A failure occurs. It could be:
- a safety related accident
- an equipment failure
- a patient safety event (sentinel event)
- a quality issue
- a shipping screw up
- a cost overrun
- a process safety related near-miss
What people do next can make a world of difference.
First, is the failure (incident or near-miss) reported? Or is it covered up?
If you are reading this you probably think that your company should learn from its mistakes to keep the mistakes from happening again. (Or to keep something even worse from happening – like the picture above.)
But if mistakes and failures are hidden, learning is unlikely.
People must know that it is safe to report a problem and that, once a problem is reported, something will be done to improve the process to make the problem go away.
Punishing the person who reported the problem or punishing someone else involved in the failure IS NOT the kind of action that will promote more reporting of failures.
OK … You have established a culture where the reporting of problems is not punished. You may even have a culture where the reporting of problems is an expected part of how you do business. NOW WHAT?
Do people know how to preserve the evidence of the failure so that an effective root cause analysis can be performed?
You might be surprised that most folks don’t know how to preserve the scene of an accident.
They don’t know that disassembling broken equipment may destroy the evidence of why the equipment broke.
They may not collect the names of everyone involved (including contractors and first responders).
They may “clean things up” to get back to normal housekeeping standards.
They may let vital fluid samples slip away.
They may even collect “souvenirs” to take home.
Reporting the failure really doesn’t help if the evidence of the failure is destroyed before the root cause analysis starts.
What are you doing to train your supervisors to preserve the scene of a failure?
I have two suggestions.
1. Have training for them on evidence collection and interviewing.
We have a TapRooT® Course that can help supervisors secure the scene of an accident and have a much better idea of what they need to do when responding to a failure.
The course can be customized to teach just the information that you think your supervisors need.
The complete 2-Day TapRooT® Effective Interviewing & Evidence Collection Course has essential information that supervisors need to stop evidence destruction and help conduct interviews of those involved. See the course outline at:
Barb Phillips, the course designer, will be happy to talk to you about customizing the course for your supervisors to give them the knowledge and practice that they need to be ready to effectively respond to a failure. To talk to Barb, call 865-548-8990. Or email 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.
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.”
Which stakeholder was impacted the most in the defective product issue above?
- The child?
- The gift purchaser?
- The distributor, like Amazon?
- 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?”
- 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:
- Company reputation
- Safety to customer
- Less delay between defect occurrence and relative evidence
- The ability to stop the production process immediately
Cons to having the customer report the defect:
- Magnitude of impact to safety and customer business can be greater
- Product fixes are closer to triage and damage control repairs as opposed to identification of root causes
- Degraded company reputation
- Harder to collect how the customer used the product in the field
- Takes more company resources to investigate the problem
- 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:
- Identify defect opportunities critical to customer success.
- Mistake-Proof for the critical opportunities when possible.
- Develop visible triggers and indicators at time of occurrence for defects that cannot be prevented 100 percent.
- Track and Trend types of defects, defect occurrence locations, gap between time of occurrence, time of identification and time to complete the corrective action.
- 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.
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.”
Stay tuned for our next contest coming soon!
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!
Saw an interesting article in Hydrocarbon Processing titled:
That reminded me of the Amoco refineries that were sold to BP and had a horrible safety record.
Regulators should have a red flag for any assists covered under a PSM program. If they are being sold, INSPECT!
Perhaps this could stop management from excessive cost cutting pre-sale to boost the bottom line at the expense of safety and the environment.
You may have reviewed the new regulations for process safety at California refineries. This is a major change to the standard PSM rules in the USA for California refineries.
Here is the section from the “Incident Investigation” portion of the rule…
– – –
(o) Incident Investigation – Root Cause Analysis.
- The employer shall develop, implement and maintain effective written procedures for promptly investigating and reporting any incident that results in, or could reasonably have resulted in, a major incident.
- The written procedures shall include an effective method for conducting a thorough Root Cause Analysis.
- The employer shall initiate the incident investigation as promptly as possible, but no later than 48 hours following an incident. As part of the incident investigation, the employer shall conduct a Root Cause Analysis.
- The employer shall establish an Incident Investigation Team, which at a minimum shall consist of a person with expertise and experience in the process involved; a person with expertise in the employer’s Root Cause Analysis method; and a person with expertise in overseeing the investigation and analysis. The employer shall provide for employee participation pursuant to subsection (q). If the incident involved the work of a contractor, a representative of the contractor’s employees shall be included on the investigation team.
- The Incident Investigation Team shall implement the employer’s Root Cause Analysis method to determine the initiating causes of the incident. The analysis shall include an assessment of management system failures, including organizational and safety culture deficiencies.
- The Incident Investigation Team shall develop recommendations to address the findings of the Root Cause Analysis. The recommendations shall include interim measures that will prevent a recurrence or similar incident until final corrective actions can be implemented.
- The team shall prepare a written investigation report within ninety (90) calendar days of the incident. If the team demonstrates in writing that additional time is needed due to the complexity of the investigation, the team shall prepare a status report within ninety (90) calendar days of the incident and every thirty (30) calendar days thereafter until the investigation is complete. The team shall prepare a final investigation report within five (5) months of the incident.
