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.
Students are working hard … In just two days they will learn the advanced techniques that are the standard part of any TapRooT® investigation and root cause analysis.
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 an ex-aircraft mechanic and a “sometimes gotta work on my own car” mechanic, I have in the past borrowed or made some of the tools pictured below. The questions remain:
Wrong Tool?
Bad Access by Design?
Mechanic’s Ingenuity?
Or a little bit of them all?
Finally, ever have one of your modified tools bite you back? Share your stories in the comment section.
Karen Migliaccio has done a tremendous job setting up this first TapRooT® Summit Quality Track. From cross industry representatives to demonstrating field successes all the way up to company process changes, you will find this Summit Week Track interesting and applicable.
Wednesday
TapRooT®; Implementation Success Stories:
Successful Implementation of TapRooT® at Steris (Kevin McManus)
High Quality TapRooT® Implementation (Dennis Osmer)
Using the Baldrige Criteria to Achieve Performance Improvement (Kevin McManus)
Root Cause Analysis of Quality Problems:
Challenges in Biotech Quality Root Cause Analysis (Michael Gorman)
Root Cause Analysis of Incidents Occurring in the Pharmaceutical
Industry (Debbie Riley)
Thursday
CAPA in Quality: The Strong and the Weak (Karen Migliaccio)
Quality Issues:
Quality Initiatives That Lead To Continuous Improvement Efforts (Bryan
Ward)
Using a Quality Plan to Drive Improvement (Zena Kaufman)
The 7 Secrets of Incident Investigation & Root Cause Analysis (Mark Paradies)
Designing Your Continuous Improvement Program (Kevin McManus)
Friday
How Pfizer Achieves Operational Excellence (Gerry Migliaccio)
What is it that produces a safe environment with safe workers? Is it people with the right attitude… is it a reduced risk environment… or is it both? Do we need reward or punishment… or both? How do different cultures interact successfully to work safely? What is the best environment for a person to work in physically? How does one know?
Listening to a radio show recently about people trying to get out of debt, the host said this, “it is not the math that got them in the situation it is the behavior; that is why changing the behavior is the first step.” It was in reference to people who wanted to know why the had to pay off small debts first and not the large credit cards with high interest.
Point being, that the more one practices a behavior, the higher the probability that the behavior becomes habit. Providing a better environment with the right tools increases the ability to perform the behavior. It is with this in mind that the sessions below were put together:
Wednesday
Proactive Prevention of Injuries and Accidents Due to Human Error
Ergonomic and Human Performance Improvement
Working Across Languages and Cultures
Thursday
Changing Behavior By Praising the 49 Character Traits
Criminal Prosecution of Accidents
Using Training Simulation to Improve Human Performance
Design for Reliable Performance
Friday
Using FACT to Measure & Analyze Fatigue (Both Reactive & Proactive)
Planning Your Improvements
The course and the Human Performance and Behavior Change Best Practice Track make a great one-two punch for improving human performance. Plus, you will save $200 off the course fee when you attend both.
Don’t miss the remarkable knowledge available in the course and the Summit. Register today!
WHAT!?! You haven’t written down your goals and developed metrics?
Get HOT!
Writing down your goals makes achieving them much more certain.
And “What gets measured, gets done!”
Don’t let important improvement initiatives get forgotten in the daily crunch to get things done.
One more idea …
Use the comment field to leave a couple of your better improvement goals and metrics here. Others can see them and get inspired to make more improvement happen at their facilities. We’ll all help each other to be challenged to get better.
A license to use the TapRooT® Enterprise Software is an investment in improved root cause analysis. To realize the most from that investment requires thought and support for the software installation and maintenance.
Who is the software guru at your site? Have they been trained in the software administrator features of the TapRooT® Enterprise Software?
Once a year, the TapRooT® Software Program Manager – Dan Verlinde – teaches a course to help TapRooT® Software Administrators and Program Managers get the most from their software investment.
is being held just prior to the TapRooT® Summit in Las Vegas on February 27-28.
