Root Cause Analysis Blog

Interesting article on brian research and distraction. See:

http://dsc.discovery.com/news/2007/03/29/attention_hea.html?category=health&guid=20070329151500

The research shows that you can’t “will” yourself not to be distracted. Willful attention and distraction are controlled by two different parts of the brain and distraction occurs even when you are trying to concentrate. Also, some people are naturally more easily distracted than others.

… or Defending Categorization
(an excerpt from a draft of the revised TapRooT® Book
available later in 2007, Copyright © 2007)

Some cause-and-effect gurus object to use of the TapRooT® System’s Root Cause Tree® because they feel that any categorization restricts the thinking of an incident investigator. They maintain that the only way to ensure a complete, unbiased, unbounded root cause analysis is to attack each problem from the viewpoint of basic engineering and human performance principles and let the evidence lead where it may by the use of cause-and-effect, deductive reasoning, and testing of hypotheses. Our extensive investigation research and development as well as basic psychological principles show that this thinking is wrong.

The deductive reasoning and “hypothesis proving” used in fault trees, 5-Whys, and cause-and-effect actually cause problems that we will explain in this article. We will explain how these problems are solved by the tools used in the TapRooT® System. For TapRooT® Users, this article supplies the evidence you need to defend the good practices that TapRooT® and the Root Cause Tree® are based on when you are faced with the argument that “categorization” is a problem.

TapRooT® and the Root Cause Tree® have extensive testing and field use that proves the Root Cause Tree® does not limit the thinking of investigators. Just the opposite is true. Once an investigator is trained in using TapRooT®, they find a broader range of causes – they are less restricted in their thinking – than before they were trained in the use of TapRooT®. This is true even if they were previously trained in using a cause-and-effect based root cause analysis system.

Why, when using TapRooT®, do analyst find causes that they would have previously overlooked? There are several reasons.

First, when using TapRooT®, investigators use tools in addition to Root Cause Tree®. These tools that are used before using the Root Cause Tree® encourage a better collection of information before the root cause analysis begins. SnapCharT® is especially helpful for organizing investigation information and spotting missing or conflicting information. Equifactor®, CHAP, Change Analysis, and Safeguards Analysis are excellent tools to help the investigator understand what happened before they start analyzing why it happened. Thus when using TapRooT®, investigators are often better prepared to find root causes and less likely to jump to conclusions than they are when they use systems based primarily on cause-and-effect (which doesn’t have these built in information collection tools).

Second, very few investigators have the broad knowledge, training, and experience in all of the fields needed to use cause-and-effect to analyze a complex accident. What kind of knowledge and experience would be needed? A short list includes: equipment engineering, maintenance, operations research, management theory, human factors, ergonomics, and training theory. Therefore, most people need guidance to direct them to the wide variety of Root Causes that should be considered when investigating a problem. They get this guidance when using TapRooT® and the Root Cause Tree®. We have not seen this level of high quality guidance in any other system.

Third, even experienced gurus fall into a common trap. They develop “favorite cause-itis”. The concept of “finding the answer you want” has been proven by independent research. Thus, experienced investigators have a tendency to ignore information that does not fit their hypothesis and look for information that confirms their hypothesis. This tendency is called a confirmation bias. A short list (of thousands) of research papers from the past 40 years that confirm the existence of a variety of types of confirmation bias, and the effects of confirmation bias to many fields, include:

Thus, experienced investigators trying to confirm a hypothesis (the method used when building a fault tree or implied in the deductive reasoning used in most applications of 5-Why’s and cause-and-effect), will not have an “unbiased analysis” that they hope to achieve by avoiding categorization. Instead, they need a system (like the Root Cause Tree®) that focuses on a broad spectrum of possibilities. They need to use facts to select or eliminate the conditions under which the problem occurs (and thus what best practices can be used to eliminate the condition – just like the Root Cause Tree® provides). They need the guidance of the 15 Questions and the Basic Cause Categories of the Root Cause Tree® to make sure they avoid the “favorite cause” confirmation bias trap.

