Root Cause Analysis Blog

(link to pictures with major findings highlighted)

If you attend a TapRooT® class you will hear the instructor promote proactive improvement including proactive use of root cause analysis tools. The instructors will show you how to find and fix the root causes of problems before a major accident occurs.

It seems that the Navy has a chance to act proactively. A recent audit (called an INSURV Inspection) turned up a litany of serious operational and safety problems on two Navy surface ships. Now the question is … Will the Navy find and fix the root causes or just fix the symptoms?

A fresh coat of paint and a haircut (tried and true Navy solutions) won’t solve these problems. Cracked gun barrels, degraded engines, and inoperable radars are signs of improper or inadequate maintenance. And poor maintenance is only an indicator of where the bigger problems lie.

My guess is that these ships and their crews have been run hard and underfunded. It would be interesting to see data that may shed light on my guess.

Support for the troops shouldn’t be just a political slogan. The real measure of support is funding to maintain equipment and to train those who go in harms way. Politics shouldn’t get in the way of the proper tools that our brave sailors, airmen, and solders need to fight a difficult war.

(Investigators gone wild!)

SPARE TIME INVESTIGATIONS

I’ve observed hundreds of companies and found that most incident investigations are carried out by untrained investigators in their spare time.

Even companies that train their investigators to use TapRooT® often assign investigators who already have full-time jobs that keep them busy 40, 50, or 60 hours per week. Where do investigators find the time to investigate? They do it in their spare time!

(Spare time maintenance.)

SOMETHING FOR NOTHING

Managers think they get “something for nothing” when they ask for a quick root cause analysis in the investigator’s spare time. You never get something for nothing. “Spare time” investigations have costs:

- Poor investigations & corrective actions

- Repeat incidents

- Increased risk of big accidents

- Risk of regulatory action after a big accident or because of repeat incidents

- Increased liability when plaintiff attorneys show that management didn’t respond to previous incidents

- Overworked, disheartened investigators

- Investigators trying to dodge investigation assignments

- Disenchanted employees who look at investigations as a waste of time

- Inaccurate investigation statistics

- Loss of management’s faith in root cause analysis

That’s quite a list.

Perhaps economizing on investigations isn’t a good idea.

(Climb the ladder to work on the roof. A reasonable assignment?)

REASONABLE ASSIGNMENTS

If investigating incidents in your spare time is bad, what is a good practice?

A measured response with a wise allocation of resources.

Let’s look at three examples.

Start with a simple incident. A simple investigation by a single investigator is adequate (unless something unexpected is discovered). The key is that the single investigator has to have the time to perform an investigation. Thus, this isn’t an investigation in the investigator’s “spare time.” You must relieve the investigator of his/her normal duties for a period of time. How long? A day or two for most simple investigations.

Next, let’s look at major investigations. Management seldom tries to have these performed in the investigator’s spare time. But, investigators are sometimes pulled away from the investigation to attend to their “normal” work. In this case, a full-time investigation team needs to be formed with an independent facilitator, a full-time team leader, an adequate team (some full-time, some part-time), clerical support, contractor support (specialty analysis and investigation support), and perhaps legal and public relations support. The size of the team and the duration of the investigation depends on the complexity of the accident and the investigation depth requested by management.

In between these two extremes lies the middle ground: investigations that require more than a single investigator but less than a full-blown team investigation. The size of these investigation teams should be based on the incident complexity and the expected return-on-investment of the investigation. Thus, management needs to provide dedicated resources that are proportional to the work and benefits.

HOW MUCH WORK?

For management to assign the appropriate resources, they must know the work required or have an investigation rule of thumb. Unfortunately, many managers haven’t performed a detailed root cause analysis and, because the work required for different investigations is so variable, there isn’t a “one-size-fits-all” investigation guideline for the work required. This means that management will have to start by assigning their best guess as to the required team size and then rely on the investigation team leader to request more support if needed. This won’t happen if team leaders are penalized for asking for help.

Management needs to keep asking, “Is there any help that you need?”

(Benchmarking at the Summit.)

BENCHMARK INDUSTRY INVESTIGATION BEST PRACTICES

Where can management learn more about the resource requirements for investigations and the best practices of industry leaders? At the TapRooT® Summit!

