Root Cause Analysis Blog

 

Caption Contest Winner!

Posted: February 17th, 2017 in Contest

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Once again, your all’s captions entertained the whole office. I hope it’s as fun for you to create them as it is for us to read them! But there can only be one winner….

The Grand Prize Winner is…*drumroll*

Eileen Delahanty with the caption: “Wanna lift – Knock yourself out.”

Congratulations Eileen!

Stay tuned for our next contest coming soon!

Technically Speaking – Helpdesk Humor

Posted: February 16th, 2017 in Software, Technical Support, Technically Speaking

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Sometimes the solutions can be simple.  Turning computers on and off has become one of the most reliable solutions for Tech Support.

TapRooT® can help us create procedures and corrective actions to the best path for a solution.

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!

Tip for Safety and Environmental Regulators – If a Refinery is being sold, INSPECT!

Posted: February 15th, 2017 in Uncategorized

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Saw an interesting article in Hydrocarbon Processing titled:

Rosneft faces $100-MM bill to boost safety at Bashneft refineries

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.

TapRooT® Users Ahead of California PSM Regulations

Posted: February 14th, 2017 in Uncategorized

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.

  1. 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.
  2. The written procedures shall include an effective method for conducting a thorough Root Cause Analysis.
  3. 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.
  4. 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.
  5. 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.
  6. 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.
  7. 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.
  8. 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.
  9. The employer shall implement all recommendations in accordance with subsection (x).
  10. 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.
  11. 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.
  12. 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.

  1. The employer shall develop, implement and maintain an effective written Human Factors program within eighteen (18) months following the effective date of this section.
  2. 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.
  3. 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.
  4. 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.
  5. The Human Factors analysis of process controls shall include:
    (A) Error-proof mechanisms;
    (B) Automatic alerts; and,
    (C) Automatic system shutdowns.
  6. The employer shall include an assessment of Human Factors in new operating and maintenance procedures.
  7. The employer shall train operating and maintenance employees in the written Human Factors program.
  8. The employer shall provide for employee participation in the Human Factors program, pursuant to subsection (q).
  9. 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.

What Does A Bad Day Look Like?

Posted: February 14th, 2017 in Accidents

8726346-R9-014-5A

EPA to Require Root Cause Analysis in RMP Required Investigations

Posted: February 13th, 2017 in Uncategorized

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:

INCIDENT INVESTIGATION

(a) The owner or operator shall investigate each incident that:

  1. Resulted in a catastrophic release (including when the affected process is decommissioned or destroyed following, or as the result of, an incident); or
  2. 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:

  1. Date, time, and location of incident;
  2. A description of the incident, inchronological order, providing all relevant facts;
  3. 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;
  4. 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;
  5. Emergency response actions taken;
  6. 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
  7. 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.

Friday Joke: You Matter

Posted: February 10th, 2017 in Jokes

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Technically Speaking – TapRooT® VI Deletion Feature

Posted: February 9th, 2017 in Software, Technical Support, Technically Speaking

Hello TapRooT® users! Check out this weeks video highlighting the new TapRooT® VI deletion feature. This feature is already there and ready to use! So, after the video, log in and check it out for yourself!

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, it doesn’t mean it has to be complicated!

Users Share Best Practices: Recertify Investigators Every Three Years

Posted: February 9th, 2017 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Here Charlotte Grainger discusses how her company has instituted a program requiring investigators to be recertified every three years.

(Click post title if the video is not displaying.)

Learn how to separate the “noise” from the “facts”!

Posted: February 8th, 2017 in Courses

Dave Janney and I were in New Orleans recently for 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training.   What did our course attendees have to say?  Check it out!

“I learned how to separate the ‘noise’ in an investigation from the facts.” ~ T. Choate

“The benefits are truly endless, and there is no one specific aspect I could point out that captures my thoughts.  On the other hand, one benefit that stands out is “consistency” based on the supporting elements of the Root Cause Tree. Too often I find subjectivity based on one’s ability to add to or take away from content of tool kits simply to derive their own outcomes.  TapRooT® invokes a method, a proven method at that, which ensure that consistent method and measures are used in every cause.” ~ J. McCartney

“All of the exercises were a benefit but it was especially helpful to relate the learned skills to a project specific to my organization.” ~ P. Hoewischer

Register today!  Choose a five day course here:  http://www.taproot.com/store/5-Day-Courses/

 

Continuous Improvement with TapRooT® Software Webinars

Posted: February 8th, 2017 in Software, Technical Support, Training
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…

Posted: February 7th, 2017 in Human Performance, Investigations, Performance Improvement, Pictures, Quality, Root Cause Analysis Tips, TapRooT, Training, Video

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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/

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Configuring Dashboards in TapRooT® VI

Posted: February 3rd, 2017 in Software, Technical Support, Technically Speaking

Let’s dive a little deeper and figure out how to have the dashboards show you exactly what you want!

