Root Cause Analysis Blog

 

Technically Speaking – Help Desk Humor

Posted: August 17th, 2017 in Software, Technical Support, Technically Speaking

Are you stuck trying to find the right questions to ask to determine the Root Cause or what lead up the incident? Let the TapRooT® method and software help you with these questions by using optional techniques. To learn about these optional techniques and the TapRooT® method check into attending a course near you by clicking HERE.

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!

Do Movie Companies Do Root Cause Analysis on Injuries and Fatalities?

Posted: August 16th, 2017 in Accidents, Current Events, TapRooT, Video

I recently saw a report on a fatality during the shooting of Deadpool 2 …

I’ve seen several other reports about filming injuries and deaths. here are a couple of them…

http://www.tmz.com/2017/08/16/tom-cruise-broke-his-ankle-during-stunt-gone-wrong-on-mission-impossible/?adid=sidebarwidget-most-popular

http://www.rollingstone.com/tv/news/walking-dead-stuntman-dies-following-on-set-accident-w492303

That made me wonder … Do movie/film companies do a root cause analysis after an injury or a death? Does Hollywood learn from their experience? Do they use advanced root cause analysis?

German Regulators Pull Pharmaceutical Manufacturing License for Bad Root Cause Analysis

Posted: August 16th, 2017 in Current Events, Pictures, Quality, TapRooT

How can bad root cause analysis get a pharmaceutical manufacturer in trouble? Read this article:

http://www.fiercepharma.com/manufacturing/german-regulators-yank-manufacturing-certificate-from-dr-reddy-s-india-plant

See the regulator’s report here:

http://eudragmdp.ema.europa.eu/inspections/gmpc/searchGMPNonCompliance.do;jsessionid=Nfjr4BxTjUIchrw5Cz8sxg2ks-g1ohm3P0FCWfkI-pRSLAnTUiyt!385493004?ctrl=searchGMPNCResultControlList&action=Drilldown&param=43089

The first step to using advanced root cause analysis is to get your people trained. But AFTER the training, management must ensure that the system is being used, the results are being documented, and the corrective actions are getting implemented.

What does management need to know about root cause analysis? They should know at least as much as the investigators and they need to know what their role is in the root cause analysis process. That’s why we wrote the new book:

Root Cause Analysis Leadership Book

TapRooT® Root Cause Analysis Leadership Lessons

Get your copy now and make sure that you are managing your high performance systems.

ACE – How do you find the root causes?

Posted: August 16th, 2017 in Investigations, Performance Improvement, Pictures, Root Cause Analysis Tips, TapRooT

Ace clipart four aces playing cards 0071 1002 1001 1624 SMU

First, for those not in the nuclear industry …

What is an ACE?

An ACE is an Apparent Cause Evaluation.

In the nuclear industry management promotes official reporting of ALL problems. The result? Many problem reports don’t deserve a full root cause analysis (like those performed for major investigation).

So how do nuclear industry professionals perform an ACE?

There is no standard method. But many facilities use the following “system” for the evaluation:

  1. Don’t waste a lot of time performing the evaluation.
  2. Make your best guess as to the cause.
  3. Develop a simple corrective action.
  4. Submit the evaluation for approval and add the corrective actions into the tracking and prioritization system.

That’s it.

How does that work? Not so good. Read about my opinion of the results here:

The Curse of Apparent Cause Analysis

That article is pretty old (2006), but my opinion hasn’t changed much.

So what do I recommend for simple incidents that don’t get a full investigation (a full investigation is described in Using TapRooT® Root Cause Analysis for Major Investigations)? I describe the process fully in:

Using the Essential TapRooT® Techniques to Investigate Low-to-Medium Risk Incidents

Here’s a flow chart of the process…

SimpleProcess

For all investigations you need to find out what REALLY happened. Then you make an important decision …

Is there anything worth learning here?

Many investigations will stop here. There is nothing worth spending more time investigating OR fixing.

The example in the book is someone falling while walking on a sidewalk.

If you decide there IS more to learn, then a simplified TapRooT® Process is used.

This process includes identifying Causal Factors, finding their root causes using the Root Cause Tree® Diagram, and developing fixes using the Corrective Action Helper® Guide.

That’s it. No Generic Cause Analysis and no fixing Generic Causes.

Want to learn more? Read the book. Get your copy here:

http://www.taproot.com/store/TapRooT-and-reg-investigation-Essentials-Book-set.html

Can Regulators Use TapRooT® Investigation Tools?

Posted: August 15th, 2017 in Investigations, Performance Improvement

Regulator Inspection Investigation

I had a question recently from one of our friends who works as a regulator in his country. He was wondering about the advantages of using TapRooT® as a regulator as opposed to an industry user. I think this is a great question.  We often think about doing incident investigations for ourselves, but how do you help those you oversee as a regulating body?

As a government agency, you have great potential to affect the safety and health of both your employees and those you oversee.