Here is the course outline:
Day One
• Review of the TapRooT® Process
• Software Interface and Basic Functionality
o Documents and Data Separation
o Security and Login
o Left Menu Structure
• Creating and Managing an Investigation
o Recording Incident Data
o Locations and Classifications
o Team Members (Security)
o Custom Details Fields
• TapRooT® Techniques
o SnapCharT®
o Causal Factors
o Root Cause Tree®
o Corrective Action and Corrective Action Helper®
o Corrective Action Status
oOptional Techniques
• Retrieving Data
o Search Function
o Investigation/Audit Reports
o Macro Reports
o Using Single User Software
• End of Day Review – Software Trivia
Day Two
• Introduction
o Course Outline and Objectives
• Business Analysis
o General Challenges of Software Implementation
o Bridging The IT/Business Knowledge Gap
o Use Case: Definition
o The TapRooT® Use Case
o Software Investigation
• From Installation to Implementation
o Procuring Hardware
o Basic System Requirements
o Installing the Software
o Installation Vs. Implementation
o Lessons Learned From Dvorak
o How To Generate Momentum
o Developing an Implementation Strategy
o Exercise One
• Administrative Tools
o User/Group Authorizations
§ Node Level Security for Groups and Individuals
§ Email Notification Subscription
§ Exercise Two
o User Import Tools
§ Exercise Three
o List Hierarchies
§ Locations
§ Classifications
§ Equipment
§ Departments
§ Numbering Scheme
§ Exercise Four
o Hierarchy Import Tools
§ Exercise Five
o Custom Details Fields
§ Exercise Six
o Email Setup
§ SMTP
§ Notifications
o Optional Techniques
§ Equifactor® Equipment Troubleshooting List
§ Change Analysis
§ Critical Huamn Action Profile (CHAP)
o Final Exercise: Configuring Your Company
o Available System Improvements Consultation Time
o Open Forum/Questions/Comments
One more note. If you are attending the TapRooT® Summit, you get a $200 discount off the course fee of $1095.
To get more information about the Summit and this course, see:
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.
How can you become certified to teach TapRooT® to people at your company?
Here the process…
1. Company/Site gets a License to use 2-Day TapRooT® Training Materials.
2. Prospective Instructor (the one who wants to become a Certified TapRooT® Instructor) attends 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training. (This helps the prospective instructor learn the system and become an expert in using it).
3. The Prospective Instructor usesTapRooT® to analyze incidents.
4. Prospective Instructor schedules a TapRooT® Train-the-Trainer Course (call SI at 865-539-2139 to schedule a course at your site).
5. Prospective Instructor studies 2-Day course instructor notes (part of the license package that they receive when they license the 2-Day TapRooT® Training Materials).
6. System Improvements ships the materials to be used in the 2-Day TapRooT® Course.
7. On the day before the 2-day course, one of System Improvements’ instructors will arrive to work with the Prospective Instructor. The Prospective Instructor will dry run the sections of the course that they plan to teach (they will teach approximately 50% of the course). The System Improvements TapRooT® Instructor will provide them feedback on their teaching and tips to improve the delivery of the material.
8. The Prospective Instructor and the System Improvements TapRooT® Instructor will work to together to teach the 2-Day TapRooT® Course. The Prospective Instructor teach about 50% of the course (or 2/3 of the course if two instructors are certifying). The System Improvements Instructor provides the Prospective Instructor with feedback at the end of each day to improve their delivery of the materials.
9. At the end of the 1-day prep and 2-day course, the Prospective Instructor becomes a Certified TapRooT® Instructor. They will receive a Certified TapRooT® Instructor Plaque after the course.
10. To maintain their certification, the Certified TapRooT® Instructor must attend an advanced TapRooT® Training Courses (one of course offered prior to the TapRooT® Summit) and the TapRooT® Summit at least once every two years.
That’s the certification process!
Contact us by CLICKING HERE if you are ready to get started!
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.
For any successful process improvement implementation, Senior Leadership support and actual presence is necessary. Aurobindo Pharma’s Leadership presence in the early stages of the course and the questions that they asked their students directly is a clear indication that this first team of investigators have full support and expectations set.
Second requirement for success is to have cross utilization during investigations and learning between departments. From the lab, materials, shipping to QA, there was complete and thorough team building.
Finally, the Senior Leadership set expectations and future growth opportunities to include future training and possible multi-user intranet based software licensing. Based on building successes and return on investment.
It was a pleasure to teach and work with this group personally in Hyderabad, India.
If you have to perform Root Cause Analysis for regulatory, equipment and safety issues in India, but are not able to set up an onsite course like the Leaders of Aurobindo Pharma did, I suggest you go to your leadership and get commitment to attend the upcoming Mumbai 2-Day course in February. Seats fill up fast and getting funds authorized may take time so do not delay if you are ready to go World Class with your peers.
Many people begin decorating for the winter holidays the day after Thanksgiving. As you string your lights up and dust off those plastic trees, keep these tips in mind from the Electrical Safety Foundation International.
