Below are sentinel event types from 2014 – 2016 as reported to the Joint Commission (taken from the 1/13/2017 report at https://www.jointcommission.org/assets/1/18/Summary_4Q_2016.pdf):
Reviewing this data, one might ask …
What can we learn?
I’m not trying to be critical of the Joint Commissions efforts to collect and report sentinel event data. In fact, it is refreshing to see that some hospitals are willing to admit that there is room for improvement. Plus, the Joint Commission is pushing for greater reporting and improved root cause analysis. But, here are some questions to consider…
- Does a tic up or down in a particular category mean something?
- Why are suicides so high and infections so low?
- Why is there no category for misdiagnosis while being treated?
Perhaps the biggest question one might ask is why are their only 824 sentinel events in the database when estimates put the number of sentinel events in the USA at over 100,000 per year.
Of course, not all hospitals are part of the Joint Commission review process but a large fraction are.
If we are conservative and estimate that there should be 50,000 sentinel events reported to the Joint Commission each year, we can conclude that only 1.6% of the sentinel events are being reported.
That makes me ask some serious questions.
1. Are the other events being hidden? Ignored? Or investigated and not reported?
Perhaps one of the reasons that the healthcare industry is not improving performance at a faster rate is that they are only learning from a tiny fraction of their operating experience. After all, if you only learned from 1.6% of your experience, how long would it take to improve your performance?
2. If a category like “Unitended Retention of a Foreign Body” stays at over 100 incidents per year, why aren’t we learning to prevent these events? Are the root cause analyses inadequate? Are the corrective actions inadequate or not being implemented? Or is there a failure to share best practices to prevent these incidents across the healthcare industry (each facility must learn by one or more of their own errors). If we don’t have 98% of the data, how can we measure if we are getting better or worse? Since our 50,000 number is a gross approximation, is it possible to learn anything at all from this data?
To me, it seems like the FIRST challenge when improving performance is to develop a good measurement system. Each hospital should have HUNDREDS or at least DOZENS of sentinel events to learn from each year. Thus, the Joint Commission should have TENS or HUNDREDS of THOUSANDS of sentinel events in their database.
If the investigation, root cause analysis, and corrective actions were effective and being shared, there should be great progress in eliminating whole classes of sentinel events and this should be apparent in the Joint Commission data.
This improved performance would be extremely important to the patients that avoided harm and we should see an overall decrease in the cost of medical care as mistakes are reduced.
This isn’t happening.
What can you do to get things started?
1. Push for full reporting of sentinel events AND near-misses at your hospital.
2. Implement advanced root cause analysis to find the real root causes of sentinel events and to develop effective fixes that STOP repeat incidents.
3. Share what your hospital learns about preventing sentinel events across the industry so that others will have the opportunity to improve.
That’s a start. After twelve years of reporting, shouldn’t every hospital get started?
If you are at a healthcare facility that is
- reporting ALL sentinel events,
- investigating most of your near-misses,
- doing good root cause analysis,
- implementing effective corrective actions that
- stop repeat sentinel events,
I’d like to hear from you. We are holding a Summit in 2018 and I would like to document your success story.
If you would like to be at a hospital with a success story, but you need to improve your reporting, root cause analysis and corrective actions, contact us for assistance. We would be glad to help.
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.
A failure occurs. It could be:
- a safety related accident
- an equipment failure
- a patient safety event (sentinel event)
- a quality issue
- a shipping screw up
- a cost overrun
- a process safety related near-miss
What people do next can make a world of difference.
First, is the failure (incident or near-miss) reported? Or is it covered up?
If you are reading this you probably think that your company should learn from its mistakes to keep the mistakes from happening again. (Or to keep something even worse from happening – like the picture above.)
But if mistakes and failures are hidden, learning is unlikely.
People must know that it is safe to report a problem and that, once a problem is reported, something will be done to improve the process to make the problem go away.
Punishing the person who reported the problem or punishing someone else involved in the failure IS NOT the kind of action that will promote more reporting of failures.
OK … You have established a culture where the reporting of problems is not punished. You may even have a culture where the reporting of problems is an expected part of how you do business. NOW WHAT?
Do people know how to preserve the evidence of the failure so that an effective root cause analysis can be performed?