  • Just attending the TapRooT® training will give your staff the basic understanding of true, human-performance based root causes.  It gives your team a new perspective on why people make poor decisions, and just as importantly, why people make good decisions.  This understanding will guide your thinking as to why problems occur.   Once this perspective is clear, your team will no longer be tempted to just blame the individual for problems.  They will think more deeply about the organizational issues that are causing people to make bad decisions.
  • The training will give you the tools to perform accurate, consistent investigations.  You can have confidence in knowing that your team has discovered not one or 2 issues, but all the problems that led to an incident.
  • Your investigations and investigation report reviews using TapRooT® will be based on human performance expertise, helping to eliminate your team’s biases.  EVERYONE has biases, and using TapRooT® helps keep you focused on the true reasons people make mistakes.
  • You will also have the tools to be able to more accurately assess the adequacy of the investigations and corrective actions that are submitted to you by those you oversee.  You can see where they are doing good investigations, and where they probably need to improve.  The corrective actions that are suggested by those you oversee are often poorly written and do not address the real reasons for the incident.  The TapRooT® training will ensure you are seeing effective corrective actions.
  • If your agency conducts trending of the their results, you’ll be able to produce consistent, trendable data from your investigations.  If you ensure your industry constituents are also using TapRooT®, the data you receive from them will also allow for more accurate trending results.
  • Finally, you can use the TapRooT® tools learned during the course to perform proactive audits of your industry partners.  When you perform onsite inspections, you can ensure you are looking for the right problems, and assigning effective corrective actions for the problems encountered.  Instead of just looking for the same problems, the tools allow you to look deeper at the processes you are inspecting to find and correct potential issues before they become incidents.

TapRooT® gives you confidence that the results of your investigations, and those of those you oversee, result in fixable root causes and effective corrective actions.

Monday Accident and Lesson Learned: Unsecured Load Falls Onto Worker

Posted: August 14th, 2017 in Accidents

Just a couple of days ago at Pacific Northwest National Laboratory in Washington, a worker backed into a cart that had a large, heavy cylinder loaded on it. He soon figured out the cylinder was not secured properly as it tipped over slightly hitting the workers back. Luckily he walked away unharmed, but large, heavy objects should be secured well to avoid any major injuries. Another lesson learned is to always check your surrounding well before you begin working.

 

(Resource: https://opexshare.doe.gov/lesson.cfm/2017/8/9/14769/Unsecured-Load-Falls-onto-Staff-Member-from-Wheeled-Cart)

Dam leaks oil into Snake River. Time for an environmental incident root cause analysis?

Posted: August 11th, 2017 in Accidents, Current Events, Investigations, Pictures

Monumental Dam

The Army Corps of Engineers reported that an estimated 742 gallons of oil leaked from a hydroelectric generator into the Snake River. The generator is part of the Monumental Lock and Dam. 

We often talk about the opportunity for an advanced root cause analysis (TapRooT®) evaluation of a safety or quality incident. This is a good example of an opportunity to apply advanced root cause analysis to an environmental issue.

Friday Joke

Posted: August 11th, 2017 in Jokes

Technically Speaking – Exporting SnapCaps into Powerpoint

Posted: August 10th, 2017 in Software, Technical Support, Technically Speaking, Video Depot

Ever wanted to take just a portion of a SnapCharT® and put it into a Powerpoint presentation? Watch as the TapRooT® Tech Guy discuss the process in our new TapRooT® VI release.

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!

How Far Away is Death?

Posted: August 10th, 2017 in How Far Away Is Death?

Lumberjacks

How to Be a Great Root Cause Facilitator (Part 2)

Posted: August 9th, 2017 in Video, Video Depot

In the second part of this series, Benna Dortch, Ken Reed and Mark Paradies, Creator of TapRooT®, discuss more important and valuable traits of a great root cause facilitator. If you want some best practice tips to help you improve your investigations and just be better at your job, watch this series.

 

A great facilitator also has great training. Register for a TapRooT® Advanced Root Cause Analysis Team Leader Training course.

What Does a Bad Day Look Like? Bike Accidents at RR Crossings – Lessons from the University of Tennessee

Posted: August 8th, 2017 in Accidents, Current Events, Investigations, Pictures, Video

Bike Accident

One of our Australian TapRooT® Instructors sent we a link to an article about a University of Tennessee safety study. I thought it was interesting and would pass it along. The video was amazing. Ouch! For the research article, see:

http://www.sciencedirect.com/science/article/pii/S2214140516303450?via%3Dihub

How to Effectively Perform a Cognitive Interview for an Incident Investigation

Posted: August 7th, 2017 in Video, Video Depot

In this video, TapRooT® Instructor, Barb Phillips, discusses the benefits of an effective cognitive interview when gathering evidence for your incident investigations.

Interested in learning more about planning your investigations and gathering evidence correctly? Take our one day course in Houston this November.

Monday Accident and Lesson Learned: Collision of Trains at Plymouth Station

Posted: August 7th, 2017 in Accidents

In April of last year a train collided with an empty, still train that was waiting at Plymouth Station. The train that caused the accident was going 15 mph when it collided, and the conductor stated that he “misjudged” the amount of space he had to pull in behind the other train. He had also never operated a train so closely to another so he lacked the experience needed to complete the procedure. There were no fatal injuries, but 48 passengers were hurt and the two trains were damaged.

Corrective action: improve the training and assessment of new drivers, look at emergency door release controls, check procedure for permissive movements between trains

(Resource: https://www.gov.uk/raib-reports/collision-at-plymouth-station)

 

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If you are a TapRooT® User, you may think that the TapRooT® Root Cause Analysis System exists to help people find root causes. But there is more to it than that. TapRooT® exists to: Save lives Prevent injuries Improve product/service quality Improve equipment reliability Make work easier and more productive Stop sentinel events Stop the …

As a stockholder, I was reading The CB&I 2014 Annual Report. The section on “Safety” caught my eye. Here is a quote from that section: “Everything at CB&I begins with safety; it is our most important core value and the foundation for our success. In 2014, our employees maintained a lost-time incident rate of 0.03 …

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