In the screenshot below, we can configure and add/remove the TapRooT® widgets we want on our Dashboard in the TapRooT® software to improve our visibility and bring light to common trends in your organization.  There are 25 widgets available in the latest version of TapRooT® VI.

Configure Dashboard widgets

**NOTE Dashboards rely on your Classifications and Locations list.  Make sure these lists reflect how you want the Dashboards to appear.

Below you can see a filter which lets you choose Date Ranges, specific Locations, or Classifications.

This lets you magnify specific areas or step back for a broad view of your organization.

Filter

table

 

 

 

 

 

 

 

 

 

 

 

Dashboards can be displayed in many different layouts:

Tables (as shown to the left)

Line Charts

Pie Charts

Pareto Charts

Horizontal & Vertical Bar Charts

Horizontal Bar Chart Dashboard Pie Chart Line CHart

Each Dashboard can be exported to PDF so you can easily add it to any presentation.  Quick management tools like these can help prioritize areas for improvement.

Contact us about getting TapRooT® VI Enterprise for your company!

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!

Why would you reject a root cause analysis report?

Posted: February 2nd, 2017 in Root Cause Analysis Tips

Count of RCA Report Defects
 

While we probably would not see a frequency chart in real life like the one above, we all have seen or perceived the above rejection reasons after sending in our root cause analysis report to senior management or a regulator. Below are a few reasons that have caused a report or corrective action in a report to be rejected.

1. Rejection Example 1 (FDA):

We have reviewed your firm’s response of February 3, 2010, and note that it lacks sufficient corrective actions.

Specific violations observed during the inspection include, but are not limited, to the following:

1. Your firm has failed to reject drug products that did not meet established standards or specifications [21 C.F.R § 211.165(f)].

In your response, you state that this product is no longer manufactured and that such practices do not represent your company’s current CGMP compliance standards. You have committed to have all current and future investigations reviewed and signed by the Vice President of Quality Operations. However, you did not review your records to ensure that other products that failed to meet AQLs were not distributed. In addition, your response does not include training of the QCU to ensure that they are capable of identifying and ensuring appropriate corrections of these types of discrepancies in the future.

Problem Assessed: Company did not look for extent of condition (generic/systemic issues) or a complete corrective action with follow through.

2. Rejection Example 2 (NRC)

Company failed to correct CAPA 15-171, closed November 30, 2015, for finding 60010. CAPA 15-171 corrective actions required a revision to work instructions to include a pressure setting for contact blocks 60010. After discussions regarding the pressure setting with Company quality inspectors, the NRC inspection team identified that Company had not updated the work instructions.

Problem Assessed: Original finding did not get addressed nor were there any root causes identified for the original issue.

Just like students in a classroom, each report writer learns what the senior executive or regulator expects when writing an investigation report, often through trial and error. Often in some industries it seems that more time is spent writing an investigation report than is spent on the actual investigation.

How can you reduce the number of rejections that you might face while still ensuring a concise root cause analysis with effective corrective actions. Follow the steps below.

1. Do not let the written report criteria drive the root cause analysis itself.

• Perform the root cause analysis using an unbiased process like we do in a TapRooT® investigation.
• Collect the type of information that is required for the written report however do not limit what is collected.

2. Define the criteria for each section of the written report and hold that criteria true when writing a report.

• There should be little overlap in terms such as Causal Factor, Root Cause and Incident. In other words, no gray areas for interpretations.
• When within your control, reduce redundancy in your written report.

3. The written report should be concise and include enough information to be a standalone document as needed for the audience reading it. There should be no doubt when reading a report as to:

• What was the incident
• What led up to the incident
• What was the response to the incident
• What were the causal factors for the incident
• What were the root cause for the incident
• How each root cause will be addressed, whether eliminated or mitigated.

While there will be additional criteria required by the report requester for the writer to meet, the truer one stays to the purpose of an investigation and its documentation, the higher the chance of reducing said incident in the future.

Want to learn how to create a paperless report?  Check out our series here.

 

Users Share Best Practices: Using Weekly Review Boards to Examine Incidents

Posted: February 2nd, 2017 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success last year! Our attendees helped one another by sharing some of their best practices. Listen as Robert Oliver talks about how his company uses weekly review boards to examine incidents.

(Click post title if the video is not displaying.)

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