You might be surprised that most folks don’t know how to preserve the scene of an accident.
They don’t know that disassembling broken equipment may destroy the evidence of why the equipment broke.
They may not collect the names of everyone involved (including contractors and first responders).
They may “clean things up” to get back to normal housekeeping standards.
They may let vital fluid samples slip away.
They may even collect “souvenirs” to take home.
Reporting the failure really doesn’t help if the evidence of the failure is destroyed before the root cause analysis starts.
What are you doing to train your supervisors to preserve the scene of a failure?
I have two suggestions.
1. Have training for them on evidence collection and interviewing.
We have a TapRooT® Course that can help supervisors secure the scene of an accident and have a much better idea of what they need to do when responding to a failure.
The course can be customized to teach just the information that you think your supervisors need.
The complete 2-Day TapRooT® Effective Interviewing & Evidence Collection Course has essential information that supervisors need to stop evidence destruction and help conduct interviews of those involved. See the course outline at:
Barb Phillips, the course designer, will be happy to talk to you about customizing the course for your supervisors to give them the knowledge and practice that they need to be ready to effectively respond to a failure. To talk to Barb, call 865-548-8990. Or email her by using this LINK.
2. Your equipment folks need training in equipment troubleshooting and failure analysis.
We have another course designed for equipment troubleshooters to help them avoid the destruction of evidence when they respond to an equipment failure. The 2-Day Equifactor® Equipment Troubleshooting and TapRooT® Root Cause Analysis Course will help them develop a troubleshooting plan that will preserve the evidence they need to troubleshoot the problem and find the problem’s root causes.
Again, the Equifactor® Course can be customized to meet the needs of your troubleshooters. Call Ken Reed, the course creator, at 865-539-2139 to discuss ways to make your training targeted to your workforce. Or contact him by e-mail at this LINK.
Whatever you do … DON’T sit back and wait for the next accident and assume that your folks will respond appropriately. I can assure you that if hoping for the best is your strategy … you will be sadly disappointed.
Saw an interesting article in Hydrocarbon Processing titled:
That reminded me of the Amoco refineries that were sold to BP and had a horrible safety record.
Regulators should have a red flag for any assists covered under a PSM program. If they are being sold, INSPECT!
Perhaps this could stop management from excessive cost cutting pre-sale to boost the bottom line at the expense of safety and the environment.
You may have reviewed the new regulations for process safety at California refineries. This is a major change to the standard PSM rules in the USA for California refineries.
Here is the section from the “Incident Investigation” portion of the rule…
– – –
(o) Incident Investigation – Root Cause Analysis.
- The employer shall develop, implement and maintain effective written procedures for promptly investigating and reporting any incident that results in, or could reasonably have resulted in, a major incident.
- The written procedures shall include an effective method for conducting a thorough Root Cause Analysis.
- The employer shall initiate the incident investigation as promptly as possible, but no later than 48 hours following an incident. As part of the incident investigation, the employer shall conduct a Root Cause Analysis.
- The employer shall establish an Incident Investigation Team, which at a minimum shall consist of a person with expertise and experience in the process involved; a person with expertise in the employer’s Root Cause Analysis method; and a person with expertise in overseeing the investigation and analysis. The employer shall provide for employee participation pursuant to subsection (q). If the incident involved the work of a contractor, a representative of the contractor’s employees shall be included on the investigation team.
- The Incident Investigation Team shall implement the employer’s Root Cause Analysis method to determine the initiating causes of the incident. The analysis shall include an assessment of management system failures, including organizational and safety culture deficiencies.
- The Incident Investigation Team shall develop recommendations to address the findings of the Root Cause Analysis. The recommendations shall include interim measures that will prevent a recurrence or similar incident until final corrective actions can be implemented.
- The team shall prepare a written investigation report within ninety (90) calendar days of the incident. If the team demonstrates in writing that additional time is needed due to the complexity of the investigation, the team shall prepare a status report within ninety (90) calendar days of the incident and every thirty (30) calendar days thereafter until the investigation is complete. The team shall prepare a final investigation report within five (5) months of the incident.