- Investigation reports shall include:
(A) The date and time of the incident;
(B) The date and time the investigation began;
(C) A detailed description of the incident;
(D) The factors that caused or contributed to the incident, including direct causes, indirect causes and root causes, determined through the Root Cause Analysis;
(E) A list of any DMR(s), PHA(s), SPA(s), and HCA(s) that were reviewed as part of the investigation;
(F) Documentation of relevant findings from the review of DMR(s), PHA(s), SPA(s) and HCA(s);
(G) The Incident Investigation Team’s recommendations; and,
(H) Interim measures implemented by the employer.
- The employer shall implement all recommendations in accordance with subsection (x).
- The employer shall complete an HCA in a timely manner for all recommendations that result from the investigation of a major incident. The employer shall append the HCA report to the investigation report.
- Investigation reports shall be provided to and upon request, reviewed with employees whose job tasks are affected by the incident. Investigation reports shall also be made available to all operating, maintenance and other personnel, including employees of contractors where applicable, whose work assignments are within the facility where the incident occurred or whose job tasks are relevant to the incident findings. Investigation reports shall be provided to employee representatives and, where applicable, contractor employee representatives.
- Incident investigation reports shall be retained for the life of the process unit.
– – –
TapRooT® Users already find management system, organizational, and cultural related root causes or generic causes that contributed to incidents they investigate. They also know about the hierarchy of controls (part of HCA analysis) and Safeguard Analysis (part of SPA) when developing corrective actions.
TapRooT® has always been ahead of its time in finding human factors related causes of incidents. Thus, TapRooT® Root Cause Analysis fits well with the Human Factors section of the California regulation…
– – –
(s) Human Factors.
- The employer shall develop, implement and maintain an effective written Human Factors program within eighteen (18) months following the effective date of this section.
- The employer shall include a written analysis of Human Factors, where relevant, in major changes, incident investigations, PHAs, MOOCs and HCAs. The analysis shall include a description of the selected methodologies and criteria for their use.
- The employer shall assess Human Factors in existing operating and maintenance procedures and shall revise these procedures accordingly. The employer shall complete fifty (50) percent of assessments and revisions within three (3) years following the effective date of this section and one hundred (100) percent within five (5) years.
- The Human Factors analysis shall apply an effective method in evaluating the following: staffing levels; the complexity of tasks; the length of time needed to complete tasks; the level of training, experience and expertise of employees; the human-machine and human-system interface; the physical challenges of the work environment in which the task is performed; employee fatigue and other effects of shiftwork and overtime; communication systems; and the understandability and clarity of operating and maintenance procedures.
- The Human Factors analysis of process controls shall include:
(A) Error-proof mechanisms;
(B) Automatic alerts; and,
(C) Automatic system shutdowns.
- The employer shall include an assessment of Human Factors in new operating and maintenance procedures.
- The employer shall train operating and maintenance employees in the written Human Factors program.
- The employer shall provide for employee participation in the Human Factors program, pursuant to subsection (q).
- The employer shall make available and provide on request a copy of the written Human Factors program to employees and their representatives and to affected contractors, employees of contractors, and contractor employee representatives, pursuant to subsection (q).
– – –
These initial drafts of the regulation have been slightly modified at a public hearing last Fall. The modifications can be viewed at: http://www.dir.ca.gov/oshsb/documents/Process-Safety-Management-for-Petroleum-Refineries-15day.pdf
The California Occupational Safety and Health Standards Board is set to review the revisions and comments on a meeting being held after the comment period expires on March 3, 2017.
While the new rule is being modified prior to adoption, California TapRooT® Users should be happy to know that they are already using a system that helps them meet and exceed the regulation being developed.
The EPA announced in December their intention to finalize a new r Risk management Plan rule for facilities with highly hazardous chemicals. Of interest to readers of this blog, the new proposal for incident investigations requires root cause analysis using a recognized method.
Here is the proposed language:
(a) The owner or operator shall investigate each incident that:
- Resulted in a catastrophic release (including when the affected process is decommissioned or destroyed following, or as the result of, an incident); or
- Could reasonably have resulted in a catastrophic release (i.e., was a near miss).
(b) A report shall be prepared at the conclusion of the investigation. The report shall be completed within 12 months of the incident, unless the implementing agency approves, in writing, an extension of time. The report shall include:
- Date, time, and location of incident;
- A description of the incident, inchronological order, providing all relevant facts;
- The name and amount of the regulated substance involved in the release (e.g., fire, explosion, toxic gas loss of containment) or near miss and the duration of the event;
- The consequences, if any, of the incident including, but not limited to: injuries, fatalities, the number of people evacuated, the number of people sheltered in place, and the impact on the environment;
- Emergency response actions taken;
- The factors that contributed to the incident including the initiating event, direct and indirect contributing factors, and root causes. Root causes shall be determined by conducting an analysis for each incident using a recognized method; and
- Any recommendations resulting from the investigation and a schedule for addressing them.
With the new administrations halt on new regulations, I’m not sure what will happen with this modification to an existing rule … so keep an eye out for the publication in the Code of Federal Regulations.
One last note if you were wondering … TapRooT® Root Cause Analysis is a recognized method.
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!
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.)
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/
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.
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.
Blame is the number one reason for bad root cause analysis.
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:
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.
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.
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:
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.
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:
And find the dates and locations for our public TapRooT® Training at: