When healthcare professionals perform root cause analysis (RCA), they want to define “What” happened, “Why” it happened, and then how to “Fix” the problem. These three pieces are considered core pieces to a “Thorough and Credible” RCA as coined and defined by the TJC. The TapRooT® process meets and, quite honestly, exceeds these requirements in many ways. Today, I want to spend a little bit of time focusing on one of the ancillary questions raised on TJC’s matrix that deals with Document Searches.
The key to responding to findings with a good solid corrective actions is understanding the root cause from every angle. It requires an open mind, creativity and tools to aid the investigator in understanding how to fix both Human Performance and Equipment related issues. Within the TapRooT® process, we have what is called Corrective Action Helper®. This tool provides guidance for identifying “Generic” issues, provides ideas for fixing the Root Causes, as well as providing a ready-made list of References for each root cause. The list of references provides both general industry and healthcare related documents that the investigator should consider reading or referencing as part of the fix. This provides the investigator with documents to review and to answer the question, “Cite any books or journal articles that were considered in developing this analysis and action plan:” from page 5 of the matrix.
Here is an example of what is included in the Documents section in Corrective Action Helper® for just one of our root causes, “Arrangement/Placement.” (This has to do with the physical location of equipment, displays, and controls):
References:
* ANSI/HFES 100-2007, Human Factors Engineering of Computer Workstations, (2007), published by The Human Factors Society.
* KODAK’s Ergonomic Design for People at Work, (2004) by Eastman Kodak Company, published by John Wiley & Sons, Hoboken, NJ.
* Handbook of Human Factors and Ergonomics, Third edition (2006), by G. Salvendy, ISBN 0-471-44917-2, published by John Wiley & Sons, New York.
* Industrial Ergonomics: A Practitioner’s Guide, (1985) by D. C. Alexander and B. M. Pulat, published by Industrial Engineering & Management Press, Atlanta, GA.
* Handbook of Human Factors and Ergonomics in Health Care and Patient Safety, (2007) by Pascale Carayon, published by Eribaum, Mahwah, NJ.
* International Encyclopedia of Ergonomics and Human Factors, Second edition (2006), edited by Waldemar Karwowski, 3 volume set. ISBN 978-0415304306.
* Medical Error and Patient Safety: Human Factors in Medicine, (2007) by George and Barbara Peters, published by CRC.
* Medical Device and Equipment Design: Usability Engineering and Ergonomics, (1995) by Michael E. Wiklund, published by CRC.
With this kind of reference list directly available through our system, why would you use anything else to find root causes???? I have no idea because not only can you provide a thorough and credible RCA, you also have a ready made list of documents and references for review.
In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training Course and in our TapRooT® book, TapRooT® Changing the Way the World Solves Problems, we introduce the Critical Human Action Profile (CHAP) tool to help collect more information to analyze any type of problem at the process task level. I like to call this looking at a problem at the 1 foot level as opposed to many investigations that analyze their problems at the 100,000 mile view only.
The tip here however, is “why wait for a problem to use CHAP?”
Identify, Evaluate and Improve before it is too late!
Using a very over simplified list of procedure steps on How to Remove a Fuel Pump, found on the internet, I would like to show you how to use CHAP proactively to improve Safety and Quality during a task.
WARNING: The steps listed in the demonstration example below on removing a fuel pump shall not be used. They are incomplete and not necessarily accurate.
Where to start? First off you already perform JHA, AHA, JSA, Observations…. So Going Out and Looking (GOAL) should not be new or require a lot more additional resources. The difference is that you will be utilizing your resources more efficiently.
1. Start by identifying a task performed by employees that are critical to:
a. Customer/client satisfaction
b. Product Quality
c. Project Timeliness
d. Employee Safety
e. Customer Safety
f. Environmental Exposure
2. Once the task is identified, list the steps to be performed like listed in the image below.
Note: Do not forget to use the Basic Cause Category Procedure in our TapRooT® Root Cause Tree to look for missing best practices as well when listing the steps.
3. Identify each step of the task that is critical to the items listed in step 1 criteria of this article.
Which steps listed above for the fuel pump removal do you think would be listed as critical?
4. For each critical step in the task perform a CHAP Profile.
Note: For each of the items listed below, do not forget to include the Best Practices listed under the Human Engineering Basic Cause Category in our TapRooT® Root Cause Tree.
Last year, a Delta employee lost his leg when it was crushed by the wheel on a jetway in Knoxville, Tennessee.
I had a little extra time waiting for my flight to Atlanta from Knoxville last Friday so I asked the gate agent about the accident and what had been done to prevent a repeat. She said they were now required to have a spotter to make sure that no one got near the wheels while the jetway was moving (the wheels aren’t visible from the jetway controls).
That’s a Human Action Safeguard.
She also said that no one is allowed to use the stairs or get near the wheels while the jetway is in motion. That was already true when the accident happened but it was re-emphasized to everyone after the accident.
That’s a rule “quasi-Safeguard” that requires human action (compliance) to work.
Thus, a near-fatal accident had two human action related Safeguards that are meant to prevent recurrence of the accident.
Here is a graphic from our root cause analysis training…
Now let’s evaluate the corrective actions used to prevent a possible future fatality using the graphic above…
First, we made a rule that required a spotter during moving of the jetway. This is a human action related Safeguard implemented through a rule. That is the second weakest type of corrective action (#5).
Reemphasizing a rule that previously failed (the second corrective action used) is a training related human performance Safeguard and is the weakest corrective action to prevent recurrence of the accident (#6).
What do you think? If you had a serious accident (lost leg due to crushing) and it had the potential to be fatal, would two weak corrective actions be enough?
Maybe we should start at the top of the hierarchy in the figure above and see what is the strongest reasonable Safeguard that we can employ is…
1. REMOVE THE HAZARD
The Hazard in this case is the jetway weight and moving pinch point when the jetway is in motion. This is difficult to remove. (At least I can’t think of a way to do it.)
2. REMOVE THE TARGET
With current aviation operations, people are required to direct the plane while parking, unload baggage, refuel the plane, etc. Perhaps someday this will be done robotically, but for now, removing people from the jetway environment seems unlikely.
3. GUARD THE TARGET
This one is possible. See this photo below from Frankfurt …
They have implemented a guard to keep people away from the wheels.
Is it 100% perfect? No. People can go around the guard (jump over it?).
Is it better than warning people to be careful?
Yes!
So I sent the photo above to the Knoxville airport management. We’ll see if there are changes in the future to implement a stronger Safeguard to the potentially fatal Hazard.
ARE WE DONE?
NO!
This corrective action (if implemented in Knoxville) only fixes one small set of Hazards – jetway pinch-points in Knoxville. This Hazard exists at airports around the world.
For corrective actions to the Generic Root Cause, Delta would need to get airports around the world to guard the Hazard.
Next time you board a plane at your local airport, see what kind of Safeguard is in place. If you don’t see any, send the airport management (you can usually find a “contact us” link at the airport’s web site) a link to this posting.
ONE MORE THING TO LEARN
How do you develop corrective actions? Do you start at the top of the Safeguard hierarchy and work your way down or do you start at the bottom and work your way up?
Your investigators should have their corrective actions evaluated to see how effective they will be. For potentially fatal accidents, I would recommend using the top three strongest on the list and sometimes allow the fourth if somehow the top three aren’t possible.
The bottom two can be allowed in combination with the top 4, but I would never allow them to be the only corrective action if a fatality was possible.
Stop taking the easy way out. Learn a lesson from this accident (and the corrective actions). Improve your corrective action process by using the strongest possible corrective actions.
We are all trained, or learn, by trial and error on how to use equipment or how to use it “properly”. What happens when you get a better “understanding” of how the equipment works? Here are some of the choices that we could make:
1. Ignore the previous training and just get the prize (work done faster, like the chimpanzee)
2. Continue the rules that you learned or were trained to do (at least in front of the bosses like the children).
3. Stop and ask what’s up?
4. Stop using the tool all together and do not tell anyone.
Often the previous training and experience overrides the new operation steps needed … ever been totally frustrated every time someone changes your computer’s Microsoft Windows version? And no, training by itself does not override experience, practice and repetition does!
I had a discussion not too long ago that OSHA forklift training requirements were met when people were retrained after changing forklifts. Unfortunately, the controls worked exactly opposite on the new forklift and the quick review did nothing to override the past knowledge and muscle motor memory.
Just something to think about when you think “Great Human Factors.”
