Root Cause Analysis Blog

 

Root Cause Tips – Causal Factors: initiating errors and stop/catch/mitigate

Posted: December 7th, 2016 in Root Cause Analysis Tips

Happy Wednesday and welcome to this week’s root cause analysis tips column. This week we will talk about Causal Factors.

The TapRooT® Definition of a Causal Factor is:

“A mistake, error, or failure that directly leads to (or causes) an Incident or fails to mitigate the consequences of the original error.”

This definition is one major thing that distinguishes TapRooT® from some other methods. We don’t just find the first thing that went wrong, we find EVERTHING that went wrong. I’ve had people say to me that “but if I fix the first problem the incident would not have happened.” That is actually true, but if I only focus on the first thing that went wrong (which is sometimes the most obvious), then I do not address everything else that is wrong with my system. It also allows people to fall into the trap of determining “the causiest causal factor” and ignoring everything else.

Consider this diagram:

Screen Shot 2016-10-11 at 8.07.26 AM
Is it possible to have an incident with only one error? Yes. But more often than not, once we’ve made a mistake, we have chances to stop/catch the problem before it becomes an incident. We also sometimes have chances to mitigate the consequences.

So when looking for Causal Factors, I find the first error/failure (initiating error), and they look for chances to stop/catch/mitigate. Each time I fail to stop/catch/mitigate, it is a new Causal Factor.

You will also notice that we could have an initiating error later in the timeline was well. It could be completely unrelated but allowed the hazard to reach the target.

Here is an example:

*Someone turns the wrong valve and allows a hazard (this is an initiating error).

*A second check of the valve configuration was not completed as required (a chance to stop/catch the first error).

*Someone lights a cigarette in an unauthorized area (another initiating error).

*Emergency response team did not arrive for 30 minutes (chance to mitigate the consequences).

Each one of these would be a Causal Factor.

Defining Causal Factors does not have to be difficult. The more you do it, the more comfortable you will be. I find that the concept of stop/catch/mitigate can really be helpful in making sure you find ALL the problems that led to an incident.

So thanks for visiting our blog. I hope you don’t have an incident anytime soon, but if you do, I hope you find the information helpful. If you’re interested in learning more about identifying causal factors and finding the root causes of incidents, register for our 2-Day TapRooT® Root Cause Analysis Training.

Enter Our Caption Contest!

Posted: December 5th, 2016 in Contest

via GIPHY

Caption this image for chance to win a prize!

Contest Instructions:
1. Create your caption to the photo above in five words or less. All captions with more than five words will be disqualified.
2. Type your caption in the comments section of this post by December 16.
3. If you haven’t already, subscribe to the Tuesday TapRooT® Friends & Experts e-newsletter.

Our  staff will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on December 5.

Have fun!

Monday Accident & Lessons Learned: Ammonia leak kills 1 at Carlsberg brewery in UK

Posted: December 5th, 2016 in Accidents, Courses, Current Events, TapRooT

SHP reported that a worker at the Carlsberg brewery died and 22 others were injured by a cooling system ammonia leak.

Are you using advanced root cause analysis to investigate near-misses and stop major accidents? That a lesson that all facilities with hazards should learn. For current advanced root cause analysis public courses being held around the world, see:

Upcoming TapRooT® Public Courses

TapRooT® can be used for both low to medium risk incidents (including near-misses) and major accidents. For people who will normally be investigating low risk incidents, the 2-Day TapRooT® Root Cause Analysis Course is recommended.

For people who will investigate all types of incidents including near-misses and incidents with major consequences (or a potential for major consequences), we recommend the 5-Day Advanced Team Leader Training.

Don’t wait! If you have attended TapRooT® Training, get signed up today!

Monday Motivation: Habit

Posted: December 5th, 2016 in Career Development, Career Development Tips, Wisdom Quote

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Good or bad, what you do every day will turn into a habit. Choose habits that will lead you to success. Over time, they will become automatic, not requiring thought, attention or effort.

What habit can you commit to today that will contribute to your success?

How Far Away is Death?

Posted: December 4th, 2016 in How Far Away Is Death?, Video

Teenagers seem to have no concept of how far away from death that they are. Very few over 25 would do this…

Friday Joke: Christmas Tree Fail

Posted: December 2nd, 2016 in Jokes

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The hipster or the poor man’s Christmas tree?

Thank You Notes Can Give You A Boost

Posted: December 1st, 2016 in Career Development

This article was reprinted with permission from the author, Captain George Burk, USAF (Ret), Plane crash, burn survivor, motivational speaker, author, writer. Visit his website at www.georgeburk.com  or contact Captain Burk at gburk@georgeburk.com.

