Root Cause Analysis Blog

 

Simple Root Cause Analysis (Don’t Settle!)

Posted: February 23rd, 2017 in Root Cause Analysis Tips, TapRooT, Training, Uncategorized

 

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.

Users Share Best Practices: Keep Subject Matter Experts for Each Work Area

Posted: February 23rd, 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 Tim Dearman informs the audience how his company keeps subject matter experts in each of their key business units to help during investigations.

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

Technically Speaking – TapRooT® VI Attachments

Posted: February 23rd, 2017 in Software, Technical Support, Technically Speaking, Video

Here is a quick video highlighting the Attachment Tab and how to upload files in TapRooT® VI.

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!

Do Your Folks Know What to Keep After an Accident?

Posted: February 22nd, 2017 in Uncategorized

NewImage

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:

http://www.taproot.com/courses#2-day-evidence

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 het 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.

 

 

Identify where a defect occurred… or when it became apparent?

Posted: February 20th, 2017 in Root Cause Analysis Tips

Vallee Tip
 

Is it more important to identify where a defect occurred or when the defect become apparent?

Several children in 2016 were left disappointed after their Christmas Gift, Hatchimals, did not hatch.

In a statement to Global News, Spin Master said they have added extra resources to help customers in the wake of a spike in calls.

“While the vast majority of children have had a magical experience with Hatchimals, we have also heard from consumers who have encountered challenges. We are 100% committed to bringing the magic of Hatchimals to all of our consumers,” said a company spokesperson.

“We are committed to doing everything possible to resolve any consumer issues. We sincerely apologize and thank everyone who is experiencing an issue for their patience.”

Spin Master

Which stakeholder was impacted the most in the defective product issue above?

  1. The child?
  2. The gift purchaser?
  3. The distributor, like Amazon?
  4. The product manufacturer, Spin Master?

While this was just a toy that went bad, think about the same questions for any other product and ask the same question again, “Is it more important to identify where a defect occurred or when the defect become apparent?”

For example:

  • Cracked syringe for onsulin injection
  • Diary product that is expired
  • Top-drive gears use on an oil-rig

Benefits of finding and analyzing a defect early in production:

  1. Company reputation
  2. Safety to customer
  3. Less delay between defect occurrence and relative evidence
  4. The ability to stop the production process immediately

Cons to having the customer report the defect:

  1. Magnitude of impact to safety and customer business can be greater
  2. Product fixes are closer to triage and damage control repairs as opposed to identification of root causes
  3. Degraded company reputation
  4. Harder to collect how the customer used the product in the field
  5. Takes more company resources to investigate the problem
  6. You have to earn the clients’ trust back no matter how well you remedy the problem

Timeliness of defect identification as well as finding the real root causes of the problem is vital for a business’s success and longevity. Recovering from a defect that escaped to the customer no matter what the fix is, becomes a loss of trust. So what are the recommendations to be proactive:

  1. Identify defect opportunities critical to customer success.
  2. Mistake-Proof for the critical opportunities when possible.
  3. Develop visible triggers and indicators at time of occurrence for defects that cannot be prevented 100 percent.
  4. Track and Trend types of defects, defect occurrence locations, gap between time of occurrence, time of identification and time to complete the corrective action.
  5. Track repeat occurrences and analyze for the failure of the previous corrective action…. Often related to poor root cause analysis and/or poor corrective action.

For continued discussion on the defect identification and correction, I look forward to your comments. Or even better, I look forward to seeing you in one of our TapRooT® Root Analysis Courses.

Caption Contest Winner!

Posted: February 17th, 2017 in Contest

winner

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.”

via GIPHY

Congratulations Eileen!

Stay tuned for our next contest coming soon!

Friday Joke

Posted: February 17th, 2017 in Jokes

Car-Parking-Funny-Sign-Board

Technically Speaking – Helpdesk Humor

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

dogsupport

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

NewImage

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

IMG_5208

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

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