As you have probably heard, on the two days before the summit we have special pre-summit courses we only teach publicly at the summit (we can do any of them onsite). The course I teach is called the Advanced TapRooT® techniques course. In this course, we cover best practices for each of the steps of our seven-step process. A big focus of the course is identifying causal factors, and I will give you some insight into some of that in the root cause tips on February 15. Today I wanted to talk about something from the course that is extremely important. Take a look at this analogy:
Have you ever wondered why sometimes you do an investigation, things get better, but there are still some of the same problems present – maybe they are not as frequent or serious, but they still occur. Why is that? A great deal of the time, I would say because you found some of the causal factors and their root causes, but you may have missed one. In order to make sure problems do not reoccur, you have to find ALL of the causal factors, and therefore, all of the root causes. And it all starts with a good SnapCharT®. You see, it is much easier to find the causal factors if your chart is very clear, is not missing important details, and is well worded. Most of the time you spend in your investigation should be on this front end of the process – the investment in collecting good information and assembling it on your chart will make finding the causal factors easier, and taking them through the Root Cause Tree® faster.
Hopefully this discussion helps. If you want to hear more, consider joining us in Las Vegas for the course. And stay for the summit.
Thanks for visiting the blog and happy investigating.
I wrote this paper for the for the BARQA Journal and they are nice enough to let me republish it here. Click on the pdf below to see the whole article.
The article is written for people interested in root cause analysis to improve pharmaceutical quality, but the problems discussed are common to all industries and apply to those looking to improve safety, operation, maintenance, process safety, and quality.
Sources of Root Cause Analysis Failures by Mark Paradies is published by:
Quasar (Members Magazine of BARQA, British Association of Research Quality Assurance) No. 118 Pages 7 – 10, Jan 2012.
In 1963 William Haddon wrote “A Note Concerning Accident Theory & Research with Special Reference to Motor Vehicles” in the Annual of The New York Academy of Sciences. This marked the start of “energy transfer” theory.
What did Haddon’s work lead to? The development (by the System Safety Development Center at EG&G in Idaho) of a new analysis technique: Barrier Analysis. Next, Linda Unger and Mark Paradies modified Barrier Analysis to develop the TapRooT® technique Safeguards Analysis. This development history is interesting but what can we learn from this history that is useful for current investigations?
First, the origin of Safeguards Analysis from motor vehicle accident research may be why Safeguards Analysis is so effective for traffic accident investigation. Safeguards Analysis does a great job showing how few safeguards are in place to prevent traffic accidents. One often finds that the “goodness” of the driver (their alertness, competence, and/or judgment) was all that stood between an accident and no accident.
Second, Safeguards Analysis shows the relationship between administrative control safeguards and human actions. Administrative controls (laws, traffic controls, …) require human action to make them work. For example, a red light doesn’t stop a car. The red light lets drivers know that THEY are required to stop. The driver must take action to comply with the light’s instructions (and avoid an accident). So the safeguard is a combination of an administrative control and human action.
Finally, Safeguards Analysis may show that instead of concentrating efforts on improving the driver, one may want to act to add additional safeguards to keep the hazard away from the target. In high hazard or high accident locations, this may mean modifying roads to add new, innovative safeguards that will prevent collisions instead of providing more driver training or adding new features to cars to reduce injuries after an accident occurs.
Knowing that policies guide what “how to’s” and “do what’s” need to be created, trained and used, why do they have to be so convoluted and difficult to read? Not to pick on lawyers, but have ever tried to understand a legal document? Aren’t legal documents supposed to keep you out of trouble and not get you in trouble?
Interestingly enough, we even pass policies on policies found in this article.
“On October 13, 2010, President Obama signed into law the “United States Plain Writing Act of 2010.” Thirteen years after President Clinton issued his own “Plain Writing in Government” memorandum, the revised set of guidelines states that by July of this year all government agencies must simplify the often perplexing bureaucratic jargon used in documents produced for the American public. Gone are the grammatically longwinded sentences, replaced with simpler English words, grammar and syntax”
Take this excerpt from a policy; what missing best practices can you identify from the TapRooT® Root Cause Tree?
“The amount of expenses reimbursed to a claimant under this subpart shall be reduced by any amount that the claimant receives from a collateral source in connection with the same act of international terrorism. In cases in which a claimant receives reimbursement under this subpart for expenses that also will or may be reimbursed from another source, the claimant shall subrogate the United States to the claim for payment from the collateral source up to the amount for which the claimant was reimbursed under this subpart.”
Using the Basic Cause Category “Procedures,” I look forward to your missing best practices in the comments section.
Whether doing it by hand or in our TapRooT® Software, what can go into the Rectangles that we call Events (Who did whats or what did whats that occurred during the timeline that you are investigating)?
Whos:
Actions by the Operator, Mechanic, Manager, Vendor, Supplier, Contractor, Technician, Customer Service Rep, Engineer, Designer, Nurse, Doctor … as you can see the list is unlimited but understanding the who (we use job titles only) helps us to see if the who was setup for success prior or during the action he/she performed.
Whats:
Caution ( … this may not be what you expected or have been doing)
Equipment Actions: Relay opened when energized, Butterfly valve stuck shut, I.V. bag port become blocked with debris, fuel gravity fed into container through piping …
Hint: If working with equipment, pull up the equipment and system functional diagram up immediately to help you map out the Events.
Chemical Process Actions: Catalysts heated up, hot mix heated up …
Transactional Process: Purchased order received by customer service, SAP sent late warning to warranty …
Hint: Yes, you can follow a piece a paper, hazardous material shipment.. that is handed off from person to person just like you would a person.
Hopefully, this should open up your investigation options even more! By the way, I even mapped out the actions of a horse and a monkey which was analayzed under Human Engineering.
Read a disturbing article from The Washington Post entitled, “The Pain of Wrong Site Surgery,” and it truly made me pause.
Seven years have passed since TJC provided a “universal protocol” outlining changes in pre-surgery routine. These included surgical site verification, and what was termed a “timeout” prior to any surgery. Based on data collected through self-reported events (not the most reliable data due to inconsistent reporting), and state provided information, there are still wrong site surgeries occurring at an estimated rate of 40 per week in the US. That is a staggering number, approximately 2,100 per year.
The article referenced Peter Pronovost, the Medical Director of the John Hopkins Center for Innovation in Quality Patient Care, stating that studies of wrong-site errors have consistently revealed a failure by physicians to participate in a timeout. This lack of participation is ritualized compliance or doctor’s lip service to the rules. That statement while true shows that even with the new protocols in place, there was little or no change in performance.
Comparing the TJC actions with the statements from Mr. Pronovost, it is clear to me that these actions are being implemented without an understanding of the Root Causes. These are all policy-based initiatives that in the end are dependent upon people following and adhering to policies and procedures. This shows that if we do not analyze situations and find root causes, we will simply implement weak safeguards that do not fix the issue or change behavior.
From the TapRooT® perspective, let’s evaluate the “universal protocol” implemented in 2004:
1) Verification of preoperative details – Quasi-Safeguard … admin control dependent on a human action.
2) Marking of the surgical site – Quasi-Safeguard … admin control or “label” if you will, dependent on a human action.
3) Timeout prior to procedure – Quasi-Safeguard … admin control or policy dependent on a human action.
All of these placed into current surgical systems and simply placed “over” the current processes have simply not worked. You are now seeing, based on the statements from Mr. Pronovost and the alarming numbers of wrong site surgeries still occurring, that we have a “SPAC Not Used.” This based on the current medical culture makes sense if people working in the process feel they are above the rules.
If TJC had performed a more thorough analysis of the actual causes, you might find that there are many other possible causes to these issues:
1) Enforcement NI – if the attitude that “I am above this” or “I should not have to do this” has become an ACCEPTED practice amongst healthcare providers. Thus, allowing the culture to grow without or with little consequence except to the patient.
2) Accountability NI – if it is believed that others are responsible for detecting these errors or are responsible for ensuring proper performance.
And there are likely others. I am not stating that I have those answers. I have not gathered the data or analyzed it. But I can tell you that without a more thorough analysis these problems will continue to happen. Simply applying Quasi-safeguards as listed in the 2004 protocol, without any additional measures to identify or address the actual root causes means you are addressing the Causal Factor without actually knowing the causes. These weak fixes that read well, are not based on actual root causes and, as they are showing, are not having a lasting affect on performance.
When similar events continue to occur (average of 40 per week), and we continue to try the same things over and over again, isn’t that the definition of insanity? And should it not also point out that the corrective actions and measures taken have not worked, were not effective, and we need to revisit not only the fixes, but the analysis as well? Food for thought …
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Trevor Kletz, Professor at Loughborough University and safety guru from the UK, recently published an article titled: “Some Common Errors in Accident Investigations” in the Safety and Reliability Society Journal.
Four of the eight common errors he listed are:
They quote human error as the cause.
They blame individuals though many people have opportunities to prevent most accidents.
They do not realize that [corrective] actions are the most important part of a report.
The worst error: they think of a possible cause and then look for evidence that supports it.
Why do I bring up this article and these four errors here?
First, because I think that investigators could learn a lot from Trevor’s insights.
But second, because TapRooT® was developed to help prevent these four errors (and help with some of the ones not listed above too). Here’s how…
First, the TapRooT® Root Cause Tree® was developed to lead investigators past the common cause of human error to the real, fixable causes of human error.