- Investigation reports shall include:
(A) The date and time of the incident;
(B) The date and time the investigation began;
(C) A detailed description of the incident;
(D) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the Root Cause Analysis;
(E) A list of any DMR(s), PHA(s), SPA(s), and HCA(s) that were reviewed as part of the investigation;
(F) Documentation of relevant findings from the review of DMR(s), PHA(s), SPA(s) and HCA(s);
(G) The Incident Investigation Team’s recommendations; and,
(H) Interim measures implemented by the employer.
- The employer shall implement all recommendations in accordance with subsection (x).
- The employer shall complete an HCA in a timely manner for all recommendations that result from the investigation of a major incident. The employer shall append the HCA report to the investigation report.
- Investigation reports shall be provided to and upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided to employee representatives and, where applicable, contractor employee representatives.
- Incident investigation reports shall be retained for the life of the process unit.
– – –
TapRooT® Users already find management system, organizational, and cultural related root causes or generic causes that contributed to incidents they investigate. They also know about the hierarchy of controls (part of HCA analysis) and Safeguard Analysis (part of SPA) when developing corrective actions.
TapRooT® has always been ahead of its time in finding human factors related causes of incidents. Thus, TapRooT® Root Cause Analysis fits well with the Human Factors section of the California regulation…
– – –
(s) Human Factors.
- The employer shall develop, implement and maintain an effective written Human Factors program within eighteen (18) months following the effective date of this section.
- The employer shall include a written analysis of Human Factors, where relevant, in major changes, incident investigations, PHAs, MOOCs and HCAs. The analysis shall include a description of the selected methodologies and criteria for their use.
- The employer shall assess Human Factors in existing operating and maintenance procedures and shall revise these procedures accordingly. The employer shall complete fifty (50) percent of assessments and revisions within three (3) years following the effective date of this section and one hundred (100) percent within five (5) years.
- The Human Factors analysis shall apply an effective method in evaluating the following: staffing levels; the complexity of tasks; the length of time needed to complete tasks; the level of training, experience and expertise of employees; the human-machine and human-system interface; the physical challenges of the work environment in which the task is performed; employee fatigue and other effects of shiftwork and overtime; communication systems; and the understandability and clarity of operating and maintenance procedures.
- The Human Factors analysis of process controls shall include:
(A) Error-proof mechanisms;
(B) Automatic alerts; and,
(C) Automatic system shutdowns.
- The employer shall include an assessment of Human Factors in new operating and maintenance procedures.
- The employer shall train operating and maintenance employees in the written Human Factors program.
- The employer shall provide for employee participation in the Human Factors program, pursuant to subsection (q).
- The employer shall make available and provide on request a copy of the written Human Factors program to employees and their representatives and to affected contractors, employees of contractors, and contractor employee representatives, pursuant to subsection (q).
– – –
These initial drafts of the regulation have been slightly modified at a public hearing last Fall. The modifications can be viewed at: http://www.dir.ca.gov/oshsb/documents/Process-Safety-Management-for-Petroleum-Refineries-15day.pdf
The California Occupational Safety and Health Standards Board is set to review the revisions and comments on a meeting being held after the comment period expires on March 3, 2017.
While the new rule is being modified prior to adoption, California TapRooT® Users should be happy to know that they are already using a system that helps them meet and exceed the regulation being developed.
The EPA announced in December their intention to finalize a new r Risk management Plan rule for facilities with highly hazardous chemicals. Of interest to readers of this blog, the new proposal for incident investigations requires root cause analysis using a recognized method.
Here is the proposed language:
(a) The owner or operator shall investigate each incident that:
- Resulted in a catastrophic release (including when the affected process is decommissioned or destroyed following, or as the result of, an incident); or
- Could reasonably have resulted in a catastrophic release (i.e., was a near miss).
(b) A report shall be prepared at the conclusion of the investigation. The report shall be completed within 12 months of the incident, unless the implementing agency approves, in writing, an extension of time. The report shall include:
- Date, time, and location of incident;
- A description of the incident, inchronological order, providing all relevant facts;
- The name and amount of the regulated substance involved in the release (e.g., fire, explosion, toxic gas loss of containment) or near miss and the duration of the event;
- The consequences, if any, of the incident including, but not limited to: injuries, fatalities, the number of people evacuated, the number of people sheltered in place, and the impact on the environment;
- Emergency response actions taken;
- The factors that contributed to the incident including the initiating event, direct and indirect contributing factors, and root causes. Root causes shall be determined by conducting an analysis for each incident using a recognized method; and
- Any recommendations resulting from the investigation and a schedule for addressing them.
