Category: Training

Trending without Purpose just Creates “Big Clumsy Data”

December 6th, 2017 by

As a TapRooT® Root Cause Analysis Instructor and person with a continuous improvement background, I often hear these questions when teaching …

“We collect lots of data, what should we be looking for?” STOP

“How do we link what we changed to if it worked?” STOP

“What would you define as a significant change?” STOP

STOP and go back 20 steps to figure out what is truly important to know …

  1. What does successful mean in numbers?
  1. Could you measure what is important today with the numbers you currently collect?
  1. What numbers should be tracked that would alert you that you must act now?
  1. What do you need to do to establish and track effective/ineffective change?
  1. What do you need to be able to do translate the numbers collected into a deliverable message to leadership and the frontline workers?
  1. Who should be inputting the daily numbers and who should be reviewing the numbers?

At the end of the day for whatever task that you are required to perform successfully, you should be able to …

  1. Prove based on reality in numbers that you have been successful.
  1. Be able to refute bad numbers that do not represent reality… no matter who made the chart.

Here are numbers with purpose …

  1. We offer our 2-Day Advanced Trending Techniques Course as a public course once a year as a Pre-Summit Course. Next year it’s scheduled for February 26-27, 2018
  1. In many cases there are only 2 or 3 of you at your company that need to run the numbers. This saves the company money to go to our Pre-Summit Course instead of setting up an Onsite Course.
  1. There will be 10-20 other attendees from other companies to talk bad numbers and good numbers. You will learn from each other.

Kevin McManus and I look forward to seeing you our Pre-Summit Trending Course.

Interviewing & Evidence Collection Tip: How to Handle an Inconsistent Statement

October 26th, 2017 by

 

 

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Not every inconsistent statement is meant to deceive.

 

A new investigator may believe that if an interviewee is telling the truth, he will be consistent in his recollection of an event every single time. However, not every inconsistent statement made by an interviewee is made to intentionally deceive.

In fact, most interviewees want to be helpful. Further, an inconsistent statement may be as accurate or even more accurate than consistent claims. That is, an account repeated three times with perfect consistency may be more of a red flag to dig deeper.

The two most important things to think about when evaluating inconsistencies are the passage of time between the incident and its recollection, and the significance of the event to the interviewee. Passage of time makes memory a bit foggy, and items stored in memory that become foggy the quickest are things that we don’t deem significant, like what we ate for lunch last Wednesday. That being said, we still have to be on the lookout for possible fallacies and know how to test them.

There are four ways to decrease the possibility of innocent inconsistent statements during the interviewing process.

  1. Encourage the interviewee to report events that come to mind that are not related or are trivial. In this way, you discourage an interviewee trying to please you by forcing the pieces to fit. They do not know about all the evidence that has been collected, and may believe that something is not related when it truly is.
  2. Tell the interviewee, explicitly, not to try to make-up anything he or she is unsure of simply to prove an answer. If they don’t know, simply request they say, “I don’t know.” This will help them relax.
  3. Do not give feedback after any statement like “good” or “right.” This will only encourage the interviewee to give more statements that you think are “good” or “right”– and may even influence them to believe that some things occurred that really didn’t.
  4. Ask the interviewee to tell the story of what happened from finish to start instead of start to finish. If the interviewee is intentionally trying to cover something up, he or she will have a hard time remembering the same order to the story he or she recited the first time because the interviewee will have a greater cognitive load to bear telling the story in reverse order.

We have plans to go over many more details on how to conduct a good interview at the 2018 Global TapRooT® Summit. Join us for TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills February 26 and 27. Learn more.

How Good is Your TapRooT® Implementation?

October 24th, 2017 by

TapRooT® provides world-class root cause analysis. But did you know that your results can vary depending upon the goodness of your implementation of the TapRooT® System?

What causes the implementation to vary? Try these factors …

  • Need to improve clearly defined.
  • Senior management support achieved.
  • Written program plan approved by senior management.
  • Proactive improvements drive improvement success.
  • Use advanced root cause analysis for both reactive and proactive investigations.
  • Improvement accomplishments being communicated successfully.
  • Adequate budget/staffing for the improvement organization.
  • Training plan implemented.
  • Employees, supervisors, managers, and contractors/suppliers willingly participate in the program.
  • Software selected, customized, and implemented.
  • Performance measures and advanced trending techniques used by management to guide the program.
  • Organizational learning occurring by effective sharing of lessons learned.
  • Plan for continuous improvement of the program is followed.
  • Leadership succession plan established.
  • Rewards program being used effectively.