Second, TapRooT®’s SnapCharT® diagram helps people see that there is not just one person to blame for an accident. It’s remarkable to see the investigation focus change from blame to understanding.
Third, the TapRooT® Corrective Action Helper® puts emphasis on developing effective corrective actions then the TapRooT® Software automatically includes the actions in the investigation report.
Finally, the TapRooT® System avoids the common cause-and-effect related error of jumping to conclusions by trying to prove a cause. Instead, TapRooT® starts with trying to understand what happened before defining causal factors and then determining their root causes.
By design, TapRooT® helps beat common accident investigation errors.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
After teaching TapRooT® for many years, there is one area that I find underutilized. Everyone knows about the SnapCharT®, the Root Cause Tree®, and the Dictionary with all of it’s definitions and questions. But within the Dictionary there are some of the most important guidance providing additional questions and possible causes for the causal factor being analyzed. This guidance is simply titled, NOTES.
The definitions in the Dictionary are all written in a YES/NO format to allow the user to easily answer them based on the data collected relating to the Causal Factor. And as taught, if you answer YES to any one portion of the definition you circle it on the Root Cause Tree® and continue down that path. If you read the definitions and answer NO to all questions in the definition, then you would cross that item off on the Root Cause Tree® and move to the next possible item. No matter whether you have a YES or a NO, you should always read the NOTES for additional guidance. In these NOTES we provide links to other possible issues and categories on the Root Cause Tree that may have impact on the issue or issues being addressed. This may prompt for the need to ask additional questions or examine areas of the Root Cause Tree® that the investigator may not have realized applied.
For example, the Training category deals with the knowledge provided to the employee through the company’s training program. But when analyzing this category we want the user to consider the relationships between multiple systems that support an employee in performing work in the proper way, those include:
Procedures
Training
Human Engineering
Work Direction
Management System
The NOTES from this Training section provide guidance on this relationship:
NOTE: Some causes initially considered as Training should instead be considered as Work Direction – Selection of Worker if a person who was not qualified by the facility’s rules was assigned to perform the work (thereby bypassing the facility’s training program).
NOTE: Some causes initially considered as Training should instead be considered as Procedures if using an appropriate procedure could alleviate or reduce the need for additional training.
NOTE: Some causes initially considered as Training should instead be considered as Human Engineering if better design could have prevented the issue.
NOTE: Some causes initially considered as Training should instead be considered as Work Direction – Preparation – pre-job briefing NI if the pre-job brief should have made additional training unnecessary.
NOTE: Some causes initially considered as Training should instead be considered as Management System – SPAC Not Used – comm. of SPAC NI if a standard, policy, procedure, or administrative control was not used because management did not adequately communicate the SPAC.
Without this guidance the investigator could possibly miss additional opportunities to examine and find root causes if these NOTES are not examined. So to thoroughly analyze an issue, and to use the Dictionary to its fullest, don’t ignore the additional guidance provided within the NOTES. They can make the difference in determining all the Root Causes for an issue, and possibly missing the opportunity to find and fix a hidden problem and allowing for a problem to reoccur.
“How is TapRooT® different from other root cause analysis tools?“
While answering the question, I concluded that it was the wrong question. The question should have been:
“Why is it that so many industry leaders have chosen TapRooT®
to be their standard for finding and fixing the root causes of problems?“
It’s not what makes TapRooT® different … It’s what makes TapTooT® clearly superior that should be the focus of the question and my answer.
Some people just don’t get this line of questioning. They say things like:
“Every techniques has its advantages and disadvantages.“
They just don’t understand that people can’t be trained in every technique.
Companies can’t afford to train everyone to be a guru problem solver.
Companies need a “best answer.” A root cause system that has been intelligently designed to meet the needs of the people in the field. People doing real investigations. A system they can adopt as a standard.
The techniques in this standard system need to be “human factored” – designed with the limitations and capabilities of the users in mind.
TapRooT® Design
When designing TapRooT®, Mark Paradies and Linda Unger not only used the human factors expertise that Mark brought to the development, but also worked with outstanding human factors experts (including Dr. Charles O. Hopkins and Smoke Price).
They human factored the TapRooT® System to make it usable. That makes it superior.
But the development efforts didn’t stop there.
Mark got reviews and comments from safety and reliability experts from a number of industries including aviation (Jerry Lederer, father of aviation safety), nuclear power and nuclear weapons (Larry Minnick, nuclear plant safety expert, and Paul Haas, DOE human factors & safety expert), and the oil/petrochemical business (Heinz Bloch, equipment reliability guru).
That’s Jerry Lederer on the left in 1926. I met Jerry in 1990.
Those named are just a sample … not an exhaustive list. There were many more TapRooT® Users who helped in the early TapRooT® development efforts.
This made TapRooT® grow beyond one philosophy – beyond a single industry perspective.
Investigation + Root Cause Analysis
All this knowledge helped us develop not just a root cause analysis system, but something more … an investigation and improvement process that includes built-in human factored root cause analysis and troubleshooting tools.
When people tack root cause analysis on to an already completed investigation, they are missing the power of the techniques to help the investigator collect and evaluate investigative information.
That’s why TapRooT® is not just root cause analysis. TapRooT® is root cause analysis meshed with troubleshooting, an investigation process, and performance improvement processes (both reactive and proactive).
The whole system is made to work together seamlessly.
That’s different and superior!
Don’t Start Off Looking for “Why?”
I don’t want to give away all the secrets that make TapRooT® superior, but I will share a few more that should help people trying to decide if they should attend TapRooT® Training.
First, unlike many root cause analysis tools (think 5-Why’s or any cause-and-effect based system), TapRooT® doesn’t start out looking for “why” something happened. Instead, it starts out trying to understand “what” happened.
That’s a key difference.
One of the big drawbacks of many systems is that people using them jump to conclusions about why something happened before they understand what happened. It’s a natural human tendency. In fact, the more knowledge about a problem someone is, the more likely they are to think they automatically know the answer.
In TapRooT®, an investigator’s first goal is to build a complete SnapCharrT®.
A SnapCharT® visually shows what happened and as much information as can be gathered about the factors that surrounded what happened before one starts looking for root causes.
Users find this initial focus a major advantage because it helps them avoid the “blame trap” and the trap of jumping to conclusions.
Expert System Helps Investigators See Beyond Their Current Knowledge
The next major advantages of TapRooT® is the way TapRooT® looks at root causes and the tool used to guide investigators to the root causes of the problems causal factors.
In TapRooT®, we realized that accidents aren’t quite like falling dominoes. In fact, most accidents have multiple causes that existed prior to the accident and just never came together in the exactly wrong fashion at one point in time to cause the accident. Sometimes people call this coincidence “bad luck.” Engineers and statisticians may think of using Monte Carlo methods to simulate the seemingly randomness of real life.
Because of this, TapRooT® encourages investigators to identify all the causal factors and to find each causal factor’s root causes. Thus, there isn’t a “root cause” for an accident. Rather, there are multiple root causes for each causal factor that contributed to an accident.
Think about this as multiple opportunities to improve performance by improving multiple defenses to keep accidents from happening.
The tool used to analyze these causal factors is called the Root Cause Tree®. It is copyrighted and, in software form, patented. It is human factored to lead investigators to the root causes of human performance and equipment problems. Nobody has anything close to our tree.
Most of the development effort of the Root Cause Tree® was focussed on helping people in the field find the causes of human performance (including behavioral) problems.
The Root Cause Tree® is unique in the guidance it gives investigators in analyzing human performance issues including an expert system to start the troubleshooting of human errors, the categorization of best practices that is embedded in the tree, and the guidance for each category built into the Root Cause Tree® Dictionary.
Some say that the goal we set out for the Root Cause Tree® is impossible to achieve. We wanted to capture 90 – 98% of the root causes of human error in the categories on the tree. They say that it is impossible to include ALL the causes of human error in a model. Instead, they say that one should start out with an open mind and analyze each problem from scratch.
There are two problems with this argument.
First, the human brain thinks categorically. For example, the language we use to describe an accident is based on words (categories). So even if you try to start with an open mind, your brain is already categorizing.
We have found that the vast majority of investigators have not had specialized training in human factors. Therefore, they don’t know what they should be looking for (they don’t have the categories in their brain). This makes it almost impossible for them to identify the causes of human errors and develop effective corrective actions.
That’s why they revert to the standard answers of blame (counseling and discipline solutions), training, and, when all else fails, writing a procedure. It’s not that these answers are always wrong. It is that these answers are just a small fraction of what needs to be done to improve human performance. And the Root Cause Tree® provides a much more complete answer.
Second, we never said the Root Cause Tree® has all the answers.
The Root Cause Tree® is just the best list we’ve ever seen. We think it is closer to the 98% end of the scale than to the 90% end. And we know it is much more complete than the answers in the models carried in the heads of the people who come to our training. Thousands of users that we train each year tell us that TapRooT®’s Root Cause Tree® expands the universe of problems they can find and solve …. It does not restrict their problem solving efforts.