With the new administrations halt on new regulations, I’m not sure what will happen with this modification to an existing rule … so keep an eye out for the publication in the Code of Federal Regulations.
One last note if you were wondering … TapRooT® Root Cause Analysis is a recognized method.
Monday Accident & Lessons Learned: Chemical Safety Board Video of Explosion at Williams Olefins Plant in Geismar, LouisianaJanuary 30th, 2017 by Mark Paradies
We have been working hard to make TapRooT® even better. Therefore, we have NEW things to share.
We have three new books that are available and three more that will be coming out in the first quarter. They are part of the new nine book set that will all be out by the end of 2017.
To see what is available now, CLICK HERE.
We’ve been updating our TapRooT® Training. Every course has had major improvements. Of course, the new courses include the new books, but there is much more that’s been improved to make TapRooT® easier to use and more effective. To find out more about our TapRooT® Courses, CLICK HERE.
Have you had a look at our new Version VI TapRooT® Software? It’s cloud-based and is device independent. Use it on your PC, Mac, or any tablet. CLICK HERE for more info.
IMPROVE YOUR ROOT CAUSE ANALYSIS BY USING THE LATEST TECHNOLOGY
The old TapRooT® Books, training, and software were good. The NEW TapRooT® Books, Training, and Software are even better. Don’t miss out in the advances in TapRooT® Technology. Get the latest by clicking on the links above and updating your technology.
Also, as more new books, courses, and software improvements are released as the year progresses, we will let you know by posting information here. Keep watch and keep up with the latest in advanced root cause analysis.
We are making a major move forward in 2017. There will be a whole NEW basis for TapRooT® when we are done writing the nine new books that will document the TapRooT® System.
Some of the new TapRooT® Books are out and are available on the TapRooT® Web Site.
What is out so far?
- Book 3: Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents
- Book 4: TapRooT® Root Cause Analysis for Major Investigations
- Book 6: TapRooT® Root Cause Analysis for Audits and Proactive Performance Improvement
If you would like to get the TapRooT® Essentials Book and The Major Investigation Book at the same time, you can get them for a discount by CLICKING HERE.
These new book sets will include the latest Root Cause Tree® (2015), Root Cause Tree® Dictionary (2016) and Corrective Action Helper® Guide (2016).
By the end of the year we are hoping to also have available:
- Book 1: The TapRooT® Root Cause Analysis Philosophy – Changing the Way the World Solves Problems
- Book 5: Using Equifactor® Troubleshooting Tools and TapRooT® Root Cause Analysis to Improve Equipment Reliability
- Book 7: TapRooT® Evidence Collection and Interviewing Techniques to Sharpen Investigation Skills
Also, watch for our translations of these books in Spanish, Portuguese, German, and French. (Not out yet but we are working on it.)
We are excited about the advances we have made and how usable the new books are.
FAST SIMPLE INVESTIGATIONS
If you want great root cause analysis for a fast, simple investigation, you need to read:
We have made major strides in making TapRooT® easy to use. We even have a new five step process for doing a low-to-medium risk incident investigation.
Not all investigations are simple. We knew we needed to write a book that explained the whole TapRooT® process and tools for investigating high potential and high risk incidents. Therefore we wrote:
There is excellent new materials that completely document the entire 7-step TapRooT® System and all the TapRooT® Tools.
Do you want to get ahead of accidents, incidents, and quality issues? Then you need:
This book details the way you can apply the TapRooT® Tools to your proactive improvement efforts – especially audits.
Each of these books are tied to new courses.
The TapRooT® Essentials Book is tied to our 2-Day TapRooT® Root Cause Analysis Training.
The TapRooT® Major Investigations Book is tied to the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. The course reviews a copy of the TapRooT® Essentials Book.
And finally, the Using TapRooT® for Audits Book is linked to our 2-Day TapRooT® four Audits Course.
We hope you will find these books (and courses) as helpful as others have.