This list is provided as a checklist and explained in more detail in Chapter 3 of our new book:

TapRooT® Root Cause Analysis Implementation – Changing the Way Your Company Solves Problems

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CLICK HERE to order your copy.

One more idea you might want to pursue to improve your performance improvement program. Attend the 2018 TapRooT® Global Summit in Knoxville, TN, on February 26 – March 2! It’s a great place to keep up with the state of the art in performance improvement and network with industry leaders.

Start by attending one of our advanced courses on Monday & Tuesday:

  • TapRooT® Root Cause Analysis Training
  • 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
  • Getting the Most from Your TapRooT® VI Software
  • TapRooT® for AuditsTapRooT®
  • Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
  • Understanding and Stopping Human Error

Then attend the Summit on Wednesday – Friday.

What’s on the agenda for the 2018 Global TapRooT® Summit? First, there are five keynote speakers:

  • Inquois “Inky” Johnson – Honor and Legacy
  • Vincent Ivan Phillips – How to Communicate Successfully
  • Dr. Carol Gunn – When Failure Becomes Personal
  • Mark Paradies – How Good is Your TapRooT® Implementation?
  • Mike Williams – Deepwater Horizon

Then there are nine different tracks that include 8 breakout sessions each. These tracks include:

  • Safety
  • Quality
  • Human Factors
  • Asset Optimization
  • Investigator
  • Patient Safety
  • TapRooT® Software
  • TapRooT® Instructor Recertification
  • Alternatives

See the Summit schedule at: http://www.taproot.com/taproot-summit/summit-schedule.

TapRooT® Around the World: Lake Charles

October 13th, 2017 by

We were busy in Lake Charles this week!  Thanks, Angie Comer, for this great class photo!

Why is Root Cause Analysis Applied Reactively More Than Proactively?

October 3rd, 2017 by

I attended an interesting talk on the brain yesterday and had a different perspective on why so many managers are reactive rather than being proactive.

What do I mean by that? Managers wait to start improvement efforts until after something BAD happens rather than using a constant improvement effort to avoid accidents before they happen.

What about “human nature” (or the brain or neuropsychology) makes us that way? It has to do with the strongest human motivators.

Dr. Christophe  Morin said that research shows that the most recognizable human emotions expressed in facial expressions are:

  • Fear
  • Sadness
  • Disgust
  • Anger
  • Surprise
  • Trust
  • Joy
  • Anticipation

What draws our attention the most? Fear and Anger.

It seems that fear and ager catch our eye because they could indicate danger. And avoiding danger is what our primitive brain (or reptilian brain) is wired to do. Before we have any conscious thought, we decide if we need to run or fight (the fight or flight reaction).

What does this have to do with root cause analysis and reactive and proactive improvement?

What happens after an accident? FEAR!

Fear of being fired if you did the wrong thing.

Fear of looking bad to your peers.

Fear of lower management getting a bad review from upper management if your people look bad.

And even fear of consequences (lower earnings and lower stock price and a reaction from the board) for upper management if the accident is bad enough and gets national press coverage.

Even senior managers may get fired after a particularly disastrous accident.

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So fear drives behavior in many cases.

Management is much more likely to spend valuable resources when they are afraid (after an accident) than before the accident when the fear is much less and the promise of improvement through proactive improvement may bring joy or the anticipation of success.

Thus, management focuses on root cause analysis for accidents and incidents rather than applying it to assessments, audits, and peer reviews.

Can your management overcome human nature and apply root cause analysis before an accident happens or do they have to wait for a disaster to learn? That may be the difference between great leaders and managers waiting to be fired.

Don’t wait. Start applying advanced root cause analysis – TapRooT® – today to prevent future accidents.

Attend one of our public 5-Day TapRooT® Advanced Root Cause Team Leader Courses to learn how to apply TapRooT® reactively and proactively.

Should you use TapRooT® to find the root causes of “simple” problems?

