Root Cause Analysis Blog

 

Weekly Wisdom: Stop Waiting, Go For It.

Posted: February 9th, 2016 in Wisdom Quote

Anne Frank

“How wonderful it is that nobody need wait a single moment before starting to improve the world.” -Anne Frank

Top 3 Worst Practices in Root Cause Analysis Interviewing

Posted: February 8th, 2016 in Root Cause Analysis Tips
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Allow interviewees to set the pace of the interview by encouraging them to tell the story of what happened during the incident instead of waiting for you to ask a “yes” or “no” answer.

Investigative interviewing is challenging because most investigators have learned how to do it on the job and do not have formal training. However, it is a very important component of evidence collection so it’s essential to know what practices to avoid.  Here are the top three worst practices in root cause analysis interviewing.

1. Not using a variety of open-ended questions. Asking too many closed-ended questions (questions that can be answered with a “yes” or “no”) will get you just that — a “yes” or “no.” Not only that, but closed-ended questions tend to be leading. Open-ended questions will help the interviewee retrieve from memory and maybe even provide information you did not know to ask. That’s not to say you should never use closed-ended questions.  Use your closed ended questions judiciously to verify something the interviewee has said or to tie up loose ends after the interviewee finishes his or her narrative.

2. Treat the interviewee with respect. When you seem uninterested in what the interviewee has to say, (i.e., you look at your phone/computer, take non-essential calls and allow other people to interrupt, sigh/show you are impatient/bored with your body language), he or she will try to make answers as brief as possible.  Interviewees will follow your lead but you really want them to set the pace – allowing them space to retrieve from memory and tell their stories as they remember them.  Set aside a time you will not be interrupted and break the ice at the beginning of the interview with a friendly tone and body language.

3. Don’t interrupt!  This goes along with #2 above but it also deserves it’s own spot because it is so important.  Even if you don’t do anything else right in the interview, don’t interrupt the interviewee while he or she is telling the story from memory. It will cause them to lose a train of thought and cause you to lose valuable information to get to the root cause.  You’ll also give out a “I already know what happened” attitude.  You don’t know the root cause until the investigation is complete, (and I hope you are nodding your head affirmatively).

What can you share about good interviewing practices?  Please leave your comments below.

And plan to attend the 2016 Global TapRooT® Summit, August 1-5, 2016 in San Antonio, Texas, where I will be teaching the 2-day Interviewing & Investigation Basics course as well as the best practice sessions, “15 Questions – Interview Topics” and “Interviewing Behaviors & Body Language” during Summit week.

Caption Writing Contest: Enter Today to Win!

Posted: February 8th, 2016 in Contest

How would you caption this image-

via GIPHY

Miss your chance to enter in our last caption contest in November? Want to give it another shot to try and win this time around? Here’s your chance! Unleash your clever side and write a caption for this image in 5 words or less. Here’s how to enter:

1. Create your caption 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 February 29th.

3. If you haven’t already, subscribe to the TapRooT® Friends & Experts e-newsletter to find out if you won.
(Email the Editor at editor@taproot.com with subject “Subscribe to Win”)

Our in-house instructors will vote on the most clever caption, and the winner will be announced via our e-newsletter and a blog post on March 1st.

Prize! The winner will receive this globe tape dispenser to thank you for joining TapRooT® in changing the way the world solves problems.

prize

TapRooT® Public Courses in Canada

Posted: February 8th, 2016 in Courses

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Calgary, Canada

Upcoming TapRooT® Public Courses

Montreal | 5-Day | March 7, 2016

Calgary | 2-Day | April 7, 2016

St. John’s | 5-Day | April 25, 2016

For more information regarding our public courses around the world, click here.

REGISTER FOR THE 2016 TapRooT® Summit NOW. 

Monday Accident & Lessons Learned: Was “Paying Attention” the Root Cause?

Posted: February 8th, 2016 in Accidents, Human Performance, Video

Watch this video and see what you think …

Meteorite Casualty: Natural Disaster in TapRooT® Root Cause Analysis

Posted: February 8th, 2016 in Accidents, Root Cause Analysis Tips

meteor

Photo of meteor from Chelyabinsk, Russia in 2013

If confirmed, here is a link to the first recorded fatality due to a meteorite strike in modern history. This would be one of the few appropriate uses of the Natural Disaster category on the Root Cause Tree®.

