Root Cause Analysis Blog

 

Is punishment the best way to improve performance in the Navy?

Posted: September 20th, 2017 in Human Performance, Performance Improvement, Pictures

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In my decades of root cause analysis, less than 2% of incidents are caused by some sort of willful action that does not have a system cause. However, in many incident responses, companies discipline people for mistakes that were caused by system problem. This unwarranted punishment leads to:

  • Covering up problems.
  • Lying about what people did.
  • Morale issues when people are punished for things that were not their fault.
  • Mystery incidents that no one seems to know anything about (no one will talk).
  • Poor performance because the root causes of the problems are not being addressed.

Thus, I was disappointed when I saw the US Navy resort to discipline before the root cause analysis was completed after the collision of the USS Fitzgerald. Then again more discipline was used (this time against an Admiral) after the collision of the USS John S. McCain.

I wrote several articles about the collisions:

What is the Root Cause of the USS Fitzgerald Collision?

US Navy 7th Fleet Announces Blame for Crash of the USS Fitzgerald

USS Fitzgerald & USS John S McCain Collisions: Response to Feedback from a Reader

Several senior naval officers and others that discipline was needed for Navy personnel when a mission fails or a ship collides with another.

This brought to mind two sayings that I learned in the Navy. The first is:

The beatings will continue until morale improves.

The second is:

Why be fair when you can be arbitrary.

Do people in the Navy really respond to random discipline? The kind of discipline that’s been proven not to work in the civilian world?

I spent 7 years in the US Navy and have had close contacts with many people in the Navy since I left to start my civilian career. What I can tell you is this:

  1. Being at sea is different than working in a civilian job
  2. The Navy generally has a stricter set of operating rules than a civilian workforce does.
  3. There is a wider range of disciplinary actions that are available in the Navy than in the civilian word. (Although flogging and keel-hauling have been eliminated.)
  4. You can’t quit in the Navy if you have a bad boss.
  5. It’s difficult to fire someone that works for you if they are incompetent (you are stuck with those who you are assigned to lead).
  6. People ARE NOT different. They don’t become some sort of robot just because they joined the Navy.

Why did I include point #6 above? Because I’m often told that discipline is needed in the Navy to improve performance (One Admiral told me that it “sharpens the Commanding Officers game”).

It seems that some believe that senior naval officers (people commanding Navy ships – the Commanding Officers or COs) would try less hard, be less alert, and have worse performance if they didn’t have the threat of being relieved of command if they run into another ship or run aground.

Yes – the CO is ultimately responsible. Therefore, how could it NOT be the CO’s fault? They have ultimate authority on their ship … don’t they?

Let’s look at a an example. What if:

  • A ship was assigned a rigorous operational schedule of demanding technical missions.
  • The ship had several key pieces of equipment that that had been reported as broken (because of lack of time, parts, and money to perform maintenance).
  • The ship had many junior, barely qualified personnel serving in key positions because of the Navy’s planned rotation of officers and enlisted personnel and planned reduction of ashore training before new personnel arrived for their tour of duty.
  • The ship was undermanned because new ships were designed with new, smaller, crews but still had the same work to be performed as on older ships with 20-30% more people. This saved the Navy budget money – especially in the time of sequester.
  • The ship had several key personnel left ashore – with no replacement – because they were pregnant.
  • The CO was new to the ship and had little experience with this type of ship because he was assigned wartime duties ashore in Iraq during the Gulf Wars and missed an Executive Officer and a Department Head tours that would have provided more applicable experience and knowledge for this assignment.
  • People were fatigued after several tough evolutions but still had to drive the ship through a narrow, busy straight to get to their next assigned mission.

Is any of this under the CO’s control? Don’t these circumstances contribute to a mission failure if one occurs (like a collision). Would discipline make any of these factors change?

Does telling the CO that you are going to punish him (or her) if he or his crew makes a mistake make ANY difference?

Please leave me your comments. I’d be interested in what you have to say.

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Kicking over rocks

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


Happy Wednesday, and welcome to this week’s root cause analysis tips.

Today I would like to address an interesting question; what do I do with information about problems I encounter during my investigation that turn out to not have anything to do with the incident I am investigating?

When we are in the beginning stages of an investigation, we are gathering as much information as possible and compiling the information on our SnapCharT®. We then define causal factors, perform root cause analysis, and apply corrective actions. In the process of gathering information, we may “kick over some rocks” and you know what happens next……things start to pop out.

For example, you might be doing an investigation and during the document review, you find that training records are out of compliance. As you continue through the investigation, you might determine that training was not an issue for this incident. But should you ignore the non-compliance? You can’t.