See: http://www.taproot.com/summit

Review the Incident Investigation & Root Cause Analysis Best Practices Track and the Management & Measuring Performance Best Practices Track for details.

Once a year we offer a special class that teaches the TapRooT® Software called “Getting the Most from Your TapRooT® Software.”
This year the course is in Las Vegas on June 23-24.

This course is an intensive review of the TapRooT® Version 5 Enterprise (web) Software including:

- installation,

- configuration,

- data migration (from Version 4),

- administration,

- best practices,

- custom reports, and

- future release information.

Learn all the capabilities built into the amazing TapRooT® Software.

If you are a TapRooT® Power User or Software Administrator, don’t miss this course. Sign up at:

http://www.taproot.com/courses.php?d=15

Portland, Oregon opened its doors to 30 employees from various industries attending a 2-Day TapRooT® Incident Investigation and Root Cause Analysis course. If you have never attended a TapRooT® public course and want to, who might you be be sitting next to? Here are the companies that attended our Portland course:

U.S. Mint
Intel Corporation
Alaska Airlines
Tidewater
Sause Bros.
Virgin America
Duke Energy Corporation
Southern California Edison
Lawrence Berkeley National Laboratory
Tyco Thermal Controls
Intrepid Potash

…. Kevin McManus (TapRooT® Root Cause Analysis Instructor & President of Great Systems!) teaches the difference between facts and events.

…. good investigation teams communicate and stay focused.

…. no blame… just the facts during the what phase of investigation.

…. facts…. facts… facts; you get it right here and your root causes and corrective actions stay connected to the true problems.

…. we teach…. you learn…. you practice …. we guide.

See:
http://www.aaib.dft.gov.uk/publications/formal_reports/5_2008_oo_tnd.cfm

WorkSafeBC has published an audio slideshow and an investigation report of a fatality in BC.

Here is a link to the report:

http://www2.worksafebc.com/Topics/AccidentInvestigations/IR-Construction.asp?ReportID=34679

Here is a link to the audio slide show:

http://www2.worksafebc.com/media/fss/gutterFall/slideshow.htm

Here is the question for readers…

Does this report and slide show find all the root causes?

There seems to be two root causes from the WorkSafeBC report:

1. Pre-job hazard assessment / pre-job briefing needs improvement.

2. Excessively long gutter.

If you think that some root causes were missed, what is your evidence?

Here’s a tip.

Try to draw a SnapCharT® with the evidence you are provided and then identify the Causal Factors.

What Causal Factors led to this fatality?

Next, take each of the Causal Factors through the Root Cause Tree® using the evidence provided. This is where you will find information that isn’t included in the WorkSafeBC report that you need to assess the thoroughness of the investigation.

One final question…

How do you assess the thoroughness of investigations at your facility?

For ideas about assessing investigations and your root cause analysis and incident investigation program, attend “The Good, The Bad, and The Ugly” Best Practice session at the TapRooT® Summit (June 25-27, Las Vegas).

After being introduced to TapRooT® through a public course, GPIC decided that they were ready to train key employees in TapRooT® Root Cause Analysis onsite. Pictured above and below after teaching the course in the Kingdom of Bahrain is Steve Swarthout (TapRooT® Root Cause Analysis Instructor & President of Performance Improvement of Virginia) with the key GPIC employees who made this course happen and GPIC course attendees.

This week we have a full 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Knoxville. I was teaching with Linda Unger, VP at SI, on Monday and too these “action” photos of the class listening, learning, and participating.

Why are so many people from industry leading companies attending TapRooT® Training? Because TapRooT® is so effective finding and helping people fix the root causes of problems. Also, our courses are interesting, fun, and effective.

For more course info, see:

http://www.taproot.com/courses.php

Linda teaching…

Welcome to the course exercise…

Drawing their first SnapCharT®…

Another topic being discussed…

Checking the Root Cause Tree® Dictionary while looking for Root Causes…

Using the TapRooT® Software Corrective Action Helper® Module to develop SMARTER Corrective Actions…

That’s just the first day of the 5-Day TapRooT® Course.

Attend the TapRooT® Summit and in addition to ideas that could save your company millions and prevent accidents and injuries, you could win a prize!