What’s a widget you ask?? If you would have asked me this question when I was a child, I would have told you that Widget was the name of my family pet cat. But today, the term widget means something else to me in regards to software. A widget is a small application within a webpage that provides useful information. You may be familiar with widgets that you use on your iPhone or Smartphone.
Well in TapRooT® VI, widgets exist to provide valuable trending data on your incidents, investigations, audits, root causes and corrective actions. Currently, if you were to visit the DASHBOARD menu, you would find just 4 basic widgets. But I am excited to announce that in our near future release we have COMPLETELY enhanced this dashboard with a variety of widgets and custom options to help meaningfully display your data.
Want to know which Basic Cause Categories, Near Root Causes or Root Causes are your biggest offenders? Want to know which locations or classifications have the most issues? Want to know how many complete, incomplete or past due Corrective Action tasks you have? These dashboard widgets will let you know. There are almost 25 widgets that can be viewed in over 70 combination display types to help you focus on exactly what sort of information you want to see. Take a look.
CLICK HERE TO VIEW IMAGE IN A NEW WINDOW
You can choose from a variety of display chart types including Table Chart, Pie Chart, Horizontal or Vertical Bar Charts, Line Charts AND Pareto Charts.
You can filter by date range, location and classification to really drill down to that level of detail that you may want to understand.
Want to print a copy of your charts? You can export them to PDF and save or print to share with others.
Customize your dashboard to display your most frequently displayed widgets every time you visit the dashboard.
Slice it, dice it, anyway you want to see it. These little widgets pack a lot of big power and information. You can look forward to seeing these new features VERY soon!
Technically Speaking is a weekly series that highlights our 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!
On this day in history, September 9, 2004, a mysterious explosion occurred in North Korea suspiciously close to the border of China. Deep in the mountains in the Ryanggang Province where a secret underground military base was located, a large mushroom cloud arose causing concern and confusion. The seismic activity reported after the accident helped them determine that the large cloud indicated a nuclear explosion, but there wasn’t enough evidence to determine if it was actually an accident. Needless to say, this explosion did not only cause concern for the local citizens, but also other countries. Fortunately, there weren’t any casualties. But the question on everyone’s mind was, “Why would there be a mysterious yet seemingly planned nuclear explosion?”.
Although this explosion was more than likely not an accident, the TapRooT® Advanced Root Cause Analysis and Team Leader Training public courses teach our dynamic techniques that are the best for investigating incidents like this. TapRooT® techniques are also frequently used so prevent incidents from ever occurring.
– Required by regulators or law
– Required by company policy
– Perceived higher return on investment
However, companies often default to less developed (and therefore less accurate) analyses for lower risk, lower consequence problems. For example, almost everyone will perform a TapRooT® investigation when there is a serious injury; this is a high-consequence incident, and preventing it in the future is perceived to have the highest ROI. But what about a near miss? Or maybe someone tripped over an air line on the floor, dropping a repair part and damaging it? Most companies will either not perform any investigation, or they will default to “easy” methods (5-Why’s, etc.). Why spend any time on these “simple” incidents? Let’s just do a quick “analysis” and move on?
While I completely understand this thought process, there are some serious flaws in this thinking.
- Low ROI. While a particular incident may not have caused a large loss, this dos not mean it automatically deserves no attention. Maybe tripping over the air line only caused $800 in damage this time. But what about the other issues that have been caused by poor housekeeping in the past? What if the person had tripped and fallen over the edge of a platform? Making a quick assumption like this can allow you to miss potentially serious issues when taken together. Performing a poor analysis will lead to repeats of the problem.
- Poor results of “quick” RCA methods. Keep in mind that a quick method probably means that you did not gather any information. You are therefore performing an “analysis” without any data to analyze. If your analysis method takes 5 minutes, you have probably just wasted 5 minutes of your time. If you’re going to perform an RCA, make sure it gets to useable and consistent answers.
- TapRooT® is only for the big stuff. This thought often frustrates me. It is true that you will not perform a TapRooT® investigation in 5 minutes. However, any method that purports to give you magic answers in a few minutes is not being honest. See #2 above. However, that does NOT mean that TapRooT® must take days of your time. For simple investigations, the results of a TapRooT® investigation may be found in just an hour or so.
