuel Services
- PCS Nitrogen
- Prarie State Generation
- Pratt & Whitney
- PSH JV
- Red Cedar Gathering
- Sacramento Municipal Utility District
- Saudi Aramco
- Teranga Gold
- Tuscon Electric
- US Well Services
- United Technologies
- Vancouver Airport Authority
- Westar Energy
What are some of the job titles of people attending the 2016 Summit?
- Airside Safety Officer
- Area HSE Manager
- Compliance Specialist
- Corporate ESH Director
- Corporate HSE Manager
- Corrective Action Program Manager
- Director of Corporate Safety
- EHS Engineer
- Electrical Engineer
- Emergency Management Manager
- Engineering Superintendant
- Environmental Steward
- Facility Manager
- Global H&S Advidor
- HSE Regional Leader
- HSE Director
- HSE Specialist
- HSE Supervisor
- Human Performance Specialist
- Industrial Hygienist
- Industrial Operations manager
- Issue Management Program Leader
- Lead Production Supervisor
- Loss Prevention System Advisor
- Manager, H&S
- Mechanical Engineer
- Operational Excellence Manager
- Operations Staff
- PDM Coordinator
- Process Safety Manager
- PSM Specialist
- QHSE Leader
- Quality Auditor
- Quality Manager
- Quality Systems Auditor
- RCA Leader
- RCA Manager
- Refining Consultant
- Reliability Specialist
- Results Supervisor
- Risk Manager
- Safety & Training Specialist
- Safety Associate
- Safety Specialist
- SHE Supervisor
- SHEQ Divisional Manager
- Site CAP Manager
- Sr. Director, Serious Injury & Fatality Prevention
- Sr. Safety Analyst
- Staff Compliance Specialist
- Supervisor Training
- Team Leader H&S
- Training Director
- Training Specialist
- Upstream HSE Team Lead
- Vice President, HSE
- VP & Regional Manager
- VP HSE
- WMS Advisor
- Work Week Coordinator
And those are just partial lists!
Imagine the things you could learn and the contacts you could make.
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Sometimes, it seems like the toughest part of an investigation is figuring out how to get started. What’s the first step? Where am I headed? Who do I need to talk to? What questions should I ask?
Unfortunately, most systems kind of leave you hanging. They assume that you’re some kind of forensic and investigation expert, with years of psychological and interviewing training already under your belt. Like you’re only job at your company is to sit around and wait for a problem to occur so that you can perform an investigation!
Luckily, TapRooT® has some great tools that are designed to walk you through an investigation process. We have recently tweaked this guidance to make it even easier to quickly progress through the investigation. Some of the tools are used for every investigation; some are used only in specialized circumstances when you need additional help gathering information.
Some of these tools are required for every investigation; some are optional data-gathering tools. Let’s first take a look at the required tools.
One of the first things you need to do is get a good understanding of exactly what happened. Instead of just grabbing a big yellow legal pad and start scribbling down random thoughts, you will use the SnapCharT® to build a visual representation and timeline of what actually occurred. By putting your thoughts down on the timeline, you can more easily see not only what you already know, but also what you still need to find out. It helps you figure out what questions to ask and who to ask. Building your SnapCharT® is ALWAYS the first step in your investigation for just this reason. There is no reason to go into the interview process if you don’t already have a basic understanding of what happened and what questions you need to ask. It’s really amazing to see a group of people start building a SnapCharT®, thinking they already have a good understanding of the issues, and watch them suddenly realize that they still need to ask a few pointed questions to truly understand the problem.
Root Cause Tree®:
Most TapRooT® users know that the Root Cause Tree® is used during the root cause analysis steps in the process. However, this tool is a treasure trove of terrific questions and guidance that can be used while building your SnapCharT®. In conjunction with the Dictionary®, it contains a comprehensive list of interview questions; the same questions that a human performance expert would ask if they were performing this same investigation. You’ll need the answers to these questions once you get to the root cause analysis phase. Why not “cheat” a little bit and ask these questions right up front while building your SnapCharT®?
The tools I listed above are used during EVERY investigation. However, in certain circumstances, you may need some additional guidance and data-gathering tools to help build your SnapCharT®. Let’s look at the non-required tools.
Change Analysis: This is a great tool to use to help you ask thought-provoking questions. It is used when either something is different than it used to be, or when there is a difference between two seemingly identical circumstances. The Change Analysis tool helps you determine what would have normally made the situation operate correctly, and (this time) what allowed the problem to show up under the exact circumstances of the incident. It is actually an extremely easy tool to use, and yet it is very powerful. I find this to be my most-used optional tool. The results of this analysis are now added to your SnapCharT® for later root cause analysis.