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I’ve heard it said many times that a person’s memory is a direct reflection of the type of life they have lived. If that’s true, and I believe it is, then I’ve been blessed with a wonderful life. Thank you to all here and those passed, who’ve given me many wonderful memories.

“Be a yardstick of quality. Some people aren’t used to an environment where excellence is expected.” Steve Jobs, Apple co-founder

Several human resources and etiquette professionals suggest that a handwritten note after an interview is more than a courtesy—the job could depend on it. I believe the same strategy is applicable when you send a handwritten “Thank you” to a conference organizer and host(s) and/or someone who invited you to their home for dinner; they’ve gone “above and beyond” to help or did you a favor, etc. The examples are almost endless.

“As a kid, I lived in a fantasy world. I used to believe that ants could talk. Not once did they say thank you.” Willard Wigan

The job interview you waited on for months is over and you think it went extremely well. But, before the position is offered to you, there’s one more important step you should complete—it’s one that I know is overlooked by the majority of people today: write and mail a handwritten thank you note to the interviewer and anyone else you met at the organization who played a role in your being interviewed.

That may sound obvious to some job applicants—especially younger job applicants—who’ve learned to believe and accept that a simple “Thanks” via a text or email is sufficient. No so, career experts suggest.

We’ve become captives of today’s rapid, convenient and quick–fix technology. Technology of the 21st Century has created the culture of texting and e-mailing the communications normal of today. Even for work, most people accept the notion that this is a valid way to express their gratitude after a job interview, says Colleen Rickenbacher, a Dallas-based etiquette expert. “Absolutely not,” says Rickenbacher, a certified protocol consultant and author of “The Big Book of People Skills Games.” “A nice, short handwritten thank you is appropriate and necessary,” she says.

“Feeling good about your life but not expressing a heartfelt ‘Thank you’ is like wrapping a gift for someone and never giving it to them.” Chip Conley

Before my presentations to the senior Midshipmen at the Capstone Character Excellence Program, United States Naval Academy, Annapolis, Maryland, I place my business cards on the tables in front of each Midshipman’s chair.

After my introduction, I mention my business cards and that I’ll tell them why I did it later. Towards the end of my presentation, I share my strategy: when they attend a seminar or conference, they should walk-in with a hand full of their business cards and leave with handful of business cards from people they meet. Make a note on the card when and where they met and follow-up later with a thank you note. I urge the Midshipmen to make this a part of their overall personal and professional strategy. I know from experience, the majority of people don’t do this today. I also suggest they write a “Thank you” when invited to someone’s home for dinner, when an author gives them a signed copy of his/her book, someone gives or sends them an unexpected a gift or writes them a professional recommendation. These are but a few examples. To me, it’s important to send some type of “Thank you” note be it hand-written, email or as a last resort, a text.

“The first responsibility of a leader is to define reality. The last is to say “Thank you.” In between, the leader is a servant.” Max de Pree

Life’s ‘funny’ as in serendipitous. You never know when you might meet the person(s) again. One day, they may your boss or sit on a promotion board…you may meet them again at the most unlikely location or time…leave them with a good impression of you. It can’t hurt, it will only help. It only takes a few minutes to write, stamp and mail a thank you note. Most of your cohorts and majority of others don’t do it. It’s a lost art.

Scottsdale, Arizona trainer Ed Scannell says, ”If a prospective employee cannot take the few minutes to handwrite a thank-you note on nice stationary, then he or she may not necessarily be the best candidate when it comes to common courtesy and good customer service.” He says that a handwritten note could be the deciding factor when several people seem equally qualified for the position.

Scannell remembers when he served as the executive vice president of a national professional association in the process of hiring a new meeting planner. Several candidates did well in the interviews. “When we did make our selection, I know for certain that one person who did send us a handwritten thank you note made an even better impression and did get the job,” he said.

“I can count on one hand the number of people who wrote me as thank you letter after having an interview, and I gave almost all of them a job.” Kate Reardon

Some managers, however, don’t automatically dismiss a candidate who sends a thank-you by e-mail. Laurel Strasshofer, human resources professional said, “Texting is too casual. But e-mail is acceptable and appropriate since we do so much work on our computers.” But, she accepts that thank you notes carry more weight because they indicate an employee likely will follow up on the details associated with their job. “A thank you note that’s mailed impresses me and shows they have interest in working here,” she says.

Even if a prospective employee sends a handwritten note and wasn’t hired or the right fit for the position, the extra effort could pay dividends later. “It adds a little something,” she says. “I would remember the candidate if another position came up that was a better fit.”