Fourth, almost all thinking is categorical in nature. For example, language is a categorization of certain sounds into standard meanings. Thus, a dictionary of a language is a book of categorized meanings and pronunciations. Thus, someone who opposes the use of the Root Cause Tree® because it is categorical is just replacing one well-thought-out, well-defined set of categories with another set. The new set is the one that they don’t realize that they have in their mind. Often, we have observed that the set of categories in a guru problem solver’s mind is more restrictive (as measured by the variety of outcomes in their investigations) than the categorization presented by the Root Cause Tree®. You can, therefore, think of using the guru approach (with no well thought out categorization) as trying to communicate without a standard language, without a dictionary, and without even having a standard alphabet. Imagine how effective this unstructured communication would be…

Finally, the Root Cause Tree® is not just categorization. The Root Cause Tree® is not a simple checklist. It has an expert system (the 15 Questions, the Basic Cause Categories, and the Root Cause Tree® Dictionary questions) built into it. Thus the problems encountered when using a “pick-list” of root causes have been solved by the structure and expert systems built into the Root Cause Tree®. The comparison of the Root Cause Tree® to a pick-list of root causes is a false comparison. When you see this false comparison used by those who wish to justify the use of other, less well developed, root cause analysis techniques, you will then realize that their system can’t compare to the robust, proven tools used by TapRooT®, including the Root Cause Tree®. Therefore, they have developed a weak straw man to make their system look superior in comparison to a purposefully chosen weak system – a simple pick list.

Our research and experience, in addition to independent research on confirmation bias, shows that the structure and categorization used in the Root Cause Tree® doesn’t need to be apologized for. Rather, the structure and categorization of the Root Cause Tree® is a vast advantage over other non-structured, poorly categorized techniques that don’t have expert systems built into them, such as 5-Why’s, cause-and-effect, and fault trees.

The next time you are asked to defend the Root Cause Tree® versus root cause analysis based on cause-and-effect analysis, fault trees, or 5-Why’s, you will be armed with the facts that show the superior design of the TapRooT® System.
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Research published in the January Journal of Occupational and Environmental Medicine puts the cost of fatigue related lost productive time for US workers at over $100 billion dollars per year.

Note that this cost does NOT include the cost of fatigue related accidents and incident.

When you perform a root cause analysis, how do you determine if an error was related to fatigue?

If you don’t have a good answer to this question, you should sign up for the TapRooT® Summit and attend the session by Bill Sirois, Executive VP and COO of Circadian Technologies. Bill will be presenting a technique called FACT that is based in fatigue research and can help you decide if an accident is due to fatigue.

The TapRooT® Summit is scheduled from April 25-28, 2007, and will be held at the Crowne Plaza Riverwalk in San Antonio, Texas. For more information see:

http://www.taproot.com/summit

We’ve all made a typo before. But did it send you 13,000 km off course?

This “incident” is a great example of what a spelling error can do when using a computer.

Using the internet to book his ticket, the 21 year old German tourist wanted to go to Sydney, Australia. But he typed in Sidney.

The computer found a Sidney, Montana, USA, and found a routing to get him there. The tourist didn’t notice the route ENDED in the US - he thought he was flying THROUGH the US.

He punched the button and went to the airport in Germany thinking he would arrive in Sydney, Australia, where his girlfriend lived.

First stop Portland, Oregon.

OK - this may be an out of the way routing to go to Australia but who can tell what airlines will do.

Next stop Billings, Montana.

WHAT - Billings? This guy really needs a US geography lesson and a map.

But when he saw the commuter plan that was going to fly to Sidney (Montana), he knew it couldn’t cross the ocean and something was definitely wrong!

He spent three days in the chilly Billings, Montana, USA, airport before he got an additional $600 wired to him from his parents and friends so that he could buy a ticket from Sidney to Sydney.

Lesson Learned … Don’t trust the computer - it only does what you tell it to do!

I know I’m laughing at this mistake but I bet the guy from Germany wasn’t laughing …

For the Reuters’ story, see: http://www.cnn.com/2006/WORLD/europe/12/29/germany.tourist.reut/index.html

Here is a Picture from the Knoxville News Sentinel:

See anything wrong?

Of course, standing on the top rung of a ladder is a common unsafe act (or at-risk behavior if you prefer that terminology).

But the other amazing fact was that they printed it with a story on the front page of the paper.

See: http://www.knoxnews.com/kns/local_news/article/0,1406,KNS_347_5217727,00.html for the story.

Many people don’t see unsafe acts even when they are taking pictures of them.

The following link is to an audio of an NPR report about tired doctors, fatigue, and error rates at hospitals:

http://www.npr.org/templates/story/story.php?storyId=6612904

Is the hospital industry the only industry that has normal shifts that last 24 hours or more?

What would you think if you were a patient and you knew your surgeon had been working for 24 hours straight?

Imagine yourself trying to diagnose a complex disease after working for 20 hours. Do you think you would be able to perform the difficult thought processes required?

Could these long hours explain some of the 98,000 deaths per year due to medical errors (the 98,000 is an IOM estimate)?

The impact of fatigue and investigating that impact is just one of the breakout sessions at the TapRooT® Summit.

This session is included in the following Summit tracks:

- Medical Error Reduction Best Practices

- Corrective Action Best Practices

- Human Error Reduction and Behavior Change Best Practices

- Investigation and Root Cause Analysis Best Practices

For a complete Summit schedule by track, click on this link:

http://www.taproot.com/summit.php?sched=1

Use the Display buttons on the lower left part of the page to see the various track schedules.