Having designed TapRooT® and spent over 20 years improving it, I could go on with other major and minor advantages that we’ve worked so hard to incorporate into the TapRooT® System. But I’ll stop here with one more reason that TapRooT® is superior…
Continuous Improvement
We started with a great design but we didn’t stop.
We search for and implement ideas that make TapRooT® ever better, including ideas from international experts and our TapRooT® Advisory Board (60+ people from industry leading companies).
Better training, better software, and better techniques.
Continuous improvement keeps TapRooT® the state-of-the-art in root cause analysis and makes it superior.
TapRooT® as Your Root Cause Analysis Standard
Of course, there are more advantages to using TapRooT® – reasons that industry leaders around the world have standardized on just one method of root cause analysis. But by now you are probably thinking…
“Why haven’t we standardized on TapRooT® yet?”
Seems like a great idea.
Get started by attending one of our public TapRooT® Courses.
Attend a TapRooT® Course. Go back to work and apply what you have learned. If you don’t find root causes that you previously would have overlooked and if you and your boss don’t agree that you develop better corrective actions that are more effective, just return the course materials and any software supplied and we will refund the entire course fee.
That’s how confident we are that you will feel the difference.
TapRooT® isn’t just different, it’s superior.
Already Using TapRooT®? Get Better!
How do those that already use TapRooT® keep up with the newest TapRooT® improvements to sustain their programs and build on their success?
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
40 Years of Research Unlock the Value of Hands-On Training
Psychologists analyzed over 40 years of research across 16 countries to find the relationship between hands-on training and job performance. Burke et al. found that hands-on training was more effective than classroom style training for tasks that carried a high risk of death or injury. In lower-risk tasks, however, classroom style and hands-on training were equally effective.
The “Dread Factor” is the Key
They explain this phenomenon with a “dread factor,” the employee’s knowledge of the high risk of the task he or she is performing. The authors conclude that hands-on training should be considered for high-risk industries, even if it does cost more money. These realistic simulations heighten the “dread factor,” making a person more likely to remember training and adhere to safety standards.
This study best applies to the Training category in the Root Cause Tree®. Look under Understanding Needs Improvement: Practice/Repetition Needs Improvement. A problem with the “dread factor” could be due to poor learning objectives or instructional style as well. However, the trainee really needs practice so he or she understands the full risk of the task, as well as the procedural steps. If the training is “not repeated enough so that information [can] be learned and skills sharpened”, or “more simulator time [is] needed for proficiency”, then your facility may want to address this issue.
Ninth Time is the Charm
Can you think of a few employees who don’t understand the full risk of their tasks? Re-train them and revise the training program for new employees. Practice and present the procedure—including the risk—nine times total, as “…presentation of material up to nine times in a variety of settings and instructional techniques is commonly needed” (Corrective Action Helper® Guide).
For more information on training tips, look at Training in Organizations: Needs Assessment, Development, and Evaluation, Third Edition (1993) by Irwin Goldstein, published by Brooks/Cole Publishing Company, Pacific Grove, CA.
Want to learn more about our 7-Step Process? Click Here and learn how to find and fix real root causes with TapRooT®.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
If you have never been around horses, you might not know that this implies that you shouldn’t be judgmental about things that are given to you.
Yet, I couldn’t help but be judgmental when I saw that an organization was “gifting” free root cause analysis training over the internet.
They claimed that in just 19 minutes you would learn to find the root causes of problems.
Why would I be judgmental about this?
Because the risk you take if you do a BAD job when you perform a root cause analysis.
What if I told you I would teach you teenage children to drive in just 19 minutes over the internet?
Would you sign them up for the course and turn them loose in a car? Of course not! The risk of failure is too high.
Teaching people root cause analysis in 19 minutes is just as ridiculous.
Yet people “send” people to this kind of training and expect a good result.
What do they get? Bad investigations.
I’ve seen these kinds of investigations. Way too many of them. And then I’ve seen major accidents that could have been prevented (but weren’t) because the root cause analysis of precursor incidents and the resulting corrective actions were ineffective.
That’s why our minimum root cause analysis course is two days.
Plus, we recommend our 5-Day TapRooT® Course for those who are going to lead teams investigating serious accidents.
Don’t be tricked into thinking that any root cause training is “good enough.” When you have serious problems that could cost big bucks, cause major quality issues, cause expensive equipment downtime, or lead to fatalities or serious injuries, you should only use the best root cause analysis technique – TapRooT®.
To see what our clients have achieved, see the success stories at:
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Earlier this year, we shared some tips for multi-taskers in our Career Development Column. But recent psychological findings indicate that multi-tasking, more accurately called “task switching”, not only endangers your schedule and productivity, but can endanger lives.
Multitasking Cuts Productivity by 40%, Says APA
Psychologists compared the time it took participants to accomplish certain tasks on their own and after switching from another task. Participants lost time when switching tasks. The more complex or unfamiliar a task, the more time lost after switching.
Researchers found two stages in switching: During “Goal Shifting” we decide, “I will now do this and not that,” and in “Rule Activation” we decide, “I’m turning off the rules for that and turning on the rules for this.” We do this each time we switch tasks. But switching frequently, especially between complex or dangerous tasks, can cut up to 40% of productive time. Errors also skyrocket.
Tailor Your TapRooT® Investigation and Reduce Task Switching
Did you know that multitasking/task switching is covered in TapRooT®’s Root Cause Tree®? Look under Human Engineering: Complex System: Monitoring Too Many Items.
The Root Cause Tree® Dictionary notes that if someone is “required to monitor too many items or variables at one time, causing personnel to overlook or fail to notice needed information”, or if “a person ignore[d] displays or indications because they were concentrating on a single display when they were required to monitor too many display or indicators” then this is likely an issue.
Are you wondering how many variables are too many? It depends on the job, the individual, and the circumstances. We suggest that 3 items at once is too many.
Lean on Expert Advice
Consider consulting a human factors expert if you find this to be a root cause or a generic cause in your company. This expert will be able to tell you what’s holding your human-machine interface back and give you ideas on how to fix it.
The Corrective Action Helper® Guide has a few suggestions as well, like revising the human-machine interface to make it easier to monitor–perhaps integrating controls into one panel.
Fatigue and Procedure Needs Improvement may also be root causes if your workplace struggles with the costs of task switching.
Multitasking or task switching is far more costly than we think. Make sure work conditions allow for focusing on one task at a time, and let the equipment work with your personnel not against them. Take a look at the American National Standard for Human Engineering of Visual Display Terminal Workstations for ideas on how to improve your human-machine interface.
If you’d like to learn more about attention and monitoring issues, attend our Stopping Human Error Pre-Summit Course next February.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” your Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Collaboration on an incident investigation can be simplified by knowing how to export your investigation and import it into another machine. This allows team members to continue to work the investigation without having to recreate data. It also aids in the creation of a single unified investigation to present to management.
Let’s look at how this is done in the TapRooT® software:
Exporting the Investigation
Starting from your Quick Launch Menu (Main Screen), select the investigation you wish to export and press the [OPEN] button which takes you to the 7 step process screen.
From here, select the [Open Investigation Info] button to enter the investigation editor.
On the bottom right side of the window, press the [Export] button to initiate the export process.
Name the file, select where you want it saved, and press the [SAVE] button to export your investigation.
**All TapRooT Investigations are stored as XML files with a .tx5 extension.
Importing the Investigation
To import an investigation, selectActivities-Import-Audit/Investigation from the left side menu to bring up the Import Investigation/Audit File window.
Press the [Browse] button and navigate to the location of the investigation you are importing, highlight the file and press [Open] and then [OK] to complete the process. You will receive a dialog box that indicates the investigation has imported successfully.
One of the highest rated sessions at the TapRooT® Summit is the “TapRooT® Users Share Root Cause Best Practices” session. Here’s a video of one TapRooT® User sharing an idea …
This idea may or may not apply to your investigations. But just one or two good ideas can “pay for” you Summit attendance by the benefits they create back at work. I had an attendee at the 2010 Summit tell me that one idea he learned was going to save his company over $100,000 in the first year he implemented it.
Does your company need to learn good ideas (best practices) from industry leaders from around the world? Then register for the TapRooT® Summit at:
Have you ever heard someone jokingly say, “Oh no, it’s the grammar police”? Well, look out, because they’re officially on patrol, enforcing the Plain Writing Act of 2010.
What is it?
President Obama signed The Plain Writing Act of 2010 last October, requiring that all government documents addressed to the public must be “accessible, consistent, written in plain language, and easy to understand.”
The goal of this act is to protect the public from legal and safety issues. For example, one woman signed a document agreeing to a hysterectomy, finding this out only after her surgery was done.
Why do I care?