When doing a root cause analysis using TapRooT®, one of the top-level paths you can follow can lead you to Natural Disaster as a possibility. We note that this doesn’t come up very often. When you go down this path, TapRooT® makes you verify that the problem was caused by a natural event that was outside of your control.

I have seen people try to select Natural Disaster because there was a rainstorm, and a leak in the roof caused damage to equipment inside the building. Using TapRooT®, this would most likely NOT meet the TapRooT® Dictionary® definition of Natural Disaster. In this case, we would want to look at why the roof leaked. There should have been multiple safeguards in place to prevent this. We might find that:

The roofing material was improperly installed.
We do not do any inspections of our roof.
We have noted minor water damage before, but did not take action.
We have deferred maintenance on the roof due to budget, etc.

Therefore, the leaky roof would not be Natural Disaster, but a Human Performance issue.

The case of the meteorite strike, however, is a different issue. There are no reasonable mitigations that an organization can put in place that would prevent injury due to a meteorite. This is just one of those times that you verify that your emergency response was appropriate (Did we call the correct people? Did medical aid arrive as expected?). If we find no issues with our response, we can conclude that this was a Natural Disaster, and there are no root causes that could have prevented or mitigated the accident.

Equipment Failure: Blackout for 46,000 Residents

Posted: February 8th, 2016 in Equipment/Equifactor®

Blackout

Here’s another example of generic “equipment failure.” Not a lot of details, but I’m pretty sure the substation was not designed to fail. We should look at not just the equipment, but what additional safeguards are in place to prevent a single-point failure from blacking out a large section of a city.
Again, we don’t have details yet, but the label of “equipment failure” should make you think about digging a little deeper.

What Does a Generic Cause Look Like in Healthcare?

Posted: February 5th, 2016 in Medical/Healthcare

I have been teaching RCA now for almost 20 years and have found that Generic Cause is many times the simplest yet most confusing step in our RCA process. The first 4 steps from Getting Started (reporting) through Root Cause Analysis (Root Cause Tree®) move very efficiently. But transitioning from “Specific” root causes linked to Causal Factors to “Generic” causes that tie multiple events together seems to trip up many professionals.

7-step Investigation Flow
I found an interesting article that can be found HERE, that provides a very good example of a generic cause.

What is a Generic Cause?

First let me start with a quick discussion of our philosophy on Generic Cause. Step 5 in the process flow above addresses this issue prior to developing your Corrective Actions. We need to first understand the “Specific” root causes from Step 4, and the “Generic” causes before we begin developing Corrective Actions so both can be addressed.

The definition of a “Generic” cause in our system is as follows:

The Systemic problem that allows a root cause to exist, across multiple incidents or sites or systems.

This is a bigger picture issue that is allowing the same root causes to exist across multiple events. So that being said, let’s dig into the article above to provide a description of a “Generic” issue.

The Duodenoscope Example

The article discusses a particular type of duodenoscope produced by one manufacturer used across the healthcare industry. This particular scope had been linked to multiple cases where infection had been spread to patients. So similar infections, when investigated by individual hospitals, provided data showing that this particular type of scope was involved. Breaking down that statement, we have the following:

  1. Same brand and model duodenoscope
  2. Used in multiple facilities over a term of 5 years
  3. Multiple instances of infection transmission following use of this scope

Are you seeing the pattern in this list? Something is similar in all these instances… the scope itself. Now, from the article (which does not provide any RCA data), I can only speculate on the Root Causes for this “spread of infection” as it relates to the scope… from the Corrective Actions taken by the manufacturer it looks as if there could be any of the following issues:

. . . A. Equipment Difficulty->Design->Specs NI
. . . B. Equipment Difficulty->Preventative/Predictive Maintenance-> PM NI-> PM for Equip NI
. . . . . .1. If you assume the cleaning procedures and recommendations to be Preventative Maintenance
…………..on the scope
. . . C. Human Performance->Procedures->Wrong->Facts Wrong
. . . . . .1. If here you assume the cleaning instructions are procedures and they did adequately provide
…………..information on cleaning the scope.

Any of these could relate back to the Corrective Actions which include the recall, a redesign of the scope as well as changes to the cleaning requirements.

Finding Generic Causes in Your Organization

Now looking at these causes, and the list of items that meet the definition of a Generic cause, I have to ask everyone reading this article:

How would you as an organization know that you are having Generic problems?