Electrical Safety
Inspect your strands of lights and extension cords for damage.
Attach them securely, but never nail or staple them.
Extinguish all candles and unplug all lights when you leave a room or go to bed.
Never use a hot extension cord.
Consider battery-operated candles.
Always purchase electronics from a reputable retailer.
Always inspect cords for damage before plugging them in.
Avoid overloading electrical outlets.
Never connect more than three strands of lights together.
Always unplug lights before changing a bulb.
Consider LED lights, they use less energy and run cooler.
Insert plugs all the way into the wall.
Don’t run cords through walls or ceilings.
Extension cords are only for temporary use. Make sure they are rated for the proper use, indoor or outdoor.
Christmas tree and holiday décor fires result in twice the injuries and five times for fatalities per fire than the average winter holiday fire.
Fall Safety
5,800 people per year are treated in emergency rooms for falls associated with holiday decorations. Over half are ladder or roof falls.
Inspect ladders for missing screws, hinges, bolts, and nuts.
Use wooden or fiberglass ladders, as metal ladders conduct electricity.
Use the right ladder height, ensuring that your ladder extends at least three feet past the edge of the roof.
Be sure to tape extension cords down, or refrain from placing them in places where someone could trip on them.
Over 4,000 injuries per year are associated with extension cords. Half of these are due to tripping over an extension cord.
Tune in next week for Child Safety and Fire Safety tips for the holidays. (Read Part 2.)
I had several new TapRooT® Users with safety backgrounds contact me lately to tell me how much TapRooT® influences them in their job.
In addition to helping them find the root causes of accidents, incidents, and near-misses, they said that it helps them:
- make decisions,
- target audits,
- plan improvement efforts,
- explain why safety rules are needed,
- see hazards that they previously might have overlooked,
- understand why rules may be broken (or ignored).
- develop new ideas for effectively enforcing safety rules, and
- have better discussions about safety with others who have also been trained in TapRooT®.
This got me thinking …
Should everyone involved in safety be trained in TapRooT®?
What do you think? Would TapRooT® Training help others involved in safety in their daily jobs?
Then I thought one step beyond that …
Isn’t everyone involved in improvement in one form or another?
Perhaps everyone should be trained in TapRooT®?
Let me know your thoughts by leaving a comment below.
It’s a beautiful day in Charleston but the class is hard at work learning to apply TapRooT® to find and fix the root causes of accidents, incidents, quality problems, and system reliability issues.
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.
Kim M. Aul, Senior Manager, Quality Systems, General Dynamics Ordnance & Tactical Systems reports that there is a new “generation out there waiting to be taught the basics of root cause analysis to use in their everyday lives.”
Meet Grace, age five:
Grace’s mom, Karen, attended TapRooT® training and brought her course materials home to review. When she looked for them later that evening, they were gone. She found them in her daughter’s room with Grace poring over them. When Karen asked what she was doing, Grace replied, “You know I love to read mom and these are wonderful books!” TapRooT® book authors, Mark Paradies and Linda Unger are very impressed!
Karen didn’t have the heart to take the training materials away, and let Grace read through the TapRooT® books before she brought them back to work.
We think Miss Grace is an inspiring addition to the TapRooT® team!
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Note from Editor: Grace’s photo was published with permission. This photo may not be electronically copied or reprinted. Thank you.
When you need TapRooT® Root Cause Analysis Software implementation advice or have other technical IT needs, who do you call? Easy… our clients call 1.865.539.2139 and ask for Steve, Zach or Dan. When the IT experts here or at your place of business need help, what do they do for help? Simple, they map out the issue using TapRooT®’s SnapCharT® first and then find out where the equipment or human performance difficulty issue needs to be addressed.
Why tell you all this today you may ask? Because Dan Verlinde, Director of Information Technology & Software Development, and several U.S based and India based software developers will be attending our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training in New Delhi this September.
Above was just one of two classes that we taught on the PotashCorp Rocanville Mine Site this week. Like many of our customers, they are going into full production with the newest version of our Web Enterprise Software. The students above were already trained in our process and wanted to learn how to use the new software upgrade in a 4 hour software class.
Have all students attend the first 2 days and then allow a select few employees who need to be lead facilitators and mentors stay for the remaining 3 days.
