Root Cause Analysis Blog

If you don’t know much about mistake proofing, I’d start to learn something by seeing John Grout’s web page. He has many easy to understand examples that easily demonstrate the concept of mistake proofing (the example below comes from page six of John’s examples).

Sometimes mistake proofing is seen as a discipline completely outside the realm of root cause analysis. But I see them as closely aligned and very complimentary.

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This is a record OSHA fine (almost twice the previous record). For more information, see links.

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In July of 2000 a Concord Jet operated by Air France crashed after takeoff. Now there is a criminal investigation.

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This is an event that you really shouldn’t miss.

Each year I personally select a set of advanced courses for people interested in improving performance. These courses are held on the Monday & Tuesday prior to the TapRooT(R) Summit so that people can attend one of these advanced courses and the Summit. I look at it as a one-two punch for performance improvement. And you save $200 OFF the course fee when you attend both. And you can save an additional $200 if you sign up three or more people at once for a course and the Summit.

Here are the courses scheduled for April 3-4, 2006. Just click on the course title for details about the course and registration information. If you want more information about the Summit, click here.

Coaching Skills

Creative Solutions

Stopping Human Error

How To Interview & Gather Evidence

TapRooT(R) Software Administrator Course

TapRooT(R) Advanced Trending Techniques

Risk Analysis & Management Best Practices

TapRooT(R) Incident Investigation & Root Cause Analysis Training

Special 2-Day TapRooT(R)/Equifactor(R) Equipment Failure Root Cause Analysis

Sunday is a good day to reflect on our blessings that for many in Texas and Louisiana, Hurricane Rita was much less devastating than the original forecasts had predicted.

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Watching the news coverage of the approach of Hurricane Rita is like watching a train wreck in slow motion. Even though the collision has not happened yet, you know the outcome is going to be bad.

I have been watching with special apprehension because so many of our clients are in the path of Rita and facing the destruction of their homes and places of employment. But just like a train wreck in slow motion, there seems to be very little that any of us can do except to get out of the way, if possible. (And for a house or a refinery, getting out of the way is not an option.)

Some might ask, “What is the root cause of such a devastating hurricane?”

On the Root Cause Tree(R) we would probably say it was a “Natural Disaster”.

Others might just say “nature”.

I found an interesting web article about the causes of the massive losses in these large hurricanes at: Hurricane Problem

If you are interested in the causes of massive losses in these types of deadly storms, this article is worth a quick read.

How did I answer this question from a client?

We are looking into options of what tool to use for our low level incident investigations. One option at the moment is to look at using a modified TapRooT(R). I am wanting to identify other organizations that use TapRooT(R) for low level incident investigations with a contact name so that I can discuss the issue with them.



Are you able to help?

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Here are my ideas about saving time when investigating “minor” incidents, near-misses, and other small problems… These are a summation of best practices that I have seen implemented by TapRooT(R) Users.

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One of our clients sent the following question:

We are looking into options of what tool to use for our low level incident investigations. One option at the moment is to look at using a modified TapRooT(R). I am wanting to identify other organizations that use TapRooT(R) for low level incident investigations with a contact name so that I can discuss the issue with them.



Are you able to help?

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I’ve seen many people suggest that Fault Trees are an excellent too for root cause analysis. I learned to use Fault Trees when I was getting my Masters Degree in Nuclear Engineering. I could see how they could be used proactively to have a systematic analysis of potential problems. The logic in the tree appeals to engineers.

But I’ve seen Fault Trees misused by engineers and others when analyzing the root causes of accidents. How were they misused? The investigators used the Fault Tree to “prove” that the cause they understood (they had seen before - they had experience with) was the cause of the accident.

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What is one of the most difficult tasks that an investigator faces? Deciding if fatigue is an issue when investigating an incident or an accident.

I e-mailed Bill Sirois, Sr. VP at Circadian Technologies, about an investigation that a TapRooT(R) User was performing and he sent me the following response:

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A TapRooT® User sent the following question:

Good Morning:

I been to TapRooT® Training and I have a question on the general definition/application of the Communication criterion in the TapRooT® Root Cause Tree® Dictionary.

Does Communication apply only to Verbal communication, or does it include written communication? It appears to me that it is best suited for verbal communications based on the info on the back of the TapRooT® Root Cause Tree®.

For example, a worker from one department needed to complete a form to have a task added to a work schedule by another department (Communication needed across organizational boundaries). The worker filled out the wrong form, so the task never got added to the schedule, resulting in the event that I am investigating. There are other applicable factors that contributed to this event, but I’m confused as to whether this example fits into the Communication section. I have struggled with this concept (verbal vs. written) on other investigations.

Please advise.

Thanks

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Would you like to see all the coverage on the BP Texas City Refinery explosion that has been published in the e-Newsletter? Then click on this link. The coverage is in order of occurrence.

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You don’t need to be Albert Einstein to pick the right root cause analysis system. But you should heed Einstein’s warning:

“We can’t solve a significant problem using the same knowledge that created it.”
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