Only government-created documents for the public are required to adhere to this law. If you work for the U.S. government or a government contracting company, you’re likely to rewrite some of your documents and create new ones that fit these guidelines.
What if you don’t work for an organization like this? Use these straightforward guidelines when writing your procedures, memos, reports and other essential documents. You reader will understand you better- he or she will follow your procedure, heed your memo, and respond to your reports and corrective actions in a way that changes your company for the better.
What should I do about it?
Use TapRooT®, your company’s guidelines, and the Center for Plain Language’s guidelines to create a seamless method of communication in your company. Use this list as a place to start:
- Conduct a TapRooT® proactive analysis on your procedures and internal communications. Use TapRooT®’s Procedures Corrective Actions to improve your procedure.
Some examples:
Simplify the steps.
Rewrite the procedure so that it can be performed more efficiently.
Flow chart a procedure that contains complex instructions.
Change the procedure’s level of detail to fit the user’s skill level.
Read Procedure Writing Principles and Practices by Douglas Wieringa, Christopher Moore, and Valerie Barnes.
For more TapRooT® guidelines, look at your Corrective Action Helper® pp. 31-33.
- Use the guidelines provided by the Center for Plain Language.
- Use the checklist from the Center for Plain Language to proofread your report. One example:
“A document, website, or other information is in plain language if…
The basic approach specifies who will use it, why they will use it, and what tasks they will do with it. Consider if the basic approach:
Identifies the audiences and is clearly created for them.
Focuses on the major audiences and their top questions and tasks.
Does not try to be everything to everyone.”
To see the full checklist including Design, Structure, Hierarchy, Language, and more click here.
Maybe the grammar police aren’t really out to get you. But make these few simple changes to your reports, procedures, and internal communications and you’ll see an improvement so huge, it must be illegal!
Happy Wednesday and welcome to this week’s Root Cause Analysis Tips column.
This week, the topic is Continuous Improvement.
Advanced Root Cause Analysis using an expert system is essential to your improvement efforts. Whatever method you decide to use for continuous improvement, TapRooT® tools can help.
Let’s discuss some of the most common improvement methods and how you can integrate TapRooT®.
Have you heard about the PDCA cycle? This acronym stands for plan, do, check, act (or PDSA; plan, do, study, act) and represents a never-ending loop that requires a constant refinement of your efforts. What I mean by that is you never really finish; you continue to improve the system, hence the term CI! This is what the PDCA cycle looks like:
So how can you use the TapRooT® tools to help? At a minimum, you should use the Root Cause Tree® during plan and check. After all, how can you fix a problem if you do not understand the root causes? You can also use the SnapCharT® to map out the process during the plan stage. The Corrective Action Helper® and Smarter Matrix can be used during the plan/do stages as well to help you develop action plans.
PDCA was born of Walter Shewhart’s general process improvement model and was adopted by W. Edwards Deming as the PDSA (plan, do, study, act) model, although it is now more often referred to as PDCA. Dr. Deming began lecturing about PDCA in Japan in 1950 and it has been widely used in many industries and applications ever since. While other concepts have come and gone, this simple process improvement model has stood the test of time.
If you are a Six Sigma person, the PDCA diagram looks familiar, since it is similar to the Six Sigma DMAIC (define, measure, analyze, improve, control) cycle. Again, the SnapCharT®, Corrective Action Helper®, and Smarter Matrix can be used to map out the system and develop corrections. In my experience, people usually love or hate Six Sigma, there is no middle ground. What I will say is that the process does work if it is implemented properly (and the people who hate it usually did not implement it properly); however, I will say the typical root cause analysis tools commonly used in SS are weak at best. Therefore, the most helpful of the TapRooT® tools for use with SS is the Root Cause Tree®. If you have SS in your company, keep doing it, just improve it and get better results with the tools available to you.
Maybe your organization does Kaizen events. Usually, these events have a smaller scope than the typical CI or SS project. Nevertheless, they can really improve the business, and again, the Root Cause Tree® can help you understand the reasons you are having problems. If Lean initiatives are part of your project (like 5S for example), you must analyze the causes of your waste before you act, otherwise, you could be wasting your time or worse, creating other problems.
As I said, the simple concept of PDCA has stood the test of time. In fact, some typical management standards even follow the process; for example, the ANSI Z10 standard for health and safety management systems and the ISO 14000 standards for environmental management:
ANSI Z10
ISO 14000
Continuous improvement is like pushing a boulder up a hill; it takes time, effort, thought, and commitment. But let me ask a question – would you rather spend your time doing CI or doing investigations after something bad happens? The answer is obvious.
If you want to learn more about PDCA and will be at the National Safety Council (NSC) conference in Philadelphia in a few weeks, attend my talk “Change your safety team into an improvement team” on November 2 at 1:00 PM.
Thanks for visiting the blog and best of luck with your continuous improvement efforts.
I attended the Milken Conference held in LA. Gary Becker, Nobel Prize and Presidential Medal of Freedom winner, explained the theory of human behavior and rewards.
Once again, the material we teach in TapRooT® Courses was confirmed through a different science – economics.
His economic theory is that people act because of the rewards built into the system.
So, if your boss with an MBA starts blaming folks after an incident – especially if rules were broken and the “enforcement” system isn’t working as intended, tell him/her to look into the research of renowned economist Gary Becker.
People are rational … The rewards system is broken.
TapRooT®’s Corrective Action Helper® can help you fix it.
For more information about TapRooT® Training, see:
Many of you have asked us if the TapRooT® software will work in Windows 7. The answer is yes! Our Version 5 software is officially supported in Windows 7. This week I want to walk you through the steps required to install the TapRooT® software on a Windows 7 machine.
In order to install in Windows 7, the first thing you need to do is disable the User Account Control(UAC) prior to installation. The steps to do this are listed below:
Disabling User Account Control (UAC)
Step 1 Go to the Start Orb and in the search box type ‘msconfig’ and press [Enter] on your keyboard. When the window comes up select the ‘Tools’ tab.
Step 2 Select Change UAC Settings and press [Launch] to open the User Account Control Settings screen.
Step 3
Move the slider to the bottom and press [OK]. Press [OK] again to close the MSCONFIG window.
Step 4 Restart your machine to finalize this change. Once your machine has been restarted, you are ready to proceed.
Software Installation
Step 1
To begin the software installation, double click on the TSS icon located in the folder where it was saved.
The installer will extract the files to a temporary location and begin the installation process.
Step 2 After the TapRooT® files have installed, you are presented with a dialog box asking for the serial number you were provided when the software was purchased.
Enter the serial number and press [OK] to continue to the database portion of the software installation.
Step 3 During this part of the installation you are presented with several dialog boxes like the one shown below:
Follow the instructions on each screen to proceed through the installation
**NOTE** DO NOT close any windows until the TapRooT® software opens. Once the software is completely installed, the TapRooT® application will open and you are ready to start your investigation.
If you are unable to successfully install the TapRooT® software, please send us an email or call Technical Support at 865-539-2139.
You get the call that there has been an incident that needs to be investigated. So, you begin mapping out the SnapCharT®, performing the root cause analysis or developing the corrective actions and this happens (Watch Video):
Never fails, too many Type “A” personalities in the room, and you are the one who has to facilitate the team. It does not matter whether you have a Type “A” or “B” personality, it can get ugly if it is not handled correctly, especially if someone was hurt (or worse) or if the company lost a lot of money. So what to do …
Here are a few facilitation hints:
1. Define who the team lead is upfront. (This prevents an Accountability NI issue.)
Note that the investigation facilitator does not have to be the one who is in charge. After all, the facilitator’s true role is to facilitate the TapRooT® 7 Step Root Cause Analysis Process, not necessarily the team members themselves. It can also help if the facilitator is a neutral person not familiar with the incident or process being investigated.
2. Allow all members to introduce themselves … often new people are introduced into an established team. The introduction gives a person, new or shy, the platform to speak up later.
3. While developing the SnapCharT®, (or time line for friends new to our process), ensure that all the people, equipment, and process actions that occurred are listed, whether people think they are an issue related to the incident or not. You can make a movie with a good time line of events.
Note that this enables the good actions of all members, divisions, contractors, clients and owners to be listed as well and removes some of the blame and finger pointing that can occur.
4. While using the Root Cause Tree Dictionary, Root Cause Tree and SnapCharT® to find Root Causes for your Causal Factors, it is never an “I am right ” or “You are wrong” discussion. Unknown to untrained TapRooT® team members, the facilitator has carried in the “Arbitrator”!
Great, another “A” type in the group you say? Well, yes and no, the “Arbitrator” is the Root Cause Tree Dictionary.
The Root Cause Tree has lots of experience and knowledge to gently nudge any group into the right choice. It comes with some explicit rules … facts, facts, facts! You select a root cause because it related to or impacted a particular Causal Factor. A Root Cause is not selected because you have already decided on what you want the corrective action to be. It is also not ignored because you think you cannot change it. Root causes are just the facts.