Brian Tink, taught this course with me and also got to go for a tour in the mine. If you have never been in a Potash Mine here is link to my first visit a few years back….http://www.taproot.com/wordpress/archives/5885
Interestingly enough I learned two things this trip. Just because your not at home in Tennessee does not mean that the heat will not follow you. We had a wonderful heatwave. A sizzling heat wave broke 16 records in communities across Canada Wednesday, despite cooler temperatures in Alberta and Saskatchewan. Markham, Ont., was the day’s hotspot at 35.9 C, breaking the record of 35.6 set back in 1991.
My second lesson is that when fishing for Wall-Eye or in Canadian words, Pic, as seen below, the man in the white truck with a badge, wants to know if you have a license…. and you can not fish within 23 yards of a dam. Do not ask me how I know.
From the articles:
“Cleanup crews in Idaho have finished clearing honey and an estimated 14 million bees that got loose after a delivery truck overturned on a highway.
Fremont County Sheriff deputies say several workers were stung during the first few hours of the cleanup Sunday.
And some observers told The Post-Register about seeing a strange black cloud and roaring noise above the spill area before realizing it was a massive swarm of bees.”
To make matters worse… more bees not contained may mean an increase of more bears.
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:
Kevin Palardy, one of our Canadian based instructors, introducing the SnapCharT® Process. As you can see below, the course is not just a sit down and lecture course… you have to apply what you learn on each of the 7 Steps learned.
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?
If you have ever sat in a TapRooT® Root Cause Analysis Course or Summit, you know that the transfer of knowledge and support from our instructors does not stop when the session ends. To help guide the next steps of continuous improvement, Mark Paradies and Linda Unger added Appendix C in our TapRooT® book, TapRooT®, Changing the Way the World Solves Problems. The tip today comes from “Topic 3: Knowledge” on page 461.
To ensure that TapRooT® Training is not just a one time event, we provide and suggest different knowledge opportunities:
The key concept to using and understanding knowledge is to identify the who, what, how and when as it relates to training. In our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Training, key investigation facilitators are introduced to the ADDIE process (Analyze, Define, Develop, Implement, Evaluate). The only way do Analyze and Define is to go out and look at the tasks that people need to perform in order to be efficient. With that in mind let’s start with the following people:
1. Investigators
2. Certified Instructors
3. Managers
4. Improvement Program Leader (Owner/Champion)
5. Coaches/Mentors/Facilitators
6. Hands on Employees/Operators
7. Top Manager (Sponsor)
Start by identifying their core task and skills required to perform the tasks. You may find cross-over of tasks which is not a problem. Actually it gives you more resources to share in times of need.
Once you identify the tasks and possible skills, assess the level of knowledge needed. Here is a template from my U.S. Air Force training Matrix in our CFETP:
Task Performance Levels
1. Can do simple parts of the task. Needs to be told or shown how to do most of
the task. (Extremely Limited)
2. Can do most parts of the task. Needs only help on hardest parts. (Partially
Proficient)
3. Can do all parts of the task. Needs only a spot check of completed work.
(Competent)
4. Can do the complete task quickly and accurately. Can tell or show others how
to do the task. (Highly Proficient)
Task Knowledge Levels
a. Can name parts, tools, and simple facts about the task. (Nomenclature)
b. Can determine step-by-step procedures for doing the task. (Procedures)
c. Can identify why and when the task must be done and why each step is needed.
(Operating Principles)
d. Can predict, isolate, and resolve problems about the task. (Advanced Theory)
Subject Knowledge Levels
A. Can identify basic facts and terms about the subject. (Facts)
B. Can identify relationship of basic facts and state general principles about the
subject. (Principles)
C. Can analyze facts and principles and draw conclusions about the subject.
(Analysis)
D. Can evaluate conditions and make proper decisions about the subject.
(Evaluation)
By identifying the who, what and how, then we need to figure out where your TapRooT® Root Cause students will get to the performance levels needed to reduce or prevent problems (Incidents).
Biggest key here is that you will need to assess the skills of each team member listed above; where it starts:
1. Good Root Cause Analysis starts with a robust and usable method taught by knowledgeable facilitators; do this by sending them to the appropriate course. We teach and then give hands-on exercises; we follow up by working one on one with students as needed.
2. Develop in-house mentors/facilatators and assign those mentors as needed to help newly trained individuals. Some even get certified to teach in-house.
3. Look for systemic issues and identify additional knowledge and performance gaps. Decide who in the list above may need to attend one of the pre-Summit or Summit Activities.