What kind of prize?

Just for being on-time for the sessions on the first day, you will become eligible to win an iPhone. (And there will be more prizes too…)

Also, if you were the “neatest” 50s/60s attire to the Summit Reception (Elvis will be there), you can win an iPod Shuffle.

Later in the week there will be additional iPods and other prizes.

These prizes help us keep the sessions on time and our our way of thanking you for your participation and timeliness.

For complete Summit information, see:

http://www.taproot.com/summit.php

Here’s a news item from the UK:

Child killed while driving tractor

The father of a 12-year-old boy who was crushed to death by a tractor has been fined £1000 for letting his son drive the machinery while underage.

Sam Stanbridge was towing a roller on 25 March 2007 at the family farm at Kibworth Harcourt, Leicestershire, magistrates in Leicester heard on 28 February. There were no witnesses to the incident, but his mother found him unconscious while out riding. He had sustained a fatal injury to the head, having apparently been crushed by a two-and-a-half-tonne roller attached to the tractor he was driving. The tractor fell into a nearby canal. Sam was pronounced dead at Leicester Royal Infirmary.

A coroner’s inquest into his death concluded that Sam either slipped, tripped, or fell out of the cab; while getting in and out of the cab; or while already out of the cab. He had undertaken the same activity the day before the incident, and during the previous year, despite the law banning children under 13 years of age from driving or riding on agricultural machinery.

There was no evidence that the tractor had been driven recklessly, nor could any horseplay on Sam’s part be attributed to the cause of the incident.

In court, the boy’s father, Mark Stanbridge, pleaded guilty to breaching reg. 4 of the Prevention of Accidents to Children in Agriculture Regulations 1998, in that he allowed Sam to drive a tractor while carrying out agricultural work, which culminated in his death. He was fined £1000 and ordered to pay costs of £1500.

http://www.shponline.co.uk/article.asp?pagename=incourt&article_id=7308

How much punishment is enough?

Do you think the father needs to be fined £1000 to prevent future accidents?

Sometimes I wonder about courts and enforcement of regulations.

These are pictures taken at a hotel where a TapRooT® Course was being held.

Do you think there will be a SPAC Not Used?

Class drawing SnapCharT®s during first exercise…

Pictures below are from a test of the new light rail line being put in service by the Charlotte Area Transit System. CATS is a TapRooT® User and two of their safety professionals are on The TapRooT® Advisory Board.

A press release from the UK Rail Accident Investigation Board:

The RAIB is carrying out an investigation into a derailment of a Docklands Light Railway train near Deptford Bridge station on 4 April 2008.

At 05:27 hrs on 4 April the 05:19 hrs service from Lewisham had just left Deptford Bridge station, and was traveling towards Greenwich, when it struck an object on the track and was derailed by the second axle of the first bogie. The front of the train came to a rest 88 meters after hitting the object. There were no injuries to the 59 persons on board the train and all were evacuated safely back to Deptford Bridge station.

The train, which was the first train of the day from Lewisham, was under automatic operation. The object on the track was found to be a steel drilling template that had been in use during engineering activities the previous night.

The RAIB’s investigation into the derailment is independent of any investigations by the safety authority.

The RAIB will publish a report, including any recommendations to improve safety, at the conclusion of its investigation.  This report will be available on the RAIB website:

http://www.raib.gov.uk

- - -

The Chief Inspector for the UK RAIB is Carolyn Griffiths. She is one of the Keynote Speakers at the TapRooT® Summit being Held on June 25-27 in Las Vegas, Nevada. For more information about the Summit and for registration, see:

http://www.taproot.com/summit.php

This of this as a class photo taken one table at a time…

And here are some shots of the instructors …

Day 1 of the 2-Day TapRooT® Course. Lot’s of team exercises and learning.

Here’s some pictures of some teams in the first team exercise.

Dromoland Castle

The RTE News reports that two men were injured when using a gas burner to seal a window at the Dromoland Castle in Ireland. The burner exploded, critically burning one of the workers and burning the other.

A link to those that were injured, the occupation, or the location, always makes an accident more personal. I’ve stayed at the castle in one of my trips to Ireland. It was very nice. If I stay there again, I’ll think of the accident.