That example is a compliance problem, so it is a no brainer, it has to be addressed. But what about process improvements? You might find some real problems with one of your processes but they may have nothing to do with the incident you are investigating. In my previous life this was one of my strengths, but it was also a curse at times, because it would create a lot of extra work! I would quickly solve the actual problems that caused the incident but end up with a two-year project over something that popped out from under the rocks. As professionals, you know what is important and you know what your resources are, so prioritize and solve some problems; I think you will find it is worth it.

So as you uncover things like this, make a list of them and address them after you have finished your investigation. Be careful not to get side-tracked, make sure you take care of the matters at hand first. After you have issued your investigation report you can work on the other things.

One best practice that one of our clients shared with me is that rather than making a list like I suggested, when they start pruning their SnapCharT®, they move the other issues they want to address to a separate page of the chart so they have it all in one place. I like that.

If you have been to one of our courses, you know that when we talk about proactive use of TapRooT®, we teach the concept of “significant issues,” the proactive equivalent of casual factors (in a reactive application). You can do root cause analysis of these significant issues you discover during an investigation just as you would those you find during an audit. If you want to look at an entire process, just map the process out and spot potential failure points, and perform root cause analysis on them.

Problem solving is a lot more fun than investigating incidents. And you never know, the problem you solve today might be the investigation you don’t have to do tommorrow!

What does a bad day look like?

Posted: September 19th, 2017 in Accidents

Monday Accidents & Lessons Learned: Five People Die After Using Weight Loss Balloons

Posted: September 18th, 2017 in Accidents, Investigations, Medical/Healthcare

 

According to the Food & Drug Administration’s report, five people have died since 2016 after being treated with weight loss balloon devices. The science behind this technology is that the balloon takes up space in the stomach after being filled with solution and this leaves less room in the stomach for food. The balloon is left in the patient’s stomach for six months while the patient learns to eat differently.

The five deaths occurred within a month of balloon placement.  We know that four of the deaths involved a balloon from the same manufacturer. However, nothing has been found linking the deaths to the medical device. In the TapRooT® System, an investigator would examine an incident like this by first creating a sequence of events. Once the sequence of events is completed,  more information would be collected.  For example:

Did the patient understand the risks?

Was the patient closely monitored by the healthcare team for possible deteriorations?

Did the patient understand which symptoms required medical assistance?

These are just a few of the types of questions that should be answered to help determine all the Causal Factors. There could be multiple things that went wrong. TapRooT® doesn’t stop at Causal Factors. Each Causal Factor is taken through the TapRooT® Root Cause Tree to find the Root Causes. Just like there may be (and probably is) more than one Causal Factor, there is probably more than one Root Cause that needs to be fixed to prevent this from happening again.

Mark Paradies recently posted an article that may be helpful in a situation like this, “Root Cause Analysis for the FDA.”

It takes some deep diving to understand all of the lessons learned here. Learn more about how to prevent unnecessary deaths like this in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

Join us for the 2018 Global TapRooT® Summit!

Posted: September 18th, 2017 in Summit

Registration is now open! Check out the Global TapRooT® Summit website to view an exciting video about our 2018 event.

Click the image above to view video on the Summit website!

What would your management do to avoid scenes like these?

Posted: September 18th, 2017 in Accidents, Pictures

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Are they ready to improve their company’s root cause analysis?

Monday Motivation: Let your accomplishments do the talking

Posted: September 18th, 2017 in Career Development, Career Development Tips

 

 

“Action speaks louder than words but not nearly as often.”
― Mark Twain

I was reading profiles on LinkedIn today and couldn’t help but notice how many people describe themselves as “innovative” and “visionary.” The funny thing is, I couldn’t find one thing in the experience/accomplishments sections of their profiles that supported that. Adjectives are easy to throw out there but are you describing yourself more in words than proving it with accomplishments?  If you truly have those magnificent characteristics and are only using words to prove it, you’re not convincing anyone.

Your accomplishments speak for themselves.  Take a look at your LinkedIn profile this week and replace those words with your proven track record. Actions always speak louder than words. And while you’re on LinkedIn, follow us! We post news every day to help you expand your knowledge for further success!

TapRooT® around the World

Posted: September 15th, 2017 in Media Room

We miss Gabby Miller, our former Marketing & Communications Strategist, but it was fun catching up with her today in her new role at WBIR. Benna Dortch and I were glad to deliver donations sponsored by TapRooT® to WBIR’s Hurricane Donation Drive at The Main Event in Knoxville.