The answer to that question will probably vary from organization to organization but there is probably one key element. That key element is consistent Classification of events, consistent Root Cause Analysis, linking your Causal Factors (on the Causal Factor Editor) to specific Equipment types and Departments, and effective trending and data analysis. Without a clear, well defined classification schema for all investigations or incidents within a healthcare facility/system it would be nearly impossible to trend your RCA data and determine where similar causes and events are happening.

Once you get a standard Classification list together, and consistently classify your events, you can now perform a couple of different Trending functions (from the TapRooT® Software v5.3) to determine Generic Causes:

  1. Search your data using our Root Cause Distribution Report by filtering Classification and over a date range to see all causes produced. If you find a particular root cause across those RCA’s you may have a generic cause.
  2. Run a Pareto Chart using Equipment as your X-axis and Counts as your Y-axis on the chart to look at counts. See if one piece of equipment is linked to 70-80% of your causes… this might give you a clue to a Generic Issue
  3. Run a Process Behavior Chart looking at a Specific Classification, and run an “Instant Rate” chart or an “Interval Chart”. These would cue you in on if your rate of failure is increasing or if your time between occurrences is decreasing respectively and may provide some insight into your overall Equipment or program health.

If you have any questions about Generic Cause or any additional Trending functions please feel free to contact me at skompski@taproot.com

Equipment Failure? Parachuting Accident

Posted: February 5th, 2016 in Accidents, Equipment/Equifactor®

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I’m going to be bringing you some examples of accidents and problems that are quickly listed as “equipment failure.” Take a look at these problems and ask yourself:

– Is this really an equipment problem?

– Have we looked deep enough into the actual reason that the equipment did not work as intended?

– Were there any safeguards that were in place that failed, or should have been in place and were not?”

Here’s an example that is just quickly labeled “equipment failure”. List the safeguards that you think should have been in place (and maybe were, maybe weren’t) to prevent the accident’s outcome.

Times are Tough … How Can TapRooT® Root Cause Analysis Help?

Posted: February 4th, 2016 in Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

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Many industries have dropped into a recession or a downright depression.

Oil, coal, iron ore, gas, and many other commodity prices are at near term (or all time) lows.

When the economy goes bad, the natural tendency is for companies to cut costs (and lay people off). Of course, we’ve seen this in many industries and the repercussion have been felt around the world.

Since many of our clients are in the effected industries, we think about how we could help. 

If you could use some help … read on!

FIRST

I think the first way we can help is to remind TapRooT® Users and management at companies that use TapRooT® that in hard times, it is easy for employees to hear they wrong message.

What is the wrong message?

Workers and supervisors think that because of the tough economic times, they need to cut corners to save money. Therefore, they shortcut safety requirements.

For example:

  • A mechanic might save time by not locking out a piece of equipment while making an adjustment. 
  • An operator might take shortcuts when using a procedure to save time. 
  • Pre-job hazard analyses or pre-job brief might be skipped to save time.
  • Facility management might cut operating staff or maintenance personnel below the level needed to operate and maintain a facility safely.
  • Supervisors may have to use excessive overtime to make up for short staffing after layoffs.
  • Maintenance may be delayed way past the point of being safe because funds weren’t available.

These changes might seem OK at first. When shortcuts are taken and no immediate problems are seen, the decision to take the shortcut seems justified. This starts a culture shift. More shortcuts are deemed acceptable. 

In facilities that have multiple Safeguards (often true in the oil, mining, and other industries that ascribe to process safety management), the failure of a single Safeguard or even multiple Safeguards may go unnoticed because there is still one Safeguard left that is preventing a disaster. But every Safeguard has weaknesses and when the final Safeguard fails … BOOM!

This phenomenon of shortcuts becoming normal has a PhD term … Normalization of Deviation

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The result of normalization of deviation? Usually a major accident that causes extensive damage, kills multiple people, and ruins a company’s reputation.

So, the first thing that we at System Improvements can do to help you through tough times is to say …

WATCH OUT!

This could be happening to your operators, your mechanics, or your local management and supervision. 

When times are bad you MUST double up on safety audits and management walk arounds to make sure that supervisors and workers know that bad times are not the time to take shortcuts. Certain costs can’t be cut. There are requirements that can’t be eliminated because times are tough and the economy is bad. 