Here is an example of how the Root Cause Tree Dictionary arbitrates and removes the emotion for the Causal Factor of “Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.” This is just one of the Causal Factors for the Incident of a motor being damaged with lots of downtime costs.
Two team members are in a heated discussion as to whether the Operator could detect or could not detect the contamination while opening the valve …
One team member who believes that the Operator had the knowledge of the contamination in the line is focused on what was seen after the fuel supply system was opened up.
The other team member believes that the Operator could not see inside the system while opening the valve.
You, (as the facilitator), walk up to the arguing pair and without telling either member who may be right or may be wrong, you say, “Open up the Root Cause Tree Dictionary and tell me which fact (condition on the SnapChrarT®) matches the bullet in the Root Cause Tree Dictionary.” Now state the fact and say, “this relates to why the Operator opened the Fuel Supply Valve with a Contaminated Fuel Supply.”
By focusing on the facts as known by the operator at the time he was opening the valve, the contamination was unknown and not detectable. The contamination was identified after the fact and only after taking apart the manifolds and valve.
The “Arbitrator” saves the day again with emotions and opinions removed!
Try these steps and also let me know in the comment section, what else you have done to reduce bias and emotions during your investigation facilitation.
Then attend a TapRooT® Course to learn about SMARTER corrective actions.
Part of the SMARTER evaluation is to review the corrective action for unintended consequences.
But the person who develops the corrective action can’t do the review for unintended consequences. That needs to be dome by someone independent who really understands the process/job being modified.
Happy Wednesday and welcome to this week’s root cause analysis tip.
This week, I wanted to give you my thoughts on a question I get asked often: who should our company train?
The answer to this question really lies in what is best for your company (your operation, culture, risks, etc.)
Since I can’t address a perfect solution that works for everyone, let me give you my general opinion:
The best-case scenario is to drive anything important (including root cause analysis) out to the operational level. How your organization is structured will dictate how that works. In one company it may be front-line supervisors; in another it could be safety committee or quality circle/continuous improvement team members. The key here is there is ownership for problems and results from everyone in the organization, not just the “safety guy/gal.”
If you are the Lone Ranger, you can make a difference, but you can make much more of a difference by being more of a mentor and facilitator and driving the message and knowledge out through the company. Having root cause analysis and best practice knowledge in the operation not only helps with investigations, but it also helps people think more proactively in the everyday operation.
One more thing; you will also want to make sure your management group is trained so they understand the process. Either one of these courses would give them that understanding.
If you do take my advice and train a large group, we do onsite training at your facility as well. If you would like information on that option, e-mail us at info@taproot.com or call us at 865-539-2139.
So don’t be the Lone Ranger, be a Game Changer (hey, that rhymes!). Thanks for visiting the blog, and until next time, happy investigating.
When you attend one of the TapRooT® courses, your instructor introduces you to the 7-step TapRooT® systematic process for finding the real root causes of problems so you can solve them once and for all. During your training, your instructor will also introduce you to our TapRooT® System software as a tool to facilitate the investigation or audit and determine what corrective actions need to be implemented. I’d like to discuss three areas where the use of the TapRooT® software saves you time: Centralization of data, Email Notifications, and the Copy/Paste Feature.
1. Centralization of Data: Typically when conducting a root cause analysis investigation or audit, you will need to collect various pieces of documentation including items such as eyewitness statements and photographic evidence. If this is a large-scale investigation, the amount of work necessary to collect and organize the data can be cumbersome and difficult to organize. The TapRooT® software provides you a central repository to store documents and can be assigned to particular investigations. When you use the centralized data store, you are more efficient in conducting your investigation and tracking what documentation you have and what documentation you still require to complete your investigation.
2. Email Notifications: The TapRooT® software also saves you time is the inclusion of a robust email notification system. This notification system is highly customizable and allows you to create unique notifications for various investigation events. This ensures that all team members stay aware of the investigation status. The notification system can also be used to inform users of their responsibilities regarding Corrective Actions. As each step of a Corrective Action is completed, the software will automatically notify the team member responsible for the next step.
3. Copy and Paste Feature: During your investigation process, you will need to determine the root cause for any causal factors you identified. The TapRooT® software includes an electronic version of the Root Cause Dictionary which provides you the ability to copy and paste definitions straight into your investigations instead of manually entering them. These definitions help guide management through the reason behind selecting certain events as causal factors in your investigation.
In conclusion, these time-saving tips are just a sample of the unique ways using the TapRooT® software can save you time when conducting your investigation. We would love to hear how the TapRooT® software saves you time! Leave a comment below or send me an email to share how the TapRooT® software helps save your organization time when conducting an investigation.
I was talking to a TapRooT® user the other day, and he expressed to me how important it is to him to use the optional TapRooT® techniques. Specifically, he was talking about:
Change Analysis
Critical Human Action Profiles (CHAP)
Safeguards Analysis
Equifactor®
These tools, while technically listed as optional, should be considered for use on every investigation. They are used mainly in Step 2 of the process while you are gathering information to build your Summer SnapCharT®. The tools can ensure you are asking more direct, probing questions, enhancing the accuracy of your investigation. They can make you see different aspects of a problem from a slightly different point of view. Let’s briefly talk about these tools to see how they can help you during your investigations.
Change Analysis:
This tool can really help focus you on why a particular incident or problem happened this time, when we actually perform that process all the time. Just by asking yourself, “What was different this time, compared to how we always do it?” can help focus you on the specific circumstances of the investigation. Did we do something differently? Were there different initial conditions? What were the environmental conditions this time? Who normally performs this job? What’s special about this piece of equipment compared to all the other ones in the plant? Using the formal Change Analysis tool can help you focus on these aspects of the investigation.
Critical Human Action Profile (CHAP):
I use this tool most often when it looks like there was just a “simple” mistake. For example, someone was packing a box and sustained an injury. CHAP is used to look at exactly how we performed a job, down to the most minute details. It is similar to a Job Task Analysis. What tools, initial conditions, training level, supervision, PPE, etc were required to perform each particular step of the job?
Safeguards Analysis: I use this tool most often when I’m identifying Causal Factors. By using Safeguards Analysis, I can more easily identify why a person might have had diffiiculty performing an action, or why they did it differently than intended. I also use it when analyzing a “simple” mistake. When someone gets hurt, or we do something contrary to company policies, it is often because we have a problem with the safeguards that were (or should have been) in place. By using Safeguards Analysis, you can more easily identify these problems, giving you a much better understanding of what actually lead to the mistake.
Equifactor® Equipment Troubleshooting Tables: These tables are a terrific resource for your maintenance and repair teams. When they have run out of ideas as to the “physical” cause of an equipment failure, they can turn to Equifactor® to give them a comprehensive list of possible causes for the failure symptoms they are seeing. Using Equifactor® can save your team hours of “easter-egging” to find the problem. And once they discover the actual physical cause of the failure (“the bearing failed because we used the wrong grease”), they can plug that back into their summer SnapCharT® and use the rest of the TapRooT® process to get to true root causes of the failure. This is just a brief description of these optional tools. While they may not be required on every investigation, you should evaluate if you need them each time. Using these tools may give you the additional insight you need to prepare more comprehensive SnapCharT®s, leading to better corrective actions in the end.
I just received an email from a contact that is using TapRooT® successfully at his facility. He said his company is asking him why his teams (which use TapRooT®) consistently come up with great investigation results. Besides just using the tool as intended, he also stressed the importance of ALWAYS checking for Generic Root Causes. This got me thinking a little more about why it is so critical to consider Generic Causes during each and every investigation.
As a reminder, Generic Causes are considered in Step 5 of the TapRooT® process. After analyzing your Causal Factors using the Root Cause Tree® in Step 4, you then do a quick check to discover if any of those root causes are also generic issues in other areas of your company. For example, if you find that Housekeeping Needs Improvement was a root cause of a particular incident (maybe someone tripped over a tool that was lying on the floor), you might write a few corrective actions to fix that problem:
1. Pick up the tool.
2. Put a tool storage cabinet in the workspace where the person tripped to allow for better storage conditions.
Your next step is to check to see if this Root Cause is also a Generic Root Cause. You could ask yourself some questions to determine if that particular root cause (Housekeeping NI) is a more widespread problem:
a. Do we have any other areas that have frequent use of tools? (if YES)
b. Is stowage of these tools an issue in these other areas? (if YES)
c. What is allowing us to have poor tool stowage in these other areas of the facility?
You would now do a little research and write a few new corrective actions to address this generic issue of poor tool stowage throughout your facility. Maybe you’ll find:
1. We need more storage cabinets throughout the facility.
2. 5S survey by your lean experts might find a way to label stowage locations for all of your tools.