Technically Speaking: New TapRooT® VI Updates

Posted: September 14th, 2017 in Software, Software Updates, Technical Support, Technically Speaking

The new release of updates in the TapRooT® VI software are here!

Check out the variety of enhancements we’ve made:

 

We are extremely excited to announce our partnership with Enablon in providing an Application Programming Interface (API) which allows TapRooT® VI and Enablon’s Safe Operations solution to share critical investigation data.

Enablon, a Wolters Kluwer business, is the world’s leading provider of Sustainability, EH&S and Operational Risk Management Software. More than 1,000 global companies and 1 million users rely on Enablon software solutions to manage their environmental and social performance, minimize risks and improve profitability. Enablon offers the most comprehensive platform in the industry, and is consistently recognized as a global leader and visionary. For more information, please visit https://enablon.com or email info@enablon.com

HOW TO GET THE UPDATE:

Are you an Enterprise License owner with TapRooT® hosting the software for you?
Great news! The update is already on your TEST site. Contact support@taproot.com when you are ready to schedule the updates to your PRODUCTION site.

Are you an Enterprise License owner that hosts the software in your network?
Contact sales@taproot.com to make sure your license is up to date and get access to this software update.

Are you a subscriber to taproot6.com?
The updates are already there and ready to use! Login to check them out.

Are you interested in getting access to taproot6.com for yourself?
Click here to purchase

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!

Root Cause Tip: Are you stopping short of exploring Human Engineering on the TapRooT® Root Cause Tree®?

Posted: September 14th, 2017 in Root Cause Analysis Tips

 

When analyzing a Causal Factor for Human Performance Difficulty during a root cause analysis investigation, a few questions under the Individual Performance section of the TapRooT® Root Cause Tree® will guide you to the basic cause category of Human Engineering. Hint: It would be great to have your Root Cause Tree® and Root Cause Tree® Dictionary handy for this discussion but it is not mandatory for learning to occur from this article.

Question 1: This question focuses on factors that can reduce human reliability and cause human errors. (Fitness of Worker performing a task)

Question 4: This question focuses on the human-machine interface that was needed to recognize conditions or problems and understand what was occurring. (Machine readouts and display feedback provided while performing a task)

Question 5: This question covers actual task performance. (Interaction while operating the equipment while performing a task)

Question 7: This question focuses on environmental factors that can degrade human performance. (Environment factors where the task is being performed)

Question 8: This question focuses on the ergonomics of the task performance. (Acute or repetitive issues and the physical impact on the person performing a task)

By now you should notice two key factors that must be identified before you can go any further in the root cause analysis of a particular Causal Factor for Human Engineering:

1. Who is the person that needed to perform the task successfully?

2. What is the task that needed to be performed successfully?

No shortcuts allowed in our TapRooT® process for these two factors. Doing so will prematurely cancel out your opportunity to explore Human Engineering in more investigative detail.

A third factor not listed yet is that you must Go Out And Look (GOAL) at where the task is being performed for questions 4, 5, 7 and 8. You cannot and should not answer the additional questions needed to evaluate the task from your desk. If you cannot get to the site and must ask the questions remotely, a person must be onsite to be your ears and eyes to GOAL.

A task can defined as an activity or piece of work which a person(s) must perform to accomplish with a successful end result. It can be a one action task or a sequence of actions to accomplish a system response. Examples….

• Press brake pedal with right foot to slow down car that you are driving
• Type words that create a sentence for others to read and comprehend
• Calculate launch equations that then get input into a computer that then guides a space capsule launch


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What would it take for a person to press a pedal with their right foot to slow down a vehicle?

• A pedal that can be reached and depressed
• A pedal that works as designed for the task
• Feedback from the car and environment to indicate that the car is slowing down at the right rate
• A person that can react in time with the right knowledge and ability to perform the slowing down task

How hard would it be to answer these questions from your desk with a reasonable amount of accuracy? Difficult at best, so don’t stop yourself from exploring Human Engineering because you did not identify the task, the equipment and the person.

Learn more about Human Engineering and TapRooT® tools like the TapRooT® Root Cause Tree in one of our upcoming 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Trainings:

October 2: Knoxville, Tennessee

October 16: Orlando, Florida

October 23: Bogota, Colombia (Spanish)

October 30: Reykjavik, Iceland

November 13: Brisbane, Australia

November 13: New Orleans

November 27: Johannesburg, South Africa

November 27: Monterrey, Mexico

November 27: Perth, Australia

Using TapRooT® Proactively – Behavior Based Safety Observations

Posted: September 14th, 2017 in Summit, Summit Videos, TapRooT, Video Depot

Here Dave Janney discusses how TapRooT® can be used to make behavior-based safety observations.