Interested in nuclear industry best practices for managing people and getting good human performance? The IAEA has published a list. See this pdf:

http://www-pub.iaea.org/MTCD/publications/PDF/te_1364_web.pdf

These kind of strikes always worry me ….



Widespread Brazilian flight delays could last to next week

11/01/06 12:19 PM, EST

Flights across Brazil were severely delayed Wednesday as air traffic controllers engaged in a so-called “work-to-rule” campaign, following regulations to the letter in a protest move that significantly slowed airline operations and could last until next week.

FULL STORY

Makes me think about the root cause:

“enforcement needs improvement”.

First Job Opportunity:

Human Factors / Operations Engineering Consultant – Aviation, Transportation and Defense

Second Job Opportunity:

Human Factors Internship or Post-Doc Opportunity

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(click on picture to enlarge)

Did you see the one step away from death video and picture that I posted last Tuesday?

I saw an incident (near-miss) and recorded it.

Now others can learn from it and use it in their safety meetings to raise awareness about fall protection and proper work practices.

If you see something that just isn’t right … for example, a:

- quality problem

- safety problem

- near-miss

- production upset

- maintenance issue

- equipment failure

- environmental release

- or any other “event”

Take a picture or a video and send it to me at “info@taproot.com” and I’ll post it here to share it with others.

If you want to remain anonymous, just let me know and I won’t use your name or your company’s name with the posting.

By passing along pictures of problems you can help others save lives, save jobs (by improving quality and preventing operating and maintenance problems), and save the environment (by preventing accidental releases).

And please feel free to use the pictures, videos, and other information from this blog to make performance better at your site.

And if you want to improve your systematic performance improvement attend a TapRooT® Course and the TapRooT® Summit.

Thanks for your help.

Mark

It is National Clean Hands Week September 17-23 and Back to School time. This is to try to raise awareness about the role clean hands play in preventing the spread of infectious disease. Clean Hands Prevent Disease Save Lives is the mission for the Clean Hands Coalition, for which Dr.Will and Henry the Hand Foundation are founding members. For activities during National Clean Hands Week visit www.cleanhandscoalition.org.

Exciting news is that Henry the Hand’s School Kit is available to start the School year off on the right foot to reducing absenteeism and try to prevent the September “spike” in illness that occurs each year. Visit www.henrythehand.com to order your School Kit and download free posters and Coloring Book to post or give away, in order to teach the children the true primary prevention for infectious disease. More than 22 million school days are missed each year due to the common cold (CDC). Some viruses and bacteria can live between 20 minutes and 2 hours on a desk top, cafeteria table or door knob.(CDC)

Thank you for helping to “spread the word not the germs”.

Just for the health of it!

Dr Will

Henry The Hand Foundation

11714 US 42

Cincinnati, Oh 45241

Henry the Hand’s 4 Principles of Hand Awareness:

1. WASH your hands when they are dirty and BEFORE eating.

2. DO NOT cough into your hands.

3. DO NOT sneeze into your hands.

4. Above all, DO NOT put your fingers into your eyes, nose or mouth.

The 4 Principles of Hand Awareness have been endorsed by the AMA and AAFP.

Click on movie above to play (Quicktime .mov format)

Click on picture to view larger version

I’m in Chicago teaching a 5-Day TapRooT® Course.

Across from our hotel is a construction site (I haven’t been able to identify the construction company but the high-rise is called the Cityfront Plaza).

I took the video above and some still photos of some block layers workin about 10 stories up with no fall protection and no railings between them and a 10 story fall.

They lean over the edge.

They work with their backs to the edge.

SO FAR no one has been killed.

But they are only one step away - just one moment of not thinking - from death.

I’m going to try to identify the general contractor and find their safey person because they obviously need to intervene before something bad happens.

PS: This isn’t the only safety problem that we’ve observed - just the one with the highest likelihood of a fatality.

I already know that allowing “power naps” during long or late night shifts INCREASES performance and reduces fatigue. So the FAA rule change below seems to “fly in the face” of actions needed to reduce controller fatigue.

Read the article at the following link and let me know what you think:

http://www.cnn.com/2006/TRAVEL/09/08/air.controller.naps.ap/index.html

The Secret Cost of Fatigue

by Bill Sirois, Circadian Technologies



On the surface of things, fatigue seems fairly straightforward. We all get tired, do what we need to do to get through it, and then catch up on our sleep when we can. We still harbor a cultural mentality of mind over matter, and of human failing if one allows themselves to get tired to the point of being unfit for duty. After all “if our people spent more time in bed getting their proper rest (and less time watching TV, sitting in a bar, or allowing themselves to be compromised by family life and personal activities), then they wouldn’t be tired on the job.” In other words, from a management perspective, fatigue is often perceived to be a behavioral problem, caused more by personal irresponsibility than by other factors (and certainly not by our operating policies and procedures). Well, those of us who have lived and worked shiftwork know better. Just try sleeping in the daytime and see how much “proper rest” YOU can get!