3. You need a housekeeping audit plan established to check for compliance with your new tool stowage policies.
I consider looking for Generic Root Causes almost a freebee! You’ve already put some time and effort into investigating, analyzing and discovering the root causes of a specific incident (or Near Miss) at your facility. Why not leverage that effort across the facility (or the entire company) and prevent future, similar accidents and problems! Why wait for a similar incident to occur again, and then realize, “Hey, this is almost exactly like the problem we saw last month!” Using Step 5 of the TapRooT® process to discover possible Generic Root Causes is a proactive method of improving the effectiveness of your investigations. DON’T SKIP STEP 5! Look for Generic Root Causes and watch the effectiveness of your investigations really take off.
If you’ve attended a TapRooT® course and are ready to learn more techniques other TapRooT® users are using for outstanding results, join us in 2012 for our exclusive 2-day Advanced TapRooT® Techniques course to be held February 27 and 28, 2012 just before the Global TapRooT® Summit in Las Vegas!
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Ken Reed is a Partner at System Improvements, Inc.
During the course of your investigations, I’m sure you’ve often found that you need to add custom fields. Custom Fields can be defined as any specific piece of data that is required to be entered in every investigation or audit. The TapRooT® Software Details/Attachments section in the lower right area of the Investigation Editor screen provides you with the ability to add attachments and custom details to your investigation.
The software includes two default details fields: Current Conditions and Immediate Corrective Actions, both of which are defined as ‘Text’ data types. Both the field description and data type can be edited and additional types can be created.
Let’s walk through creating a new Custom Field called “Images” which will contain photos from the investigation. The first step is to navigate to the left side menu and select Admin-Setup-Custom Details Fields where you will be presented with the Customize Fields screen.
At this point we want to press the [Add] button and fill in the fields with the information we want to use for our “Images” custom field:
Field Description: Images Sort Order: 300 NOTE: This field is a numerical value that allows you to determine the order that custom fields appear in the drop-down menu. The software lists fields sequentially based on Sort Order value. I advise setting your Sort Values in increments of 100 to accommodate any future additional custom fields.
Data Type: Binary(Attachment)
We also want select the Investigation/Audit and Submission checkboxes and press the [Save] button to complete the process.
Congratulations! The Customize Fields screen now reflects our newly created custom field. This custom field is now available for future investigations and audits.
You can repeat this process for as many custom fields as you would like. If you have any questions, please feel free contact Technical Support via email or call 865-539-2139.
Software users: plan now to attend the exclusive 2-day “Getting the Most from Your TapRooT® Software” course held in Las Vegas, Nevada, February 27-28, 2012 right before the Global TapRooT® Summit. Learn more on the Summit website.
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Steve Raycraft is a member of the TapRooT® Tech Support Team.
In last week’s Root Cause Tip, I discussed how to design a presentation that will wow your management. Once you’ve created a professional, streamlined management presentation, you need to get ready for the meeting and practice, prepare, and finally present.
Practice
Make sure you practice your presentation, with your visuals, until you’re sick of it. In his book, Enchantment, former Apple evangelist Guy Kawasaki recommends this. He tells us that even Steve Jobs does this. And if Steve Jobs needs to prepare that much, so do I.
Prepare
Check beforehand to see if your meeting room has the necessary technology, and arrive early to set up. Make sure your PowerPoint presentation is saved in multiple places, and compatible with older versions of the program. And remember Murphy’s Law: If something can go wrong, it will. Be ready to give your presentation without visual aids. You may even want to print handouts of the essential visual aids (SnapCharT®s, Corrective Action Matrix®) for your audience in case this happens.
Present
During the presentation, don’t use your visual aids as a crutch, says Chris Witt, expert presentation coach of 20 years. You’ve included them to enhance the audience’s understanding, not to hinder it. Engage your audience by looking at them while you’re talking, not the aid. You should be familiar enough with the material that you don’t need to read from your screen or use a pointer. Consider ditching your laser pointer, because these can easily become a crutch or a distraction. If you must use one, Witt recommends, set it down when you’re done so you aren’t tempted to over-use it.
When a visual aid appears on your screen, explain it immediately to avoid confusing your audience. Describe what’s in your SnapCharT®, but you don’t have to read each event. Highlight the most important one with color, and do this with the causal factors, too. Don’t make your audience read and listen at the same time. They’ll listen and understand better if you choose one or the other. Remove the SnapCharT®, graph, photo, or Corrective Action Matrix® when you’re done with it, and continue to the next item. You can make your Power Point screen go black by simply hitting the B key. Hit any other key to bring it right back up.
Conclusion
Prepare for your presentation extensively and always be ready for the worst to happen. Do these and management is sure to understand and support your corrective actions, and you are sure to improve your company greatly.
What are some challenges you’ve faced when creating a management presentation of your investigation? Any advice for the novices out there? Use the comments section below for discussion.
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Megan Craig is the Media Specialist at System Improvements, Inc.
In our TapRooT® Root Cause Analysis courses and TapRooT® book (pgs 477-78), we discuss management presentations. They’re essential to the success of your corrective actions, because these presentations communicate your investigation’s results and proposed corrective actions to your company’s decision makers. You’ve got to convince management of the truth: You’ve seen the problem, you’ve done your homework, and you’ve got the solutions.
How do you do this? Make sure your visual aids have relevant content, readable text, and professional graphics and you’ll wow your management.
Content
Begin with creating an outline of your presentation:
what happened
how it will get fixed
who will fix it
costs and timeframe.
Click here to learn more about our presentation content guidelines. I recommend using Microsoft PowerPoint for your presentation, because it’s user-friendly and creates professional-looking visuals.
Create your outline before considering visual aids. Each slide should serve only one purpose so your audience follows you easily, recommends Chris Witt , business presentation expert and coach of 20 years. The essential visuals you’ll need are a title slide, SnapCharT® of events, SnapCharT® including causal factors, and your Corrective Action Matrix®. These will communicate the most important elements of your investigation to your management.
Text
Guy Kawasaki, former Apple evangelist, recommends his 10-20-30 rule for presentations: Create a 10-slide presentation in 20 minutes using a minimum font size of 30. You may not be able to stick to the 10-slide rule if you have a long investigation. But begin with an outline, and creating your Power Point presentation in around 20 minutes will be a breeze. It will also protect you from complicating your visuals for your audience.
Each slide also needs a title, says Witt. Use text sparingly and choose a sans serif font like Arial. Research shows that it’s easier for to read on electronic screens than serif fonts like Times New Roman. Choose font colors that reflect your brand or logo. This ensures you’ll stick to a coherent, professional, and familiar color scheme, and will associate your presentation with your company’s brand reputation.
Graphics
Your graphics must be clear and relevant to the message. Use these sparingly as well. The essential graphics are your SnapCharT®, Causal Factors, and Corrective Action Matrix®. Consider adding photos, videos, diagrams, and sketches of the incident, equipment, or scene. You can also use charts, graphs, simulations, logs, test results, and other relevant data to support your assessment of the incident. There’s no need to include the Root Cause Tree®. Its details may confuse your audience, who wants only the essential information needed to make a decision.
Avoid ClipArt and stock photos as well, says Witt, because they look unprofessional and clutter your presentation. Your graphics need a high resolution, whether they are photos or charts. Microsoft Excel’s charts, tables, and graphs are easy to create, clear, and customizable in color. You can also use the TapRooT® software to add color to your SnapCharT® and highlight a certain event or causal factor. The TapRooT® Software organizes your investigation and is the most effective tool for creating your SnapCharT® and Corrective Action Matrix.
Conclusion
Visual aids are meant to be just that: Aids to your presentation. Use them wisely, and your management will be even more impressed with your investigation results and convinced that your corrective actions will solve the problem.
What are your best practices for management presentations? What challenges have you faced? Tell us about it in the comments below!
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Megan Craig is the Media Specialist at System Improvements, Inc.
I’d like to clarify the reason some of our users are experiencing ‘The ConnectionString property has not been initialized’ error when trying to open the TapRooT® Single-User Version 5 software.
This is typically caused by Microsoft SQLExpress 2005 not installing correctly during the installation of the TapRooT® Single-User Software. The TapRooT® software installation is composed of two parts. The first part is the installation of the TapRooT® software specific files. Once those files are installed, a few ‘command’ windows will pop up asking the user to press any key and the MS SQLExpress 2005 installation portion on the installation will initiate.
You will be prompted to ‘Press any key’ twice during this process. During the database installation, there will be a window that will open in the background indicating that the software has finished installing and you can press the [Close] button to complete the installation. You do NOT want to press that button yet. That message indicates that only the TapRooT® files have been installed.
Once the TapRooT® files AND MS SQLExpress 2005 have been successfully installed and configured, the software will automatically open. At this point it is now safe to press the [Close] button to complete the TapRooT® installation.
If the software does not open or you receive any other error message, please visit our Knowledge Base or send us an email.
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Steve Raycraft joined System Improvements in 2007 and is part of the TapRooT® Technical Support Team.