“I think about what has touched me in the notes I’ve received from people. I try to just let my heart speak and not worry that I’m being ‘gushy’ or ‘over the top.’ When you’re sincere, I don’t think you can be.” Thank you advice from a longtime Hallmark writer.

Several months ago, I read a short article in the “Arizona Republic Newspaper.” The article addressed our society’s growing psychological reliance on communications technology. Several psychologists stated they’re concerned that people are losing the ability to effectively communicate verbally and via the handwritten word because of their reliance on electronic communications. People will lose the ability to communicate face-to-face and how to write the syntax in a sentence that makes sense. The “LMOA” and other abbreviations used in texting are not acceptable! (For safety’s sake, please don’t use your cell phone or text while driving and while refueling your car. The life you save…may be mine!)

“God gave you a gift of 86,400 seconds today. Have you used one today to say ‘Thank you?’” William Arthur Ward

A few tips for thank you notes:
The “3-3-3” policy—Take three minutes to write a note, use three lines to thank the person for their time and send the note within three days.

The look—Notes should be professional looking, fold-over note/cards in a solid color with matching envelopes. Nothing loud or “cutesy.” I developed a blue grey card and blue fonts that match my business card in color. On the card, my name is across the top, the quote on my business card is under my name and at the bottom of the card are my toll free and cell phone numbers and my web site.

The writing—Write the note on the inside of the card. I use the front of the card and sometimes continue on the back. If you don’t have neat, legible cursive, it’s okay to print. This gets tricky for me. My cursive (my scrawl) often times requires interpretation and so does my print. My one functional hand doesn’t always respond well. But…I write my notes anyhow.

Example: “Thank you so much for inviting me to interview for your open account specialist position. I truly appreciate the time you took to talk with me about this opportunity and the company. I enjoyed learning more about your work group and how I might fit into the team. Please don’t hesitate to contact me with any follow-up questions you might have. I hope to talk with you again soon.”

The envelope—Color contrast it with the note paper. Double and triple check all spelling, titles and the address.  I have a pre-made stamp with my/our name, address and city, state and zip code.

“Thank you, God, for this good life and forgive me (us) if I (we) don’t do not love it enough.” Garrison Keillor

One final note: I over the past 45 years, I’ve tried to write a thank you note to the many who’ve helped me on my journey and to my hosts, those who’ve read my books, interviewed me, published my articles and others who’ve been gracious, kind and thoughtful. Thank you to my hosts who’ve invited me to speak at various venues. Thank you to those who’ve invited me into their lives, homes, and for their friendship. Each of you has helped me realize my purpose.

Thank you!

TapRooT® Is Going to Houston!

Posted: December 1st, 2016 in Courses, Local Attractions

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TapRooT® is going to Houston December 12-15 for a 5-Day Advanced Root Cause Analysis and Team Leader Training course. You can learn how to optimize your investigations and enjoy a city with a big personality. Houston lives up to the western character that we all know and love about Texas, but that’s not all it is. You’ll find cuisine of all kinds, sophisticated downtown shops and a wide variety of industrial powerhouses. Visit and see for yourself!

Register for the 5-Day TapRooT® course here.

Things to do:

Oxheart: This is a crowd favorite for classic American food with a twist.

Hugo’s: When you’re in Texas, you have to have Mexican food! Give Hugo’s a try and you won’t be disappointed.

Saint Arnold Brewery: Learn how this local craft brewery makes their beer and give it a try for a great afternoon.

Market Square Park: Historical area, modern feel, heart of downtown. Enjoy a stroll and learn more about Houston!

 

See all the 2017 TapRooT® course locations here.

Inquire about an onsite course here.

Technically Speaking – Creating a Paperless Report (Part 1)

Posted: December 1st, 2016 in Software, Software Updates, Technical Support, Technically Speaking, Video, Video Depot

I wanted to introduce you to a short three part series detailing the steps to take a paper report and re-create it in the TapRooT® VI software.

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!

Users Share Best Practices: Allow Leadership To Be A Champion For Your Investigation

Posted: November 30th, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. William McClung describes how they allow leadership to be a champion for their investigation.

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Using TapRooT® Safeguard Analysis to Investigate Biopharmaceutical Defects

Posted: November 29th, 2016 in Root Cause Analysis Tips

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After Mark Paradies presented a talk on root cause analysis at the 2016 PDA/FDA Joint Regulatory Conference, a question was asked,

“How can we use TapRooT® Root Cause Analysis specifically to help solve “biological” driven problems that occur during biopharmaceutical product processing?”

