Category: Great Human Factors

The 7 Secrets of Root Cause Analysis – Video

December 12th, 2016 by

Hello everyone,

Here is a video that discusses some root cause tips, common problems with root cause analysis, and how TapRooT® can help. I hope you enjoy!

Like what you see? Why not join us at the next course? You can see the schedule and enroll HERE

Would you know if your corrective action resulted in an accident?

June 30th, 2015 by

“Doctor… how do you know that the medicine you prescribed him fixed the problem,” the peer asked. “The patient did not come back,” said the doctor.

No matter what the industry and or if the root causes found for an issue was accurate, the medicine can be worse than the bite. Some companies have a formal Management of Change Process or a Design of Experiment Method that they use when adding new actions.  On the other extreme, some use the Trial and Error Method… with a little bit of… this is good enough and they will tell us if it doesn’t work.

You can use the formal methods listed above or it can be as simple for some risks to just review with the right people present before implementation of an action occurs. We teach to review for unintended consequences during the creation of and after the implementation of corrective or preventative actions in our 7 Step TapRooT® Root Cause Analysis Process. This task comes with four basic rules first:

1. Remove the risk/hazard or persons from the risk/hazard first if possible. After all, one does not need to train somebody to work safer or provide better tools for the task, if the task and hazard is removed completely. (We teach Safeguard Analysis to help with this step)

2. Have the right people involved throughout the creation of, implementation of and during the review of the corrective or preventative action. Identify any person who has impact on the action, owns the action or will be impacted by the change, to include process experts. (Hint, it is okay to use outside sources too.)

3. Never forget or lose sight of why you are implementing a corrective or preventative action. In our analysis process you must identify the action or inaction (behavior of a person, equipment or process) and each behaviors’ root causes. It is these root causes that must be fixed or mitigated for, in order for the behaviors to go away or me changed. Focus is key here!

4. Plan an immediate observation to the change once it is implemented and a long term audit to ensure the change sustained.

Simple… yes? Maybe? Feel free to post your examples and thoughts.

FASTEST WAY TO GET FIRED

May 14th, 2015 by

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When a major accident happens, look out. The tradition is for “heads to roll.”

That’s right, people get fired.

Who get’s fired? Those that are seen as “part of the problem.”

You need to be part of the solution.

How?

Investigate the incident using the TapRooT® Root Cause Analysis System, find the real, fixable root causes, suggest corrective actions that will prevent the problem from happening again, and be ready to help implement the solutions.

Then you are part of the answer … Not part of the problem.

Or you could just sit around and wait to get fired.

The choice is yours.

Get trained to use TapRooT® root cause analysis to solve problems. See:

http://www.taproot.com/courses

Another successful TapRooT® course!

February 28th, 2013 by

I just finished our 5-Day TapRooT® Advanced Root Cause Analysis Team Leader Course in Dubai.  What a great group we had.  Here is the class picture:

IMG_0278

Our next courses in the region will be in April, the 5 Day in Doha and 2 Day in Dubai.  Both courses are already half full, so if you want to attend, you should register right away.  DOHA OR DUBAI REGISTRATION CLICK HERE

Great Human Factors: When a Hand Control is Called a "Suicide Shifter"

February 16th, 2012 by

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I am a sucker for a 1948 Indian Chief motorcycle.  So I  thought … what a great opportunity to talk about Human Factors Design and show off a little nostalgia. The topic of today is the Suicide Shifter.

The Suicide Shifter is located on the left side of the fuel tank and was used to shift gears while riding. Called a Suicide Shifter because you had to take your left hand off the handle bar grip to shift it.

So the question for you today is how many equipment control designs used today at your work area are not placed in the safest area to use while operating?

Great Human Factors: The New Windows 8

February 9th, 2012 by

In the human factors world there is an acronym, HCI. This stands for Human Computer Interaction. A subset of the human factors field, HCI is where computer software programers meet the computer user’s needs by design BEFORE they sell it. So…… have you seen the marketing and pre-beta download for Windows 8?

  • Will the new version frustrate new or experienced window users? or both?
  • Will Microsoft help experienced users transition?
  • How will Microsoft help experience users transition (if they do) to the new version?
  • Will software developers who have software used on Microsoft help transition their existing customers?

Windows 8 Developer Preview is available for you to try now: http://msdn.microsoft.com/en-us/windows/apps/br229516

Great Human Factors: Can Intuitive Tool Design Override Previous Training?

February 2nd, 2012 by

Watch the chimpanzee vs. human child in a learning experiment.

Here is the video link: http://youtu.be/nHuagL7x5Wc

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.”

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