If today was Wednesday … what measurements (metrics) could be used to describe it:
1. There are 52 Wednesdays in the Calendar Year of 2012.
2. There were 53 Wednesdays in the Calendar Year of 1873.
3. Wednesdays make up 14% of the Days of a Calendar Year.
4. There are 9 letters in the word Wednesday: 2 e’s, 1 w, 2 d’s, 1 s, 1 n, 1 a and 1 y to be exact.
5. There are two syllables in the word Wednesday.
The point of my number parade? Simple, we can measure anything … but does it provide value or predictability? Are the numbers representative of what one is truly trying to measure?
In the Changing the Way the World Solves Problems book provided to all our TapRooT® students, there is a section titled A Guide to Improving the Use of TapRooT®. The tip today from this guide focuses on Topic 1: Measurements. With the first question being, has your company agreed on a reliable measurement system?
Why a measurement system and not standalone metrics that represent individual problems in individual departments? The answer is because no one person or one department works in true isolation. Measurements of money savings, defect reductions, tool repair or tool selection reported by one department may actually cause an increase of those measurements in another department. So no actual money saved for the company!
Developing a Reliable Measurement System starts with the developing and defining the fundamental components and rules for your company. I caution against generic one-fits all Systems developed outside of your company.
Components:
Measurement: An observable (observed either by human or equipment) behavior (behavior of equipment, people or process) that can be measured quantitatively or qualitatively.
Rules for Measurements:
Only used to measure for what it was intended to measure. Nothing worse than using someone else’s numbers for your own needs just to find out it does not measure what you thought it did.
Collected and Documented using the same method with the same types of tools (equipment, forms). Not sure of the consistency of your measurement collection process? Perform a Measurement System Analysis (MSA) on it.
Types Measurements (Just to mention a few):
Operation
Production
Human Resources
Safety
Customer
Warranty
Financial (Fringe or Burdened)
Maintainability and Reliability
Regulatory
Direct or Indirect Labor/Costs
Purpose for Measurements:
Predictive Indicator- Can tell you what could happen before it happens. Note: No predictor is 100% correct but many are very reliable.
Lagging Indicator- Too late! Good or bad news, it already happened but it is a necessary to know. Note that some Lagging indicators can be a leading indicator for another lagging indicator. For example, an increase in near misses can be a predictor of a severe incident if not corrected.
Measurement System: A system allows good measurements to produce good indicators. Of course it also allows junk in junk out, even with the best system in place. So to help define what a measurement system is or could be, answer these questions:
Based on the measurements input, can you see the company “big picture” and can you then break down these indicators to their lowest input level?
Are reports and graphs pulled from one central location to prevent duplication?
Are measurements pulled from the same set of numbers to increase consistent trending?
Is the system audited for consistency and accuracy?
Seems like a lot to make sure you know where your company is going and where it has been doesn’t it? Did I also tell you that you should also be able to translate all measurement indicators into company production and operation dollars? As the our book says, “dollars are the language and measuring stick of management.”
If this post gets you to think … “Why does this make so much sense and why did I not think of this before with the same perspective”?
If the answer is yes, then I have some options for you that appear once a year in a public setting this February:
Users in the new v5 application can easily add color to every shape on their SnapCharT® by following these simple steps:
Open the investigation or audit you are working on by highlighting it in the My Documents section of the User Landing Page and selecting OPEN.
User Landing Page
Through the 7-Step Process Menu select OPEN for the investigation you are working on under Manage Documents by any SnapCharT® step. Then selecting NEW on the Associated Documents Screen.
Manage Documents - 7-Step
New SnapCharT®
Add a shape to the chart by selecting the proper shape under Create Chart and then double clicking in the editor.
With the shape selected, select the Shape Color drop-down and select the desired color, and select OK.
Shape Color Pick Screen
While the shape is selected, click inside the shape once the color is added (this ensures the shape is selected).
Simply hit CTRL-V and you will be able to duplicate that shape with colors. Do this multiple times to add as many shapes as you like.
Repeat this process for other shapes as added.
Move shapes where needed and add text using the Text editor at the top center.
This process can be used when creating a SnapCharT® Template as well. Here is a link to that article:
Let’s be honest, all companies want a good Return on Investment (ROI) on any investment. This is exactly why Mark Paradies and Linda Unger provide a section in our TapRooT®, Changing the Way the World Solves Problems book titled A Guide to Improving the Use of TapRooT®. The tip today focuses on Topic 2: Target Selection.
If you have set up good metrics to measure (Read these for more ideas on metrics: (Tip 1, Tip 2), you can start by looking for your Top Drivers in a Pareto Chart. The idea is that if 80% of your issues are caused by or correlated to 20% of a sampled set of categories, then start there first for more ROI. Review the Chart below and then read the cautions below:
Cautions:
1. “Never Ever Ever” define a category as “Miscellaneous” or “Other”! I promise you that it will always be in the Top Three every time.
2. When it comes to the y-Axis on the Chart, do not just use Cost as a measurement, also use Risk and Frequency. One near miss may not have cost any money but it could have killed someone. If you look at Cost or Frequency only, this would not show up as a Top Driver.
Another Quick Way to decide where to Target your resources is to use a Plot Map. Read more here as to how this map reduced illnesses from the water supply in certain areas.
Finally you may want to measure how accurate and precise your improvements have been. In earlier trending articles (1, 3) we introduced the Process Behavior Chart. Below is one more example of how to measure Risk Reduction using a scatter and bulls-eye chart.
Here is a quick description on what the charts represent:
1. The Center (Bulls-Eye) of the chart represents that the risk targeted has been eliminated.
2. Each subsequent ring of the target indicates risk mitigation at lower levels (the outside rings do show risk mitigation but not as strong as the inner rings).
3. The red dots indicate the actual risk level mitigated for each RCA performed with corrective actions implemented and verified for effectiveness (sounds like SMARTER technique from class don’t it?).
Looking at charts above, which two Charts would you be happy with and why?
Boy, that was close.
Luckily, no one was hurt.
It’s a good thing no one was standing there.
It’s a wonder no one was killed.
How many times have you heard phrases like that? Whenever I hear things like that, it sends chills down my spine. Some companies would categorize these types of problems as Near Misses. George Carlin had a great definition for a “near miss”:
Watch this video from an earlier post. Determine if you would consider this to be an incident or a near miss. Believe it or not, companies would classify this both ways, depending on their trip points.
So what do you do with one of these near misses? Do you investigate them, just track them, or are they just ignored? Many companies have policies in place that cover these situations. For example, your policy might state that you would be required to perform a TapRooT® investigation if an incident caused one of the following:
- Lost Time Injury
- Damage to equipment in excess of $5,000
- Lost production totaling more than $30,000
- Any motor vehicle accident - Any problem that had the potential to cause one of the above
This is a good start, but it can be just too overwhelming to consider all the possible problems we see as fitting our definition. We don’t want to be too broad with our definition; otherwise, we’ll end up investigating everything. We just don’t have time for that, right?
So where is the dividing line? When do I investigate a near miss, and when do I just document and trend the problem? One great way to figure out what needs to be investigated is to look at it from a resource perspective. The ideal would be that we investigate all of our problems. However, I’m a realist enough to know this just isn’t possible.
Instead, follow your policy as closely as you can. Investigate those problems that cause $5,000 damage, or $30,000 in lost production. Then conduct a periodic evaluation to determine how we’re doing. Do I have the time and resources to investigate more problems? If so, maybe you can lower your trip point to $2,000 damage and $15,000 in lost production.
The ideal is that your investigators are exactly maxed out with the number of investigations, but not so overburdened that they can’t keep up. This is good resource allocation. Keep performing these periodic evaluations and see if your trip points need to be adjusted. You should find, over time, that you are able to lower your trip points gradually, conducting more (and smaller) investigations. You’ll find a higher percentage start going toward near misses and audits, because you’ll be having fewer actual incidents as your investigation results provide effective corrective actions.
Another item to consider is, “How do I convince my boss that I need to spend money on problems that have not yet occurred?” In other words, nobody got hurt, you didn’t break anything, and you didn’t break any laws. Why should you be given money to implement corrective actions when there were no actual consequences?
The answer to this is obvious to most of us, and yet the allocation of funds is still a common problem. The issue isn’t that we don’t think the near miss is important. The problem is that we need to convince those with the funds that the problem is worth dedicating resources to fix. Often, the disconnect occurs because we as safety experts haven’t done a good job proving the return on investment. You might try looking back at history and showing that, although the near miss didn’t cost us anything this time, you can show how much similar problems cost you in the past. Add to that how much this near miss could have cost if it had occurred just slightly differently, and you might be able to prove how cheap your corrective actions really are.
Investigating near misses is one of the most basic forms of Proactive Improvement. Take a look at how you handle near misses, and see if you can leverage even more effectiveness from TapRooT® and your improvement programs.
Learn more about proactive improvement by registering for TapRooT® training or contact us for more information.
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