4. Develop in-house group sessions to discuss lessons learned.
5. Schedule refresher training to give competency levels high.
I often hear, “We trend lots of issues … see all the numbers and charts?” Heck, I have even said it myself a few times in my life. Then we go and check our “numbers” ask, “what does it show us today?” Or even worse, the boss asks, “can you show me ……….. ?”
Here are some of the reactive action items that I have had to follow up on in order to try and answer a question for someone else:
1. “Everything was just fine and now things seem to be out of control; show me where it went wrong?”
2. “After starting YOUR new metric, things really got bad, why?”
3. “Looking at both of these charts, show me the correlation.”
4. “But we have only had 5 incidents in 5 years (infrequent data), how can we trend that?”
5. “Look at these great trends … , what did WE… I mean you change?”
As I started this post, this article appeared in the news discussing the Numbers Game:
Just because we’ve seen an increase in the number of tornadoes doesn’t mean there has actually been an increase in the number of tornadoes,” said Greg Carbin, the warning coordination meteorologist with the Storm Prediction Center in Norman, Okla.
Decades ago, when the country was more sparsely populated — and not everyone had a camera-equipped cell phone — there were simply fewer people around to spot and report tornadoes, Carbin said.
In addition, Carbin said, many initial tornado tallies include tornadoes that are counted more than once.
According to NOAA’s preliminary count, April saw 875 tornadoes. “That’s a gigantic number,” Carbin said. “It may turn out there were that many tornadoes, but I can guarantee that many of those were not significant tornadoes, but they get into the database now because everyone has a tornado they want to report.”
The highest number of tornadoes on record for any month is 542, from May 2003. Carbin said he suspects that once all the data are compiled, April’s numbers will be closer to the May 2003 numbers.
In addition, both Carbin and Crouch pointed to the fact that with increasing urbanization, more people are affected when storms do hit, putting tornadoes in the spotlight.
Numbers and climate conditions aside, one thing is for certain, the scientists said — this tornado season has been unusually violent, as the horrific images splashed across the evening news attest, and it’s not even close to being over.
But it is not hopeless, I promise. The first step is to back out of your numbers and ask:
1. Where did these numbers come from?
2. What were the numbers originally designed to measure?
3. Are these numbers part of the same set of behaviors and tasks or are they independent?
4. Were the numbers created with limited bias and not driven by a reward or discipline factor?
5. Are these numbers occurring frequently or is this intermittent and infrequent data?
6. Finally, do you understand your numbers and does the boss know what the numbers mean when you show the charts and trends or lack of trends?
Does this mean I think you need to go back to school for six weeks of statistics … no!
Does this mean that you need to throw all your old numbers away and start from scratch … maybe!
Does this mean that you may need a couple of days to reassess what you use and how you use it to trend … yes!
Since two days is not too much out of a busy schedule there are three resources that can help in you in your love-hate relationship with trending and metrics:
1. Read Chapter 5 in the TapRooT® book, TapRooT®, Changing the Way the World Solves Problems by Mark Paradies and Linda Unger
2. Read the Making Sense of Data by Donald Wheeler
3. Attend our upcoming Advanced Trending Techniques course where you receive the Making Sense of Data book, Course Workbook and hands on exercises taught by experts in the field who use real world applicable trending.
“The world’s largest passenger aircraft clipped a much smaller commuter plane on a dark, wet tarmac at New York City’s Kennedy Airport, spinning it like a toy as hundreds of passengers sat in both planes. No one was injured.”
Interesting article today titled: “Restaurant to retrain staff after mixed-drink mixup”
On Friday, Taylor Dill-Reese went to an Applebee’s in Madison Heights, Michigan, where — among other things — she ordered her 15-month-old son Dominick an apple juice.
What the little boy apparently got instead was a margarita. His mom told WDIV-TV that she only realized something was wrong when Dominick “kind of laid his head on the table and dozed off a little bit and woke up and got real happy.”
The little boy reportedly began hailing strangers, too.
According to the article the restaurant stated, that it would begin to serve apple juice to children only from single-serve containers at the table and would “retrain all severs on our beverage pouring policy, emphasizing that non-alcoholic and alcoholic beverages must be stored in completely separate and identified containers.”
…. for our TapRooT® trained investigators, can you think of any other root causes than training? (more…)
According to an Edelman study of more than 20 countries, global trust in business is at an all-time low and diminishing. Another study I read indicates that online news sources are still the first choice for most people when looking for information on companies.
This combination of global mistrust combined with blind faith in online media reporting means to be a better leader, it’s important to know how to avoid bad press for your company.