So, how do we use TapRooT® for lower risk or low consequence problems? This year, we have modified the TapRooT® methodology to allow you to use the steps of the process that you need to perform a great investigation on simple problems. This updated process isn’t really new; it just codifies how we’ve taught you to use TapRooT® in the past for these simpler problems. We make the process more efficient and give you the opportunity to optionally skip some of the steps.
Here is the new process flow for low to medium risk incidents:
There are some important points that I wanted to highlight about this new process flow:
- You always start with a SnapCharT®. There is no way to perform any type of analysis unless you first gather some information. Again, any other process that advocates performing an analysis on the information you received in a quick phone call is not a real analysis. The SnapCharT® ensures you have the right information to actually look for root causes.
- There is an off-ramp right at the beginning. Once you’ve gathered information in a SnapCharT®, you can then make an intelligent decision as to whether this problem has the potential to uncover significant problems. You may find, after building your SnapCharT®, that this really was an extremely low potential problem, with minimal consequences. You will then stop the analysis at that point, put simple corrective actions in place to fix what you found, and then document the problem for later trends. That’s it. While most investigations will continue on with the rest of the process, there are some issues that do not require any further analysis and don’t deserve any further resources.
- For most investigations, you will continue by identifying Causal Factors, and run those Causal Factors through the Root Cause Tree®. No different than before.
- For these simpler problems, it probably is not worth the effort of looking for generic causes. We have made this step optional. It you feel the problem has the potential to be more widespread, you can continue to look for generic issues, otherwise, go straight to corrective actions.
- Low to medium risk incidents probably do not need the resources you would normally expend writing full SMARTER corrective actions. We encourage you to write corrective actions based on the guidance in the Corrective Action Helper®, but writing fully SMARTER fixes is probably not necessary.
For more serious incidents, we would still use the full 7-Step TapRooT® Process that you are familiar with. However, for lower risk or lower consequence problems, this abbreviated process flow is much easier to use, allowing you to more quickly work through a TapRooT® investigation. Why use 5-Why’s and get poor results (as expected) just to “save time,” when you can use the simplified TapRooT® process to get MUCH better answers with less effort than before?
The 2-Day TapRooT® Root Cause Analysis Course not covers this simpler method of performing TapRooT® investigations. Attendees will still be able to perform investigations on any incident, but we stress this more efficient process flow.
Choose a course and register here!
Did you know… TapRooT® has a block of rooms at the Westin Riverwalk hotel in San Antonio for attendees to get a discounted rate? Not only is the Westin hotel ideally located on the historic and beautiful Riverwalk, it is also the venue for the 2016 Summit. With these perks plus a discount, why would you not book your room today?
The deadline for booking your room with the TapRooT® room block is July 15. Hurry now before they all fill up!
Click here for all the information you need to book and prepare for your trip to San Antonio.
There is also still time to register for the TapRooT® Summit. Follow the links below to find all the reasons why you need to be in San Antonio for the 2016 Summit.
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…
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.
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:
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!
Want to learn more? I have a couple of opportunities that might interest you:
If you already collect good information and have good trending in place, consider attending the new TapRooT® for Audits Course on August 1-2.
If you are not there yet and want to learn how to collect data and trend, consider the Advanced Trending Techniques Course, also on August 1-2.
Thanks for taking the time to read the blog, and happy investigating/auditing.
We sometimes take conveyor belts for granted. “Just a motor, some rollers, and a big flexible belt.” But for those of us that use conveyor belts as a critical part of our business, we know how impactful a belt system failure can be. Additionally, a failure can cause more than just an inconvenience; failures in your belt system can lead to overheating and serious fires.
Here are some good ideas to help keep your conveyor belts running smoothly and safely.
A colleague at a recent Rail Safety conference pointed me to this article on how to change people’s behavior on rail lines in London. How do we influence people to:
– put trash in trash bins
– be courteous while playing music
– keep feet off the train seats
They’ve tried signs and warnings. I think we can all agree those have limited effect. There are audible reminders. The escalators in Atlanta Airport talk to you continuously on the way down to the trains.
Here are some other (gentler) ways the London Underground is trying to influence passengers to do what is required.
Upcoming TapRooT® Public Courses:
From Transocean Discoverer Enterprise …