The group had many general questions during his talk titled, “Identification of True Root Cause – and Impact to the Quality System,” and liked the points that he made. The question above however made me wonder why some industries or some industry-specific issues appear more complex than others when it comes to problem solving.

We use Safeguard Analysis to help identify the factor hazard/safeguards/target during our TapRooT® Root Cause Analysis. We look for errors of loss of control in these factors to find if these changes impacted the big problem that we are investigating. We also look for these changes formally by using a Change Analysis Table, taught in our 5-Day Courses. The linked Safeguard Analysis article above walks you through a near miss incident with a fast moving train and people. Once you identify your Hazards, your Targets, and any Safeguards we ask simple questions such as:

– was there an error that allowed a Hazard that shouldn’t have been there, or was larger than it should have been;
– was there an error that allowed a Safeguard to be missing;
– was there an error that allowed a Safeguard to fail;
– was there an error that allowed the Target to get too close to a Hazard; or
– was there an error that allowed the Incident to become worse after it occurred.

So here is the complexity question, what makes a near miss with a train incident different or a biopharmaceutical product processing near miss more complex to investigate than a train incident? Can we use the same root cause process for both types of problems?

Let’s walk through how we can turn the complex into the simple.

Simplifying the Issue:

In safety investigations, either the target got hurt or almost hurt. If the target got hurt, how badly?

In biopharmaceutical investigations, either it is a True Batch Failure, a False Batch Failure, a Safety Compromised or a Non-Standard Efficacy issue.

The similarity between seeming complex productions verses a train incident? Either a hazard got to the Batch (target) knowingly or unknowingly and was the loss of control caught in time?

The other questions would be….

1. How easy would it be to document the process of transactions that occurred during the Batch Process?
2. How easy would it be to identify the hazards of say…moisture, catalyst issues, enzyme or bacteria controls for the Batch Process? Simply, did they get the recipe right?
3. Finally, once identified, can the SME’s identify the error opportunities listed above?

If you are in the Biopharmaceutical Industry whether from the GCP or GMP side, give us a call or just sign up for a course and apply it.

What does a bad day look like?

Posted: November 29th, 2016 in Pictures

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Old Fashioned Definition of Root Cause vs. Modern Definition of Root Cause

Posted: November 29th, 2016 in Pictures, Root Cause Analysis Tips, TapRooT

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When we first started the development of TapRooT® back in the 1980s, we developed this definition of a root cause:

Root Cause
The most basic cause (or causes)
that can reasonably be identified 
that management has control to fix
and, when fixed, will prevent 
(or significantly reduce the likelihood of)
the problem’s recurrence.

The modern definition of a root cause, which was proposed in 2006 by Mark Paradies at the Global TapRooT® Summit and really isn’t so new, is:

Root Cause
The absence of best practices
or the failure to apply knowledge
that would have prevented the problem.

 This modern definition of a root cause leads to this definition of root cause analysis:

Root Cause Analysis
The search for the best practices
and/or the missing knowledge that
will keep a problem from recurring

Since most people (including, in the past, me) say that root cause analysis is the search for why something failed, this reversal of thinking toward looking for how to make something succeed is truly a powerful way of thinking. The idea changes the concept of root cause analysis.

Even though a decade had passed since proposing this new definition, I still have people ask:

Why did you change the definition? I liked it like it was!

Therefore, I thought that with the new TapRooT® Books coming out, I would explain our reasoning to show the clear advantage of the modern definition.

The modern definition focuses on the positive. You will search for best practices and knowledge. You aren’t looking for people to blame or management faults. Yes, a best practice or knowledge is missing, but you are going to find out how to do the work more reliably. Thus, the focus is on improvement … the opportunity to improve vision!

The same thing can be said about the old fashioned definition too. But the old definition focused on cause. The difference in the definitions is a matter of perspective. Looking up at the Empire State Building from the bottom is one perspective. Looking down the Empire State Building from the top is quite another. The old definition looked at the glass as half empty. The new definition looks at the glass as half full. The old definition focuses on the “cause.” The modern definition focuses on the solution.

This shift in thinking leads people to a better understanding of root causes and how to find them. When it is combined with the Root Cause Tree® and Dictionary, the thinking revolutionizes the search for improved performance.

The concept of looking for ways to improve has always been a part of the TapRooT® System. It is the secret that makes TapRooT® such a powerful tool. But the modern definition – the new perspective – makes it easier to explain to others why TapRooT® works so well. TapRooT® is a tool that finds the missing knowledge or best practices that are needed to solve the toughest problems.