August 30th, 2017 by

Everybody knows that TapRooT® Root Cause Analysis is a great tool for a team to use when investigating a major accident. But can you (and should you) use the same techniques for a seemingly simple incident?

Lots of people have asked us this question. Instead of just saying “Yes!” (as we did for many years), we have gone a step further. We have created guidance for someone using TapRooT® when investigating low-to-moderate risk incidents.

Can you get this guidance? YES! Where? In our new book:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

TapRooT Essentials Book

For “simple” incidents, we just apply the essential TapRooT® Techniques. This makes the investigation as easy as possible while still getting great results. Also, because you perform a good investigation, you can add your results to a database to find trends and then address the Generic Causes as you collect sufficient data.

Also, this “simple” process is what we teach in the 2-Day TapRooT® Training. See our upcoming public 2-Day TapRooT® Courses here:

http://www.taproot.com/store/2-Day-Courses/

Now … WHY should you use TapRooT® to analyze “simple” problems rather than something “simple” like 5-Whys?

Because:

  1. Even though the incident may seem simple, you want to find and fix the real root causes and not just focus on a single causal factor and end up with “human error” as a root cause (as happens many times when using 5-Whys).
  2. When you use TapRooT® for simple incidents, you get more practice using TapRooT® and your investigators will be ready for a bigger incident (if you have one).
  3. You want to solve small problems to avoid big problems. TapRooT® helps you find and fix the real root causes and will help you get the great results you need.
  4. The root causes you find can be trended and this allows analysis of performance to spot Generic Causes.
  5. Your management and investigators only learn one system, cutting training requirements.
  6. You save effort and avoid needless recommendations by applying the evaluation tool step built into the simple TapRooT® Process. This stops the investigation of problems that aren’t worth investigating.

That’s six good reasons to start using TapRooT® for your “simple” investigation. Get the book or attend the course and get started today!

How Much Do You Believe?

August 1st, 2017 by

I was talking to my kids about things they read (or YouTube videos) on the internet and asked them …

How much of what you see online do you believe?

I told them that less than half of what I see or read online is believable (maybe way less than half).

But the next question I asked was more difficult …

How do you know if something is believable? How would you prove it?

This made them think …

I said that I have a lifetime of experience that I can use to judge if something sounds believable or not. Of course, that isn’t proof … but it does make me suspicious when something sounds too good to be true.

They didn’t have much life experience and therefore find it harder to judge when things are too good to be true.

However, we all need to step back and think … How can I prove something?

What does that have to do about accident and incident investigations?

Do you have a built-in lie detector that helps you judge when someone is making up a story?

I think I’ve seen that experienced investigators develop a sense of when someone is making up a story.

We all need to think about how we collect and VERIFY facts. Do we just accept stories that we are told or can we verify them with physical evidence.

The 1-Day TapRooT® Effective Interviewing & Evidence Collection Course that will be held in Houston on November 8th will help you think about your interviews and evidence collection to make your SnapCharT® fact based. In addition to the 1-Day Interviewing Course you can also sign up for the 2-Day TapRooT® Root Cause Analysis Course being held in Houston on November 6-8 by CLICKING HERE.

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Barb Phillips will be the instructor for the Effective Interviewing & Evidence Collection Course. Don’t miss it!

What do course attendees say about TapRooT® Root Cause Analysis Training?

July 27th, 2017 by

Are you thinking about taking 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training? Here’s what some recent attendees shared about their experiences:

“Very useful to use a real event. Learned some mistakes that we made in original investigations. Also, helped with our corrective actions.” ~ J. Bosman

“I have gained a lot of skills that I can take to work and implement.  I am involved in equipment failures and this will help in analysis.” ~ Q. North

“The best thing about this course is that it taught me how to look at each individual causal factor alone, isolate the issue and analyze them individually.  Will be using this technique for work every day.” ~ J. Pu

“It will really up my game as an investigator. I’m actually really amped to use the proactive and auditing tools.” ~ C. Menefee

“I can definitely see how using all the software tools can be very effective at getting the facts of any system/process failure.” ~ B. Vascellaro

Check out our global schedule and select a course here.