Technically Speaking – Maintenance Feature

Posted: September 14th, 2017 in Software, Technical Support, Technically Speaking

TapRooT® 6.3.1 introduces a Maintenance mode feature that allows administrators to post a global message across the software notifying users that the site will be entering maintenance mode.

 

 

While in Maintenance mode users will NOT be allowed to login to the software.  If they are already logged in, they will see a countdown appear across the top of every page in the software.  This will not kick-off or end a users session if they are logged in when the time runs out.  We don’t want to interrupt any users frantically trying to complete an investigation, but this does allow the admins to see those users and contact them.

Administrators can enable/disable this under Admin > Maintenance.  Here they can also set the exact time and length for the outage to see if anyone is active in TapRooT®. Only Administrators can login during Maintenance mode, so they can disable it once service is restored as normal.

 

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!

Root Cause Analysis for the FDA

Posted: September 13th, 2017 in Investigations, Performance Improvement, Pictures, Quality, Root Cause Analysis Tips, TapRooT

RootCauseAnalysis

What does the FDA want when you perform a root cause analysis?

The answer is quite simple. They want you to find the real, fixable root causes of the problem and then fix them so they don’t happen again.

Even better, they would like you to audit/access your own processes and find and fix problems before they cause incidents.

And even better yet, they would like to arrive to perform a FDA 483 inspection and find no issues. Nothing. You have found and fixed any problems before they arrive because that’s the way you run your facility.

How can you be that good? You apply root cause analysis PROACTIVELY.

You don’t want to have to explain and fix problems found in a FDA 483 inspection or, worse yet, get a warning letter. You want to have manufacturing excellence.

TapRooT® Root Cause Analysis can help you reactively find and fix the real root causes of problems or proactively improve performance to avoid having quality issues. Want to find out how? Attend one of our guaranteed root cause analysis courses. See:

http://www.taproot.com/courses

I’d suggest one of our public 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Courses to get started. Then have a course at your site to get everyone involved in improving performance.

Want more information before you sign up for a course? Contact us by CLICKING HERE.

TapRooT® in Monterrey, Mexico

Posted: September 12th, 2017 in Courses

We recently received these great photos from a recent public course in Monterrey, Mexico. Get in the picture! REGISTER for one of many root cause analysis courses around the world!

TapRooT® Root Cause Analysis Course in Reykjavik!

Posted: September 12th, 2017 in Courses, Local Attractions

TapRooT® is excited to go to Reykjavík to see the beautiful nature and rich Viking heritage. While we’re there, we’ll be teaching a 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. Join us for this course and check out the delicious food, attractions, and beautiful scenery Reykjavik has to offer.

Food:

Fjorugardurinn – Viking style decor and meals make this a one-of-a-kind Icelandic experience!

Icelandic Fish & Chips – Traditional English-style food with an organic & Icelandic spin.

Gandhi – Indian cuisine using a combination of local ingredients and spices shipped straight from India.

Hereford Steakhouse – Carefully selected cuts of steak, chicken, and pork in an upscale setting.

Attractions:

Nightlife – Reykjavík is famous for its nightlife that has only just begun when the clock strikes midnight.

Whale watching – Join a tour group to see these majestic creatures.

Fishing – Go alone or with a day tour group and enjoy the waters of Iceland.

Hallgrímskirkja – The largest church building in Iceland houses a pipe organ reaching 15 meters tall and weighing 25 tons. It is truly a beautiful sight to see.

Tjörnin – “The pond” in Icelandic, this small lake is located in the city center and is perfect for strolling or just relaxing after a long week of learning TapRooT®.

 

REGISTER for our 5-Day TapRooT® Reykjavik, Iceland October 30, 2017.

What does a bad day look like?

Posted: September 12th, 2017 in Accidents

Monday Accident and Lesson Learned: Eyes-only inspection didn’t see Ohio fair ride’s corrosion

Posted: September 11th, 2017 in Accidents

An 18-year-old man lost his life and seven others were injured when an amusement park ride ripped apart. Hidden corrosion may be what caused the malfunction. States set their own rules on ride testing and many do not have the resources to conduct nondestructive testing on their own.

Read:

Eyes-only inspection didn’t see Ohio fair ride’s corrosion

on USA Today.

TapRooT® at Torex Gold, Minera Media Luna Project

Posted: September 11th, 2017 in Courses

TapRooT® instructor, Jesus Alonso sent in these great photos from a recent onsite course. Get in the picture! Contact us to schedule an onsite course at your facility!


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