One last note about the modern definition: In the real world, absolutes like “will prevent” can seldom be guaranteed. So the root cause definition should probably be augmented with the additional phrase: “or significantly reduce the likelihood of the problem’s recurrence.” We chose not to add this phrase in the definition to keep the message about the new focus as strong as possible. But please be aware that we understand the limits of technology to guarantee absolutes and the ingenuity of people to find ways to cause errors even in well-designed systems.

That’s the reasons for the definition change. You may agree or disagree, but what everyone finds as true is that TapRooT® helps you find and fix the root causes of problems to improve safety, quality, productivity, and equipment reliability.

Attend a TapRooT® Course and find out how TapRooT® can help your company improve performance.

Monday Accident & Lessons Learned: Collision at Yafforth, UK, level crossing, 3 August 2016

Posted: November 28th, 2016 in Accidents, Current Events, Investigations, Pictures

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For a report from the UK Rail Accident Investigation Branch, see:

www.gov.uk

Technically Speaking – Happy Thanksgiving!

Posted: November 24th, 2016 in Software, Technical Support, Technically Speaking, Uncategorized

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TapRooT® is a company based in the United States and we wanted to wish all other U.S. clients a Happy Thanksgiving today, November 24! We are out of the office Thursday and Friday, but will be back ready to go on Monday morning. We are grateful for all our U.S. and global clients and look forward to connecting with you next week!

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!

Happy Thanksgiving

Posted: November 24th, 2016 in Pictures

Here is my Thanksgiving posting. I post it every year, lest we forget…

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In America, today (Thursday) is a day to get together with family and friends and reflect on our blessings – which are many!

One of my ancestors, Peregrine White, was the first child born to the Pilgrims in the New World.

During November of 1620, Peregrine’s mother Susanna, gave birth to him aboard the ship Mayflower anchored in Provincetown Harbor. His father, William, died that winter – a fate shared by about half of the Pilgrim settlers.

The Pilgrims faced death and the uncertainty of a new, little explored land. Why? To establish a place where they could worship freely.

With the help of Native Americans that allied with and befriended them, they learned how to survive in this “New World.” Today, we can be thankful for our freedom because of the sacrifices that these pioneers made to worship God in a way that they chose without government control and persecution.

Another interesting history lesson about the Pilgrims was that they initially decided that all food and land should be shared communally. But after the first year, and almost starving to death, they changed their minds. They decided that each family should be given a plot of land and be able to keep the fruits of their labors. Thus those that worked hardest could, in theory, reap the benefits of their extra labor. There would be no forced redistribution of the bounty.

The result? A much more bountiful harvest that everyone was thankful for. Thus, private property and keeping the fruits of one’s labor lead to increased productivity, a more bountiful harvest, and prosperity.

Is this the root cause of Thanksgiving?

This story of the cause of Thanksgiving bounty is passed down generation to generation in my family. But if you would like more proof, read the words of the first governor of the Plymouth Colony, William Bradford:

“And so assigned to every family a parcel of land, according to the proportion of their number, or that end, only for present use (but made no division for inheritance) and ranged all boys and youth under some family. This had very good success, for it made all hands very industrious, so as much more corn was planted than otherwise would have been by any means the Governor or any other could use, and saved him a great deal of trouble, and gave far better content. The women now went willingly into the field, and took their little ones with them to set corn; which before would allege weakness and inability; whom to have compelled would have been thought great tyranny and oppression.”

William Bradford, Of Plymouth Plantation 1620-1647, ed. Samuel Eliot Morison (New York : Knopf, 1991), p. 120.

Users Share Best Practices: Practice on the Previous Investigations

Posted: November 23rd, 2016 in Root Cause Analysis Tips, Summit, Summit Videos, Video Depot

Our 2016 Global TapRooT® Summit was a great success this year! Our attendees helped one another by sharing some of their best practices. Here Rajesh Malik talks about how his company encourages students to go back and apply what they learned in the TapRooT® course to their previous investigations.

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Remembering an Accident: MESIT Factory Collapse

Posted: November 23rd, 2016 in Accidents

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This day in history…an explosion occurred that remains a mystery to this day.

On November 23, 1984, in Uherské Hradiště, Czechoslovakia, part of the MESIT factory collapsed. It is unknown the exact root cause, but this manufacturing plant disaster killed 18 workers and injured 43. Being in the mid 1980’s, the communist regime decided to keep the accident a secret from the public. People speculate it was to hide confidential work from the rest of the world. However, media caught a hold of it from an anonymous source which then spread across the sea to western media. Although not much is known, it’s no secret that proactive measures need to be enforced and investigations must always be done to make improvements.

 

What does a bad day look like?

Posted: November 22nd, 2016 in Pictures

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