SECOND

When times are tough you need the very BEST performance just to get by.

When times are tough, you need to make sure that your incident investigation programs and trending are catching problems and keeping performance at the highest levels to assure that major accidents don’t happen.

Your incident investigation system and your audit programs should produce KPI’s (key performance indicators) that help management see if the problems mentioned above are happening (or are being prevented).

If you aren’t positive if your systems are working 100%, give us a call (865-539-2139) and we would be happy to discuss your concerns and provide ideas to get your site back on the right track. For industries that are in tough times, we will even provide a free assessment to help you decide if you need to request additional resources before something bad happens. 

Believe me, you don’t want a major accident to be your wake up call that your cost cutting gone too far.

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THIRD

How would you like to save time and effort and still have effective root cause analysis of small problems (to prevent big problems from happening)? 

For years I’ve had users request “TapRooT®-Lite” for less severe incidents and near-misses. I’ve tried to help people by explaining what needed to be done but we didn’t have explicit instructions.

Last summer I started working on a new book about using TapRooT® to find the root causes of low-to-medium risk incidents. And the book is now finished and back from the printers.

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Good news:

  • The book is only 50 pages long.
  • It makes using TapRooT® easy.
  • It provides the tools needed to produce excellent quality investigations with the minimum effort.
  • It will become the basis for our 2-Day TapRooT® Root Cause Analysis Course.

When can you get the book? NOW! Our IT guys have a NEW LINK to the new book on our store.

By April, we should have our 2-Day TapRooT® Course modified and everything should be interlinked with our new TapRooT® Version VI Software.

In hard economic times, getting a boost in productivity and effectiveness in a mission critical activity (like root cause analysis) is a great helping hand for our clients.

The new book is the first of eight new books that we will be publishing this year. Watch for our new releases and take advantage of the latest improvements in root cause analysis to help your facility improve safety, quality, and efficiency even when your industry is in tough economic times. For more information on the first of the new books, see:

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

FINALLY

If you need help, give us a call. (865-539-2139)

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Are you having a backlog of investigations because of staff cuts? We can get you someone to help perform investigations on a short term basis.

Need to get people trained to investigate low-to-medium risk incidents effectively (and quickly)? We can quote a new 2-Day TapRooT® Root Cause Analysis Course t to be held at your site.

Need a job because of downsizing at your company? Watch the postings at the Root Cause Analysis Blog. We pass along job notices that require TapRooT® Root Cause Analysis skills.

This isn’t the first time that commodity prices have plummeted. Do you remember the bad times in the oil patch back in 1998? We helped our clients then and we stand by to help you today! We can’t afford to stop improvement efforts! Nobody wants to see people die to maintain a profit margin or a stock’s price. Let’s keep things going and avoid major accidents while we wait for the next economic boom.

Technically Speaking – Backing up a TapRooT® Database

Posted: February 4th, 2016 in Software, Technical Support, Technically Speaking, Video Depot

This week I ‘d like to discuss the steps to backup your TapRooT® database. This is great to know should you need to move your software to a new machine and want to retain your data.

Technically Speaking is a weekly series that highlights various aspects of our Version 5 software, introduces you to the upcoming TapRooT® VI release and occasionally includes a little Help Desk humor.

Remember, just because it’s technical, doesn’t mean it has to be complicated!

Will They Really Find the Root Causes?

Posted: February 3rd, 2016 in Current Events, Investigations, Pictures

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The new littoral combat ship USS Milwaukee suffered an embarrassing breakdown while transiting to Norfolk. The Navy is doing a “root cause analysis” of the failure. See the story at:

http://dodbuzz.com/2016/02/01/navy-seeks-answers-as-2-lcss-break-down-in-a-month/

When I read these press stories I always think:

What techniques are they using and will they really find the root causes and fix them?

All too often the final answer is “No.”

What does a bad day look like?

Posted: February 3rd, 2016 in Video

They try to make this sound like a good day … but when you wreck your boat … it is never a good day.

Eagle Takes Down a Drone

Posted: February 2nd, 2016 in Video

I thought this was interesting …

Weekly Wisdom: The Opportunities Are Endless When You Have Courage

Posted: February 2nd, 2016 in Wisdom Quote

Life shrinks

“Life shrinks or expands in proportion to one’s courage.” -Anais Nin

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