Similarly, we have this notion that, like our machinery, employee work capacity is a lineal function. In other words, one can work as many days in a row as they (or we) would like without any significant problem, and we’re happy to let them do it. Overtime saves having to hire more people and paying all their costly benefits, and it sure makes a supervisor’s job a whole lot easier to fill absences, vacations, and other benefit days off by dishing out the overtime to those who want it. Plus, we rationalize, people are happy to have the extra money. I used to think this way too, when I worked and managed shifts, but after several close calls, I realized that I was kidding myself and putting myself and others at risk.

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



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

From: Michael Baer



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

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

Thanks



Mike

Here was my reply:

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Interesting report from CNN:

http://www.cnn.com/2006/US/04/20/driving.study/index.html

Here is MSNBC’s take on the same report:

Study: Driver drowsiness big safety problem

Tired drivers are four times more likely to crash than rested motorists

http://msnbc.msn.com/id/12405053/

Hmmm… little different take.

Here’s what the NHTSA said in their press release:

Breakthrough Research on Real-World Driver Behavior Released

http://nhtsa.gov/portal/site/nhtsa/template.MAXIMIZE/menuitem.416f74e8613992381601031046108a0c/?javax.portlet.tpst=4427b997caacf504a8bdba101891ef9a_ws_MX&javax.portlet.prp_4427b997caacf504a8bdba101891ef9a_viewID=detail_view&javax.portlet.begCacheTok=token&javax.portlet.endCacheTok=token&itemID=71052f9b8559a010VgnVCM1000002c567798RCRD&viewType=standard

I thought that this quote was important:

“Drivers who engage frequently in distracting activities are more likely to be involved in an inattention-related crash or near-crash. However, drivers are often unable to predict when it is safe to look away from the road to multi-task because the situation can change abruptly leaving the driver no time to react even when looking away from the forward roadway for only a brief time.”

Here is the link to the university report about the study:

http://www-nrd.nhtsa.dot.gov/departments/nrd-13/driver-distraction/PDF/DriverInattention.pdf

What lessons can we learn from all this accident data?

FIRST, sometimes you have to install monitoring devices or you won’t get real data about human performance in accidents.

SECOND, people may not be a good judge of when it is safe to multi-task. This may apply to situations other than driving cars.

THIRD, drowsiness increased the crash risk by 4-6 times but that being drowsy during accidents was probably under-reported in actual accidents (without monitoring).

Finally, imagine … These people drove while distracted and drowsy even though they knew that they were being monitored. Do you think the general population (unmonitored drivers) is even worse? Or did these drivers get so used to be monitored that they accurately reflect the general driving public?

As asked, here is a pdf of the talk I gave this morning on human error and modeling human error.

(Call me at 865-539-2139 if you are interested in this talk.)

Thanks

Mark

This has been a very busy week at SI and with the Summit coming up and my two week trip to Europe to teach a 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Course in Aberdeen, Scotland, and a 3-Day TapRooT(R)/Equifactor(R) Equipment Troubleshooting and Root Cause Failure Analysis Course in Brussels, Belgium, I need a lighthearted joke to get me ready for the weekend. So don’t be offended. Just click the black box (mpeg movie) above, watch and laugh.

And if you have more serious human performance problems to investigate, attend one or all of these courses/meetings:

• Attend the 5-Day TapRooT(R) Advanced Root Cause Analysis Team Leader Training.
• Attend the Stopping Human Error Course on April 3-5, 2006, in Gatlinburg, TN.
• Attend the Human Performance and Behavior Change Best Practices Track at the TapRooT(R) Summit, April 5-8, 2006.

What are these graphics about?

Can they help you understand human error?

Can they help you find the root causes of problems?

Can the help you improve human performance?

Can the help you prevent accidents?

The answer is YES!

To find out how, attend the TapRooT(R) Summit in Gatlinburg, Tennessee, USA, on April 5-8, 2006.

I’ll be one of the keynote speakers ( for a complete list click here) and I’ll discuss these models more in the Getting Beyond Slips, Lapses, Mistakes, and Latent Errors - A Unified Understandable Model of Human Error.

Learn how to get beyond the simple cognitive models of human performance and understand a complete system for improving human and equipment performance.

PS: For more information about the advanced human performance models built into the TapRooT(R) System, click here.