I couldn’t help but notice that recent headlines appearing in my online media source for local news sounded like case studies for TapRooT® training:
Two Die When Wall Falls at Gatlinburg Sewage Treatment Plant
McGhee Tyson Traffic Controller Faces Firing After FAA Says
He Slept on the Job
In this day of rapid technology, the people you market to are breaking down all of the information the media is putting out about your company, and blogging and sharing the information online in a matter of minutes of release.
TapRooT® is a systematic process, software, and training for finding the root causes of problems and developing effective fixes to keep problems from happening again.
TapRooT® is the most effective, tested, documented root cause system used by industry leaders around the world. One of the most impressive parts of the TapRooT® System is the training that helps people see problems in a whole new light. TapRooT® is not only used to react to incidents, but it’s also used proactively to keep them from occurring.
Are you noticing the same type of problems happen over and over again – safety incidents, equipment failures, quality issues, sentinel events, or production upsets? Stop trying “fixes” that just don’t work. You can become a better leader and avoid bad press for your company. Find the real root causes of problems so that you can fix them once and for all and never end up in tomorrow’s negative headlines.
There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.
Entry #4: Saving Time, Resources & Effort with Single User Sofware
Our company was utilizing the Web Based version of the TapRooT® Software globally to perform and record all RCAs but our work is very project-based and often in remote locations with internet connectivity issues. The challenge was to enable unconnected people in the field to use the software but maintain a central database without repetitive data entry tasks. In addition, these remote users needed a way to get feedback on their investigations to improve overall investigation quality.
Action
All field users were set up with Single User Versions of the TapRooT® Software throughout the Business Unit. To make data entry consistent, the Single User Versions of the TapRooT® Software had to have the same pull down menu selection fields that were in the intranet based Enterprise Version. This was made possible by creating lists of the Departments, Equipment, Locations, Classifications, and Users from the Enterprise version of the Software.
Then the “list Import Tool” and the “User Import Tool” were used to populate these fields in the Single User version of the TapRooT® Software. A Single User version Installation and User’s Guide was created for the field users (who had been through the 5-Day TapRooT® Course) who then used the lists and tools to set up their software on their computers. Now, individual users can work on an investigation and export it and e-mail it for others to review at various points in the investigation. When the final report is approved, it can then be imported into the Enterprise version of the TapRooT´® Software, which is the central database for our global operations, and becomes available to anyone with web access.
Results
The flexibility to use the PC based TapRooT® Software in addition to the web based TapRooT® Software has empowered our investigators to utilize the productivity enhancement tools in the TapRooT® Software without having to have internet connectivity. We have seen a significant increase in the number of TapRooT® RCA’s performed on smaller investigations and proactively at our remote locations. In addition, the ability to easily send these reports to others for review and comment has improved the quality.
There are four best practice entries published on this weblog in the success story contest (view all entries here). Click the “Like” button for the entry you think should win an Apple iPad. All votes cast before Friday, March 4 at 6:00 p.m. EST will be tallied for the winner. In the event of a tie, the in-house instructors at System Improvements will cast the tie-breaking votes.
Entry #3: Investigation Detects Lack of Experience in Experienced Personnel And Leads To Job Simulation To Improve Performance
Submitted by: Errol De Freitas Rojas, SHE Coordinator
Company: ExxonMobil, Caracus, Venezuela
Challenge
We investigated a Marine incident where an anchor cable picked up tension during maneuvers and caused a job to be stopped. We needed to find the root cause of what happened and make sure that that job and similar jobs could be done safely.
Action
The situation was evaluated with divers and other disciplines, and a decision was made to form investigation team and use TapRooT® to evaluate the incident. After the interviews, the team went back to shore and drew a SnapCharT® to evaluate the information they had collected. When they compared the Captain’s actions and timing to other Captains doing the same type of work in a similar area with similar conditions, the investigation team found that even though the tug captain had many years of experience, he didn’t have experience laying a four point anchor. Thus, the detailed analysis using SnapCharT® and TapRooT® helped the team spot a lack of experience of an otherwise experienced Captain.
Results
We develop a training program for all Captains performing this kind of work. It includes a simulation/practice of anchor laying in a safe area prior to entering the fields. This will ensure training is adequate on laying a four point anchor and eliminate down time and wasted of resources.
Today, Linda is teaching CHAP (Critical Human Action Profile), one of the optional techniques in the TapRooT® System and one of several important topics on the third day of the course. The students learn and then apply their knowledge by performing an exrecise (the road grader example).
Practical analysis for real problems, that’s TapRooT® …