Aviation is often mentioned as an example of a high-reliability industry. Yet accidents continue to occur.

There is much to be learned - good and bad - from the many investigation processes and reports published around the world. So this posting will review some of the web links that investigators may review.

First, there is the international aviation accident investigation standard: ICAO Annex 13 - Aircraft accident and incident investigation. You can find about 1/4 of it on-line at:

http://www.icao.int/icao/en/dgca/Annex13attE_en.pdf

Or you can purchase it on-line at:

http://icaodsu.openface.ca/documentItemView.ch2?ID=6594

The International Civil Aviation Organization - Air Navigation Bureau also has a Accident Invesigation & Prevention web page at:

http://www.icao.int/icao/en/anb/aig/

Another aviation accident investigation manual that is available on-line is the NTSB’s Aviation Investigation Manual for Major Team Investigations. See:
http://www.iprr.org/manuals/ntsbaviationman.pdf

Many countries have their equivalent of the NTSB. A list of national aviation investigation boards with links to their web sites can be found at:

http://aviation-safety.net/investigation/aaibs.php

These links should keep you busy and lead to many other sites with more information on aviation accident investigation.

Sanjay Gandhi, TapRooT® instructor from Kenya, sent these photos from a 5-Day TapRooT® Course for Sasol in Africa…

Class taking a break (Sanjay is on left in back row).

Class working on a team exercise.

Interviewing exercise (using cognitive interviewing techniques).

With Hearings on Capital Hill about the FAA and Aviation Safety, I thought I’d reprint some aviation accident photos to remind us where we’ve come from and how much progress has been made.

An article in the Daily Express described the trouble at Heathrow as a “Baggage Meltdown.”

The results of thousands of “lost” bags are called a “Luggage Mountain.”

They have had to fly jumbo jets loaded with just bags across the ocean to try to unite travelers with their luggage.

And news outlets say the problem could get WORSE!

The cost of this “incident” is more than just the immediate costs to the airlines and travelers. Some say it has caused damage to the whole British reputation.

What is the “cause?” Everyone has an opinion. Most are looking for someone to blame.

But instead of looking for someone to blame, they should try advanced root cause analysis.

TapRooT® has been applied by many major airlines. Alaska Airlines even used it to analyze delayed flights and improve on-time departure statistics.

Perhaps British Air should try TapRooT® to stop the baggage meltdown and improve customer service?

And next time they should use root cause analysis as a PROACTIVE tool to improve performance BEFORE they open a new terminal and thus avoid a major quality of service incident.

Last week I spent a couple of days working on the IEEE Root Cause Analysis Standard for Nuclear Power Plants. The picture about is four of the collaborators “relaxing” after a hard day of standard development.

Kay Gallogly (second from the right), founder of The 42 Group, will be describing the progress made so far at the TapRooT® Summit in Las Vegas (June 25-27). See: http://www.taproot.com/summit.php for more information about her talk and the rest of the Summit.

Go to:

http://edlabor.house.gov/issues/workerdeaths.shtml

to see the 2007 Work Related Accident Death Map.

The map is produced by the US House of Representatives Committee on Education and Labor. It has about 10% of the total deaths that occurred in 2007.

Each pinpoint is interactive. Click on it to see a short story of the fatality.

Reviewing the map has to make you think of safety and all the things that can go wrong on a job. It should be employee safety training required reading!

Read this history of the TapRooT® Summit to understand why the TapRooT® Summit has developed into a highly rated, blockbuster event - our history of continuous improvement.

You will also understand why we decided to hold the TapRooT® Summit, what the Summit is, why you will want to attend to help your company turbo-charge performance.

Don’t confuse the TapRooT® Summit with the many excellent courses we sponsor each year. After all, what is the difference between a Summit and a course?

Although the Summit shares the TapRooT® name with the courses, the focus of the Summit is quite different. This quick Summit history lesson will show you the difference between the Summit and our great root cause analysis courses.

HOW THE SUMMIT STARTED

I organized the first Summit in 1993 (to be held in 1994) because, after attending, and even helping organize, many conferences between 1983 and 1994, I saw a need for a conference with a focus on performance improvement, human factors, incident investigation, and the latest improvement technology. A conference that was NOT oriented toward research (although I appreciate good research). A meeting oriented toward practical applications that could be implemented at industrial facilities and in service organizations.