Troubleshooting and Root Cause Analysis Issues Keep Military from Finding and Fixing the Causes of Oxygen Issues on Military Aircraft

June 15th, 2017 by

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Let me start by saying that when you have good troubleshooting and good root cause analysis, you fix problems and stop having repeat incidents. Thus, a failure to stop problems by developing effective corrective actions is an indication of poor troubleshooting and bad root cause analysis.

Reading an article in Flight Global, I decided that the military must have poor troubleshooting and bad root cause analysis. Why? Because Vice Admiral Groskiags testified to congress that:

“We’re not doing well on the diagnosis,” Grosklags told senators this week.
“To date, we have been unable to find any smoking guns.”

 What aircraft are affected? It seems there are a variety of problems with the F/A-18, T-45, F-35. F-22, and T-45. The article above is about Navy and Marine Corps problems but Air Force jets have experience problems as well.

Don’t wait for your problems to become operation critical. Improve your troubleshooting and root cause analysis NOW! Read about our 5-Day TapRooT® Root Cause Analysis Team Leader Course HERE.

Construction Safety: Human Cost, OSHA Fines and Lawsuits…

June 5th, 2017 by

Knowing that each year about 900 construction workers do not come home to their families after work, safety on construction work sites must be taken seriously.

AGC, the Associated General Contractors of America recently published a study together with Virginia Tech, “Preventing Fatalities in the Construction Industry”. There are some interesting findings:

  • Dangerous Lunch Hour: construction site fatalities peak at noon, and are much lower on Fridays than Monday through Thursday
  • Small Contractors (less than 9 employees) are overrepresented in the statistics, with a fatality rate of 26 per 100,000 workers
  • Fully 1/3 of fatalities are from falls, and about 29% from Transportation incidents with e.g trucks or pickups
  • More experienced workers are not safer: fatalities start increasing after age 35 and keep growing so that 65 year olds are at the highest risk
  • Industrial projects are the most dangerous, followed by Residential and Heavy construction projects

The consequences of a fatality are devastating. There is a great human cost where families will have to deal with grief as well as financial issues. For the company there may be OSHA fines, law suits and criminal investigations. There really is no excuse for a builder not to have an active safety program, no matter how small the company.

Basic safety activities include providing and checking PPE and fall protection, correct use of scaffolding and ladders, on- going safety training, check- ins and audits. It is also a good idea to actively promote a safety culture, and to use a root cause analysis tool to investigate accidents and near misses, and prevent them from happening again.

The TapRooT® Root Cause Analysis methodology is a proven way of getting to the bottom of incidents, and come up with effective corrective actions. Focus is on human performance, and how workers can be separated from hazards like electricity, falls or moving equipment.

We can organize on- site training, or start by signing up for a public course. We offer the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training as well as the introductory 2-Day TapRooT® Root Cause Analysis Training class.

Be proactive, do not let preventable accidents catch up with you… call us today!

#TapRooT_RCA #safety

To Hypothesize or NOT to Hypothesize … that is the Question!

May 16th, 2017 by

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Yet again, another article in Quality Progress magazine (May 2017 – Solid Footings) suggests that the basis for a root cause analysis is a hypothesis.

We have discussed the problems of starting a root cause analysis with a hypothesis before but it is probably worth discussing it one more time…

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Don’t start with the answer.

Starting with the answer (a hypothesis) is a bad practice. Why? Because of a human tendency called “confirmation bias.” You can read about confirmation bias in the scientific literature (do a Google search) but the simple answer is that people focus on evidence that proves their hypothesis and disregard evidence that conflicts with their hypothesis. This is a natural human tendency that is difficult to avoid if you start with a hypothesis.

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I’ve seen many root cause experts pontificate about investigators “keeping an open mind” and disprove their own hypothesis. That’s great. That’s like saying, “Don’t breath.” Once you propose an answer … you start to believe it and PROVE it.

What should you do?

Use a system that doesn’t start with a hypothesis.Try TapRooT® Root Cause Analysis.

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You will learn to use a SnapCharT® to collect information about what happened without jumping to conclusions.

Once you understand what happened and identify the Causal Factors, you will then be ready to analyze why the Safeguards failed (find the root causes) without jumping to conclusions by using advanced tools: the Root Cause Tree® Diagram and the Root Cause Tree® Dictionary.