Critical Human Action Profile (CHAP): Sometimes, you need help understanding those “dumb” mistakes. How can someone be walking down the stairs and just plain fall down? The person must just be clumsy! This is a great time to use CHAP. It allows you to do an in-depth job task analysis, understanding exactly what the person was doing at each step in the task. What tools were they using (and supposed to be using)? How did we expect them to perform the individual steps in the task? This tool forces you to drill down to a very detailed analysis of exactly what the person was doing, and also should have been doing. The differences you find will be added to your SnapCharT® to help you understand EXACTLY what was going on.
Equifactor®: If your investigation includes equipment failures, you may need some help understanding the exact cause of the failure. You can’t really progress through the root cause analysis unless you understand the physical cause of the equipment problem. For example, if a compressor has excessive vibration, and this was directly related to your incident, you really need to know exactly why the vibration was occurring. Just putting “Compressor begins vibrating” on your SnapCharT® is not very useful; you have to know what lead to the vibration. The Equifactor® equipment troubleshooting tables can give your maintenance and reliability folks some expert advice on where to start looking for the cause of the failure. These tables were developed by Heinz Bloch, so you now have the benefit of some of his expertise as you troubleshoot the failure. Once you find the problem (maybe the flexible coupling has seized), you can add this to your SnapCharT® and look at the human performance issues that were likely present in this failure.
The TapRooT® System is more than just the Root Cause Tree® that everyone is familiar with. The additional tools provided by the system can give you the guidance you need to get started and progress through your investigations. If you need some help getting started, the TapRooT® tools will get you going! Learn more in our 2-day TapRooT® Incident Investigation and Root Cause Analysis Course.
Many years ago when I was in the Navy, I was writing an application to become an Assistant Professor at the University of Illinois. My boss was reviewing what I wrote and we got into a long discussion over whether a problem we had had was an event or an incident. A couple of years later, while I was doing my Master’s Degree research, I got into a very similar discussion over whether a significant problem at a nuclear plant was an accident or an incident.
OK, let’s look at the dictionary definitions… (from the Merriam-Webster on-line Dictionary)
- an unforeseen and unplanned event or circumstance
- lack of intention or necessity : chance <met by accident rather than by design>
- an unfortunate event resulting especially from carelessness or ignorance
- an unexpected and medically important bodily event especially when injurious <a cerebrovascular accident>
- an unexpected happening causing loss or injury which is not due to any fault or misconduct on the part of the person injured but for which legal relief may be sought
- used euphemistically to refer to an involuntary act or instance of urination or defecation
- a nonessential property or quality of an entity or circumstance <the accident of nationality>
- something dependent on or subordinate to something else of greater or principal importance
- an occurrence of an action or situation that is a separate unit of experience : happening
- an accompanying minor occurrence or condition : concomitant
- an action likely to lead to grave consequences especially in diplomatic matters <a serious border incident>
- outcomeb : the final outcome or determination of a legal actionc :
- a postulated outcome, condition, or eventuality <in the event that I am not there, call the house>
- something that happens : occurrence
- a noteworthy happeningc : a social occasion or activity
- an adverse or damaging medical occurrence <a heart attack or other cardiac event>
- any of the contests in a program of sports
- the fundamental entity of observed physical reality represented by a point designated by three coordinates of place and one of time in the space-time continuum postulated by the theory of relativity
- a subset of the possible outcomes of an experiment
So let’s make this simple …
In safety terminology, an EVENT is something that happens.
An INCIDENT is a minor accident.
An ACCIDENT is something that has serious human consequences (injury or fatality).
Thus we probably talk about:
- lost time accidents
- near-miss incidents
- events that led to a near-miss
In the TapRooT® System, an Event is an action step in the sequence of events on the SnapCharT®. The Incident is the worst thing that happened in the SnapCharT® sequence of events. Thus, and Incident is a special kind of Event. Plus, if the SnapCharT® is describing a serious injury, the Incident describes the Accident. Thus an Event could be an Incident that describes an Accident!
Do you define these terms at your facility?
If so, please add your definitions as a comment here.
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!
What can you learn about planning a high risk business activity from the planning for a high risk criminal activity?
Probably much more than you might think!
The Global TapRooT® Summit is all about learning from other industries and disciplines and it certainly is different learning from criminal activities and criminal investigations. This talk is based on Alan’s first hand experience with a murder investigation that will keep you riveted to his every word. Don’t miss it.
We have just scheduled a new talk in the Safety Track at the 2016 Global TapRooT® Summit. “Risk Assessing the Perfect Murder” will be held on Thursday, August 4, 2016 from 12:45 p.m. to 1:35 p.m.
Alan Smith, a former Detective Superintendant with the Grampian Police in Scotland, is now a TapRooT® Instructor and a Director of Matrix Risk Control in Aberdeen, Scotland and is leading this intriguing course.
See the complete 2016 Global TapRooT® Summit schedule by CLICKING HERE.
Register for the Safety Track at the 2016 Global TapRooT® Summit (August 1-5 in San Antonio, Texas) by CLICKING HERE. Or add Alan’s talk to another track to customize your Summit experience.