Wow! That’s a mouthful!

I also saw that there was MUCH to be gained by sharing information and ideas ACROSS INDUSTRY BOUNDARIES.

Thus this summit could not be held by one professional organization (with only a safety, quality, or equipment focus) or by a society oriented toward one industry (nuclear, refining, healthcare, aviation, pharmaceuticals, semiconductors, utilities, mining, shipping, oil exploration, …). And it had to be international — as most companies were expanding to worldwide operations.

This was a problem.

I had to start from scratch to organize, publicize, and pay for a meeting that needed to be held, but didn’t have an already established audience nor did I have a conference staff.

Some (Linda) said I was nuts!

But I knew it needed to be done. And nobody else was going to do it. So I become a conference organizer.

SUMMIT HISTORY

So in 1994 we held our first Summit in Gatlinburg, TN (with 33 participants).

It was a start. We learned a lot.

Feedback was very favorable.

And we decided to do it again.

1995 - Orlando - 72 participants.

At this Summit we started to figure out how to make the networking really special. That’s one of the things we’ve continued to improve as the Summit grows. Perhaps that’s why participants frequently remark about the valuable, new professional contacts and friends they make at the Summit.

(We went to Disney on Saturday after the Orlando Summit.)

1996 - Nashville - 85 participants.

Benchmarking became even a bigger part of the Summit.

Also, this was the first Summit with a session dedicated to medical errors at hospitals - an idea that was ahead of its time.

(We had a night at the Grand Ole Opry.)

1997 - San Antonio - 105 participants and growing strong.

Our first of many Texas Summits. We learned to make the networking even more enjoyable and how to get people together for a reception/party to continue networking in an informal environment.

(The Alamo in San Antonio)

After San Antonio in 1997, we decided to make the schedule about every 15 months to rotate the seasons. So our schedule would shift and occasionally “skip” a year. Thus Dallas was in the Fall of 1998, but we skipped 1999.)

1998 - Dallas - 119 participants.

We started having TapRooT® User present the results of their work in Success Stories. A great way to get best practice sharing started.

(We had a JR look-a-like. He didn’t look like the picture above. More like JR after a binge!)

2000 - Gatlinburg - 125 participants.

This was the start of the outstanding Keynote Speakers that wowed participants.

(Linda and Mark with our keynote speaker - a Shuttle Astronaut that discussed the first Shuttle disaster.)

2001 - Galveston - 133 participants.

Two days before the Summit, a Tropical Storm dropped 2 feet of rain! Lesson Learned: This is the last time we will schedule a Summit on the Gulf coast in late June!

This year we also started expanding the pre-Summit course selection. We’ve grown from 3 courses to choose from in 2001 to 11 to choose from in 2008.

(Band at the reception.)

2002 - Gatlinburg - 140 participants.

The networking and best practice sharing took a step up. And the reception was outstanding! Participants said it couldn’t get any better. But it did every year.

(Mark at opening talk.)

2003 - Dallas - 155 participants.

This was the Summit with the first TapRooT® Cup Golf Tournament - something that has become a fixture of Friday afternoon at the Summit and a part of the great networking that every Summit includes.

(Linda at dinner with participants on Thursday night.)

2005 - San Antonio - 169 participants.

Wow! What amazing Keynote Speakers, networking, and best practice sharing. The Summit that couldn’t get any better has hit a new high.

(Audience listening to the start of Scott Waddle’s talk. He was the CO of the submarine USS Greeneville when it collided with the Emime Maru (a Japanese fishing vessel). Most of the audience was in tears by the end of his talk - it was quite powerful.)

And golfing at the Quarry was also a high point.

2006 - Gatlinburg - 175 participants.

The best Summit so far. Each year we build upon the successes of the past and add new ideas to improve the best practice sharing and networking.

(Panel Discussion Debate)

This was also the Summit where we learned that smaller hotels promote better networking. People get lost in mega-complexes. Therefore, we try to hold Summits in nice, affordable, middle-sized hotels with convenient facilities.

2007 - San Antonio - 224 participants.