July 24, 2006 | Mark Paradies

MONDAY ACCIDENT & LESSONS LEARNED • ACTIONS WITHOUT THOUGHT … WHAT IS THE ROOT CAUSE???

ACTIONS WITHOUT THOUGHT … WHAT IS THE ROOT CAUSE???



Here is a question from a new TapRooT® user who attended a course and sent me this question…

From: Michael Baer



Just a quick follow up from the training class last week – I talked to Ken a little bit about this there & he suggested following up by email. We were discussing
routine actions without thought; one of the things that comes through from the video ‘Remember Charlie’ that we use for our safety training. If I recall correctly, CCPS defines this as one of their possible immediate causes – I wasn’t clear about how (or if) this would fit in under the TapRooT® Root Cause Tree®.

After looking at the Root Cause Tree® & the dictionary again, I’m still not clear on the subject & would be grateful for your input. I would think that it would fall out under the 1st one of the 15 questions – but I’m not seeing something similar in the dictionary under Human Engineering or Work Direction. Did I miss something?

Thanks



Mike

Here was my reply:

From: Mark Paradies

To: Michael Baer



Mike:




Thanks for the question.

These types of errors are sometimes categorized as “slips” and sometimes even as “mistakes” under James Reason’s classification system. Another psychological term for this type of error is “Situational Awareness”. However, these classifications don’t help much when developing corrective actions.



Routine actions without thought could be listed as a causal factor of “Bubba just goofed up”.



These types of errors are hard to analyze because people often take the easy way out – they just tell Bubba … “Be more careful next time!”




But there are root causes. The analysis requires the investigator to open their eyes to causes they may not have previously considered. I’ll should you how the Root Cause Tree
® works to make this happen…



When this general type of causal factor is taken through the Root Cause Tree
®, there are several of the 15 questions that should be considered (and I will bold the most applicable part of the questions):



1. Was the person excessively
fatigued, impaired, upset, bored, distracted?



2. Should the person have had and
used a written procedure but did not?



3. Was a
mistake made while using a procedure?



4. Were alarms or displays to recognize or respond to a condition unavailable or
misunderstood.



5. Were displays, alarms, controls, tools, or equipment
identified or operated improperly?



6. Was work performed in an
adverse environment (such as hot, humid, dark, cramped, or hazardous)?



7. Was task
performed in a hurry or a shortcut used?



8. Were policies, administrative controls, or
procedures, not used, missing, or in need of improvement?



As you can see when you look at your tree, there are lots of places that this type of mistake can lead including the following Near-Root-Cause Categories:




Procedure – Not Use/Not Followed

Procedures – Followed Incorrectly

Management System – SPAC Not Used

Human Engineering – Human-Machine Interface

Human Engineering – Work Environment

Human Engineering – Non-Fault Tolerant System

Work Direction – Preparation

Work Direction – Selection of Worker




From these Near-Root-Cause Categories, the root causes that I think are most likely to be found by my experience are:




Procedures – Not Used/Not Followed – (no root cause)

Management System – SPAC Not Used – Enforcement NI (related to Procedure usage)

Human Engineering – Human-Machine Interface – monitoring alertness NI

Human Engineering – Human-Machine Interface – controls NI

Human Engineering – Work Environment – … could be almost any of the categories

Human Engineering – Non-Fault Tolerant System – errors not recoverable

Work Direction – Preparation – scheduling (see Dictionary for ideas)

Work Direction – Selection of Worker – … either fatigued, upset, or substance abuse




What I usually find is that people have not done the analysis to be able to say if any of the root causes above were applicable to the mistake.




For example, how do they investigate fatigue?




Another example, are they using procedures to improve human reliability?




Another example, are the controls prone to simple errors (controls NI)?




Once one uses the full power of the Root Cause Tree
® in their investigations, they can find that simple errors like “Routine actions without thought” usually have causes that just have not been investigated. A very small percentage (perhaps less than 5%) are actually errors that we can’t explain (understand?) or fix.



I see that you’ve been to a
2-Day TapRooT® Course. These topics are covered much more thouroughly in the 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course that has several sections on the causes of human error – causes that often seem to be simple, but are in fact fairly complex.



Hope this helps.




Mark


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