This system gets you to think beyond your current knowledge!

The system has been proven to work at major companies and different industries around the world.

Want to learn more to improve quality and safety at your company? Attend one of our public root cause analysis courses. See the list of upcoming courses at:

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

Technically Speaking – Help Desk Humor

April 27th, 2017 by

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.

Get the most out of your investment.
 What you need to know: 
  • 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.

Interested? REGISTER HERE FOR WEBINAR WEDNESDAY MAY 24th, 2017.

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!

Keep Up Your TapRooT® Software Skills with Our Software Webinars

April 19th, 2017 by

mark your calendars

Join us for Webinar Wednesdays!

If you have been trained in TapRooT®, and want to enhance your software skills, join us for our webinar. Every month we will be offering a software webinar to give you more practice with basic investigations and show you the ins and outs of our dynamic root cause analysis software. We’ll even go over the newest features!
Get the most out of your investment. Register today.

What you need to know: 

  • 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.

HERE IS A COMPLETE LIST OF UPCOMING WEBINARS

THE NEXT ONE IS APRIL 26, 2017

TapRooT® Around the World: Silao, Mexico

April 18th, 2017 by

Another great TapRooT® root cause analysis course in Mexico. Looks like a great class!

Interested in bringing TapRooT® to your company for training? Inquire here. 

Interested in sending your team to a TapRooT® course? Check our course schedule here.

A Webinar to Optimize Your TapRooT® VI Software Skills

March 13th, 2017 by
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.
Get the most out of your investment.

What you need to know: 

  • 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.

HERE IS A COMPLETE LIST OF UPCOMING WEBINARS

THE NEXT ONE IS MARCH 22, 2017

Simple Root Cause Analysis (Don’t Settle!)

February 23rd, 2017 by

 

RCA, Root Cause analysis, 5-why, 5-whys
OK, show of hands:

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:

5-Whys

  • 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.

Simple RCA, TapRooT, root cause analysisWe 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.

Continuous Improvement with TapRooT® Software Webinars

February 8th, 2017 by
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.
Get the most out of your investment.

What you need to know: 

  • 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.

HERE IS A COMPLETE LIST OF UPCOMING WEBINARS

THE NEXT ONE IS FEBRUARY 22, 2017

Top 3 Reasons for Bad Root Cause Analysis and How You Can Overcome Them…

February 7th, 2017 by

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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.

 

1. BLAME

Blame is the number one reason for bad root cause analysis.

Why?

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:

TapRooT® Training

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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.

Why?

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.

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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:

Confirmation Bias

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.

THAT’S IT…

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: 

http://www.taproot.com/products-services/about-taproot

And find the dates and locations for our public TapRooT® Training at:

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

NewImage

NEW TapRooT® VI Software Webinars

January 10th, 2017 by
We are excited to introduce Webinar Wednesdays!
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.

 

Get the most out of your investment.

What you need to know: 

  • 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.

Interested? REGISTER HERE FOR THE FIRST WEBINAR JANUARY 25, 2017

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!

 

Where do you draw the line on what to investigate?

May 27th, 2016 by

At what point is something important enough to investigate? View the Slideshare below to examine this important question and REGISTER for Advanced Trending Techniques.

 

 

Interviewing & Evidence Collection Techniques

May 26th, 2016 by

I’m so excited to be co-teaching Interviewing & Evidence Collection Techniques at the 2016 Global TapRooT® Summit with Alan Smith. If you want to learn a little about Alan, click here.  With Alan’s background as a former Detective Superintendent with the Grampian Police in Scotland, and my background in psychology and legal (preparing accident/injury cases for court), we will leave no stone unturned.  I guarantee there is no other course like this anywhere. Register today!

 

 

Can you answer “YES” to any of these six questions?

May 26th, 2016 by

Check out the Slideshare below  If you can answer “YES” to any of the six questions, THIS is the course you are looking for!

 

LEARN MORE!

Are you Using these FIVE Dynamic NEW Features of TapRooT® VI?

May 26th, 2016 by

LEARN MORE!

We have a 3-day Software Track at the 2016 Global Summit too!  
Look for “Software” on the left menu bar HERE to view the track schedule!

 

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